Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma
MASSHEALTH
TRANSMITTAL LETTER OXY-23
April 2003

TO:      Oxygen and Respiratory Therapy Equipment Providers Participating in MassHealth
FROM:      Douglas S. Brown, Acting Commissioner
RE:     Oxygen and Respiratory Therapy Equipment Manual (Revised Service Codes and Descriptions).
This letter transmits revisions to Subchapter 6 (service codes and descriptions) of the Oxygen and Respiratory Therapy Equipment Manual. These revisions are effective for dates of service on and after April 1, 2003.
2003 Healthcare Common Procedure Coding System (HCPCS) codes have been added to replace certain MassHealth local codes. The local codes have been replaced so that the Division can continue the process of making its covered-service code set compliant with the Health Insurance Portability and Accountability Act (HIPAA). The Division will issue additional updates to other local codes at a later date. Subchapter 6 has also been reorganized to list covered codes in sequential order.
Please note that you must use a modifier with some of the new codes to accurately reflect the service provided. The attached Service Code Crosswalk identifies where modifiers are applicable. The crosswalk also identifies the only methodology by which the Division will pay for each of the covered codes included on the attachment.
The Division of Health Care Finance and Policy (DHCFP) recently issued regulations certifying new fees and methodologies for the products for which the Division is now updating its codes. These new fees are also effective for dates of service on and after April 1, 2003. The DHCFP regulation, including the fee schedule, is available on the DHCFP Web site at www.mass.gov/dhcfp.
Alternatively, if you wish to obtain a hard copy of the fee schedule, you may purchase the schedule from either the Massachusetts bookstore or from the Division of Health Care Finance and Policy (see addresses and telephones numbers below). You must contact them first to find out the price of the regulation. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment is 114 CMR 22.00.

Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr

Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp

MASSHEALTH
TRANSMITTAL LETTER OXY-23 April 2003 Page 2
DMA Web Site
This transmittal letter and attached pages are available on the Division’s Web site at www.mass.gov/dma.
Capped Rental for Respiratory Equipment
The Division will no longer consider a provider’s adjusted acquisition cost for Service Codes:
 •	E0600 (respiratory suction pump, home model, portable or stationary, electric);
 •	E0601 (continuous airway pressure (CPAP) device);
 •	K0532 (respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask);
 •	K0533 (respiratory assist device, bi-level pressure capability, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask); and
 •	K0534 (respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube). The Division will pay a monthly rental fee for up to 15 months as indicated in DHCFP’s regulation.
These products remain covered items after 15 months, but the provider should not bill the Division, as the Division will not pay a monthly rental fee after the 15th month. If the product will be provided for 15 months or more, the provider must indicate the modifier “BP” on the claim for the 15th month to indicate that it is the last claim for a monthly rental fee.
The provider may bill for a repair, if needed, during or after the 21st month, to maintain the equipment in proper working condition for the member’s use. The provider must request prior authorization for the repair, and must indicate a complete list of parts and hours of labor needed to complete the repair in the prior-authorization request.
The respiratory assist device codes (E0601, K0532, K0533, and K0534) continue to require prior authorization. If approved, the initial authorization will be issued for a period of time not greater than 90 days. The member’s physician must document the therapeutic benefit and member’s compliance for continued approval of months four through 15. Prior authorization remains a requirement for E0600 and, if approved, the length of time approved will be determined from medical documentation submitted with the prior- authorization request up to 15 months. At the end of the 15 months, the Division will have purchased the equipment. This equipment is considered durable medical equipment with a life span of five years.

MASSHEALTH
TRANSMITTAL LETTER OXY-23 April 2003 Page 3
Oxygen Therapy
The Division will no longer consider a provider’s adjusted acquisition cost for the following service codes:
 •	E1390 (oxygen concentrator, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate);
 •	E0424 (stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing);
 •	E0431 (portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing);
 •	E0434 (portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adapter, contents gauge, cannula or mask, and tubing);
 •	E0443 (portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used);
 •	E0441 (oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned, one month’s supply=1 unit);
 •	X0440 stationary liquid oxygen system, includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing (PA); and
 •	X0442 (oxygen contents liquid, per unit). The Division will pay a monthly rental fee as indicated in DHCFP’s regulation.
Prior Authorization
Effective for dates of service on and after April 1, 2003, all requests for products specified in the attached crosswalk that require prior authorization (PA) must be submitted using the new codes. Providers who have already requested and received prior authorization using the old codes will not have to request adjustments to their PAs, The Division will convert existing PAs with unused units to the new codes. Providers will receive letters notifying them of the PA adjustments.
Billing Guidelines
Effective for dates of service on and after April 1, 2003, providers billing for the services specified in the attached crosswalk may use only the new codes. Claims submitted using miscellaneous or other codes will be denied.
Questions
Providers with questions about the information in this transmittal letter may contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.

