Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter DME-32 July 2012 TO: Durable Medical Equipment Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Durable Medical Equipment Manual (2012 HCPCS) This letter transmits revisions to Subchapter 6, Service Codes and Descriptions, of the Durable Medical Equipment Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) codes for 2012. Revisions have been made to service codes in Subchapter 6 of the Durable Medical Equipment Manual to comply with federal coding mandates, to incorporate coding and rate changes previously described in informational bulletins issued by the Division of Health Care Finance and Policy (DHCFP), and remind providers of certain existing durable medical equipment (DME) and medical supplies policies and requirements. The revised Subchapter 6 is effective for dates of service on or after January 1, 2012. Providers may consult the CMS website at www.cms.gov for a full description of the service codes. Prior authorization (PA) requirements, service limits, and place-of-service (POS) codes now appear in an updated version of the interactive MassHealth DME and Oxygen Payment and Coverage Guidelines Tool that has been posted on the MassHealth website. New DME Service Codes The additions to the MassHealth service codes included in this section are effective for dates of service on or after January 1, 2012. The following codes have been added to Subchapter 6 of the Durable Medical Equipment Manual and the MassHealth DME and Oxygen Payment and Coverage Guidelines Tool. A5056 E0988 E2359 E2627 E2629 E2631 E2633 A5057 E2358 E2626 E2628 E2630 E2632 Revised Rates DHCFP has established new DME service code rates for the above service codes, effective for dates of service beginning January 1, 2012. The DHCFP fee schedule and informational bulletins can be viewed on the DHCFP website at www.mass.gov/dhcfp. Diagnosis Codes ICD-9-CM diagnosis codes are required on all claims. The ICD-9-CM service codes must be directly related to the service billed on the claim. PA Requests for DME Units in Excess of the Maximum Allowable Units MassHealth requires PA for any DME service codes if the number of units requested exceeds the maximum allowable units, specified in the MassHealth DME and Oxygen Payment and Coverage Guidelines Tool. When requesting PA for services in excess of the maximum allowable units, the provider must * submit to MassHealth, in addition to the PA request that was submitted for units up to the maximum allowable, a separate PA request to MassHealth for the number of units being requested that exceed the maximum allowed; and * include clinical documentation that supports the medical necessity of the additional units, including requirements under 130 CMR 409.417 and 130 CMR 409.418. Additionally, a provider of DME that has been assigned an oxygen specialty, in accordance with 130 CMR 409.404(D), and provides OXY services to MassHealth members in Massachusetts, must have an oxygen and respiratory therapy equipment specialty. Further, DME providers that have an oxygen and respiratory therapy equipment specialty assigned to their DME provider contract with MassHealth must * adhere to oxygen and respiratory equipment therapy regulations 130 CMR 427.000, as well as 130 CMR 409.000, 130 CMR 450.000, and 114.3 CMR 22.00; * have a servicing facility in Massachusetts and employ (W2 employees), at a minimum, one respiratory-care practitioner with a current Massachusetts license on a full-time