Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/dma MASSHEALTH TRANSMITTAL LETTER OXY-24 January 2004 TO: Oxygen and Respiratory Therapy Providers Participating in MassHealth FROM: Beth Waldman, Director, Office of Medicaid RE: Oxygen and Respiratory Therapy Equipment Manual (Revised Service Codes) This letter transmits a substantially revised Subchapter 6, including covered service codes, for the Oxygen and Respiratory Therapy Equipment Manual. The revised Subchapter 6 is effective for dates of service on and after January 1, 2004. MassHealth local codes and miscellaneous codes have been replaced with codes that are compliant with the Health Insurance Portability and Accountability Act (HIPAA), of 1996. Subchapter 6 now lists all covered service codes in alphanumeric order. Descriptions of codes are no longer included. Providers should refer to www.cms.hhs.gov for code descriptions. Subchapter 6 is organized as follows: 601 Covered Services 602 Modifiers 603 Place-of-Service (POS) Codes 604 Payment Categories Section 602 of Subchapter 6 identifies the payment category, whether prior authorization (PA) is required, and specifies other requirements and limits for each code. The limits were developed in consultation with clinical experts and are based on generally accepted clinical practice guidelines. Providers may submit a PA request for all members for coverage of additional units, if additional units are medically necessary. The request should be submitted before the additional units are provided, and must be supported by medical documentation. Section 602 of Subchapter 6 identifies covered place-of-service codes for each HCPCS code. Please refer to Section 604 in Subchapter 6 to determine the appropriate place-of-service codes if billing claims electronically. Providers are reminded that the place of service is where the product is used (e.g., member’s home, nursing facility, or rest home). The PA, if applicable, and the claim must reflect the accurate place of service. MASSHEALTH TRANSMITTAL LETTER OXY-24 January 2004 Page 2 Revised Fee Schedule In December of 2003, MassHealth of Health Care Finance and Policy (DHCFP) issued new regulations certifying new fees and payment methodologies for the services and products in Subchapter 6 of the Oxygen and Respiratory Therapy Equipment Manual. The new fees and methodologies are effective for dates of service on and after January 1, 2004. The DHCFP regulations, including the fee schedule, are available on the DHCFP Web site at www.mass.gov/dhcfp. If you wish to obtain a paper copy of the fee schedule, you may purchase the schedule 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 regulation. The DHCFP also has the regulations available on disk. The regulation title for Durable Medical Equipment and Oxygen and Respiratory Therapy Equipment is 114 CMR 22.00. Massachusetts State Bookstore Division of Health Care Finance and Policy State House, Room 116 Two Boylston Street Boston, MA 02133 Boston, MA 02116 Telephone: 617-727-2834 Telephone: 617-988-3100 www.mass.gov/sec/spr www.mass.gov/dhcfp MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/dma. Billing Guidelines Effective for dates of service on and after January 1, 2004, providers can bill for services provided to MassHealth members using only the HCPCS specified in the attached Subchapter 6. PAs and claims submitted with codes not included in Subchapter 6 will be denied. You must also use a modifier with certain codes to accurately reflect the service provided and ensure the appropriate payment. All claims submitted on paper with an explanation of benefits (EOB) from another insurer must be submitted to MassHealth with the same HCPCS code that was billed to the other insurer. MassHealth will deny all claims billed using service code A9270. Effective for dates of service on and after January 1, 2004, ICD-9-CM codes are required on all claims. The ICD-9-CM codes must be directly related to the equipment or supplies on the claim. Oximeters Effective for dates of service on and after January 1, 2004, MassHealth will no longer differentiate between a portable (spot check) oximeter and a stationary oximeter (with alarms). MassHealth will use one code and pay one fee as indicated in DHCFP’s regulation. MassHealth will no longer consider a provider’s adjusted acquisition cost. Phototherapy (bilirubin) Effective for dates of service on and after January 1, 2004, phototherapy does not require a PA and will be paid on a capitated (per