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-27 May 2006 TO: Oxygen and Respiratory Therapy Equipment Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Oxygen and Respiratory Therapy Equipment Manual (Revised Service Codes) This letter transmits revisions to Subchapter 6 of the Oxygen and Respiratory Therapy Equipment Manual. MassHealth has revised Subchapter 6 to list only the oxygen and respiratory therapy equipment service codes that are covered under the oxygen and respiratory therapy program regulations at 130 CMR 427.000. Providers may consult the Centers for Medicare and Medicaid Services (CMS) Web site at www.cms.gov for a full description of the service codes. Prior-authorization (PA) requirements, limitations, and place-of-service code requirements that used to be found in Subchapter 6 now appear in a new, interactive MassHealth DME and Oxygen Payment and Coverage Guidelines tool that is posted on the MassHealth Web site. In addition to the revised format, Subchapter 6 contains updates to codes for 2006 to comply with federal coding mandates and incorporate coding changes previously described in bulletins issued by the Division of Health Care Finance and Policy (DHCFP). MassHealth will provide a comprehensive update of Subchapter 6 later in 2006. The revised Subchapter 6, the new MassHealth DME and Oxygen Payment and Coverage Guidelines tool described in detail below, and the instructions detailed in this transmittal letter are effective for dates of service on or after May 1, 2006. New MassHealth DME and Oxygen Payment and Coverage Guidelines Tool MassHealth has posted its new DME and Oxygen Payment and Coverage Guidelines tool to its Web site. The tool will help providers understand the payment requirements and limitations for each DME and oxygen service code covered by MassHealth. The MassHealth DME and Oxygen Payment and Coverage Guidelines tool provides abbreviated descriptions for all DME and oxygen service codes covered by MassHealth, identifies 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 new tool will help providers calculate the payable amount, based on information entered into certain fields on the tool. For service codes for which DHCFP has established a rate, the provider can determine the payment by reviewing the DHCFP regulations at 114.3 CMR 22.00. To get to the new MassHealth DME and Oxygen Payment and Coverage Guidelines tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library, then on MassHealth DME and Oxygen Payment and Coverage Guidelines Tool. The MassHealth DME and Oxygen Payment and Coverage Guidelines tool also contains links to DHCFP regulations, MassHealth Guidelines for Medical Necessity Determination, 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. 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 by sending an e-mail to providersupport@mahealth.net, by faxing to 617-988-8973, or by calling 1-800-841-2900. Revised Fee Schedule DHCFP has issued revised regulations certifying new fees and payment methodologies for the codes listed 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 May 1, 2006. Providers are reminded to submit an invoice with a PA request or with a claim for services, as applicable, for items that are priced on an individual consideration basis. These services are listed as “I.C.” in the DHCFP fee schedule and on the MassHealth DME and Oxygen Payment and Coverage Guidelines tool. 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. DCHFP also has the regulations available on disk. The regulation title for Durable Medical Equipment and Oxygen and Respiratory Therapy Equipment is 114.3 CMR 22.00. 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 Coverage for Products Provided to Members Aged 21 Years and Younger You may request PA for a medically necessary product or service for a member aged 21 years or younger even if the corresponding code is not listed in Subchapter 6 of the Oxygen and Respiratory Therapy Equipment Manual. The request must include documentation as required in 130 CMR 450.144. If MassHealth approves a request for a product or service for which there is no established payment rate, MassHealth will establish the appropriate payment rate on an individual-consideration basis in accordance with 130 CMR 450.271. Billing and PA Requirements * PA for Units in Excess of Specified Maximum For products that are listed on the MassHealth DME and Oxygen Payment and Coverage Guidelines tool with a unit maximum, you may request PA for coverage of additional units even if the product or service does not ordinarily require PA. You must submit the request, along with supporting medical documentation, before the additional units are provided. * Diagnosis Codes MassHealth updates ICD-9-CM codes on a regular basis. Current ICD-9-CM codes are required on all claims. The ICD-9-CM codes entered on the claim must be directly related to the service billed. * Prescription Requirements for Services Provided to Members Residing in Nursing Facilities A prescription from a physician on a prescription pad or physician’s letterhead is no longer required when providing services to MassHealth members residing in nursing facilities. In lieu of this documentation, providers may submit a copy of the order from the member’s medical record along with any treatment plan (for example, oxygen treatment) written by the facility’s staff. * Individual Consideration (I.C.) Providers must submit an invoice for claims for services that are priced on an I.C. basis. Providers must enter the acquisition cost, plus the appropriate markup, in the Usual Fee data element of the claim, and provide a complete description of the service in the Remarks field on claim form no. 9 or in the Notes section of the 837 transaction. You can use the MassHealth DME and Oxygen Payment and Coverage Guidelines tool to calculate the amount to enter in the usual fee data element for codes that are paid on an I.C. basis. * Continuous Positive Airway Pressure Device (CPAP) Effective for dates of service on or after May 1, 2006, MassHealth no longer includes heated and non-heated humidifiers in the cost of a CPAP rental and allows providers to bill separately for the rental of the equipment until