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 OXY-26
	September 2005

	TO:	Oxygen and Respiratory Therapy Equipment Providers Participating in MassHealth

	FROM:	Beth Waldman, Medicaid Director  

	RE:	Oxygen and Respiratory Therapy Equipment Manual (Changes and Corrections to Subchapter 6)

This letter transmits revisions and clarifications to Subchapter 6 of the Oxygen and Respiratory Therapy Equipment Manual.  The revisions update service codes and modifiers, and are effective for dates of service on and after July 1, 2004.  In addition, this letter clarifies MassHealth policy and billing requirements for certain services.

Services Requiring Prior Authorization (PA) 

To clarify which service codes require prior authorization (PA), MassHealth has revised the entries in Section 601 of Subchapter 6, under the column “PA Required?.”  Under this column, “Yes” means PA is always required, and “No” means PA is never required, unless you want to ask for more than the limit.  The only change in this column is when “ST” is entered, which means a PA is sometimes required. Specifically, PA is required when the requested units exceed the limits listed for the service code in Subchapter 6.

Requesting Prior Authorization for Additional Units Beyond the Specified Limits

Section 601 of Subchapter 6 identifies the payment category, indicates whether prior authorization (PA) is required, and specifies other requirements and limits for each code.  The limits were developed in consultation with clinicians from the MassHealth Office of Clinical Affairs and are based on generally accepted clinical practice guidelines.  PA was removed from many service codes that required PA prior to July 1, 2004, allowing providers to supply products without requesting a PA.

Providers must submit a PA request for all members for all services (even if a PA is not typically required for the service) for coverage of additional units beyond the specified limits, if additional units are medically necessary.  The request must be submitted before the additional units are provided, and must be supported by medical documentation. 

To request a PA for additional units the provider must document in Item 11 of the PA Request form, if submitting on paper, or in the providers comment section, if submitting on APAS, that the PA is being requested for additional units beyond the limits listed in Subchapter 6, Section 601.

Tracheostomy and Laryngectomy Tubes

MassHealth has revised Subchapter 6 to reflect changes in PA requirements and limits for tracheostomy tubes and laryngectomy tubes.  Effective September 1, 2005, MassHealth is changing the limit before prior authorization is required for cuffed and noncuffed tracheostomy and laryngectomy tubes from one every three months to 12 per calendar year.  However, providers may dispense no more than two units at a time.

Updates to Service Codes

A summary of updates to service codes is provided below.  All of these changes are reflected in the attached Subchapter 6.

Clarification of Place-of-Service Codes (POS) 

Effective September 1, 2005, MassHealth will accept the POS code for a nursing facility for the following service codes.  Please refer to Section 603 of Subchapter 6 for a list of POS codes.

•	E0470, E0471, E0550, and E1340
•	L8501

Requirements and Limits

MassHealth is increasing the number of units that are billable within certain time frames for the following service codes.  PA is required when the units requested exceed the limits specified in Subchapter 6.

Service Code		Revised Limits

A7005		1 unit = each, 3 per 6 months
A7501		1 unit = each, 3 per 6 months
A7502		1 unit = each, 3 per 6 months
A7520		1 unit = each, 12 per year, providers cannot dispense more than 2 at a time
A7521		1 unit = each, 12 per year, providers cannot dispense more than 2 at a time
A7524		1 unit = each, 1 per 3 months
A7526		1 unit = each 10 per month

MassHealth has now added a number of units that are billable within a certain time frame for the following service codes.  PA is required when the units requested exceed the limits specified in Subchapter 6.

S8180		1 unit = each, 4 per month
S8190 		1 unit = each, 1 per 5 years
S8210		1 unit = 1 box (50), 3 per month

New Service Codes 

The following service codes are billable and were adopted effective July 1, 2004, by the Division of Health Care Finance and Policy (DHCFP), but were inadvertently omitted from Transmittal Letter OXY-25 (July 2004).  These codes are included in the attached Subchapter 6.