episode) basis as indicated in DHCFP’s regulation. MASSHEALTH TRANSMITTAL LETTER OXY-24 January 2004 Page 3 Apnea Monitor Effective for dates of service on and after January 1, 2004, MassHealth no longer requires a PA for the first three months of rental for an apnea monitor. Claims for the first three months must be submitted with KH (initial claim) and KI (claim months 2 and 3) modifiers. After three months of use providers are required to download the memory, and send the report to the ordering physician for interpretation of events. If the physician has determined the equipment is required for more than three months, MassHealth will require PA. The provider must submit a copy of the signed physician’s interpretation, noting any and all events using the KJ modifier, and initial dates of service. An apnea monitor is covered within the capped rental payment methodology. MassHealth will pay a monthly rental fee for up to 15 months as indicated in DHCFP’s regulation. This equipment remains a covered item after 15 months, but the provider should not bill MassHealth, as MassHealth will not pay a monthly rental fee after the 15th month. If the equipment is provided for 15 months or more, the provider must indicate the modifier “BR” on the claim for the 15th month to indicate that is the last claim for a monthly rental fee. The provider must retain ownership of the equipment and continue providing the equipment to the member without any charge until either the medical necessity for the equipment ends or the eligibility of the member for MassHealth ends, whichever is sooner. Noncovered Services Providers are reminded that air conditioners, HEPA filters, and light boxes are not covered under MassHealth. Prior Authorization Effective for dates of service on and after January 1, 2004, all requests for PA must be submitted using the codes appearing in the new Subchapter 6. Providers who have already received PAs using obsolete local codes must request adjustments to those PAs for unused units. When requesting an adjustment, include the number of units already billed, the new code and any remaining units needed (not to be exceed unit on original decision), and a date-of-service change, if applicable. PA requests require an ICD-9-CM code that directly relates to the equipment or supplies being requested along with description of the diagnosis. Case Management for Complex–Care Members Beginning August 1, 2003, the Home Health Agency Manual was revised to include a new initiative for MassHealth members under the age of 22 who require a nurse encounter of more than two continuous hours. MassHealth refers to these members as complex-care members. MASSHEALTH TRANSMITTAL LETTER OXY-24 January 2004 Page 4 The new initiative, called Community Case Management (CCM), assigns each complex-care member a case manager who performs a comprehensive needs assessment and authorizes all medically necessary home health and other community services, including oxygen and respiratory equipment, for these members. The Recipient Eligibility Verification System (REVS) will identify those complex-care members whom MassHealth has enrolled in CCM. All requests for PA for members enrolled in CCM will be reviewed and authorized by the case manager assigned to the member. PA requests received from providers will automatically be forwarded to the appropriate case manager for review. Providers must continue to follow the PA process as outlined in the regulations in Subchapter 4 of the Oxygen and Respiratory Therapy Equipment Manual. The case manager will be responsible for direct interaction with the prescriber to ensure proper documentation is received. Questions Providers with questions about this information may contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231. NEW MATERIAL (The pages listed here contain new or revised language.) Oxygen and Respiratory Therapy Equipment Manual Pages vi, and 6-1 through 6-10 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Oxygen and Respiratory Therapy Equipment Manual Pages vi — transmitted by Transmittal Letter OXY-22 Pages 6-1 through 6-6 — transmitted by Transmittal Letter OXY-23 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL SUBCHAPTER NUMBER AND TITLE TABLE OF CONTENTS PAGE vi TRANSMITTAL LETTER OXY-24 DATE 01/01/04 6. SERVICE CODES 601 Covered Services ................................................................................................................. 