or part-time basis; and * have a Medicare billing provider number and comply with Medicare requirements, including being open to the public for a minimum of 30 hours a week. Modifiers LT and RT Modifiers LT (left side) and RT (right side) have been added to the following wheelchair accessory service codes on the MassHealth Durable Medical and Oxygen Payment and Coverage Guideline Tool. E0951 E0974 E1020 E2215 E2224 E2384 E2392 E2630 K0037 K0045 K0069E0952 E0994 E2205 E2216 E2225 E2385 E2394 E2631 K0038 K0046 K0070E0958 E0995 E2206 E2217 E2226 E2386 E2395 E2632 K0039 K0047 K0071E0959 E1009 E2209 E2218 E2227 E2387 E2396 E2633 K0040 K0050 K0072E0961 E1015 E2211 E2219 E2228 E2388 E2626 K0015 K0041 K0051 K0073E0967 E1016 E2212 E2220 E2381 E2389 E2627 K0017 K0042 K0052 K0077 E0971 E1017 E2213 E2221 E2382 E2390 E2628 K0018 K0043 K0053 E0973 E1018 E2214 E2222 E2383 E2391 E2629 K0019 K0044 K0065 If bilateral items are provided as a “purchase,” and the unit of service described in the service code description is “each,” bill both items on the same line using the LT/RT modifiers and two units of service. If a single item is provided as a “purchase” for either the left or right side, bill one claim line using the appropriate modifier (LT or RT) and one unit of service. Place-of-Service MassHealth has added place-of-service (POS) 14 (group home) as an allowable place of service for certain HCPCS in the MassHealth Durable Medical and Oxygen Payment and Coverage Guideline Tool codes listed. Providers must include the applicable POS code when submitting claims to MassHealth. POS code 14 is now covered for the following service codes. E0951 E0974 E1020 E2215 E2224 E2384 E2392 E2630 K0037 K0045 K0069 E0952 E0994 E2205 E2216 E2225 E2385 E2394 E2631 K0038 K0046 K0070 E0958 E0995 E2206 E2217 E2226 E2386 E2395 E2632 K0039 K0047 K0071 E0959 E1009 E2209 E2218 E2227 E2387 E2396 E2633 K0040 K0050 K0072 E0961 E1015 E2211 E2219 E2228 E2388 E2626 K0015 K0041 K0051 K0073 E0967 E1016 E2212 E2220 E2381 E2389 E2627 K0017 K0042 K0052 K0077 E0971 E1017 E2213 E2221 E2382 E2390 E2628 K0018 K0043 K0053 E0973 E1018 E2214 E2222 E2383 E2391 E2629 K0019 K0044 K0065 Providers Supplying Oral Enteral Nutrition Covered by WIC Providers must refer to Durable Medical Equipment Bulletin 16 (issued in January 2010) for clarification of coverage for the provision of certain enteral nutrition products, for MassHealth members who may be eligible for enteral nutrition products provided by the Department of Public Health (DPH), Women, Infants, and Children (WIC) nutrition program. This DME bulletin contains information on enteral products that are not covered by WIC, general PA documentation requirements for enteral nutrition PA requests, and PA guidelines. Providers may refer to the DPH WIC website for any changes in the WIC-covered enteral formulas at www.mass.gov/eohhs/consumer/basic-needs/food/wic. When prescription and medical necessary documentation is presented to the provider of DME, for the purpose of submitting a PA for regular formula for infants and children under the age of five, the provider must ascertain from the MassHealth member’s caregiver if the member/family is WIC-eligible, before submitting the PA. Fee Schedule If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The specific regulation title for Durable Medical Equipment and Oxygen and Respiratory Therapy Equipment is 114.3 CMR 22.00. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp Obsolete Appendix D This letter also obsoletes Appendix D of the Durable Medical Equipment Manual. As described in DME Bulletin 15 (January 2009), PA is no longer required for personal emergency response systems (PERS). Please remove Appendix D, which describes where to send requests for PA for PERS, from your manual. 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 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.) Durable Medical Equipment Manual Pages vi and 6-1 through 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Durable Medical Equipment Manual Pages vi, 6-1 through 6-4, D-1, and D-2 — transmitted by Transmittal Letter DME- 31 Commonwealth of Massachusetts MassHealth Provider Manual Series Durable Medical Equipment Manual Subchapter Number and Title Table of Contents Page vi Transmittal Letter DME-32 Date 01/01/12 6. Services Codes Introduction 6-1 Modifiers 6-1 Service Codes 6-1 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-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 and Messages Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Durable Medical Equipment Manual Subchapter Number and Title 6. Service Codes Page 6-1 Transmittal Letter DME-32 Date 01/01/12 601 Introduction MassHealth pays for the services for codes listed in Section 603 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 409.000 and 450.000. In addition, a provider may request prior authorization (PA) for any medically necessary durable medical equipment or supplies. Providers should consult Transmittal Letter DME- 32 for the specific effective dates of service for the service codes. Providers should refer to the MassHealth DME and Oxygen Payment and Coverage Guidelines Tool for service descriptions, applicable modifiers, place-of-service codes, PA requirements, service limits, and pricing and markup information. For certain services that are payable on an individual consideration (I.C.) basis, the tool will calculate the payable amount, based on information entered into certain fields on the tool. For service codes for which the Division of Health Care Finance and Policy (DHCFP) has established a rate, the provider can determine the payment by reviewing the DHCFP regulations at 114.3 CMR 22.00. The MassHealth DME and Oxygen Payment and Coverage Guidelines Tool also contains links to DHCFP regulations, MassHealth Guidelines for Medical Necessity Determination, and Part 6 of the administrative and billing instructions, which lists the error codes and explanations for claims that have been denied or suspended by MassHealth. To get to the MassHealth DME and Oxygen Payment and Coverage Guidelines Tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library, then on MassHealth DME and Oxygen Payment and Coverage Guidelines Tool. If you want a paper copy of the tool, you can print it from the website, or request a copy from MassHealth Customer Service. See Appendix A of your provider manual for applicable contact information. 602 Modifiers Modifiers LT (left side) and RT (right side) have been added to specific wheelchair accessory service codes. Please refer to the MassHealth Durable Medical and Oxygen Payment and Coverage Guideline Tool. 603 Service Codes This section lists Level II HCPCS codes that are payable under MassHealth. Refer to the Centers for Medicare & Medicaid Services website at www.cms.gov for more detailed descriptions when billing for Level II HCPCS codes provided to MassHealth members. A4206 A4210 A4213 A4215 A4220 A4221 A4222 A4223 A4233 