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-21 June 2010 TO: Orthotic Providers Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Orthotics Manual (2010 HCPCS) This letter transmits revisions to the service codes described in Subchapter 6 of the MassHealth Orthotics Manual to comply with federal coding mandates, incorporates coding and rate changes previously described in informational bulletins issued by the Division of Health Care Finance and Policy (DHCFP); and reminds providers of certain existing orthotic policies and requirements. Providers may consult the Centers for Medicare & Medicaid Services (CMS) Web site at www.cms.gov for a full description of the service codes. Prior-authorization (PA) requirements, service limits, and place-of-service codes now appear in an updated version of the interactive MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool that has been posted on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and other Publications, then on Provider Library, and then select MassHealth Payment and Coverage Guideline Tools. Orthotics Service Code Additions Effective for Dates of Service Beginning January 1, 2010 The following service codes have been added to Subchapter 6 of the Orthotics Manual and the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool, and are effective for dates of service on or after January 1, 2010. A9283 L0113 L3900 L3925 L3929 Orthotics Service Code Deletions Effective for Dates of Service Beginning January 1 2010 The following codes have been deleted from Subchapter 6 of the Orthotics Manual and the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool, effective for dates of service beginning January 1, 2010. Claims for dates of service on or after January 1, 2010, submitted with deleted codes identified in this section will be denied. Claims denied for deleted codes can be resubmitted with the appropriate codes. L0210 L1800 L1815 L1825 L1855 L1858 L1870 L1880 L1901 L2770 L2860 L3205 L3651 L3652 L3700 L3701 L3800 L3805 L3810 L3815 L3820 L3825 L3830 L3835 L3840 L3845 L3850 L3855 L3860 L3890 L3907 L3909 L3910 L3911 L3916 L3918 L3920 L3922 L3924 L3926 L3928 L3930 L3932 L3934 L3936 L3938 L3940 L3942 L3944 L3946 L3948 L3950 L3952 L3954 L3968 L3969 L3970 L3972 L3974 L3986 L4399 Diagnosis Codes Providers are reminded that ICD-9-CM diagnosis codes are required on all claims. The ICD-9- CM diagnosis codes must be directly related to the service billed on the claim. Claims with Multiple Modifiers As of the implementation of NewMMIS, MassHealth can accept claims with two modifiers on a single claim line. When billing a service code with more than one modifier, providers must submit both modifiers on a single claim line. Prior to implementation of NewMMIS, MassHealth required providers to submit the claim with the code and each modifier on a separate claim line. Claims submission example using legacy MMIS Claim Line 1) A5513 RT 1 unit Claim Line 2) A5513 LT 1 unit Claims submission example using NewMMIS Claim Line 1) A5513 RT LT 2 units Shoe Forms The MassHealth Shoe Medical Necessity Form ORT-1, Rev.07/04) is being replaced with two new forms: the MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Therapeutic Shoes, Inserts, and Modifications (for Diabetics); and the MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Foot Orthoses, Footwear, and Modifications (Non-Diabetic). MassHealth has developed instructions to be used with each of these forms that providers must follow when completing the forms. The new forms meet MassHealth’s recordkeeping requirements at 130 CMR 442.423 and 450.205. The forms and their corresponding instructions are available on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Provider Forms under the Publications panel on the right side of the home page. Providers may begin using the above forms immediately. MassHealth will not accept the ORT-1 form after dates of service beginning August 31, 2010, and will deny claims submitted with the old form for dates of service after that date. Providers must submit a completed shoe form when requesting prior authorization for therapeutic shoes or, if no PA is required, when submitting the claim for the shoes. Providers should consult the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool to determine which shoe form needs to be submitted for a specific service code, and whether or not the service code requires PA. Acceptable Prescriber Signatures for Shoe Forms MassHealth will accept only the signature from the member’s physician (MD) or a doctor of osteopathy (DO) in Section 5 of the MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Therapeutic Shoes, Inserts, and Modifications (Diabetics). MassHealth will accept only the signature of the member’s physician (MD), nurse practitioner (NP), doctor of osteopathy (DO), podiatrist (DPM), or physician assistant (PA) in Section 6 of the MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Foot Orthoses, Footwear, and Modifications (Non-Diabetic). Invoices Service codes priced at adjusted acquisition cost (AAC +) require current invoices. MassHealth will not accept a Web-printed invoice or order form from a manufacturer’s Web site. The invoice must clearly identify which products are applicable to the service codes being billed. Providers must circle the product on the invoice and attach the applicable service code to the item to identify what is being billed. Providers are also reminded they must use the service code that is applicable to that product. Please Note: Effective May 1, 2010, MassHealth no longer requires an invoice be submitted with the claim or PA request for minor part replacements and repairs, where the total cost of the repair is less than $35.00. However, the provider must submit a work order with the claim or PA that describes the parts repaired or replaced. Revised Rates The Division of Health Care and Finance Policy (DHCFP) has established new rates for the above service codes effective for dates of service beginning January 1, 2010. The DHCFP fee schedule and informational bulletins can be viewed on the DHCFP Web site at www.mass.gov/dhcfp. If you wish to obtain a fee schedule, you may download DHCFP regulations at no cost at www.mass.gov/dhcfp. 