6-1 602 Modifiers.............................................................................................................................. 6-8 603 Place-of-Service Codes........................................................................................................ 6-9 604 Payment Categories ............................................................................................................. 6-9 Appendix A. DIRECTORY ................................................................................................................ A-1 Appendix B. ENROLLMENT CENTERS ......................................................................................... B-1 Appendix C. THIRD-PARTY-LIABILITY CODES ......................................................................... C-1 Appendix W. EPSDT SERVICES: MEDICAL PROTOCOL AND PERIODICITY SCHEDULE..... W-1 Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES ............................. X-1 Appendix Y. REVS CODES/MESSAGES ........................................................................................ Y-1 Appendix Z. EPSDT SERVICES LABORATORY CODES .............................................................. Z-1 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-1 OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL TRANSMITTAL LETTER OXY-24 DATE 01/01/04 601 Covered Services Subchapter 6 contains, service codes, modifiers and descriptions, place of service codes, attachment requirements, and categories. Providers may submit a prior-authorization request for all members for coverage of additional units, if additional units are medically necessary. The request should be submitted before the additional units are provided, and must be supported by medical documentation. Service Payment Modifiers PA POS Codes Category Required Required? Required Requirements and Limits A4216 OS I.C. NU No 02 07 1 unit = each, 100 per month A4217 OS I.C. NU No 02 07 1 unit = each, 31 per month A4481 OS NU No 02 07 ICD-9-CM V44.0 or V55.0 A4556 SU NU No 02 07 A4556 can be billed separately only if patient owns E0619; otherwise included in monthly rental. A4557 SU NU No 02 07 A4557 can be billed separately only if patient owns E0619; otherwise included in monthly rental. A4558 SU NU No 02 07 1 unit = each, 1 per 3 months A4606 IN NU No 02 07 1 unit = each, 1 per 12 months A4608 OX NU Yes 02 07 1 unit = each, 2 per 3 months. ICD-9-CM V44.0 or V55.0 A4609 IN NU Yes 02 07 1 unit = each, 11 per month (not to be used with A4624. Can be billed separately when E0600 is owned by patient, not for use with E0200.); ICD-9-CM V44.0 or V55.0 A4610 IN NU Yes 02 07 1 unit = each, 6 per month (Not to be used with A4624. Can be billed separately when E0600 is owned by patient; not for use with E2000.) ICD-9-CM V44.0 or V55.0 A4611 IN NU RR Yes 02 07 1 unit = each, 1 per 36 months UE A4612 IN NU RR Yes 02 07 1 unit = each, 1 per 12 months UE A4613 IN NU RR Yes 02 07 1 unit = each, 1 per 12 months UE A4614 IN No 02 07 1 unit = each, 1 per 3 months A4619 OX No 02 07 1 unit = each, 1 per month (used with E0565 and E0585) A4621 OX No 02 07 1 unit = each, 1 per month (used with E0564 E0570 and E0585); ICD-9-CM V44.0 or V55.0. A4622 OS No 02 07 1 unit = each, 1 per 3 months; ICD-9-CM V44.0 or V55.0 A4623 OS No 02 07 1 unit = each; ICD-9-CM V44.0 or V55.0 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-2 OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL TRANSMITTAL LETTER OXY-24 DATE 01/01/04 601 Covered Services (cont.) 601 Covered Services (cont.) 601 Covered Services (cont.) 601 Covered Services (cont.) Service Payment Modifiers PA POS Codes Category Required Required? Required Requirements and Limits A4624 IN NU No 02 07 1 unit = each, 150 per month (Billed separately only when E0600 is owned by the patient, not for use with E2000.); ICD-9-CM V44.0 or V55.0 A4625 OS No 02 07 1 unit = each, 14 per post-op episode (A4625 is only to be used two weeks post-operatively, after two weeks use A4629.) A4626 OS No 02 07 1 unit = each, 31 per month (included in A4625 and A4629 and cannot be billed separately) A4627 IN NU No 02 07 1 unit = each, 1 per 3 months A4628 IN NU No 02 07 1 unit = each, 4 per month (billed separately only when E0600 is owned by patient) A4629 OS No 02 07 1 unit = each, 31 per month A7000 IN NU No 02 07 1 unit = each, 1 per month (A7000 can be billed separately if patient owns E6000; otherwise included in monthly rental.) A7001 IN NU No 02 07 1 unit = each, 1 per month (A7001 can be billed separately if patient owns