MASSHEALTH
TRANSMITTAL LETTER OXY-23 April 2003 Page 4
NEW MATERIAL
(The pages listed here contain new or revised language.)
Oxygen and Respiratory Therapy Equipment Manual
Pages 6-1 through 6-6
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Oxygen and Respiratory Therapy Equipment Manual
Pages 6-1 through 6-6— transmitted by Transmittal Letter OXY-22

TL OXY-23
Attachment Page 1 Oxygen and Respiratory Therapy Equipment Service Code Crosswalk and New and Obsoleted Codes Effective April 1, 2003

Old                        Description                        New       Modifier                  Description                     Methodology code                                                                  code	
E1404 E1394 E1403 E1377 E1400	Oxygen concentrator; manufacturer-specified maximum flow rate greater than five liters per minute, at 85 percent or greater concentration (P.A.)	E1390	RR	Oxygen concentrator, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate (P.A.)	Monthly rental	
X0425 X0441	Stationary compressed gas system, purchase (or rental); includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing (P.A.)
Oxygen contents, gaseous, per unit (for use with stationary system) (P.A.)	E0424	RR	Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing (P.A.)	Monthly rental	
X0430 X0443	Portable compressed gaseous oxygen system, includes regulator, flowmeter, humidifier, cannula or mask, tubing, and carrying stand or carrying bag (P.A.) Oxygen contents, gaseous, per unit (for use with portable system) (P.A.)	E0431	RR	Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing (P.A.)	Monthly rental	
X0435	Portable liquid oxygen system, includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter (P.A.)	E0434	RR	Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing (includes contents) (P.A.)	Monthly rental	
		X0440	RR	Stationary liquid oxygen system, includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing (P.A.)	Monthly rental	
		X0442	RR	Oxygen contents, liquid, per unit (one unit=one pound) (P.A.)	Monthly rental	
X0443	Oxygen contents, gaseous, per unit (for use with portable system)	E0443	RR	Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), one month’s supply = 1 unit (P.A.)	Monthly rental	
X0441	Oxygen contents, gaseous, per unit (for use with stationary system)	E0441	RR	Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), one month’s supply = 1 unit (P.A.)	Monthly rental	

TL OXY-23
Attachment Page 2 Oxygen and Respiratory Therapy Equipment Service Code Crosswalk and New and Obsoleted Codes Effective April 1, 2003

Old                        Description                        New       Modifier                  Description                     Methodology code                                                                  code	
X5370 X5371 X5372	Suction pump, home model, stationary (rental, per month) Suction pump, home model, stationary (purchase) (P.A.) Suction pump, home model, portable (purchase) (P.A.)	E0600	KH, KI, KJ, BP	Respiratory suction pump, home model, portable or stationary, electric (P.A.)	Capped Rental X 15 months	
X5373
X5054 X5031
E0452 X5430	Continuous positive airway pressure (CPAP) device (continued rental after six months, per month) (P.A.) BiPAP purchase (P.A.) (I.C.) Continuous positive airway pressure (CPAP) device (includes accessories) (purchase) (P.A.) (I.C.) Intermittent assist device with continuous positive airway pressure device (CPAP or BiPAP) (rental, first six months, per month) (P.A.) Intermittent assist device with continuous positive airway pressure device (CPAP or BiPAP) (continued rental after six months, per month) (P.A.)	E0601	KH, KI, KJ, BP	Continuous airway pressure (CPAP) device (P.A.)	Capped Rental X 15 months	
		K0531	NU	Humidifier, heated, used with positive airway pressure device (P.A.)	Purchase	
		K0532	KH, KI, KJ, BP	Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) (P.A.)	Capped Rental x 15 months	
		K0533	KH, KI, KJ, BP	Respiratory assist device, bi-level pressure capability, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) (P.A.)	Capped Rental x 15 months	
		K0534	KH, KI, KJ, BP	Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device) (P.A.)	Capped Rental x 15 months	

TL OXY-23 Attachment Page 3 Oxygen and Respiratory Therapy Equipment Service Code Crosswalk and New and Obsoleted Codes Effective April 1, 2003

Old	Description	New	Modifier                  Description	Methodology	
code		code			
		E0565	RR	Compressor, air power source for equipment which is not self-contained or cylinder driven (P.A.)	Monthly Rental	
Modifier Descriptions

Modifier	Description	
BP	Member to purchase the item (Division purchases item)	
NU	New equipment	
QE	Prescribed amount of oxygen is less than 1 liter per minute (LPM)	
QF	Prescribed amount of oxygen exceeds 4 liters per minute (LPM) and portable oxygen is prescribed	
QG	Prescribed amount of oxygen is greater than 4 liters per minute (LPM)	
QH	Oxygen conserving device is being used with an oxygen delivery system	
RR	Rental	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-1	

