Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter CHC-95 June 2012 TO: Community Health Centers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Community Health Center Manual (New Modifiers for Provider Preventable Conditions That Are National Coverage Determinations) This letter transmits updates to Subchapter 6 of the Community Health Center Manual to add modifiers for Provider Preventable Conditions (PPCs) that are National Coverage Determinations. For more information about PPCs and related billing instructions, see Transmittal Letter ALL-195. Please Note: Two modifiers that are currently allowed by MassHealth, technical component (TC) and professional component (26), have also been added to Subchapter 6. These updates are effective for dates of service on or after on or after July 1, 2012. MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Community Health Center Manual Pages vi, 6-15, and 6-16 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Community Health Center Manual Pages vi, 6-15, and 6-16 — transmitted by Transmittal Letter CHC-94 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page vi Community Health Center Manual Transmittal Letter CHC-95 Date 07/01/12 6. Service Codes and Descriptions Introduction and Explanation of Abbreviations 6-1 Payable Radiology Service Codes 6-1 Payable Laboratory Service Codes 6-4 Payable Visit Service Codes 6-9 Payable Obstetrics Service Codes 6-11 Payable Surgery Service Codes 6-11 Payable Nurse-Midwife Service Codes 6-12 Payable Audiology Service Codes 6-12 Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): HealthAssessment Service Codes 6-12 Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Test Service Codes 6-13 Payable Tobacco Cessation Service Codes 6-13 Payable Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes 6-14 Payable Behavioral Health Screening Tool Service Codes 6-14 Modifiers 6-15 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix D. Supplemental Instructions for TPL Exceptions D-1 Appendix E. Utilization Management Program E-1 Appendix F. Admission Guidelines F-1 Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditions U-1 Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions V-1 Appendix W. EPSDT Services Medical and Dental Protocols and Periodicity Schedules W-1 Appendix X. Family Assistance Copayments and Deductibles X-1 Appendix Y. EVS Codes/Messages Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-15 Community Health Center Manual Transmittal Letter CHC-95 Date 07/01/12 613 Payable Behavioral Health Screening Tool Service Codes (cont.) Service Code Modifier Special Requirement or Limitation 96110 U6 Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; and behavioral health need identified* (Eligible providers are nurse practitioners employed by community health centers.) 96110 U7 Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; with no behavioral health need identified* (Eligible providers are physician assistants employed by community health centers.) 96110 U8 Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; and behavioral health need identified* (Eligible providers are physician assistants employed by community health centers.) * “Behavioral health need identified” means the provider administering the screening tool, in his or her professional judgment, identifies a child with a potential behavioral health services need. 614 Modifiers The following service code modifiers are allowed for billing under MassHealth for CHCs. Modifier Description 26 Professional Component 50 Bilateral procedure 51 Multiple procedures 54 Surgical care only 62 Two surgeons 66 Surgical team 80 Assistant surgeon 82 Assistant surgeon (when qualified resident surgeon not available) 99 Multiple modifiers TC Technical Component The following modifiers are for Provider Preventable Conditions that are National Coverage Determinations PA Surgical or other invasive procedure on wrong body part PB Surgical or other invasive procedure on wrong patient PC Wrong surgery or other invasive procedure on patient For more information on the use of these modifiers, see Appendix V of your provider manual. This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS codes are defined in the Current Procedural Terminology (CPT) code book. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-16 Community Health Center Manual Transmittal Letter CHC-95 Date 07/01/12 This page is reserved.