•	A4483
•	E1399
•	S8100

Modifiers Corrected

In Section 601, replace the modifier QE for Service Codes E0439 and E1390 with modifier QF.

Modifiers Deleted

MassHealth has deleted the modifier NU from the following service codes:

A4216	A4610	A7011	A7032	A7046	A7520
A4217	A4624	A7012	A7033	A7502	A7521
A4481	A4627	A7013	A7034	A7503	A7522
A4557	A4628	A7014	A7035	A7504	A7524
A4558	A7003	A7015	A7036	A7505	A7525
A4566	A7004	A7025	A7037	A7506	A7526
A4606	A7005	A7026	A7038	A7507	S8999
A4608	A7006	A7030	A7039	A7508	
A4609	A7010	A7031	A7044	A7509	

Repair Policy 

Providers are reminded that Service Codes E1340 RP (labor) and E1399 RP (parts) must be used when submitting claims for all repairs of equipment not under warranty.  E1399 RP can be used only for parts that do not have a more specific service code.

PA is required for all repairs, in all settings, when the fee for the repairs will exceed $1000 (labor and parts).  A prescription is not required for the repair of equipment that was previously authorized by MassHealth.  Note:  Providers must use Service Codes E1340 RP and E1399 RP when requesting prior authorization for labor and parts.

An itemized bill indicating parts and labor must support claims for repairs.  Payment for repairs is all-inclusive, and must not exceed either the purchase price of a new item, or the cost of renting a replacement item for the remaining period that the product has been determined as necessary.

Claims for labor must be submitted using Service Code E1340 RP and must be billed in 15-minute increments (1 unit = 15 minutes).  The following documentation must be submitted with the claim:

•	a description of the repair;
•	an explanation as to why the repair is necessary;
•	an itemization of parts; and 
•	invoices for all parts.

If the equipment has been sent to the manufacturer for repair, but cannot be repaired due to age, or because improved technology has made the equipment obsolete, the provider must request a PA for new equipment.  However, the provider must obtain a letter from the member’s physician stating that the member has been using the equipment and the equipment continues to be necessary.  The provider must submit the PA request with the letter from the physician and enclose a copy of the documentation received from the manufacturer explaining why the repair cannot be done.

Billing Updates for Service Codes on a PA

Providers are reminded that when submitting claims for items on a PA, they must attach the PA number to the claim and bill only for the items on the PA.  If a claim is received with a PA number, it applies to all lines of the claim.  If the claim includes one service code that sometimes (ST) requires a PA, and the code is not included, the claim will be denied.  On the other hand, if the service code never (No) requires a PA, but one is added to the claim, it will not be denied.

Claims for Noncovered Services with Other Insurers

All claims submitted to MassHealth for which MassHealth is a secondary payer, must be billed to MassHealth with the same service code as was billed to the primary insurer.  Claims submitted to MassHealth with an attached explanation of benefits (EOB) from Medicare showing Service Code A9270 (noncovered service) will be denied by MassHealth, as noted in Oxygen and Respiratory Therapy Equipment Bulletin 11 (August 1998.)

If a service code is not covered by Medicare under any circumstances, but is covered by MassHealth, providers must submit the claim to MassHealth directly and should not attach a copy of the EOB from the primary insurer.

Service Codes Covered by MassHealth 

The Division of Health Care Finance and Policy (DHCFP) periodically publishes coding updates and corrections.  Providers are reminded that even though DHCFP issues new service codes or updates to its regulations, MassHealth may not necessarily pay for these services.  Providers must consult Subchapter 6 of the MassHealth Oxygen and Respiratory Therapy Equipment Manual to determine what service codes are billable by MassHealth.  MassHealth will notify providers when changes are made to Subchapter 6.

MassHealth Web Site

This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth.  Providers with questions about this information may contact MassHealth Customer Services at 1-800-841-2900, by e-mail at providersupport@mahealth.net, or by fax at 
617-988-8974.

NEW MATERIAL
(The pages listed here contain new or revised language.)