the CPAP unit is purchased. Once MassHealth decides to purchase the CPAP unit on behalf of the member, the number of rental months will be subtracted from the NU modifier payment. * E0601 – Continuous Positive Airway Pressure Device (CPAP) * E0561 – Humidifier, non-heated, used with positive airway pressure device * E0562 – Humidifier, heated, used with positive airway pressure device All PA requests must initially contain E0601 and either E0561 or E0562. If the humidifier is not ordered by the physician initially and is subsequently needed, the provider must request an adjustment to the existing PA to add the humidification device, and submit claims accordingly. * Billing for Members with Other Insurance When a member has other insurance, providers must bill MassHealth with the same HCPCS codes that were billed to the primary insurer. MassHealth will deny all claims for services provided to members with other insurance if those claims are billed using Service Code A9270. If a service code is never covered by a primary insurer, but it is covered by MassHealth, an explanation of benefits (EOB) is not required when billing MassHealth. For example, Medicare does not cover diapers. If the member is covered by Medicare, you do not need to bill Medicare first before billing MassHealth. If a service code is covered by Medicare, but not in the place of service in which the service was provided, you must obtain a letter from CMS that indicates that the specific code is not covered by Medicare in the specific setting. For example, oxygen is a service that Medicare covers for a member in the community, but not for a member in a nursing facility. If the member is covered by Medicare, the provider must obtain a letter from CMS on at least an annual basis to submit in support of each claim. * Medical Necessity Documentation Medical necessity determinations are based on specific clinical information and documentation that supports appropriate medical use of the services being requested. This is a reminder that providers must include all documentation of medical necessity as required in 130 CMR 427.000 when submitting requests for PA to MassHealth or its designee(s). * Case Management for Complex-Care Members MassHealth members, primarily those under the age of 22 years, who require a nurse encounter of more than two continuous hours per visit, are enrolled in Community Case Management (CCM), a program administered for MassHealth by the University of Massachusetts Medical School. Each CCM enrollee is assigned a nurse case manager who performs a comprehensive needs assessment and authorizes all medically necessary home health and other community services, including oxygen and respiratory therapy equipment. The Recipient Eligibility Verification System (REVS) identifies members enrolled in CCM. Providers must mail PA requests for oxygen and respiratory therapy equipment for members identified as CCM members in REVS to: Community Case Management P.O. Box 2586 100 Century Drive Worcester, MA 01613-2586 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 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.) Oxygen and Respiratory Therapy Equipment Manual Pages vi, vii, 6-1, and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Oxygen and Respiratory Therapy Equipment Manual Page vi — transmitted by Transmittal Letter OXY-25 Pages vii and vii-a — transmitted by Transmittal Letter OXY-1 Pages 6-1 through 6-8 — transmitted by Transmittal Letter OXY-26 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page Vi Oxygen and Respiratory Therapy Equipment Manual Transmittal Letter OXY-27 Date 05/01/06 6. Service Codes 601 Introduction 6-1 602 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 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 MassHealth Provider Manual Series Subchapter Number and Title Preface Page vii Oxygen and Respiratory Therapy Equipment Manual Transmittal Letter OXY-27 Date 05/01/06 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, 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. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. 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 oxygen and respiratory therapy equipment, those matters are covered in 130 CMR Chapter 427.000, reproduced as Subchapter 4 in the Oxygen and Respiratory Therapy Equipment Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("penandink" revisions), and by 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6 Service Codes Page 6-1 Oxygen and Respiratory Therapy Equipment Manual Transmittal Letter OXY-27 Date 05/01/06 601 Introduction MassHealth pays for the services for codes listed in section 602 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 427.000 and 450.000. In addition, a provider may request prior authorization (PA) for any medically necessary respiratory therapy equipment or service. Providers should refer to the MassHealth DME and Oxygen 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 22.00. The MassHealth DME and Oxygen Payment and Coverage Guidelines tool also contains links to DHCFP regulations, MassHealth Guidelines for Medical Necessity Determination, 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 DME and Oxygen Payment and Coverage Guidelines tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library, then on MassHealth DME and Oxygen Payment and Coverage Guidelines Tool. 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 provider manual for applicable contact information. 602 Service Codes A4216 A4217 A4481 A4483 A4556 A4557 A4558 A4605 A4606 A4608 A4610 A4611 A4612 A4613 A4614 A4619 A4623 A4624 A4625 A4626 A4627 A4628 A4629 A7000 A7001 A7002 A7003 A7004 A7005 A7006 A7010 A7011 A7012 A7013 A7014 A7015 A7017 A7018 A7025 A7026 A7030 A7031 A7032 A7033 A7034 A7035 A7036 A7037 A7038 A7039 A7044 A7045 A7046 A7501 A7502 A7503 A7504 A7505 A7506 A7507 A7508 A7509 A7520 A7521 A7522 A7524 A7525 A7526 A7527 E0424 E0431 E0434 E0439 E0445 E0450 E0457 E0459 E0460 E0461 E0463 E0464 E0470 E0471 E0480 E0482 E0483 E0484 E0500 E0550 E0560 E0561 E0562 E0565 E0570 E0572 E0585 E0600 E0601 E0605 E0606 E0619 E1340 E1372 E1390 E1399 L8501 S8100 S8101 S8180 S8181 S8185 S8186 S8190 S8210 S8999 This page is reserved.