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 ORT-20 September 2007 TO: Orthotic Providers Participating in MassHealth FROM: Thomas Dehner, Medicaid Director RE: Orthotics Manual (2007 New HCPCS Codes and Modifiers) This letter transmits revisions to the service codes described in Subchapter 6 of the Orthotics Manual to comply with federal coding mandates and to incorporate coding changes previously described in informational memoranda issued by the Division of Health Care Finance and Policy (DHCFP). This letter also reminds providers of certain existing MassHealth policies and requirements. Providers may consult the Centers for Medicare & Medicaid Services for a full description of the service codes, or the CMS Web site at www.cms.gov. Prior-authorization (PA) requirements, service limitations, and place-of-service requirements now appear in a new, interactive MassHealth Orthotic and Prosthetic Payment and Coverage Guidelines tool (O&P Guidelines tool) that has been posted on the MassHealth Web site (see below). The revised Subchapter 6, instructions detailed in this transmittal letter, and the new MassHealth Orthotic and Prosthetic Payment and Coverage Guidelines tool described below, are effective for dates of service on or after June 1, 2007. New MassHealth Orthotic and Prosthetic Payment and Coverage Guidelines Tool MassHealth has posted a new Orthotic and Prosthetic Payment and Coverage Guidelines tool on its Web site. This interactive tool is designed to help providers understand the payment requirements and service limitations for each orthotic and prosthetic service code covered by MassHealth. The O&P Guidelines tool provides descriptions for all orthotic and prosthetic service codes covered by MassHealth, along with interpretive descriptions of each service code provided by the American Orthotic and Prosthetic Association (AOPA). It also identifies applicable modifiers, place-of-service codes, PA requirements, service limitations, and AAC mark up information. For certain services that are payable on an individual consideration (IC) basis, the O&P Guidelines tool helps providers calculate the payable amount based on information provided. To access the MassHealth O&P Guidelines tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, Provider Library, MassHealth Payment and Coverage Guideline Tools, and the link for the Orthotic and Prosthetic Payment and Coverage Guidelines tool. This tool also contains links to DHCFP regulations, the MassHealth Shoe Medical Necessity Form, Subchapter 4 of both the Orthotics Manual and Prosthetics Manual, 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. MassHealth Transmittal Letter ORT-20 September 2007 Page 2 Diabetic Shoe MassHealth covers diabetic shoes prescribed to prevent or alleviate painful or disabling conditions associated with diabetes by minimizing pressure on the foot. A custom-molded shoe is covered when the member has a foot deformity that cannot be accommodated by a depth shoe. The nature and severity of the deformity must be well documented on the Shoe Medical Necessity Form. Depth Shoe MassHealth covers a depth shoe if it: 1) has a full-length, heel-to-toe filler that, when removed, provides a minimum of 3/16th” of additional depth used to accommodate custom-molded or customized inserts; 2) is made from leather or other suitable material of equal quality; 3) has some form of foot closure; and 4) is available in full and half sizes with a minimum of three widths so that the sole is graded to the size and width of the upper portions of the shoe, according to the American standard last sizing schedule or its equivalent. Orthopedic Shoe MassHealth covers orthopedic shoes that are specially constructed to aid in the correction of a deformity of the musculoskeletal structure of the foot and to preserve or restore the function of the musculoskeletal function of the foot. The nature and severity of the deformity must be well documented on the Shoe Medical Necessity Form. Inserts MassHealth covers separate orthopedic inserts for footwear if the prescribing provider verifies in writing that the member has appropriate footwear into which the insert can be placed. The footwear must meet