A4234 A4235 A4236 A4244 A4245 A4246 A4247 A4250 A4253 A4255 A4256 A4258 A4259 A4265 A4310 A4311 A4312 A4313 A4314 A4315 A4316 A4320 A4321 A4322 A4326 A4327 A4328 A4330 A4331 A4332 A4333 A4334 A4338 A4340 A4344 A4346 A4349 A4351 A4352 A4353 A4354 A4355 A4356 A4357 A4358 A4361 Commonwealth of Massachusetts MassHealth Provider Manual Series Durable Medical Equipment Manual Subchapter Number and Title 6. Service Codes Page 6-2 Transmittal Letter DME-32 Date 01/01/12 603 Service Codes (cont.) A4362 A4363 A4364 A4366 A4367 A4368 A4369 A4371 A4372 A4373 A4375 A4376 A4377 A4378 A4379 A4380 A4381 A4382 A4383 A4384 A4385 A4387 A4388 A4389 A4390 A4391 A4392 A4393 A4394 A4395 A4396 A4397 A4398 A4399 A4400 A4402 A4404 A4405 A4406 A4407 A4408 A4409 A4410 A4411 A4412 A4413 A4414 A4415 A4416 A4417 A4418 A4419 A4420 A4422 A4423 A4424 A4425 A4426 A4427 A4428 A4429 A4430 A4431 A4432 A4433 A4434 A4450 A4452 A4455 A4456 A4461 A4463 A4490 A4495 A4500 A4510 A4558 A4595 A4600 A4601 A4630 A4635 A4636 A4637 A4638 A4640 A4649 A4660 A4663 A4670 A4927 A4930 A5051 A5052 A5053 A5054 A5055 A5056 A5057 A5061 A5062 A5063 A5071 A5072 A5073 A5081 A5082 A5083 A5093 A5102 A5105 A5112 A5113 A5114 A5120 A5121 A5122 A5126 A5131 A5200 A6010 A6011 A6021 A6022 A6023 A6024 A6154 A6196 A6197 A6198 A6199 A6203 A6204 A6205 A6206 A6207 A6208 A6209 A6210 A6211 A6212 A6213 A6214 A6215 A6216 A6217 A6218 A6219 A6220 A6221 A6222 A6223 A6224 A6228 A6229 A6230 A6231 A6232 A6233 A6234 A6235 A6236 A6237 A6238 A6239 A6240 A6241 A6242 A6243 A6244 A6245 A6246 A6247 A6248 A6250 A6251 A6252 A6253 A6254 A6255 A6256 A6257 A6258 A6259 A6260 A6266 A6402 A6403 A6404 A6407 A6410 A6411 A6442 A6443 A6444 A6445 A6446 A6447 A6448 A6449 A6450 A6451 A6452 A6453 A6454 A6455 A6456 A6457 A6501 A6502 A6503 A6504 A6505 A6506 A6507 A6508 A6509 A6510 A6511 A6512 A6513 A8000 A8001 A8002 A8003 A8004 A9274 A9276 A9277 A9278 A9280 A9281 B4034 B4035 B4036 B4081 B4082 B4083 B4087 B4088 Commonwealth of Massachusetts MassHealth Provider Manual Series Durable Medical Equipment Manual Subchapter Number and Title 6. Service Codes Page 6-3 Transmittal Letter DME-32 Date 01/01/12 603 Service Codes (cont.) B4100 B4102 B4103 B4104 B4149 B4150 B4152 B4153 B4154 B4155 B4157 B4158 B4159 B4160 B4161 B4162 B4164 B4168 B4172 B4176 B4178 B4180 B4185 B4189 B4193 B4197 B4199 B4216 B4220 B4222 B4224 B5000 B5100 B5200 B9000 B9002 B9004 B9006 E0100 E0105 E0110 E0111 E0112 E0113 E0114 E0116 E0117 E0130 E0135 E0140 E0141 E0143 E0144 E0147 E0148 E0149 E0153 E0154 E0155 E0156 E0157 E0158 E0159 E0160 E0161 E0162 E0163 E0165 E0167 E0168 E0170 E0171 E0172 E0175 E0181 E0182 E0184 E0185 E0186 E0187 E0188 E0189 E0190 E0191 E0193 E0194 E0196 E0197 E0198 E0199 E0202 E0210 E0215 E0235 E0240 E0241 E0242 E0243 E0244 E0245 E0246 E0247 E0248 E0250 E0251 E0255 E0256 E0260 E0261 E0265 E0266 E0271 E0272 E0274 E0275 E0276 E0277 E0280 E0290 E0291 E0292 E0293 E0294 E0295 E0296 E0297 E0300 E0301 E0302 E0303 E0304 E0305 E0310 E0315 E0316 E0325 E0326 E0328 E0329 E0371 E0372 E0373 E0602 E0603 E0604 E0605 E0606 E0607 E0610 E0621 E0625 E0627 E0628 E0629 E0630 E0635 E0636 E0637 E0638 E0639 E0640 E0641 E0642 E0650 E0651 E0652 E0655 E0656 E0657 E0660 E0665 E0666 E0667 E0668 E0669 E0671 E0672 E0673 E0675 E0700 E0705 E0710 E0720 E0730 E0731 E0747 E0748 E0760 E0776 E0779 E0780 E0781 E0784 E0791 E0840 E0849 E0850 E0855 E0856 E0860 E0870 E0880 E0890 E0900 E0910 E0911 E0912 E0920 E0930 E0935 E0936 E0940 E0941 E0942 E0944 E0945 E0946 E0947 E0948 E0950 E0951 E0952 E0955 E0956 E0957 E0958 