Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth	

MASSHEALTH
TRANSMITTAL LETTER HHA-37 
June 2005 

	TO:	Home Health Agencies Participating in MassHealth

	FROM:	Beth Waldman, Medicaid Director

	RE:	Home Health Agency Manual (Prior Authorization Policy for Rehabilitative Therapy Services)

This letter transmits revisions to the home health agency regulations.  The revisions reflect the policy changes that MassHealth announced under Home Health Agency Bulletin 44, dated December 2004.    

Increase in Number of Payable Visits Before PA Is Required

The revised regulations increase the number of medically necessary physical therapy (PT), occupational therapy (OT), and speech therapy (ST) visits that are payable by MassHealth within a 12-month period before prior authorization (PA) is required.  The number of medically necessary visits payable by MassHealth without PA is now 20 PT visits, 20 OT visits, and 35 ST visits within a 12-month period.  

Please Note:  Although the attached regulations are revised July 1, 2005, the increase in the number of payable therapy visits have been in effect since January 1, 2005, as stated in the above-mentioned bulletin.

Maintenance Programs

The attached revisions also provide a revised definition of maintenance program and change the policy on coverage for maintenance programs.  See 130 CMR 403.424(D).  

MassHealth defines maintenance programs as “repetitive services, required to maintain or prevent the worsening of function, that do not require the judgment and skill of a licensed therapist for safety and effectiveness.”    

130 CMR 403.424(D) now states:

(D)  Maintenance Programs.
(1)  The MassHealth agency pays for the establishment of a maintenance program and the training of the member, member’s family, or other persons to carry it out, as part of a regular treatment visit, not as a separate service.  The MassHealth agency does not pay for performance of a maintenance program, except as provided in 130 CMR 403.424(D)(2).  

(2)  In certain instances, the specialized knowledge and judgment of a licensed therapist may be required to perform services that are part of a maintenance program, to ensure safety or effectiveness that may otherwise be compromised due to the member’s medical condition.  At the time the decision is made that the services must be performed by a licensed therapist, all information that supports the medical necessity for performance of such services by a licensed therapist, rather than a non-therapist, must be documented in the medical record.  

New Definitions

MassHealth has also added definitions for Occupational Therapy, Occupational Therapist, Physical Therapy, Physical Therapist, Speech/Language Therapy, and Speech/Language Therapist.  

Updated Subchapter 6

This letter also transmits a revised Subchapter 6 of the Home Health Agency Manual. MassHealth has updated Subchapter 6 to reflect the revised prior-authorization requirements.  

Tips on Requesting PA

MassHealth encourages providers to use its Web-based Automated Prior Authorization System (APAS) at www.masshealth-apas.com when requesting PA for therapy services in excess of 20 PT visits, 20 OT visits, or 35 ST visits, within a 12-month period.  To receive more information about requesting PA using APAS, including training and access to APAS, call 1‑866‑378-3789.

A number of PA requests for therapy services have been returned to providers or delayed in processing because of confusion about how to request PA.  The following are guidelines for completing PA requests for PT, OT, and ST.  

Responsibility for Requesting PA

If the home health agency has a physician’s verbal orders at the time the PA is requested, the PA request must include a copy of the documented physician’s verbal order.  As stated in 130 CMR 403.419(D), the member’s clinical record must contain a documented physician’s verbal order for the care before the services are provided, and the physician’s signature must be on the 60-day plan of care either before the claim is submitted or within 45 days after submitting a claim for that period. 
 
Note:  A nurse may sign the Request and Justification for Therapy Services (R&J) form, as long as the form indicates that the therapy notes are attached and signed by the therapist.