the definitions of diabetic and orthopedic shoes as described in 130 CMR 442.402. Shoe Medical Necessity Form The Shoe Medical Necessity Form must be submitted with all claims. The provider supplying the shoe must complete only sections 1 and 2 of the Shoe Medical Necessity Form. The authorizing prescriber must complete Section 3. Cranial Orthoses (S1040) Effective for dates of service on or after July 1, 2007, MassHealth covers cranial molding orthoses (S1040) with prior authorization from MassHealth. The MassHealth Office of Clinical Affairs has developed clinical guidelines that describe the clinical conditions for medical necessity. These guidelines are posted on the MassHealth Web site. In addition, the O&P Guidelines tool contains a link to the clinical guidelines. A rate for S1040 has been established by DHCFP. MassHealth Transmittal Letter ORT-20 September 2007 Page 3 Noncovered Services MassHealth does not cover sneakers or athletic shoes. MassHealth does not pay for shoes where there is no diagnosis of an associated foot deformity or for a matching shoe where there is no foot deformity. MassHealth does not pay a separate fee for nursing facility visits. MassHealth does pay for orthotics furnished to members in a nursing facility provided all other payment conditions are met. Prescription Requirements for Services Provided to Members Residing in Nursing Facilities A prescription from a physician on a prescription pad or physician’s letterhead is no longer required when providing services to MassHealth members residing in a nursing facility. In lieu of this documentation, providers may submit a copy of the order from the member’s nursing facility medical record along with any treatment plan written by the facility’s staff. Revised Fee Schedule DHCFP has established new fees and payment methodologies for the codes listed in Subchapter 6 of the Orthotics Manual. The new fees and methodologies are effective for dates of service on or after June 1, 2007, and can be viewed at www.mass.gov/dhcfp. Providers must submit an invoice with the PA request or with a claim for services, as applicable, for items that are paid on an individual-consideration (IC) basis. These services are listed as “AAC + % mark-up” in the DHCFP fee schedule and on the O&P Guidelines tool. If you wish to obtain a paper copy of the fee schedule, you may purchase DHCFP regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses and telephone numbers below). You must contact them first to find out the price of the publication. DHCFP also has the regulation available on disk. The regulation title for Prostheses, Prosthetic Devices and Orthotic Devices is 114.3 CMR 34.00. Massachusetts State Bookstore Division of Health Care Finance and Policy State House, Room116 Two Boylston Street Boston, MA 02133 Boston, MA 02116 Telephone: 617-727-2834 Telephone: 617-988-3100 Billing and PA Requirements PA for Units in Excess of Specified Allowable Maximums For products that are listed on the MassHealth O&P Guidelines tool with a unit maximum and a designation that prior authorization is required “Sometimes,” providers may directly bill up to the allowable maximum units without requesting PA. If documentation is provided to support medical necessity for the member to receive more than the maximum allowable units, providers may request a PA for coverage of the additional units only. Providers must submit the request, along with supporting medical documentation, before providing the member with the additional units. MassHealth Transmittal Letter ORT-20 September 2007 Page 4 Diagnosis Codes MassHealth updates ICD-9-CM codes on a regular basis. Current ICD-9-CM codes are required for all claims. The ICD-9-CM codes entered on the claim must be directly related to the service billed and the foot deformity. Repairs PA is required for all repairs (combined parts and labor) totaling over $1000 per repair in all settings. All PAs and claims submitted for repairs must be supported by an itemized work order indicating parts and labor. Payment for repairs will be a lump-sum payment and may not exceed the purchase price. PAs submitted for repairs must be billed in 15-minute increments, and must be supported by