Oxygen and Respiratory Therapy Equipment Manual

Pages 6-1 through 6-8

OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)

Oxygen and Respiratory Therapy Equipment Manual

Pages 6-1 through 6-10— transmitted by Transmittal Letter OXY-25

601  Covered Services

Subchapter 6 contains service codes, modifiers and descriptions, place-of-service (POS) codes, attachment requirements, and categories.  Section 602 describes the modifiers.  Section 603 explains POS codes, Section 604 describes payment categories.

The entries in the “PA Required?” column mean the following:
•	No means that PA is not required unless you want to provide more units than allowed.
•	Yes means that PA is always required.
•	ST means that PA is sometimes required.

Providers may submit a prior-authorization request for any members for the coverage of additional units, if additional units are medically necessary.  The request must be submitted before the additional units are provided, and must be supported by medical documentation. 

Service Code	Payment 
Category	Modifiers 
Required	PA
Required?	POS
Required	Requirements and Limits	
						
A4216	OS	-- --	 ST	02 07	1 unit = each, 100 per month	
A4217	OS 	-- --	 ST	02 07	1 unit = each, 31 per month	
A4481	OS	-- --	 No	02 07	Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.	
A4483	OS	-- --	 ST	02 07	1 unit = 1 box (50), 3 per month	
A4556	SU	-- --	 No	02 07	A4556 can be billed separately from E0619.	
A4557	SU	-- --	 No	02 07	A4557 can be billed separately from E0619.	
A4558	SU	-- --	 ST	02 07	1 unit = each, 1 per 3 months	
A4606	IN	-- --	 Yes	02 07	1 unit = each, 1 per 12 months	
A4608	OX	-- --	 Yes	02 07	1 unit = each, 2 per 3 months.  Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.	
A4609	IN	-- --	 Yes	02 07	1 unit = each, 11 per month (not to be used with A4624 or E2000).  Can be billed separately when using E0600.  Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.	
A4610	IN	-- --	 Yes	02 07	1 unit = each, 6 per month (not to be used with A4624 or E2000).  Can be billed separately when using E0600.  Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.	
A4611	IN	NU RR UE	 Yes	02 07	1 unit = each, 2 per 36 months	
A4612	IN	NU RR UE	 Yes	02 07	1 unit = each, 2 per 12 months	
A4613	IN	NU RR UE	 Yes	02 07	1 unit = each, 2 per 12 months	
A4614	IN	--  --	 ST	02 07	1 unit = each, 1 per month	
A4619	OX	--  --	 ST	02 07	1 unit = each, 1 per month (used with E0565 and E0585)	

A4623	OS	--  --	 No	02 07	1 unit = each.  Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.	
A4624	IN	-- --	 ST	02 07	1 unit = each, 150 per month (can be billed separately for use with E0600, not for use with E2000).  Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.	
A4625	OS	--  --	 No	02 07	1 unit = each, 14 per post-op episode (A4625 is to be used only two weeks post-operatively.  After two weeks use A4629.)	
A4626	OS	--  --	 ST	02 07	1 unit = each, 31 per month (included in A4625 and A4629 and cannot be billed separately).	
A4627	IN	-- --	 ST	02 07	1 unit = each, 1 per 3 months	
A4628	IN	-- --	 ST	02 07	1 unit = each, 6 per month (Can be billed separately from E0600.)	
A4629	OS	--  --	 ST	02 07	1 unit = each, 31 per month	
A7000	IN	--  --	 ST	 02 07	1 unit = each, 1 per month (A7000 can be billed separately from E0600.)	

A7001	IN	--  --	 ST	  02 07	1 unit = each, 1 per month (A7001 can be billed separately from E0600.)	

A7002	IN	--  --	ST	  02 07	1 unit = each, 1 per month (A7002 can be billed separately from E0600, but not if it is included in A7001.)	