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0971 E0973 Commonwealth of Massachusetts MassHealth Provider Manual Series Durable Medical Equipment Manual Subchapter Number and Title 6. Service Codes Page 6-4 Transmittal Letter DME-32 Date 01/01/12 603 Service Codes (cont.) E0974 E0978 E0980 E0981 E0982 E0983 E0984 E0985 E0986 E0988 E0990 E0992 E0994 E0995 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1009 E1010 E1011 E1014 E1015 E1016 E1017 E1018 E1020 E1028 E1029 E1030 E1031 E1035 E1036 E1037 E1038 E1039 E1050 E1060 E1070 E1083 E1084 E1087 E1088 E1092 E1093 E1100 E1110 E1150 E1160 E1161 E1170 E1171 E1172 E1180 E1190 E1195 E1200 E1220 E1221 E1222 E1223 E1224 E1225 E1226 E1227 E1228 E1231 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1240 E1270 E1280 E1295 E1296 E1297 E1298 E1399 E1800 E1801 E1802 E1805 E1806 E1810 E1811 E1812 E1815 E1816 E1818 E1820 E1821 E1825 E1830 E1831 E1840 E1841 E1902 E2000 E2100 E2101 E2201 E2202 E2203 E2204 E2205 E2206 E2207 E2208 E2209 E2210 E2211 E2212 E2213 E2214 E2215 E2216 E2217 E2218 E2219 E2220 E2221 E2222 E2224 E2225 E2226 E2227 E2228 E2231 E2291 E2292 E2293 E2294 E2295 E2300 E2310 E2311 E2312 E2313 E2321 E2322 E2323 E2324 E2325 E2326 E2327 E2328 E2329 E2330 E2331 E2340 E2341 E2342 E2343 E2351 E2358 E2359 E2360 E2361 E2362 E2363 E2364 E2365 E2366 E2367 E2368 E2369 E2370 E2371 E2372 E2373 E2374 E2375 E2376 E2377 E2381 E2382 E2383 E2384 E2385 E2386 E2387 E2388 E2389 E2390 E2391 E2392 E2394 E2395 E2396 E2397 E2500 E2502 E2504 E2506 E2508 E2510 E2511 E2512 E2599 E2601 E2602 E2603 E2604 E2605 E2606 E2607 E2608 E2609 E2610 E2611 E2612 E2613 E2614 E2615 E2616 E2617 E2619 E2620 E2621 E2622 E2623 E2624 E2625 E2626 E2627 E2628 E2629 E2630 E2631 E2632 E2633 E8000 E8001 Commonwealth of Massachusetts MassHealth Provider Manual Series Durable Medical Equipment Manual Subchapter Number and Title 6. Service Codes Page 6-5 Transmittal Letter DME-32 Date 01/01/12 603 Service Codes (cont.) E8002 K0001 K0002 K0003 K0004 K0005 K0006 K0007 K0009 K0015 K0017 K0018 K0019 K0020 K0037 K0038 K0039 K0040 K0041 K0042 K0043 K0044 K0045 K0046 K0047 K0050 K0051 K0052 K0053 K0056 K0065 K0069 K0070 K0071 K0072 K0073 K0077 K0098 K0105 K0108 K0195 K0455 K0552 K0601 K0602 K0603 K0604 K0605 K0606 K0607 K0608 K0609 K0733 K0739 K0800 K0801 K0802 K0806 K0807 K0808 K0813 K0814 K0815 K0816 K0820 K0821 K0822 K0823 K0824 K0825 K0826 K0827 K0828 K0829 K0830 K0831 K0835 K0836 K0837 K0838 K0839 K0840 K0841 K0842 K0843 K0848 K0849 K0850 K0851 K0852 K0853 K0854 K0855 K0856 K0857 K0858 K0859 K0860 K0861 K0862 K0863 K0864 K0868 K0869 K0870 K0871 K0877 K0878 K0879 K0880 K0884 K0885 K0886 K0890 K0891 L8501 S5160 S5161 S5497 S5498 S5501 S5502 S5517 S5518 S5520 S5521 S5522 S5523 S8265 S8420 S8421 S8422 S8423 S8424 S8425 S8426 S8427 S8428 S8429 S8430 S9325 S9326 S9327 S9328 S9329 S9330 S9331 S9336 S9338 S9339 S9340 S9341 S9342 S9343 S9345 S9346 S9347 S9348 S9349 S9351 S9353 S9355 S9357 S9359 S9361 S9363 S9364 S9365 S9366 S9367 S9368 S9370 S9372 S9373 S9374 S9375 S9376 S9377 S9434 S9435 S9490 S9494 S9497 S9500 S9501 S9502 S9503 S9504 S9537 S9538 S9542 S9558 S9559 S9560 S9562 S9590 T4521 T4522 T4523 T4524 T4525 T4526 T4527 T4528 T4529 T4530 T4531 T4532 T4533 T4534 T4535 T4536 T4537 T4538 T4539 T4540 T4541 T4542 T4543 T5001 99601 99602 Commonwealth of Massachusetts MassHealth Provider Manual Series Durable Medical Equipment Manual Subchapter Number and Title 6. Service Codes Page 6-6 Transmittal Letter DME-32 Date 01/01/12 This page is reserved.