	TRANSMITTAL LETTER
OXY-23	DATE
04/01/03	
601	Explanation of Abbreviations
The following abbreviations are used in Subchapter 6.
 (A)	I.C. indicates that the claim will receive individual consideration to determine payment.
 (B)	P.A. indicates that prior authorization is required.
602	Service Codes and Descriptions
Service
Code Service Description
A4481	Tracheostoma filter, any type, any size, each
A4556	Electrodes (e.g., apnea monitor), per pair
A4557	Lead wires (e.g., apnea monitor), per pair
A4558	Conductive paste or gel
A4611	Battery, heavy duty; replacement for patient-owned ventilator (P.A.)
A4612	Battery cables; replacement for patient-owned ventilator (P.A.)
A4613	Battery charger; replacement for patient-owned ventilator (P.A.)
A4615	Cannula, nasal
A4616	Tubing (oxygen), per foot
A4617	Mouthpiece
A4618	Breathing circuits
A4619	Face tent
A4620	Variable concentration mask
A4621	Tracheostomy mask or collar
A4622	Tracheostomy or laryngectomy tube (adult)
A4623	Tracheostomy, inner cannula (replacement only)
A4624	Tracheal suction catheter, any type, other than closed system, each
A4625	Tracheostomy care kit for new tracheostomy
A4626	Tracheostomy cleaning brush, each
A4627	Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler
A4628	Oropharyngeal suction catheter, each
A4629	Tracheostomy care kit for established tracheostomy
E0424	Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator,
flowmeter, humidifier, nebulizer, cannula or mask, and tubing (P.A.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-2	

	TRANSMITTAL LETTER
OXY-23	DATE
04/01/03	
602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
E0431      Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter,
humidifier, cannula or mask, and tubing (P.A.) E0434      Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier,
flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing, (includes contents) (P.A.) E0441      Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary
and portable gaseous system are owned), one month’s supply = 1 unit (P.A.) E0443      Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary
gas or liquid system is used), one month’s supply = 1 unit (P.A.) E0450      Volume ventilator, stationary or portable, with backup rate feature, used with invasive interface
(e.g., tracheostomy tube) (rental, first six months, per month) (P.A.) E0452      Intermittent assist device with continuous positive airway pressure device (CPAP or BiPAP) (rental,
first six months, per month) (P.A.) E0453      Therapeutic ventilator; suitable for use 12 hours or less per day (P.A.) E0455      Oxygen tent, excluding croup or pediatric tents (P.A.) (I.C.) E0457      Chest shell (cuirass) (P.A.) (I.C.) E0459      Chest wrap (P.A.) (I.C.) E0460      Negative pressure ventilator, portable or stationary (i.e., Porta-Lung) (rental, first six months, per
month) (P.A.) E0462      Rocking bed, with or without side rails (P.A.) (I.C.) E0480      Percussor, electric or pneumatic, home model (P.A.) E0500      IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external
power source (P.A.) E0550      Humidifier, durable for extensive supplemental humidification during IPPB treatments or oxygen
delivery (P.A.) E0555      Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter
(P.A.) (I.C.) E0560      Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery
(P.A.) E0565      Compressor, air power source for equipment which is not self-contained or cylinder driven (P.A.) E0570 Nebulizer; with compressor

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-3	

	TRANSMITTAL LETTER
OXY-23	DATE
04/01/03	
602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
E0575	Nebulizer; ultrasonic, large volume (P.A.)
E0580	Nebulizer; durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter
(P.A.)
E0585	Nebulizer; with compressor and heater (P.A.)
E0600	Respiratory suction pump, home model, portable or stationary, electric (P.A.)
E0601	Continuous airway pressure (CPAP) device (P.A.)
E0605	Vaporizer, room type (purchase)
E0606	Postural drainage board (purchase)
E0608	Apnea monitor (rental, first six months, per month) (P.A.)
E1340	Repair or nonroutine service for durable medical equipment requiring the skill of a technician
technician, labor component, per 15 minutes (i.e., breaking down sealed components) (parts
only) (I.C.)
E1353	Regulator (P.A.) (I.C.)
E1355	Stand/rack
E1372	Immersion external heater for nebulizer
E1375	Nebulizer, portable with small compressor, with limited flow (P.A.)
E1390	Oxygen concentrator, capable of delivering 85 percent or greater oxygen concentration at the
prescribed flow rate (P.A.)
E1399	Durable medical equipment, miscellaneous (P.A.) (I.C.)
K0168	Administration set, small volume nonfiltered pneumatic nebulizer, disposable
K0169	Small volume nonfiltered pneumatic nebulizer, disposable
K0170	Administration set, small volume nonfiltered pneumatic nebulizer, nondisposable (P.A.)
K0171	Administrative set, small volume filtered pneumatic nebulizer
K0172	Large volume nebulizer, disposable, unfilled, used with aerosol compressor
K0173	Large volume nebulizer, disposable, prefilled, used with aerosol compressor
K0174	Reservoir bottle, nondisposable, used with large volume ultrasonic nebulizer
K0175	Corrugated tubing, disposable, used with large volume nebulizer, 100 feet
K0176	Corrugated tubing, nondisposable, used with large volume nebulizer, 10 feet (I.C.)
K0177	Water collection device, used with large volume nebulizer
K0178	Filter, disposable, used with aerosol compressor
K0179	Filter, nondisposable, used with aerosol compressor or ultrasonic generator
K0180	Aerosol mask, used with DME nebulizer