General Instructions

When requesting PA, whether on the Automated Prior Authorization System (APAS) or on the paper Request for Prior Authorization, you must:
•	submit a complete, legible Request and Justification form (R&J); 
•	submit a current (within 60 days) physician prescription for initial requests, and a physician’s order for renewal for subsequent requests or a copy of a physician’s verbal orders in accordance with 130 CMR 403.419(D);
•	submit a copy of the most recent comprehensive evaluation or reevaluation;
•	summarize the member’s medical necessity in Section VII of the R&J form and submit all appropriate information for substantiating medical necessity for the requested service;
•	use the most appropriate code for the service (see below for more information about service codes); and
•	make sure that the services and number of units you are requesting on the PA request are consistent with the information shown on the R&J form.  
 
Service Codes

The following service codes may be used for therapy services provided by a home health agency.  These codes are also noted in Subchapter 6 of the MassHealth Home Health Agency Manual.

G0151	Services of physical therapist in home health setting, each 15 minutes 
G0152	Services of occupational therapist in home health setting, each 15 minutes 
G0153	Services of speech and language pathologist in home health setting, each 15 minutes 

Calculating Units

To calculate the total number of units, identify the:
•	number of visits needed per week;
•	number of weeks for which you will need to schedule visits; and 
•	amount of time needed for each visit.

Example:  If the R&J form indicates that you plan to see the member twice a week, for one hour each visit, for a four-week period, the number of units is as follows:
•	2 visits x 4 15-minute units = 8 15-minute units per week
•	8 15-minute units x 4 weeks = 32 15-minute units over the course of four weeks.

Service Code	
Units per week	
Duration of PA request	Total units requested for PA 	
G0151 (PT) 	8	4 weeks	32	
G0152 (OT)	8	4 weeks	32	
G0153 (ST) 	8	4 weeks	32	

Revised R&J

MassHealth has revised the R&J form to reflect the revised regulations.  In addition, the sites of service delivery have been expanded to include rehabilitation centers and “other” locations.  The revised form also clarifies that a summary of the member’s medical necessity must be provided in Section VII of the R&J.  This requirement is in addition to the requirement to attach supporting documentation to the form.  The revised form is available on the MassHealth Web site at www.mass.gov/masshealthpubs.  Click on “Provider Library,” then on “Provider Forms.”  You may continue to submit PA requests with the previous version of the R&J form, but you should make note of the new language.  

To order supplies of the new form, send a written request to MassHealth Customer Service or call them at 

MassHealth
P.O. Box 9118
Hingham, MA  02043
Telephone:  1-800-841-2900
E-mail:  publications@mahealth.net 
Fax:  617-988-8973.  

Include your provider number, mailing address, contact name, and desired quantity with all requests for forms. 

MassHealth Guidelines

To provide additional assistance to MassHealth providers requesting prior authorization for therapy services, MassHealth has developed Guidelines for Medical Necessity Determination for Physical Therapy, for Occupational Therapy, and for Speech and Language Therapy.  These Guidelines are intended to clarify the specific medical information that MassHealth needs to determine medical necessity.  They are not intended to replace or supersede program regulations.  All MassHealth Guidelines for Medical Necessity Determination are available at www.mass.gov/masshealth/guidelines.  From this site, you can also sign up to receive e-mail notification of updates to the MassHealth Guidelines.

Effective Date

These regulations are effective July 1, 2005.

Questions

If you have any questions about the information in this transmittal letter before July 1, 2005, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.  If you will be making your inquiry on or after July 1, 2005, please call MassHealth Customer Service at 1‑800‑841-2900 or e-mail your inquiry to providersupport@mahealth.net.  

NEW MATERIAL
(The pages listed here contain new or revised language.)

