Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma
MASSHEALTH
TRANSMITTAL LETTER DHP-24
October 2003

TO:      Day Habilitation Programs Participating in MassHealth FROM:      Beth Waldman, Acting Commissioner
RE:      Day Habilitation Program Manual (Revisions to Service Codes and Descriptions)
This letter transmits revisions to the service codes and descriptions in the Day Habilitation Program Manual to reflect the implementation of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended. The revised Subchapter 6 is effective for dates of service on or after October 16, 2003. Subchapter 5 (billing instructions) will be revised at a later date.
The Centers for Medicare and Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2003. New national service codes have been added, and MassHealth local service codes have been removed from the Day Habilitation Program Manual. Please note that you must use a modifier with some codes to accurately reflect the service provided. The attached Subchapter 6 contains codes with modifiers, where applicable.
Place of Service Codes
Effective October 16, 2003, providers will no longer be required to use different service codes when billing for day habilitation services provided in a nursing facility. Providers are required to report on the claim form the place of service (POS) where services are provided. Using this POS code, the Division will automatically pay for such services in accordance with the applicable fee schedule of the Division of Health Care Finance and Policy.
Please note that the HIPAA-compliant CMS POS codes are different from the Division’s POS codes. The attached crosswalk details which code set is to be used for different claim types.
Providers should refer to Subchapter 5 (billing instructions) of the Day Habilitation Program Manual for a complete listing of all allowable Division POS codes. For 837 Professional claims, please coordinate the Division’s POS code list with the HIPAA-compliant CMS POS code list that is available at http://cms.hhs.gov/states/posdata.pdf.
Day Habilitation, Low-Need
Effective for dates of service on or after October 16, 2003, the MassHealth local service codes for day habilitation, low-need (X2303 full day, X2300 three-quarter day, X2304 half day, X2305 one-quarter day) have been replaced with HCPCS code H2014 (skills training and development, per 15 minutes). Providers must bill in 15-minute units with a minimum of one unit and a maximum of 24 units allowed per attendance day.

MASSHEALTH
TRANSMITTAL LETTER DHP-24 October 2003 Page 2
Day Habilitation, Moderate-Need
Effective for dates of service on or after October 16, 2003, the MassHealth local service codes for day habilitation, moderate-need (X2306 full day, X2301 three-quarter day, X2307 half day, X2308 quarter day) have been replaced with HCPCS code H2014 with modifier TF (skills training and development, per 15 minutes; intermediate level of care). Providers must bill in 15-minute units with a minimum of one unit and a maximum of 24 units allowed per attendance day.
Day Habilitation, High-Need
Effective for dates of service on or after October 16, 2003, the MassHealth local service codes for day habilitation, high-need (X2309 full day, X2302 three-quarter day, X2310 half day, x2311 one-quarter day) have been replaced with HCPCS code H2014 with modifier TG (skills training and development, per 15 minutes; complex/high tech level of care). Providers must bill in 15-minute units with a minimum of one unit and a maximum of 24 units allowed per attendance day.
Day Habilitation, Supplemental Staffing
Effective for dates of service on or after October 16, 2003, the MassHealth local service code for supplemental staffing (X2325) has been replaced with HCPCS code H2014 with modifier 22 (Skills training and development, per 15 minutes; unusual procedural services). Providers must bill in 15-minute units with a minimum of one unit and a maximum of 24 units allowed per attendance day. Please refer to Day Habilitation Provider Bulletin 2, dated November 1999, for complete instructions on how to use this service.
Day Habilitation, In-Facility Services, 1:2 or 1:3 staff-to-participant ratio
Effective for dates of service on or after October 16, 2003, the MassHealth local service code for day habilitation in a nursing facility, multiple members, less than four members (X2327) has been replaced with HCPCS code H2014 with modifier U1 (skills training and development, per 15 minutes). Providers must bill in 15-minute units with a minimum of one unit and a maximum of 24 units allowed per attendance day. Please refer to Day Habilitation Provider Bulletin 3, March 2000, for complete instructions on how to utilize this service.
Day Habilitation, In-Facility Services, 1:1 staff-to-participant ratio
Effective for dates of service on or after October 16, 2003, the MassHealth local service code for day habilitation in a nursing facility, individual member (X2326) has been replaced with HCPCS code H2014 with modifier U2 (skills training and development, per 15 minutes). Providers must bill in 15-minute units with a minimum of one unit and a maximum of 24 units allowed per attendance day. Please refer to Day Habilitation Provider Bulletin 3, dated March 2000, for complete instructions on how to use this service.
Day Habilitation, In-Facility Services, Staff Transportation
Effective for dates of service on or after October 16, 2003, MassHealth local service code for transportation to a nursing facility (X2320) has been replaced with HCPCS code T2003 (non-emergency transportation; encounter/trip). Providers must bill for this service per trip with a maximum of two trips per program day.