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. The regulation title for Prostheses, Prosthetic Devices, and Orthotic Devices is 114.3 CMR 34.00. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.goc/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp 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 vi and 6-1 through 6-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Orthotics Manual Page vi — transmitted by Transmittal Letter ORT-18 Pages 6-1 through 6-4 — transmitted by Transmittal Letter ORT-20 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Orthotics Manual Transmittal Letter ORT-21 Date 06/01/10 6. Service Codes Introduction................................................................................................................................. 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 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 Preface Page vii Orthotics Manual Transmittal Letter ORT-21 Date 06/01/10 The regulations and instructions governing provider participation in MassHealth are published in the Provider Manual Series. MassHealth publishes a separate manual for each provider type. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, administrative and billing instructions, and general information. MassHealth regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. MassHealth regulations are assigned Title 130 of the Code. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For orthotics providers, those matters are covered in 130 CMR Chapter 442.000, reproduced as Subchapter 4 in the Orthotics Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead MassHealth’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with MassHealth and its members. MassHealth pays for the services represented by the codes listed in Section 602 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 442.000 and 450.000. In addition, a provider may request prior authorization (PA) for any medically necessary orthotic devices. Providers should consult Transmittal Letter ORT-21 for the specific effective dates of service for the service codes. Providers should refer to the MassHealth Orthotic and Prosthetic 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 34.00. The MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool also contains links to DHCFP regulations 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 Orthotic and Prosthetic Payment and Coverage Guidelines Tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and other Publications, click on Provider Library, and then select MassHealth payment and Coverage Guideline- Tools. 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 MassHealth 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 A5501 A5503 A5504 A5505 A5506 A5507 A5508 A5510 A5512 A5513 A6530 A6531 A6532 A6533 A6534 A6535 A6536 A6537 A6538 A6539 A6540 A6541 A6544 A6549 A8000 A8001 A8002 A8003 A8004 A9283 L0112 L0113 L0120 L0130 L0140 L0150 L0160 L0170 L0172 L0174 L0180 L0190 L0200 L0220 L0430 L0450 L0452 L0454 L0456 L0458 L0460 L0462 L0464 L0466 L0468 L0470 L0472 L0480 L0482 L0484 L0486 L0488 L0490 L0491 L0492 L0621 L0622 L0623 L0624 L0625 L0626 L0627 L0628 L0629 L0630 L0631 L0632 L0633 L0634 L0635 L0636 L0637 L0638 L0639 L0640 L0700 L0710 L0810 L0820 L0830 L0859 L0861 L0970 L0972 L0974 L0976 L0978 L0980 L0982 L0984 L0999 L1000 L1001 L1005 L1010 L1020 L1025 L1030 L1040 L1050 L1060 L1070 L1080 L1085 L1090 L1100 L1110 L1120 L1200 L1210 L1220 L1230 L1240 L1250 L1260 L1270 L1280 L1290 L1300 L1310 L1499 L1500 L1510 L1520 L1600 L1610 L1620 L1640 L1650 L1652 L1660 L1680 L1685 L1686 L1690 L1700 L1710 L1720 L1730 L1755 L1810 L1820 L1830 L1831 L1630 L1832 L1834 L1836 L1840 L1843 L1844 L1845 L1846 L1847 L1850 L1860 L1900 L1902 L1904 L1906 L1907 L1910 L1920 L1930 L1932 L1940 L1945 L1950 L1951 L1960 L1970 L1971 L1980 L1990 L2000 L2005 L2010 L2020 L2030 L2034 L2035 L2036 L2037 L2038 L2040 L2050 L2060 L2070 L2080 L2090 L2106 L2108 L2112 L2114 L2116 L2126 L2128 L2132 L2134 L2136 L2180 L2182 L2184 L2186 L2188 L2190 L2192 L2200 L2210 L2220 L2230 L2232 L2240 L2250 L2260 L2265 L2270 L2275 L2280 L2300 L2310 L2320 L2330 L2335 L2340 L2350 L2360 L2370 L2375 L2380 L2385 L2387 L2390 L2395 L2397 L2405 L2415 L2425 L2430 L2492 L2500 L2510 L2520 L2525 L2526 L2530 L2540 L2550 L2570 L2580 L2600 L2610 L2620 L2622 L2624 L2627 L2628 L2630 L2640 L2650 L2660 L2670 L2680 L2750 L2755 L2760 L2768 L2780 L2785 L2795 L2800 L2810 L2820 L2830 L2840 L2850 L2999 L3000 L3001 L3002 L3003 L3010 L3020 L3030 L3031 L3040 L3050 L3060 L3070 L3080 L3090 L3100 L3140 L3150 L3160 L3170 L3201 L3202 L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L3224 L3225 L3230 L3250 L3251 L3252 L3253 L3254 L3255 L3257 L3260 L3265 L3300 L3310 L3320 L3330 L3332 L3334 L3340 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 L3520 L3530 L3540 L3550 L3560 L3570 L3580 L3590 L3595 L3600 L3610 L3620 L3630 L3640 L3649 L3650 L3660 L3670 L3671 L3672 L3673 L3675 L3677 L3702 L3710 L3720 L3730 L3740 L3760 L3762 L3763 L3764 L3765 L3766 L3806 L3807 L3808 L3900 L3901 L3904 L3905 L3906 L3908 L3912 L3913 L3915 L3917 L3919 L3921 L3923 L3925 L3927 L3929 L3931 L3933 L3935 L3956 L3960 L3961 L3962 L3967 L3971 L3973 L3975 L3976 L3977 L3978 L3980 L3982 L3984 L3995 L3999 L4000 L4002 L4010 L4020 L4030 L4040 L4045 L4050 L4055 L4060 L4070 L4080 L4090 L4100 L4110 L4130 L4205 L4210 L4350 L4360 L4370 L4380 L4386 L4392 L4394 L4396 L4398 S1040 This page is reserved.