Home Health Agency Manual

Pages iv, 4-1 through 4-4, 4-17, 4-18, 6-1, and 6-2

OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)

Home Health Agency Manual

Pages iv, 4-1 through 4-4, 4-17, and 4-18 — transmitted by Transmittal Letter HHA-36

Pages 6-1 and 6-2 — transmitted by Transmittal Letter HHA-35

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	
PAGE

iv	

HOME HEALTH AGENCY MANUAL	
TRANSMITTAL LETTER

HHA-37	
DATE

07/01/05	

4.  PROGRAM REGULATIONS

	403.401:  Introduction		4-1
	403.402:  Definitions		4-1
	403.403:  Home Health Services 		4-3
	403.404:  Eligible Members 		4-3
	403.405:  Provider Eligibility:  In State		4-4
	403.406:  Provider Eligibility:  Out of State		4-4
	(130 CMR 403.407 and 403.408 Reserved)
	403.409:  Services Provided Under Contract 		4-4
	403.410:  Home Health Conditions of Coverage 		4-5
403.411:  Members Aged 60 and Over 		4-7
403.412:  Complex-Care Members 		4-8
403.413:  Prior-Authorization Requirements 		4-9
403.414:  Notice of Approval or Denial of Prior Authorization		4-11
(130 CMR 403.415 through 403.418 Reserved)
	403.419:  Physician Plan-of-Care Requirements 		4-12
	403.420:  Nursing Services 		4-13
	403.421:  Home Health Aide Services 		4-14
	403.422:  Intermittent or Part-Time Requirement 		4-15
	403.423:  Personal-Care Worker Services 		4-16
	403.424:  Physical, Occupational, and Speech and Language Therapy 		4-17
	403.425:  Payment Rules for Initial Patient Assessments, Observation and Evaluation
Visits, and Supervisory Visits 		4-18
	403.426:  Medical Supplies 		4-18
	403.427:  Recordkeeping Requirement and Utilization Review		4-18
	403.428:  Administrative Requirements 		4-19
	403.429:  Maximum Allowable Fees 		4-19
	403.430:  Denial of Services and Administrative Review		4-19

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS
(130 CMR 403.000)	
PAGE

4-1	

HOME HEALTH AGENCY MANUAL	
TRANSMITTAL LETTER

HHA-37	
DATE

07/01/05	

403.401:  Introduction

	All home health agencies participating in MassHealth must comply with MassHealth regulations, including, but not limited to 130 CMR 403.000 and 450.000.

403.402:  Definitions

	The following terms used in 130 CMR 403.000 have the meanings given in 130 CMR 403.402, unless the context clearly requires a different meaning.  The reimbursability of services defined in 130 CMR 403.402 is not determined by these definitions, but by the application of regulations elsewhere in 130 CMR 403.000 and 450.000.

Calendar Week – seven consecutive days.

Case Management – a function performed by the MassHealth agency or its designee that assesses and reassesses the medical needs of complex-care members and authorizes or coordinates community long-term-care (CLTC) services that are medically necessary for such members to remain safely in the community.

Case Manager – a registered nurse employed by the MassHealth agency or its designee to provide case management to complex-care members, to work cooperatively with that member, his or her family and primary caregiver(s), and all relevant providers.

Certification Period – a period of no more than 60 days in which the member's physician has certified that the plan of care is medically appropriate and necessary.

Chore Services – household duties (for example, heavy cleaning or minor home repairs) performed on behalf of a person who is unable to manage these tasks due to impairment.

Community Long-Term-Care (CLTC) Services – certain MassHealth-covered services intended to enable a complex-care member to remain in the community.  Such services include, but are not limited to, home health, durable medical equipment, oxygen and respiratory equipment, personal-care attendant, and other health-related services as determined by the MassHealth agency or its designee.

Complex-Care Member – a MassHealth member, under the age of 22 at enrollment, whose medical needs, as determined by the MassHealth agency or its designee, are such that he or she requires a nurse encounter of more than two continuous hours of nursing services to remain in the community.

Home Health Agency – a public or private organization that provides nursing and other therapeutic services to individuals whose place of residence conforms to the requirements of 
42 CFR 440.70(c).

Home Health Aide – a person who is employed by a MassHealth-approved home health agency to perform certain personal-care and other health-related services as listed in 130 CMR 403.421(B).