MASSHEALTH
TRANSMITTAL LETTER DHP-24 October 2003 Page 3
This service is allowable only for in-facility services when staff-to-participant ratio is 1:4 or more and the provider uses this code in combination with the community-based day habilitation service codes and modifiers (H2014 including use of modifiers TF and TG).
In-facility services for members with a staff-to-participant ratio of 1:1, 1:2, or 1:3 includes the transportation rate in the service code/modifier. Please refer to Day Habilitation Program Bulletin 2, dated November 1999, for complete instructions on how to utilize this service.
Crosswalk
Please find attached a crosswalk from the obsolete MassHealth local service codes and modifiers to the new national service codes and modifiers for the revised Subchapter 6.
Regulations from the Division of Health Care Finance and Policy
If you wish to obtain a copy of the Division of Health Care Finance and Policy’s Regulations about the conversion of these codes, submit a request to the address or phone number listed below.
Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100
You can also view these regulations on-line at www.mass.gov/dhcfp.
Web Site Access and Questions
This transmittal letter and the day habilitation regulations are available on the Division’s Web site at www.mass.gov/dma. If you have any questions, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Day Habilitation Program Manual
Pages 6-1 and 6-2
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Day Habilitation Program Manual
Pages 6-1 and 6-2 — transmitted by Transmittal Letter DHP-23

Day Habilitation Program Service Code Crosswalk
Effective 10/16/2003

MassHealth
Transmittal Letter DHP-24
October 2003
Attachment
Page 1

Obsolete Code	Obsolete Service Description	New Code-Modifier	New Service
Description/Modifier
Description	CMS POS
To be used on 837P
transactions:
Loop 2300 (line level);
Field CLM05-01; OR
Loop 2400 (claim level);
Field SV105	DMA POS
To be used on paper
claims/EMC transactions: Enter in Item 15 of the paper claim 09, or equivalent Item on EMC	Limitation/ Comment	
X2303	Low-need full-day day habilitation services	H2014	Skills training and development, per 15 minutes	11 (office), 31 (skilled nursing facility) or 32 (nursing facility)	01 (office), 06
(nursing
facility)	Day habilitation, low-need. Bill in 15-minute units. Report the actual time spent by the member in the day habilitation program. Minimum one unit per day; maximum 24 units per day.	
X2300	Low-need three-quarter day day habilitation services	H2014	Skills training and development, per 15 minutes	11 (office), 31 (skilled nursing facility) or 32 (nursing facility)	01 (office), 06
(nursing
facility)	Day habilitation, low-need	
X2304	Low-need half-day day habilitation services	H2014	Skills training and development, per 15 minutes	11 (office), 31 (skilled nursing facility) or 32 (nursing facility)	01 (office), 06
(nursing
facility)	Day habilitation, low-need	
X2305	Low-need one-quarter day day habilitation services	H2014	Skills training and development, per 15 minutes	11 (office), 31 (skilled nursing facility) or 32 (nursing facility)	01 (office), 06
(nursing
facility)	Day habilitation, low-need	
X2306	Moderate-need full-day day habilitation services	H2014-TF	Skills training and development, per 15 minutes, intermediate level of care	11 (office), 31 (skilled nursing facility) or 32 (nursing facility)	01 (office), 06
(nursing
facility)	Day habilitation, moderate-need	
X2301	Moderate-need three-quarter day day habilitation services	H2014-TF	Skills training and development, per 15 minutes, intermediate level of care	11 (office), 31 (skilled nursing facility) or 32 (nursing facility)	01 (office), 06
(nursing
facility)	Day habilitation, moderate-need	
X2307	Moderate-need half-day day habilitation services	H2014-TF	Skills training and development, per 15 minutes, intermediate level of care	11 (office), 31 (skilled nursing facility) or 32 (nursing facility)	01 (office), 06
(nursing
facility)	Day habilitation, moderate-need	
X2308	Moderate-need one-quarter day day habilitation services	H2014-TF	Skills training and development, per 15 minutes, intermediate level of care	11 (office), 31 (skilled nursing facility) or 32 (nursing facility)	01 (office), 06
(nursing
facility)	Day habilitation, moderate-need	
X2309	High-need full-day day habilitation services	H2014-TG	Skills training and development, per 15 minutes, complex/high tech level of care.	11 (office), 31 (skilled nursing facility) or 32 (nursing facility)	01 (office), 06
(nursing
facility)	Day habilitation, high-need	
X2302	High-need three-quarter day day habilitation services	H2014-TG	Skills training and development, per 15 minutes, complex/high tech level of care	11 (office), 31 (skilled nursing facility) or 32 (nursing facility)	01 (office), 06
(nursing
facility)	Day habilitation, high-need	