A7003	IN	-- --	ST	  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	-- --	ST	  02 07	1 unit = each, 2 per month (A7004 can be billed separately when used with E0570 or A7003.)	
A7005	IN	-- --	ST	  02 07	1 unit = each, 3 per 6 months (A7005 can be billed separately when used with E0570.)	
A7006	IN	-- --	ST	  02 07	1 unit = each, 1 per month (A7006 can be billed separately when used with E0565, E0570, or E0585.)	
A7010	IN 	-- --	ST	  02 07	1 unit = each (100 ft.), 2 per month (A7010 can be billed separately when used with E0565 or E0585.) 	
A7011	IN 	-- --	ST	  02 07	1 unit = each (10 ft.), 1 per 12 months (A7011 can be billed separately when used with E0565 or E0585 only when patient owns equipment; otherwise A7011 is included in monthly rental.)	

A7012	IN	-- --	ST	  02 07	1 unit = each, 2 per month (A7012 can be billed separately when used with E0565 or E0585 only when patient owns equipment; otherwise A7012 is included in monthly rental.)	
A7013	IN	-- --	ST	  02 07	1 unit = each, 2 per month (A7013 can be billed separately when used with E0565, E0570, or E0585 only when patient owns equipment; otherwise A7013 is included in monthly rental.)	

A7014	IN 	-- --	ST	  02 07	1 unit = each, 1 per 3 months (A7014 can be billed separately when used with E0565, E0572, or E0585 only when patient owns equipment; otherwise A7014 is included in monthly rental.)	
A7015	IN 	-- --	 ST 	  02 07	1 unit = each, 1 per month (A7015 can be billed 
separately when used with E0565, E0570, or E0585.)	
A7017	IN	NU RR UE	 No	  02 07	1 unit = each, 1 per 36 months (A7017 can be billed separately when used with E0565 or E0572 only when patient owns equipment; otherwise A7017 is included in monthly rental.)	
A7018	SU	--  --	 ST	  02 07	1 unit (1000 ml.) = each, 15 per month	
A7025	IN	-- --	 Yes	  02 07	1 unit = each, 1 per 3 years	
A7026	IN	-- --	 Yes	  02 07	1 unit = each, 1 per 3 years	
A7030	IN	-- --	 ST	  02 07	1 unit = each, 1 per 3 months (used with E0470, E0471 or E0601) 	
A7031	IN	-- --	 ST	  02 07	1 unit = each, 1 per 3 months (used with E0470, E0471 or E0601)	
A7032	IN	-- --	 ST	  02 07	1 unit = each, 2 per month (used with E0470, E0471 or E0601)	
A7033	IN	-- --	 ST	  02 07	1 unit = each, 2 per month (used with E0601, E0470, or E0741)	
A7034	IN	-- --	 ST	  02 07	1 unit = each, 1 per 3 months (A7034 is included in monthly rental and cannot be billed separately for 6 months after E0470, E0471, or E0601 has been purchased for the patient.)	
A7035	IN	-- --	 ST	  02 07	1 unit = each, 1 per 6 months (used with E0470, E0471, or E0601)	
A7036	IN	-- --	 ST	  02 07	1 unit = each, 1 per 6 months (used when E0470, E0471, or E0601 has been purchased for the patient.)	
A7037	IN	-- --	 ST	  02 07	1 unit = each, 1 per month (used with E0470, E0471, or E0601)	

A7038	IN	-- --	 ST	  02 07	1 unit = each, 2 per month (A7038 is included in monthly rental and cannot be billed separately for 6 months after E0470, E0471, or E0601 has been purchased for the patient.)	
A7039	IN	-- --	 ST	  02 07	1 unit = each, 1 per 6 months (used with E0470, E0471, or E0601)	
A7044	IN	-- --	 ST	  02 07	1 unit = each, 1 per 3 months	
A7046	IN 	-- --	 ST	  02 07	1 unit = each, 1 per 6 months (only when an appropriate humidifier has been purchased)	
A7501	OS	--  --	 ST	  02 07	1 unit = each, 3 per 6 months	
A7502	OS	-- --	 ST	  02 07	1 unit = each, 3 per 6 months	
A7503	OS	-- --	 ST	  02 07	1 unit = each, 2 per 12 months	
A7504	OS	-- --	 ST	  02 07	1 unit = each (packages of 30), 90 per month 	