E6000; otherwise included in monthly rental.) A7002 IN NU No 02 07 1 unit = each, 1 per month (A7002 can be billed separately if patient owns E6000 but not if it is included in A7001; otherwise included in monthly rental.) A7003 IN NU No 02 07 1 unit = each, 2 per month (A7003 can be billed separately when used with E0570 only when the patient owns equipment; otherwise A7003 is included in rental.) A7004 IN NU No 02 07 1 unit = each, 2 per month (A7004 can be billed separately when used with E0570 and A7003 only when patient owns equipment; otherwise A7004 is included in monthly rental.) A7005 IN NU No 02 07 1 unit = each, 1 per 6 months (A7005 can be billed separately when used with E0570 only when patient owns equipment; otherwise A7005 is included in monthly rental.) A7006 IN NU No 02 07 1 unit = each, 1 per month (A7006 can be billed separately when used with E0565, E0570, and E0585 only when patient owns equipment; otherwise A7006 is included in monthly rental.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-3 OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL TRANSMITTAL LETTER OXY-24 DATE 01/01/04 Service Payment Modifiers PA POS Codes Category Required Required? Required Requirements and Limits A7010 IN NU No 02 07 1 unit = each (100 ft.), 2 per month (A7010 can be billed separately when used with E0565 and E0585 only when the patient owns equipment; otherwise A7010 is included in monthly rental.) A7011 IN NU No 02 07 1 unit = each (10 ft.), 1 per 12 months (A7011 can be billed separately when used with E0565 and E0585 only when patient owns equipment; otherwise A7011 is included in monthly rental.) A7012 IN NU No 02 07 1 unit = each, 2 per month (A7012 can be billed separately when used with E0565 and E0585 only when patient owns equipment; otherwise A7012 is included in monthly rental.) A7013 IN NU No 02 07 1 unit = each, 2 per month (A7013 can be billed separately when used with E0565, E0570, and E0585 only when patient owns equipment; otherwise A7013 is included in monthly rental.) A7014 IN NU No 02 07 1 unit = each, 1 per 3 months (A7014 can be billed separately when used with E0565, E0572, and E0585 only when patient owns equipment; otherwise A7014 is included in monthly rental.) A7015 IN NU No 02 07 1 unit = each, 1 per month (A7015 can be billed separately when used with E0565, E0570, and E0585 only when patient owns equipment; otherwise A7015 is included in monthly rental.) A7017 IN NU RR No 02 07 1 unit = each, 1 per 36 months (A7017 can be UE billed separately when used with E0565 or E0572 only when patient owns equipment; otherwise A7017 is included in monthly rental.) A7018 SU No 02 07 1 unit (1000 ml.) = each, 15 per month A7020 SU No 02 07 1 unit (1000 ml.) = each, 15 per month A7025 IN NU Yes 02 07 1 unit = each, 2 per 3 months A7026 IN NU Yes 02 07 1 unit = each, 2 per 3 months Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-4 OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL TRANSMITTAL LETTER OXY-24 DATE 01/01/04 Service Payment Modifiers PA POS Codes Category Required Required? Required Requirements and Limits A7030 IN NU No 02 07 1 unit = each, 1 per 3 months (A7030 is included in monthly rental and cannot be billed separately for 6 months after E06001, K0532, or K0533 has been purchased for the patient.) A7031 IN NU No 02 07 1 unit = each, 1 per 3 months (A7031 is included in monthly rental and cannot be billed separately for 6 months after E06001, K0532, or K0533 has been purchased for the patient.) A7032 IN NU No 02 07 1 unit = each, 2 per month (A7032 is included in monthly rental and cannot be billed separately for 6 months after E06001, K0532, or K0533 has been purchased for the patient.) A7033 IN NU No 02 07 1 unit = each, 2 per month (A7033 is included in monthly rental and cannot be billed separately for 6 months after E06001, K0532, or K0533 has been purchased for the patient.) A7034 IN NU No 02 07 1 unit = each, 1 per 3 months (A7034 is included in monthly rental and cannot be billed separately for 6 months after E06001, K0532, or K0533 has been purchased for the patient.) A7035 IN NU No 02 07 1 unit = each, 1 per 6 months (A7035 is included in monthly rental and cannot be billed separately for 6 months after E06001, K0532, or K0533 has been purchased for the patient.) A7036 IN NU No 02 07 1 unit = each, 1 per 6 month (A7036 is included in monthly rental and cannot be billed separately for 6 months after E06001, K0532, or K0533 has been purchased for the patient.) A7037 IN NU No 02 07 1 unit = each, 1 per month (A7037 is included in monthly rental and cannot be billed separately for 6 months after E06001, K0532, or K0533 has been purchased for the patient.) A7038 IN NU No 02 07 1 unit = each, 2 per month (A7038 is included in monthly rental and cannot be billed separately for 6 months after E06001, K0532, or K0533 has been purchased for the patient.