Day Habilitation Program Service Code Crosswalk
Effective 10/16/2003

MassHealth
Transmittal Letter DHP-24
October 2003
Attachment
Page 2

Obsolete	Obsolete Service	New	New Service	CMS POS	DMA POS	Limitation/	
Code	Description	Code-	Description/Modifier	To be used on 837P	To be used on	Comment	
		Modifier	Description	transactions: Loop 2300 (line level); Field CLM05-01; OR Loop 2400 (claim level); Field SV105	paper
claims/EMC transactions: Enter in Item 15 of the paper claim 09, or equivalent Item on EMC		
X2310	High-need half-day	H2014-TG	Skills training and	11 (office), 31 (skilled	01 (office), 06	Day habilitation, high-	
	day habilitation		development, per 15	nursing facility) or	(nursing	need	
	services		minutes, complex/high tech level of care	32 (nursing facility)	facility)		
X2311	High-need one-	H2014-TG	Skills training and	11 (office), 31 (skilled	01 (office), 06	Day habilitation, high-	
	quarter day day		development, per 15	nursing facility) or	(nursing	need	
	habilitation services		minute, complex/high tech level of care	32 (nursing facility)	facility)		
X2325	Supplemental staffing, member resides in a nursing facility	H2014-22	Skills training and development, per 15 minutes, unusual procedural services	11 (office)	01 (office)	Supplemental staffing for members who reside in a nursing facility and attend a community-based day habilitation program.	
X2326	Day habilitation in a	H2014-U2	Skills training and	31 (skilled nursing	06 (nursing	Use modifier U2 to	
	nursing facility,		development, per 15	facility) or	facility)	denote day	
	individual member		minutes	32 (nursing facility)		habilitation in a nursing facility with a staff-to-participant ratio of 1:1.	
X2327	Day habilitation in a	H2014-U1	Skills training and	31 (skilled nursing	06 (nursing	Use modifier U1 to	
	nursing facility,		development, per 15	facility) or	facility)	denote day	
	multiple members,		minutes	32 (nursing facility)		habilitation in a	
	less than four					nursing facility with a staff-to-participant ratio of 1:2 or 1:3.	
X2320	Transportation to	T2003	Nonemergency	31 (skilled nursing	06 (nursing	Staff transportation to	
	nursing facility (round		transportation;	facility) or	facility)	nursing facility, bill per	
	trip)		encounter/trip	32 (nursing facility)		one way trip, up to a maximum of two trips. Use this in conjunction with H2014 TG and TF only when services occur in a nursing facility.