Homemaker – a person who performs light housekeeping duties (for example, cooking, cleaning, laundry, shopping) for the purpose of maintaining a household.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS
(130 CMR 403.000)	
PAGE

4-2	

HOME HEALTH AGENCY MANUAL	
TRANSMITTAL LETTER

HHA-37	
DATE

07/01/05	

Maintenance Program – repetitive services, required to maintain or prevent the worsening of function, that do not require the judgment and skill of a licensed therapist for safety and effectiveness.

Member – an individual determined by the MassHealth agency to be eligible for MassHealth.

Nurse – a person licensed as a registered nurse, a licensed practical nurse, or a licensed vocational nurse by a state’s board of registration in nursing.

Nursing Services – the planning, provision, and evaluation of goal-oriented nursing care that requires specialized knowledge and skills acquired under the established curriculum of a school of nursing approved by a board of registration in nursing.  Such services include only those services that require the skills of a nurse.

Occupational Therapy – therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct, rehabilitate, or prevent the worsening of functions that affect the activities of daily living that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries.  Occupational therapy programs are designed to improve quality of life by recovering competence, preventing further injury or disability, and to improve the individual’s ability to perform tasks required for independent functioning, so that the individual can engage in activities of daily living.

Occupational Therapist – a person who is licensed by the Massachusetts Division of Registration in Allied Health Professions and registered by the American Occupational Therapy Association (AOTA) or is a graduate of a program in occupational therapy approved by the Committee on Allied Health Education and Accreditation of the American Medical Association and engaged in the supplemental clinical experience required before registration by AOTA.

Personal-Care Worker (PCW) – a person employed by a MassHealth-approved home health agency provider and trained as required by the MassHealth agency, whose function is to provide certain personal-care and related ancillary services, and who plays an integral, ongoing role in the complex-care member’s plan of care, under the supervision of a nurse.

Physical Therapy – therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct, rehabilitate, or prevent the worsening of physical functions that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries.  Physical therapy emphasizes a form of rehabilitation focused on treatment of dysfunctions involving neuromuscular, musculoskeletal, cardiovascular/pulmonary, or integumentary systems through the use of therapeutic interventions to optimize functioning levels.

Physical Therapist – a person licensed by the Massachusetts Division of Registration in Allied Health Professions.

Primary Caregiver – the individual, other than the nurse, home health aide, or personal-care worker, who is primarily responsible for providing ongoing care to the member.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS
(130 CMR 403.000)	
PAGE

4-3	

HOME HEALTH AGENCY MANUAL	
TRANSMITTAL LETTER

HHA-37	
DATE

07/01/05	

Request and Justification Form – the form (paper, electronic, or other) authorized by the MassHealth agency or its designee, on which the nursing-care needs of the member, other than a complex-care member, as identified in the screening are described by the provider.  This form is submitted to the MassHealth agency or its designee with the request for prior authorization for nursing services.

Respite Services – a range of services provided on a short-term or intermittent basis in response to the need for relief of those persons who normally provide this care.

Speech/Language Therapy – therapy services, including diagnostic evaluation and therapeutic intervention, that are designed to improve, develop, correct, rehabilitate, or prevent the worsening of speech/language communication and swallowing disorders that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries.  Speech and language disorders are those that affect articulation of speech, sounds, fluency, voice, swallowing (regardless of presence of a communication disability), and those that impair comprehension, spoken, written, or other symbol systems used for communication.

Speech/Language Therapist – a person who is licensed by the Massachusetts Division of Registration in Speech-Language Pathology and Audiology and has either a Certificate of Clinical Competence from the American Speech, Language, and.Hearing Association (ASHA) or a statement from ASHA of certification of equivalency.

Visit – a personal contact in the member’s home, for the purpose of providing a covered service by a registered or licensed nurse, home health aide, or physical, occupational, or speech and language therapist employed by, or contracting with, the home health agency.

