Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter ORT-22 July 2011 TO: Orthotics Providers Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Orthotics Manual (2011 HCPCS) This letter transmits revisions to the service codes in Subchapter 6 of the Orthotics Manual to comply with federal coding mandates, 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 orthotic (ORT) policies and requirements. The Centers for Medicare & Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2011, and providers may consult the 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. Orthotics Service Code Additions and Deletions Effective for Dates of Service Beginning January 1, 2011 The additions and deletions to the MassHealth service codes and descriptions included in this section are effective for dates of service on or after January 1, 2011. Claims for dates of service on or after January 1, 2011, submitted with deleted codes identified in this section will be denied. Claims denied for deleted codes may be resubmitted with the appropriate new codes. The following codes have been added to Subchapter 6 of the Orthotics Manual and the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool. K0672 L3674 L4631 The following codes have been deleted from Subchapter 6 of the Orthotics Manual and the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool. L3672 L3673 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. MassHealth Transmittal Letter ORT-22 July 2011 Page 2 Claims with Multiple Modifiers MMIS can now accept claims with multiple modifiers. Providers can now use one line instead of two. In MassHealth’s previous system, providers were required to put HCPCS service codes with different modifiers on two different lines on a claim, as follows. Claim Line 1—A5513 RT 1 unit Claim Line 2—A5513 LT 1 unit MMIS can now accept multiple modifiers, so claims should now be billed on one claim line as follows. A5513 RT LT 2 units Signatures MassHealth has changed the requirements for who is required to sign the MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Therapeutic Shoes, Inserts and Modifications (for diabetics) (ORT-D) (08/10). The form must be signed by a doctor of medicine (MD), nurse practitioner (NP), doctor of osteopathic medicine (DO), doctor of podiatric medicine (DPM), or a physician’s assistant (PA). The MassHealth Orthotic and Prosthetic Prescription and Medical Neccessity Review Form for Foot Orthoses, Footwear, and Modifications (non-diabetic)(ORT-ND)(08/10) must be signed by a doctor of medicine (MD), doctor of osteopathic medicine (DO), nurse practitioner (NP), physician’s assistant (PA), or podiatrist (DPM). Invoices Service codes priced at AAC+ (adjusted acquisition cost plus markup) 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 services. Providers must circle the product on the invoice and annotate the applicable service code for the item to identify what is being billed. For minor part replacements and repairs that do not have invoices, if the total cost of the repair is less than $35.00, invoices are not required. However, the provider must include a work order with a summary of the description of parts repaired or replaced with a claim or a PA. Revised Rates DHCFP has established new rates for the new orthotics service codes effective for dates of service beginning January 1, 2011. The DHCFP fee schedule and informational bulletins can be viewed on the DHCFP Web site at www.mass.gov/dhcfp. MassHealth Transmittal Letter ORT-22 July 2011 Page 3 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 MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth. 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.) 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 6-4 — transmitted by Transmittal Letter ORT-21 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Orthotics Manual Transmittal Letter ORT-22 Date 01/01/11 601 Introduction 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. 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(a), and 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 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 Orthotics and Prosthetics 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 K0672 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 L1630 L1640 L1650 L1652 L1660 L1680 L1685 L1686 L1690 L1700 L1710 L1720 L1730 L1755 L1810 L1820 L1830 L1831 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 L3674 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 L4631 S1040 This page is reserved.