the following information: • a description of the problem; • the reason the repair is needed; • an itemization of parts and labor; and • invoices for all parts and products used that do not have an assigned HCPCS service code. Claims for Custom-Made Products Provided to Members Who Become Ineligible for MassHealth As stated in 130 CMR 450.231(B), the date of the service is the date on which a medical service is furnished or delivered to a member. If a provider delivers a product to a member that has been ordered, fitted, or altered for the member, and the member ceases to be eligible for such MassHealth services on a date before the final delivery of the product, MassHealth will pay the provider for the product. Providers must submit paper claims for these services to the following address with all applicable documentation as outlined in 130 CMR 450.231(B). MassHealth Claims Operations ATTN: After Cancel Unit 600 Washington Street Boston, MA 02111 Billing for Members with Other Insurance When a member has other insurance, providers must bill MassHealth with the same HCPCS codes that were billed to the primary insurer. Medical Necessity Documentation Medical necessity determinations are based on specific clinical information and documentation that supports appropriate medical use of the services being requested. Providers must include all documentation of medical necessity as required in 130 CMR 442.000 when submitting requests for PA to MassHealth or its designee. MassHealth Transmittal Letter ORT-20 September 2007 Page 5 MassHealth Automated Prior Authorization System (APAS) MassHealth’s Automated Prior Authorization System (APAS) enables providers to submit PA requests and receive responses electronically. APAS also allows providers to attach additional documentation to their requests electronically when the attachments are needed to determine medical necessity. Providers may contact ACM at 1-866-378-3789 to request access to APAS. Providers are strongly encouraged to explore and utilize this automated business solution. Case Management for Complex-Care Members MassHealth members who are under the age of 22 years and are authorized to receive Continuous Nursing Services (CNS) are enrolled in Community Case Management (CCM). Some members aged 22 and older may also be enrolled with CCM. The program is administered for MassHealth by the University of Massachusetts Medical School. Each CCM enrollee is assigned a nurse case manager who performs a comprehensive needs assessment and authorizes all medically necessary home health and other community services, including orthotics. The Recipient Eligibility Verification System (REVS) identifies members enrolled in CCM. Providers should consult Appendix A of the Orthotics Manual to determine where to send prior authorization requests for all members, including CCM members. 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.) Orthotics Manual Pages 6-1 through 6-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Orthotics Manual Pages 6-1 through 6-12 — transmitted by Transmittal Letter ORT-18 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Orthotics Manual Transmittal Letter ORT-20 Date 06/01/07 601 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 442.000 and 450.000. An orthotics 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(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Orthotics Manual. Providers should refer to the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines tool (O&P Guidelines) for service descriptions, applicable modifiers, place-of-service codes, PA requirements, service limits, American Orthotic and Prosthetic Association (AOPA) interpretive language (if applicable), AAC mark-up information, and MassHealth Shoe Medical Necessity Form requirements. 