403.403:  Home Health Services 

	The MassHealth agency pays for the following home health services for eligible MassHealth members, subject to the restrictions and limitations described in 130 CMR 403.000 and 450.000:
	
(A)  nursing;
	
(B)  home health aide; 

(C)  personal-care worker for complex-care members; and 

(D)	 physical, occupational, and speech and language therapy.

403.404:  Eligible Members

(A) (1)  MassHealth Members.  MassHealth covers home health services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in 130 CMR 403.000 and 450.000.  130 CMR 450.105 specifically states, for each MassHealth coverage type, which services are covered and which members are eligible to receive those services.
(2)  Recipients of the Emergency Aid to the Elderly, Disabled and Children Program.  For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106.

(B)  For information on verifying member eligibility and coverage type, see 130 CMR 450.107.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS
(130 CMR 403.000)	
PAGE

4-4	

HOME HEALTH AGENCY MANUAL	
TRANSMITTAL LETTER

HHA-37	
DATE

07/01/05	

403.405:	Provider Eligibility:  In State

	A Massachusetts home health agency is eligible to participate in MassHealth only if the Department of Public Health has certified that the home health agency is qualified to participate as such in the Medicare program.  The MassHealth agency does not pay a home health agency for services provided before the home health agency obtains a MassHealth provider number. 

403.406:	Provider Eligibility:  Out of State 

	A home health agency located outside of Massachusetts must be certified as a home health agency by the Medicare‑certifying agency in its state.  The MassHealth agency does not pay a home health agency for services provided before the home health agency is approved as a MassHealth provider.

(130 CMR 403.407 and 403.408 Reserved)

403.409:	Services Provided Under Contract

(A)  Introduction.  A home health agency may provide home health services directly or through contractual arrangements made by the agency.  Whether the services are provided directly or through contracts, the home health agency is responsible for submitting claims for services and for meeting the requirements in 130 CMR 403.000 and all other applicable state and federal requirements.  A home health agency may provide services through contracts in the following situations:
(1)  when an agency or organization, in order to be approved to participate in MassHealth, makes arrangements with another agency or organization to provide the nursing or other therapeutic services that it does not provide directly; and
(2)  when a home health agency that is already approved for participation in MassHealth makes arrangements with others to provide services it does not provide.

(B)  Contract Requirements.
(1)  If the home health agency contracts with another provider participating in MassHealth (hospital, nursing facility, another home health agency, or hospice), a written contract must document the services to be provided and the corresponding financial arrangements.
(2)  If the home health agency contracts with a provider that does not participate in MassHealth, the written contract must include:
(a)  a description of the services to be provided;
(b)  the duration of the agreement and how frequently it is to be reviewed;
(c)  a description of how personnel are supervised;
(d)  a statement that the contracting organization will provide its services in accordance with the plan of care established by the patient's physician in conjunction with the home health agency's staff;
(e)  a description of the contracting organization's standards for personnel, including qualifications, functions, supervision, and in-service training;
(f)  a description of the method of determining reasonable costs and payments by the home health agency for the specific services to be provided by the contracting organization; and
(g)  an assurance that the contracting organization will comply with Title VI of the Civil Rights Act and all relevant MassHealth provider requirements. 

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS
(130 CMR 403.000)	
PAGE

4-17	

HOME HEALTH AGENCY MANUAL	
TRANSMITTAL LETTER

HHA-37	
DATE

07/01/05	

403.424:  Physical, Occupational, and Speech and Language Therapy

(A)  Physical Therapy. The MassHealth agency pays for up to 20 visits within a 12-month period for physical therapy without prior authorization when provided to an eligible MassHealth member, if the services are:
(1)  prescribed by a physician;
(2)  directly and specifically related to an active treatment regimen;
(3)  of such a level of complexity and sophistication that the judgment, knowledge, and skills of a licensed physical therapist are required;
(4)  performed by a licensed physical therapist, or by a licensed physical therapy assistant under the supervision of a licensed physical therapist;
(5)  considered under accepted standards of medical practice to be a specific and effective treatment for the member's condition; 
(6)  medically necessary for treatment of the member's condition.  Services related to activities for the general good and welfare of patients (for example, general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation) do not constitute physical therapy services for purposes of MassHealth payment; and
(7)  certified by the physician every 60 days.
	