A7505	OS	-- --	 ST	  02 07	1 unit = each, 4 per month	
A7506	OS	-- --	 ST	  02 07	1 unit = each (packages of 30), 90 per month	
A7507	OS	-- --	 ST	  02 07	1 unit = each, 90 per month	
A7508	OS	-- --	ST	  02 07	1 unit = each, 90 per month	
A7509	OS	-- --	ST	  02 07	1 unit = each, 90 per month	
A7520	OS 	-- --	ST	  02 06 07	1 unit = each, 12 per year, providers may not dispense more than two at one time	
A7521	OS 	-- --	ST	  02 06 07	1 unit = each, 12 per year, providers may not dispense more than two at one time	
A7522	OS 	-- --	ST	  02 06 07	1 unit = each, 1 per 12 months	
A7524	OS 	-- --	ST	  02 06 07	1 unit = each, 1 per 3 months	
A7525	OS	-- --	ST	  02 07	1 unit = each, 1 per month.  Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.	
A7526	OS 	-- --	ST	  02 07	1 unit = each, 10 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  QF 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.  ABG required for liter flow of 4 LPM or more.  Maximum allowed PA approval for 4 LPM or more is 3 months.	
E0445	IN	NU RR UE	Yes	  02 07	Covers portable or monitor, for use when SPO2 is transient, variable, and unpredictable, even in the presence of supplemental oxygen, and occurs on a regular basis requiring frequent changes in liter flow.	
E0450	FS 	RR U2	Yes	  02 06 07	RR modifier is to be used for any existing equipment that has an initial service date prior to 07/01/04 and/or rental months 7 and more after 07/01/04.  U2 modifier is for use on rental months 1 through 6 only (not to be used if member received this equipment before 07/01/04); otherwise RR modifier is to be used.	
E0454	FS	RR	Yes	02 06 07	--  --	
E0457	IN	NU RR UE	Yes	02 06 07	1unit = each, 1 per 5 years	
E0459	CR	KH KI KJ BP NU UE	Yes	02 06 07	1 unit = each, 1 per 5 years	
E0460	FS	RR	Yes	02 06 07	  --  --	
E0461	FS	RR U2	Yes	02 06 07	RR modifier is to be used for any existing equipment with an initial service date before 07/01/04, and/or rental months 7 and more after 07/01/04.  U2 modifier is for use on rental months 1 through 6 only (not to be used if member received this equipment before to 07/01/04); otherwise RR modifier is to be used.	
E0470	IN 	KH KI KJ BP NU UE	Yes	02 06 07	The physician must document therapeutic benefit and compliance of equipment use after the first 90 days of use.	
E0471	IN 	KH KI KJ BP NU UE	Yes	02 06 07	The physician must document therapeutic benefit and compliance of equipment use after the first 90 days of use.	
E0480	CR	KH KI KJ BP NU UE	Yes	02 07	1 unit = each, 1 per 5 years	
E0482	CR	KH KI KJ BP NU UE	Yes	02 07	1 unit = each, 1 per 5 years.  Must include one of the ICD-9 codes on claim, or claim will be denied:  ICD-9-CM 335.0 – 335.9, 340, 344.00 – 344.09, 359.0, 359.1 V4.0 or V55.0 (used to clear secretions for patients who cannot clear themselves)	