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-4	

	TRANSMITTAL LETTER
OXY-23	DATE
04/01/03	
602 Service Codes and Descriptions (cont.)
Service
Code       Service Description
K0181      Dome and mouthpiece, used with small volume ultrasonic nebulizer
K0182      Water, distilled, used with large volume nebulizer, 1000 ml
K0183      Nasal application device, used with CPAP device (P.A.)
K0184      Nasal pillows/seals, replacement for nasal application device, pair (P.A.)
K0185      Headgear, used with CPAP device (P.A.)
K0186      Chin strap, used with CPAP device (P.A.)
K0187      Tubing, used with CPAP device (P.A.)
K0188      Filter, disposable, used with CPAP device
K0189      Filter, nondisposable, used with CPAP device
K0190      Canister, disposable, used with (patient-owned) suction pump
K0191      Canister, nondisposable, used with (patient-owned) suction pump
K0192      Tubing, used with suction pump
K0268      Humidifier, nonheated, used with positive airway pressure device (P.A.)
K0269      Aerosol compressor, adjustable pressure, light duty for intermittent use (with CPAP device) (P.A.)
(I.C.) K0270      Ultrasonic generator with small volume ultrasonic nebulizer (P.A.) (I.C.) K0531      Humidifier, heated, used with positive airway pressure device (P.A.) K0532      Respiratory assist device, bi-level pressure capability, without backup rate feature, used with
noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous
positive airway pressure device) (P.A.) K0533      Respiratory assist device, bi-level pressure capability, with backup rate feature, used with
noninvasive interface, e.g. nasal or facial mask (intermittent assist device with continuous
positive airway pressure device) (P.A.) K0534      Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with invasive
interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway
pressure device) (P.A.) X0440      Stationary liquid oxygen system, includes use of reservoir, contents indicator, regulator, flowmeter,
humidifier, nebulizer, cannula or mask, and tubing (P.A.) X0442      Oxygen contents, liquid, per unit (one unit = one pound) (P.A.) X5032      Airway clearance device (rental, first six months, per month) (P.A.) X5033      Airway clearance device (continued rental after six months, per month) (P.A.) X5034 Airway clearance device (purchase) (P.A.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-5	

	TRANSMITTAL LETTER
OXY-23	DATE
04/01/03	
602 Service Codes and Descriptions (cont.)
Service
Code	Service Description
X5045	Oximetry monitor, portable (spot check) (rental, first six months, per month) (P.A.)
X5046	Comprehensive aerosolized pentamidine treatment (with portable booth)
X5048	Suction kit; contains catheter, glove, and pop-up basin
X5050	Peak flow meter
X5053	Oximetry monitor, portable (spot check) (continued rental after six months, per month) (P.A.)
X5356	Tracheostomy or laryngectomy tube (pediatric) (I.C.)
X5357	Tracheostomy twill tape, ¼”
X5358	Tracheostomy, Velcro ® collar
X5360	Resuscitator, manual (nondisposable)
X5362	Volume ventilator, stationary or portable (continued rental after six months, per month) (P.A.)
X5367	Negative pressure ventilator, portable or stationary (i.e., Porta-Lung) (continued rental after six
months, per month) (P.A.)
X5368	Negative pressure ventilator, stationary (rental, first six months, per month) (P.A.)
X5369	Negative pressure ventilator, stationary (continued rental after six months, per month) (P.A.)
X5376	Apnea monitor (continued rental after six months, per month) (P.A.)
X5377	Oximetry monitor (rental, first six months, per month) (P.A.)
X5378	Oximetry monitor (continued rental after six months, per month) (P.A.)
Y9858	Repair (labor, per hour only)
Z6509	Comprehensive aerosolized pentamidine treatment

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-6	

	TRANSMITTAL LETTER
OXY-23	DATE
04/01/03	
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