(B)  Occupational Therapy.  The MassHealth agency pays for up to 20 visits within a 12-month period for occupational therapy without prior authorization when provided to an eligible MassHealth member, if the services are:
(1)  prescribed by a physician;
(2)  performed by a licensed occupational therapist, or by a licensed occupational therapy assistant under the supervision of a licensed occupational therapist; 
(3)  medically necessary for treatment of the member's illness or injury; and
(4)  certified by the physician every 60 days.

(C)  Speech and Language Therapy.  The MassHealth agency pays for up to 35 visits within a 12-month period for speech and language therapy without prior authorization when provided to an eligible MassHealth member, if the services are:
(1)  prescribed by a physician;
(2)  performed by a licensed speech and language therapist; 
(3)  medically necessary for treatment of the member's illness or injury; and
(4)  certified by the physician every 60 days.

(D)  Maintenance Program.  
(1)  The MassHealth agency pays for the establishment of a maintenance program and the training of the member, member’s family, or other persons to carry it out, as part of a regular treatment visit, not as a separate service.  The MassHealth agency does not pay for performance of a maintenance program, except as provided in 130 CMR 403.424(D)(2).

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS
(130 CMR 403.000)	
PAGE

4-18	

HOME HEALTH AGENCY MANUAL	
TRANSMITTAL LETTER

HHA-37	
DATE

07/01/05	

(2)  In certain instances, the specialized knowledge and judgment of a licensed therapist may be required to perform services that are part of a maintenance program, to ensure safety or effectiveness that may otherwise be compromised due to the member’s medical condition.  At the time the decision is made that the services must be performed by a licensed therapist, all information that supports the medical necessity for performance of such services by a licensed therapist, rather than a non-therapist, must be documented in the medical record.

403.425:  Payment Rules for Initial Patient Assessments, Observation and Evaluation Visits, and Supervisory Visits

(A)  Initial Patient Assessments.  The MassHealth agency pays for an initial patient assessment visit by a home health agency with or without a physician's order.  The MassHealth agency does not pay for any subsequent services provided to the member unless the physician includes them in the written plan of care.

(B)  Observation and Evaluation Visits.  The MassHealth agency pays for observation and evaluation (or reevaluation) visits when they are made by a registered or licensed nurse or physical, occupational, or speech and language therapist ordered by the physician, for the purpose of evaluating the member's condition and his or her continuing need for nursing services.

(C)  Supervisory Visits.  The MassHealth agency does not pay for a supervisory visit made by a nurse or physical, occupational, or speech and language therapist for the purpose of evaluating the specific personal-care needs of the member, or reviewing the manner in which the personal-care needs of the member are being met by the home health aide or personal-care worker.  These visits are administrative and are, therefore, not payable.

403.426:  Medical Supplies

	Home health agencies must submit prescriptions and orders for medical supplies only to vendors who are participating in MassHealth.  Medical supplies, equipment, and appliances must be prescribed or ordered by the member's physician and must be provided and claimed directly by appropriate vendors in accordance with MassHealth regulations governing drugs, restorative therapy services, rehabilitative services, and durable medical equipment. 

403.427:  Recordkeeping Requirement and Utilization Review

	The record maintained by a home health agency for each member must conform to MassHealth administrative and billing regulations at 130 CMR 450.000.  The home health agency must submit requested documentation to the MassHealth agency or its designee for purposes of utilization review and provider review and audit, within the MassHealth agency’s or its designee’s time specifications.  The MassHealth agency or its designee may periodically review a member’s plan of care and other records to determine if skilled nursing services are medically necessary in accordance with 130 CMR 403.410(C).  The home health agency must provide the MassHealth agency or its designee with any supporting documentation the MassHealth agency or its designee requests within 10 business days of that request.  If the MassHealth agency or its designee determines that the skilled nursing services are no longer medically necessary, the MassHealth agency will not pay the home health agency for continuing services. 