E0483	CR	KH KI KJ BP NU UE	Yes	02 07	1 unit = each, 1 per 5 years (used for patients that have the ability to clear their own secretions)	
E0484	IN	NU RR UE	Yes	02 07	1 unit = each, 1 per 12 months (used for patients that have the ability to clear their own secretions)	
E0500	FS	RR	Yes	02 07	  --  --	
E0550	CR	KH KI KJ BP NU UE	Yes	02 06 07	1 unit = each, 1 per 5 years.  E0550 is included in oxygen delivery systems and cannot be billed separately.	
E0560	IN	NU RR UE	Yes	02 07	1 unit = each, 1 per 5 years	
E0561	IN	NU RR UE	Yes	02 06 07	Included in rental of E0470, E0471, and E0601 (Can be purchased on last month rental of E0470, E0471, and E0601.)	
E0562	IN	NU RR UE	Yes	02 06 07	Included in rental of E0470, E0471, and E0601 (Can be purchased on last month rental of E0470, E0471, and E0601.) 	
E0565	CR	KH KI KJ BP NU UE	Yes 	02 06 07	Accessories associated with E0565 are A4619,  A7006, A7011, A7012, A7013, A7014, A7015, A7017, and E1372.	
E0570	CR	KH KI KJ BP NU UE	No	02 07	Accessories associated with E0570 are A4621, A7003, A7004, A7005, A7006, A7013, and A7015.	
E0572	CR	KH KI KJ BP NU UE	Yes	02 07	Accessories associated with E0572 are A7006 and A7014.	
E0585	CR	KH KI  KJ BP NU UE	Yes	02 07	Accessories associated with E0585 are A4619, A4621, A7006 A7010, A7011, A7012, A7013, A7014, and A7015.	
E0600	CR	KH KI KJ BP NU UE	Yes	02 07	1 unit = each, 1 per 5 years.  Physician must document therapeutic benefit for renewal after 90 days.	
E0601	CR	KH KI KJ BP NU UE	Yes	02 06 07	1 unit = each, 1 per 5 years	
E0605	IN	NU RR UE	No	02 07	1 unit = each, 1 per 24 months	
E0606	CR	KH KI KJ BP NU UE	No	02 07	1 unit = each, 1 per 5 years	
E0619	CR	KH KI KJ BR	No	02 07	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.)	
E1340	IN	RP 	ST	02 06 07	PA required when E1340 RP and E1399 RP combined equal more than $1000.	

E1372	IN	NU RR UE	Yes	02 07	1 unit = each, 1 per 36 months 	
E1390	OX	RR  QF 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.  ABG required for liter flow of 4 LPM or more. Maximum allowed PA approval for 4 LPM or more is 3 months.	
E1399		RP	ST	02 06 07	PA required when E1340 RP and E1399 RP combined equal more than $1000.	
L8501	IN	--  --	ST	02 06 07	1 unit = each, 1 per 3 months.  Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.	
S8100	IN	-- --	ST	02 07	1 unit = each, 1 per 3 months	
S8180	IN	--  --	ST	02 07	1 unit = each, 4 per month.  Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.	
S8181	IN	--  --	No	02 07	1 unit = each.  Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.	
S8186	IN	--  --	ST	02 07	1 unit = each, 1 per month	
S8190	IN	NU RR 
UE	Yes	02 07	1 unit = each, 1 per 5 years.  Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.  ICD-9-CM V42.6 post-operative lung transplants only	
S8210	IN	--  --	Yes	02 07	1 unit = 1 box (50), 3 per month	
S8999	IN	-- --	No	02 07	Must include either ICD-9-CM V44.0 or V55.0 on claim, or claim will be denied.  (S8999 can be used in conjunction with E0450, E0454, and E0461.)	

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 capped 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)
NU	New equipment
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)
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.)
U2	Modifier is used on rental months 1 through 6 (for designated HCPCS codes) (not to be used if member has had equipment since before 07/01/04).
UE	Used durable medical equipment

603  Place-of-Service Codes

The following place-of-service (POS) codes are used when billing for oxygen and respiratory therapy equipment on paper.

Place-of-Service Code	Description	
02
06
07	Member’s home
Nursing home
Rest home	

604  Payment Categories

Each billable 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.  Refer to Department of Health Care and Finance Policy (DHCFP) regulations.

Category	Description 

CR	Capped rental
FS	Frequently serviced items
IN	Inexpensive and routinely purchased DME
OS	Ostomy, tracheostomy, and urologicals
OX	Oxygen and oxygen equipment
SU	Supplies