Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter HCBS-2 August 2013 TO: Home- and Community-Based Services Waiver Service Providers Participating in MassHealth FROM: Kristin L. Thorn, Acting Medicaid Director RE: Home- and Community-Based Services (HCBS) Waiver Manual (Adoption of New HCBS Service Codes, Descriptions, and Modifiers) This letter transmits the newly established Subchapter 6 of the Home- and Community-Based Services Waiver Manual. Subchapter 6 provides service codes, descriptions, and modifiers for the home- and community-based services (HCBS) waiver services program. The regulations for these programs (130 CMR 630.000) are provided as Subchapter 4 of the HCBS provider manual and went into effect retroactive to April 1, 2013, as emergency regulations. Subchapter 4 was transmitted by Transmittal Letter HCBS-1. Subchapters 1 through 3 contain the MassHealth Administrative and Billing Regulations (130 CMR 450.000). These regulations apply to all MassHealth providers. Subchapter 5 contains Administrative and Billing Instructions, which also apply to all providers. MassHealth Website The Home- and Community-Based Services Waiver Manual is maintained on the MassHealth website. Go to www.mass.gov/masshealthpubs. Click on Provider Library, then on MassHealth Provider Manuals. This transmittal letter is also available in the Provider Library of the MassHealth website. 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.) Home- and Community-Based Services Waiver Manual Pages vi and 6-1 through 6-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Home- and Community-Based Services Waiver Manual None Commonwealth of Massachusetts MassHealth Provider Manual Series Home- and Community-Based Services Waiver Manual Subchapter Number and Title 6. Service Codes Page vi Transmittal Letter HCBS-2 Date 05/24/13 6. Service Codes Introduction .................................................................................................................................... 6-1 Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Services ....................................... 6-1 Modifiers for the Money Follows the Person (MFP) Waivers ....................................................... 6-1 Service Codes and Descriptions for Money Follows the Person (MFP) Waiver Services ............. 6-2 Modifiers for the Acquired Brain Injury (ABI) Waivers ................................................................ 6-3 Service Codes and Descriptions for Acquired Brain Injury (ABI) Waiver Services ...................... 6-4 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/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 Page 6-1 Home- and Community-Based Services Waiver Manual Transmittal Letter HCBS-2 Date 05/24/13 601 Introduction MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 450.000 and 630.000. For complete descriptions of the service codes listed in Subchapter 6 of the Home- and Community-Based Services Waiver Manual, providers must refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 602 Early Periodic Screening, Diagnosis and Treatment (EPSDT) Services An HCBS waiver services provider may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard member enrolled in a home- and community-based services waiver who is younger than 21 years of age, even if the service is not designated as covered or payable in Subchapter 6 of the Home- and Community-Based Services Waiver Manual. 603 Modifiers for the Money Follows the Person (MFP) Waivers The following service code modifiers are allowed for billing under MassHealth. See Subchapter 5 of the Home- and Community-Based Services Waiver Manual for billing instructions related to the use of modifiers. MFP Modifiers Modifier Description U8 MFP Community Living (MFP-CL) Waiver U9 MFP Residential Supports (MFP-RS) Waiver U1 Agency Provider U2 Individual Provider UB Self-Directed Worker Definitions for Money Follows the Person (MFP) Waivers, the MFP Community Living (MFP-CL) waiver, and the MFP Residential Supports (MFP-RS) waiver, can be found in MassHealth regulations at 130 CMR 630.000. Definitions for Agency, Individual Provider, and Self-Directed Worker can be found in Executive Office of Health and Human Service (EOHHS) regulations at 101 CMR 357.00. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-2 Home- and Community-Based Services Waiver Manual Transmittal Letter HCBS-2 Date 05/24/13 604 Service Codes and Descriptions for Money Follows the Person (MFP) Waiver Services Service Code First Position Modifier Second Position Modifier Service Description S5135 U8 adult companion care; per 15 minutes (Agency) S5125 U8 UB adult companion, attendant care; per 15 minutes (Individual and Self-directed) T2031 U9 assisted living services, waiver; per diem S5120 U8 U1, U2, or UB chore services; per 15- minutes S5110 U8 or U9 U1 or U2 residential and community family training, home care; per 15 minutes S5102 U8 day services, adult; per diem S5165 U8 or U9 U1 or U2 home accessibility adaptations, modifications; per service G0156 U8 services of a home health aide in a home health setting; per 15 minutes S5130 U8 U1, U2, or UB homemaker services; per 15 minutes H0043 U8 independent living supports, supported housing; per diem S5108 U8 or U9 individual support and community habilitation, skills training; per 15 minutes (Agency) H2014 U8 or U9 UB individual support and community habilitation, skills training; per 15 minutes (Individual Provider and Self-directed) S9129 U8 or U9 U1 or U2 occupational therapy, in the home; per visit H0038 U8 or U9 U1, U2, or UB peer support, self-help/peer services; per 15 minutes T1019 U8 U1, U2, or UB personal care services; per 15 minutes S9131 U8 or U9 U1 or U2 physical therapy, in the home; per visit T2018 U8 or U9 prevocational services, habilitation, waiver; per diem T2019 U8 or U9 prevocational services; per 15 minutes T2016 U9 residential habilitation, waiver; per diem Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-3 Home- and Community-Based Services Waiver Manual Transmittal Letter HCBS-2 Date 05/24/13 604 Service Codes and Descriptions for Money Follows the Person (MFP) Waiver Services (cont.) Service First Position Second Position Code Modifier Modifier Service Description H0045 U8 respite care not in the home, waiver; per diem H2016 U8 shared home supports, comprehensive community support services; per diem T2033 U9 shared living - 24 hour support, residential care, waiver; per diem G0154 U8 or U9 skilled nursing services of a licensed nurse in a home health setting; per visit T2029 U8 or U9 specialized medical equipment; per service S9128 U8 or U9 U1 or U2 speech therapy, in the home; per visit H2023 U8 or U9 supported employment; per 15 minutes T1004 U8 supportive home care aide; per 15 minutes T2003 U8 or U9 nonemergency transportation; per encounter/one-way trip T2039 U8 vehicle modification, waiver; per service 605 Modifiers for the Acquired Brain Injury (ABI) Waivers The following service code modifiers are allowed for billing under MassHealth. See Subchapter 5 of the Home and Community-Based Services Waiver Manual for billing instructions related to the use of modifiers. ABI Modifiers Modifier Description U4 ABI Non-Residential Habilitation (ABI-N) Waiver U5 ABI Non-Residential Habilitation (ABI-N) Waiver Definitions for the Acquired Brain Injury (ABI) Waivers, the ABI Residential Habilitation (ABI-RH) waiver, and the ABI Non-Residential Habilitation (ABI-N) waiver can be found in MassHealth regulations at 130 CMR 630.000. Definitions for Agency and Self-employed Provider can be found in Executive Office of Health and Human Service (EOHHS) regulations at 101 CMR 357.00. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-4 Home- and Community-Based Services Waiver Manual Transmittal Letter HCBS-2 Date 05/24/13 606 Service Codes and Descriptions for Acquired Brain Injury (ABI) Waiver Services Service Code S5135 S5125 Modifier U4 U4 S5120 S5102 S5165 S5130 S5108 U4 U4 or U5 U4 U4 U4 H2014 U4 S9129 T1019 S9131 T2016 H0025 T2029 S9198 H2023 T2038 T2003 U4 or U5 U4 U4 or U5 U5 U4 U4 or U5 U4 or U5 U4 or U5 U4 or U5 U4 or U5 Service Description adult companion care; per 15 minutes (Agency Provider) adult companion, attendant care; per 15 minutes (Self-employed Provider) chore services, per 15 minutes day services, adult; per diem home accessibility adaptations, modifications; per service homemaker services, per 15 minutes individual support and community habilitation, skills training; per 15 minutes (Agency Provider) individual support and community habilitation, skills training; per 15 minutes (Self-employed Provider) occupational therapy, in the home; per visit personal care services; per 15 minutes physical therapy, in the home; per visit residential habilitation, waiver; per diem respite care not in the home, waiver; per diem specialized medical equipment; per service speech therapy, in the home; per visit supported employment; per 15 minutes transitional assistance; per service non-emergency transportation; per encounter/one-way trip