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE

6 SERVICE CODES AND DESCRIPTIONS	
PAGE

6-1	

HOME HEALTH AGENCY MANUAL	
TRANSMITTAL LETTER

HHA-37	
DATE

07/01/05	

601   Explanation of Abbreviation

The abbreviation "P.A." indicates that MassHealth prior authorization is required (see program regulations in Subchapter 4 of the Home Health Agency Manual).

602   Definitions

	With nursing service codes T1002 and T1003, nursing services provided on a “weekend” or “holiday” will be automatically reimbursed in accordance with the applicable fee schedule of the Division of Health Care Finance and Policy (DHCFP).  Providers must use a service code that accurately reflects the nursing service provided.

(A)	Day – the hours from 7:00 A.M. to 2:59 P.M., Sunday through Saturday.

(B)	Night – the hours from 3:00 P.M. to 6:59 A.M., Sunday through Saturday.

(C)	Nursing modifiers –
UJ – night
TT – one nurse to two members (day)
U1 – one nurse to two members (night)
U2 – one nurse to three members (day)
U3 – one nurse to three members (night)
  
603	Service Codes and Descriptions:  Home Health Aide, Personal Care Worker, Therapy, and Nursing Services

Service
Code-Modifier	Service Description

				Nursing (for a Visit of Two Hours or Less), Home Health Aide, and Personal Care

G0154				Services of skilled nurse in home health setting, each 15 minutes (P.A. for MassHealth Basic members not enrolled with a managed care organization and for Complex Care members)
99058				Office services provided on an emergency basis
G0156				Services of home health aide in home health setting, each 15 minutes (P.A. for Complex Care members)
T1019			Personal care services, per 15 minutes

				Therapy

G0151			Services of physical therapist in home health setting, each 15 minutes (P.A. after 20 visits)
G0152				Services of occupational therapist in home health setting, each 15 minutes (P.A. after 20 visits)
G0153			Services of speech and language pathologist in home health setting, each 15 minutes (P.A. after 35 visits)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE

6 SERVICE CODES AND DESCRIPTIONS	
PAGE

6-2	

HOME HEALTH AGENCY MANUAL	
TRANSMITTAL LETTER

HHA-37	
DATE

07/01/05	

603	Service Codes and Descriptions:  Home Health Aide, Personal Care Worker, Therapy, and Nursing Services (cont.)

Service
Code-Modifier	Service Description

			Nursing Services (More Than a Two-Hour Visit)

			Individual Patient Nursing

			The following service codes must be used for nursing care provided by one nurse to one member.

T1002			RN services, up to 15 minutes (day) (P.A.)
T1003			LPN/LVN services, up to 15 minutes (day) (P.A.)
T1002-UJ			RN services, up to 15 minutes (night) (P.A.)
T1003-UJ			LPN/LVN services, up to 15 minutes (night) (P.A.)

				Multiple-Patient Nursing

		The following service codes are to be used for nursing care provided by one nurse simultaneously to two members.

T1002-TT			RN services, up to 15 minutes (day) (each member) (P.A.)
T1003-TT			LPN/LVN services, up to 15 minutes (day) (each member) (P.A.)
T1002-U1			RN services, up to 15 minutes (night) (each member) (P.A.)
T1003-U1			LPN/LVN services, up to 15 minutes (night) (each member) (P.A.)

		The following service codes are to be used for nursing care provided by one nurse simultaneously to three members.

T1002-U2			RN services, up to 15 minutes (day) (each member) (P.A.)
T1003-U2			LPN/LVN services, up to 15 minutes (day) (each member) (P.A.)
T1002-U3			RN services, up to 15 minutes (night) (each member) (P.A.)
T1003-U3			LPN/LVN services, up to 15 minutes (night) (each member) (P.A.)