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-5 OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL TRANSMITTAL LETTER OXY-24 DATE 01/01/04 Service Payment Modifiers PA POS Codes Category Required Required? Required Requirements and Limits A7039 IN NU No 02 07 1 unit = each, 1 per 6 months (A7039 is included in monthly rental and cannot be billed separately for 6 months after E06001, K0532, or K0533 has been purchased for the patient.) A7044 IN NU No 02 07 1 unit = each, 1 per 3 months A7046 IN NU No 02 07 1 unit = each, 1 per 6 months (only when appropriate humidifier has been purchased) A7501 OS No 02 07 1 unit = each, 1 per 6 months A7502 OS NU No 02 07 1 unit = each, 1 per 6 months A7503 OS NU No 02 07 1 unit = each, 2 per 12 months A7504 OS NU No 02 07 1 unit = each, 90 per month (packages of 30) A7505 OS NU No 02 07 1 unit = each, 4 per month A7506 OS NU No 02 07 1 unit = each, 90 per month (packages of 30) A7507 OS NU No 02 07 1 unit = each, 90 per month A7508 OS NU No 02 07 1 unit = each, 90 per month A7520 OS NU No 02 07 1 unit = each, 1 per 3 months A7521 OS NU No 02 07 1 unit = each, 1 per 3 months A7522 OS NU No 02 07 1 unit = each, 1 per 12 months A7524 OS NU No 02 07 1 unit = each, 1 per 6 months A7526 OS NU No 02 07 1 unit = each, 5 per month (A7526 is included in A4625 and A4629 and cannot be billed separately.) E0424 OX RR Yes 02 06 07 Qualifying ABGs or SPO2 within 2 days of discharge from facility or within 30 days of new or renewal order. E0431 OX RR Yes 02 06 07 Qualifying ABGs or SPO2 within 2 days of discharge from facility or within 30 days of new or renewal order. Documentation of hours away from stationary required. E0434 OX RR Yes 02 06 07 Qualifying ABGs or SPO2 within 2 days of discharge from facility or within 30 days of new or renewal order. Documentation of hours away from stationary required. E0439 OX RR QE QG Yes 02 06 07 Qualifying ABGs or SPO2 within 2 days of discharge from facility or within 30 days of new or renewal order. E0445 IN NU RR Yes 02 07 Covers portable or monitor, for use when UE SPO2 is transient, variable, and unpredictable, even in the presence of supplemental oxygen, occurs on a frequent basis and regular basis requiring frequent changes in liter flow. E0450 FS RR Yes 02 06 07 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-6 OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL TRANSMITTAL LETTER OXY-24 DATE 01/01/04 601 Covered Services (cont.) Service Payment Modifiers PA POS Codes Category Required Required? Required Requirements and Limits E0454 FS RR Yes 02 06 07 E0457 IN NU RR Yes 02 06 07 1 unit = each, 1 per 5 years UE E0459 CR KI KH KJ Yes 02 06 07 1 unit = each, 1 per 5 years BP NU UE E0460 FS RR Yes 02 06 07 E0461 FS RR Yes 02 06 07 E0480 CR KI KH KJ Yes 02 07 1 unit = each, 1 per 5 years BP NU UE E0482 CR KI KH KJ Yes 02 07 ICD-9-CM 335.0 – 335.9, 340, 344.00 – BP NU UE 344.09 359.0 and 359.1 (stimulate cough to clear secretions) E0483 CR KI KH KJ Yes 02 07 1 unit = each, 1 per 5 years BP NU UE E0484 IN NU RR Yes 02 07 1 unit = each, 1 per 12 months UE E0500 FS RR Yes 02 07 E0550 CR KI KH KJ Yes 02 07 1 unit = each, 1 per 5 years. E0550 is included BP NU UE in oxygen delivery systems and cannot be billed separately. E0560 IN NU RR Yes 02 07 1 unit = each, 1 per 5 years UE E0565 CR KI KH KJ Yes 02 06 07 Accessories associated with E0565 are A4619, BP NU UE A4621, A7006, A7011, A7012, A7013, A7014, A7015, A7017, and E1372. E0570 CR KI KH KJ Yes 02 07 Accessories associated with E0570 are A4621, BP NU UE A7003, A7004, A7005, A7006, A7013, and A7015. E0572 CR KI KH KJ Yes 02 07 Accessories associated with E0572 are A7006 BP NU UE and A7014. E0585 CR KI KH KJ Yes 02 07 Accessories associated with E0585 are A4619, BP NU UE A4621, A7006 A7010, A7011, A7012, A7013, A7014, and A7015. E0600 CR KI KH KJ Yes 02 07 1 unit = each, 1 per 5 years. Therapeutic BP NU UE benefit must be documented by physician for renewal after 90 days. E0601 CR KI KH KJ Yes 02 06 07 1 unit = each, 1 per 5 years BP NU UE E0605 IN NU RR No 02 07 1 unit = each, 1 per 24 months UE E0606 CR KI KH KJ No 02 07 1 unit = each, 1 