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 34.00. The MassHealth O&P Guidelines tool also contains links to DHCFP regulations, MassHealth Shoe Medical Necessity Form, Subchapter 4 of the Orthotics Manual, Subchapter 4 of the Prosthetics Manual, 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. Please note that the online O & P Guidelines tool is updated frequently. To ensure that you are using the most updated version, check the date in the upper-left corner, above the word Program Link. To get to the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, Provider Library, MassHealth Payment and Coverage Guideline Tools, and MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool. If you want a paper copy of the tool, you can print it from the Web site, or request a copy from MassHealth Customer Service. See Appendix A of your provider manual for applicable contact information. 602 Service Codes This section lists codes for services that are payable under MassHealth. Refer to the Centers for Medicare & Medicaid Web site at www.cms.gov for more detailed descriptions. A5500 A6534 A8003 L0220 L0482 L0629 L0820 A5501 A6535 A8004 L0430 L0484 L0630 L0830 A5503 A6536 L0112 L0450 L0486 L0631 L0859 A5504 A6537 L0120 L0452 L0488 L0632 L0861 A5505 A6538 L0130 L0454 L0490 L0633 L0970 A5506 A6539 L0140 L0456 L0491 L0634 L0972 A5507 A6540 L0150 L0458 L0492 L0635 L0974 A5508 A6541 L0160 L0460 L0621 L0636 L0976 A5510 A6542 L0170 L0462 L0622 L0637 L0978 A5512 A6543 L0172 L0464 L0623 L0638 L0980 A5513 A6544 L0174 L0466 L0624 L0639 L0982 A6530 A6549 L0180 L0468 L0625 L0640 L0984 A6531 A8000 L0190 L0470 L0626 L0700 L0999 A6532 A8001 L0200 L0472 L0627 L0710 L1000 A6533 A8002 L0210 L0480 L0628 L0810 L1001 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-2 Orthotics Manual Transmittal Letter ORT-20 Date 06/01/07 602 Service Codes (cont.) L1005 L1755 L2035 L2375 L2850 L3254 L3652 L1010 L1800 L2036 L2380 L2860 L3255 L3660 L1020 L1810 L2037 L2385 L2999 L3257 L3670 L1025 L1815 L2038 L2387 L3000 L3260 L3671 L1030 L1820 L2040 L2390 L3001 L3265 L3672 L1040 L1825 L2050 L2395 L3002 L3300 L3673 L1050 L1830 L2060 L2397 L3003 L3310 L3675 L1060 L1831 L2070 L2405 L3010 L3320 L3677 L1070 L1832 L2080 L2415 L3020 L3330 L3700 L1080 L1834 L2090 L2425 L3030 L3332 L3701 L1085 L1836 L2106 L2430 L3031 L3334 L3702 L1090 L1840 L2108 L2492 L3040 L3340 L3710 L1100 L1843 L2112 L2500 L3050 L3350 L3720 L1110 L1844 L2114 L2510 L3060 L3360 L3730 L1120 L1845 L2116 L2520 L3070 L3370 L3740 L1200 L1846 L2126 L2525 L3080 L3380 L3760 L1210 L1847 L2128 L2526 L3090 L3390 L3762 L1220 L1850 L2132 L2530 L3100 L3400 L3763 L1230 L1855 L2134 L2540 L3140 L3410 L3764 L1240 L1858 L2136 L2550 L3150 L3420 L3765 L1250 L1860 L2180 L2570 L3160 L3430 L3766 L1260 L1870 L2182 L2580 L3170 L3440 L3800 L1270 L1880 L2184 L2600 L3201 L3450 L3805 L1280 L1900 L2186 L2610 L3202 L3455 L3806 L1290 L1901 L2188 L2620 L3203 L3460 L3807 L1300 L1902 L2190 L2622 L3204 L3465 L3808 L1310 L1904 L2192 L2624 L3205 L3470 L3810 L1499 L1906 L2200 L2627 L3206 L3480 L3815 L1500 L1907 L2210 L2628 L3207 L3485 L3820 L1510 L1910 L2220 L2630 L3208 L3500 L3825 L1520 L1920 L2230 L2640 L3209 L3510 L3830 L1600 L1930 L2232 L2650 L3211 L3520 L3835 L1610 L1932 L2240 L2660 L3212 L3530 L3840 L1620 L1940 L2250 L2670 L3213 L3540 L3845 L1630 L1945 L2260 L2680 L3214 L3550 L3850 L1640 L1950 L2265 L2750 L3215 L3560 L3855 L1650 L1951 L2270 L2755 L3216 L3570 L3860 L1652 L1960 L2275 L2760 L3217 L3580 L3890 L1600 L1970 L2280 L2768 L3219 L3590 L3901 L1660 L1971 L2300 L2770 L3221 L3595 L3904 L1680 L1980 L2310 L2780 L3222 L3600 L3905 L1685 L1990 L2320 L2785 L3224 L3610 L3906 L1686 L2000 L2330 L2795 L3225 L3620 L3907 L1690 L2005 L2335 L2800 L3230 L3630 L3908 L1700 L2010 L2340 L2810 L3250 L3640 L3909 L1710 L2020 L2350 L2820 L3251 L3649 L3910 L1720 L2030 L2360 L2830 L3252 L3650 L3911 L1730 L2034 L2370 L2840 L3253 L3651 L3912 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-3 Orthotics Manual Transmittal Letter ORT-20 Date 06/01/07 602 Service Codes (cont.) L3913 L3928 L3948 L3971 L3986 L4060 L4380 L3915 L3930 L3950 L3972 L3995 L4070 L4386 L3916 L3932 L3952 L3973 L3999 L4080 L4392 L3917 L3933 L3954 L3974 L4000 L4090 L4394 L3918 L3934 L3956 L3975 L4002 L4100 L4396 L3919 L3935 L3960 L3976 L4010 L4110 L4398 L3920 L3936 L3961 L3977 L4020 L4130 L4399 L3921 L3938 L3962 L3978 L4030 L4205 S1040 L3922 L3940 L3967 L3980 L4040 L4210 L3923 L3942 L3968 L3982 L4045 L4350 L3924 L3944 L3969 L3984 L4050 L4360 L3926 L3946 L3970 L3985 L4055 L4370 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-4 Orthotic Providers Manual Transmittal Letter ORT-20 Date 06/01/07 This page is reserved.