per 5 years BP NU UE Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-7 OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL TRANSMITTAL LETTER OXY-24 DATE 01/01/04 601 Covered Services (cont.) Service Payment Modifiers PA POS Codes Category Required Required? Required E0619 CR KI KH KJ No 02 07 BR E1340 RP No 02 07 E1372 IN NU RR Yes 02 07 UE E1390 OX RR QE Yes 02 06 07 QG K0268 IN NU RR Yes 02 06 07 UE K0531 IN NU RR Yes 02 06 07 UE K0532 CR KI KH KJ Yes 02 06 07 BP NU UE K0533 CR KH KI KJ Yes 02 06 07 BP NU L8501 IN No 02 07 S8180 IN No 02 07 S8181 IN No 02 07 S8185 IN No 02 07 S8186 IN No 02 07 S8190 IN NU RR Yes 02 07 UE S8210 IN Yes 02 07 S8999 IN NU No 02 07 Requirements and Limits PA required after 3 months of use (After three months of use providers are required to download the memory, and send the report to the ordering physician for interpretation of events.) 1 unit = each, 1 per 36 months (E1372 can be billed separately only when patient owns equipment; otherwise E1372 is included in monthly rental.) Supplies are included in monthly rental and cannot be billed separately. Included in rental of E0601, K0532, and K0533 (Can be purchased on last month rental of E0601, K0532, and K0533.) Included in rental of E0601, K0532, and K0533 (Can be purchased on last month rental of E0601, K0532, and K0533.) K0268 or K0502 is included in the monthly rental of K0532. Therapeutic benefit must be documented by physician for renewal after 90 days. K0268 or K0502 is included in the monthly rental of K0533. Therapeutic benefit must be documented by physician for renewal after 90 days. ICD-9-CM V44.0 or V55.0 ICD-9-CM V44.0 or V55.0 ICD-9-CM V44.0 or V55.0 1 unit = each, 1 per 6 months 1 unit = each, 1 per month ICD-9-CM V42.6 post-operative lung transplants only 1 unit = each, 31 per month ICD-9-CM V44.0 or V55.0 (S8999 can be used in conjunction with E0450, E0454, and E0461.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-8 OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL TRANSMITTAL LETTER OXY-24 DATE 01/01/04 602 Modifiers Modifier Description BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item (For MassHealth members, MassHealth has purchased the item for the member.) (used on the 15th month of rental) BR The beneficiary has been informed of the purchase and rental options and has elected to rent the item (For MassHealth members, member continues to rent, no more claims can be submitted, purchase price has been met. MassHealth will not purchase the item.) (used on the 15th month of rental) KH DME POS item, initial claim, purchase or first month rental (For MassHealth member’s first claim.) KI DME POS item, second or third month rental KJ DME POS item, parenteral enteral nutrition (PEN) pump or capped rental, months four to 15 (for MassHealth members months four through 14) KR Rental item, billing for partial month NR New when rented (Use the NR modifier when DME that was new at the time of the rental is subsequently purchased.) 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 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 RP Replacement and repair - RP may be used to indicate replacement of DME, orthotic, and prosthetic devices that have been in use for some time. The claim shows the code for the part, followed by the RP modifier and the charge for the part. RR Rental (Use the RR modifier when DME is to be rented.) UE Used durable medical equipment Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-9 OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL TRANSMITTAL LETTER OXY-24 DATE 01/01/04 603 Place-of-Service Codes The following are codes and descriptions for paper or electronic submission. Paper Claim Description Submission Description 0206 07 Member’s home Nursing home Rest home 12 31, 32 33 Home Skilled nursing facility, nursing facility custodial care facility 604 Payment Categories Each covered service code is assigned to one of the following payment categories. These categories help providers to identify applicable modifiers, and explain how MassHealth pays for the service. Category Description CAP Capitated rate (per episode) CR Capped rental FS Frequently serviced items IN Inexpensive and routinely purchased DME OS Ostomy, tracheostomy, and urologicals OX Oxygen and oxygen equipment PO Prosthetics and orthotics SU Supplies Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-10 OXYGEN AND RESPIRATORY THERAPY EQUIPMENT MANUAL TRANSMITTAL LETTER OXY-24 DATE 01/01/04 This page is reserved.