Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter OXY-30 June 2011 TO: Oxygen and Respiratory Therapy Providers Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Oxygen and Respiratory Therapy Equipment Manual (2011 HCPCS) This letter transmits revisions to the service codes described in Subchapter 6 of the Oxygen and Respiratory Therapy Equipment Manual to comply with federal coding mandates, to incorporate coding and rate changes previously described in informational bulletins issued by the Division of Health Care Finance and Policy (DHCFP), and to remind providers of certain existing oxygen and respiratory therapy equipment policies and requirements. Providers may consult the Centers for Medicare & Medicaid Services (CMS) Web site at www.cms.gov for a full description of the service codes. Prior- authorizations (PA) requirements, service limits, and place-of-service codes now appear in an updated version of the interactive MassHealth DME and Oxygen Payment and Coverage Guidelines Tool that has been posted on the MassHealth Web site. New Oxygen and Respiratory Therapy Equipment Service Code Additions and Deletions Effective for Dates of Service on or After January 1, 2011 The additions and deletions to the MassHealth service codes included in this section are effective for dates of service on or after January 1, 2011. Claims for dates of service on or after January 1, 2011, submitted with deleted codes identified in this section will be denied. Claims denied for deleted codes should be resubmitted with appropriate new codes. The following codes have been added to Subchapter 6 of the Oxygen and Respiratory Therapy Equipment Manual, and the MassHealth DME and Oxygen Payment and Coverage Guidelines Tool. A7020 E0487 The following code has been deleted from Subchapter 6 of the Oxygen and Respiratory Therapy Equipment Manual and the MassHealth DME and Oxygen Payment and Coverage Guidelines Tool. S8185 MassHealth Transmittal Letter OXY-30 June 2011 Page 2 Other Changes to Service Codes in Subchapter 6 The following service codes were inadvertently listed in Subchapter 6 of the Oxygen and Respiratory Therapy Equipment Manual. These service codes have been deleted from Subchapter 6 of the Oxygen and Respiratory Therapy Equipment Manual and have been added to Subchapter 6 of the Durable Medical Equipment Manual. A4558 E0605 E0606 The following oxygen and respiratory therapy equipment service codes were inadvertently listed in Subchapter 6 of the Durable Medical Equipment Manual. These service codes have been deleted from Subchapter 6 of the Durable Medical Equipment Manual, and have been added to Subchapter 6 of the Oxygen and Respiratory Therapy Equipment Manual. A4216 A4557 A4614 A4626 A7000 K0730 A4481 A4605 A4623 A4627 A7001 K0738 A4483 A4606 A4624 A4628 A7002 S8186 A4556 A4608 A4625 A4629 E0619 Diagnosis Codes ICD-9-CM diagnosis codes are required on all claims. The ICD-9-CM codes must be directly related to the service billed on the claim. Prior Authorization Requests for Units in Excess of the Maximum Allowable Units MassHealth requires prior authorization (PA) for any oxygen and respiratory therapy equipment service codes if the number of units requested exceeds the maximum allowable units specified in the MassHealth DME and Oxygen Payment and Coverage Guidelines Tool. * When requesting PA to exceed the maximum allowable units, the provider must submit to MassHealth, in addition to any PA request that is required for units up to the maximum allowable, a separate PA request for the number of units being requested that exceed the maximum allowed. The provider must include medical documentation that supports the medical necessity of the additional units, including requirements under 130 CMR 427.408; and * If the PA request for units in excess of the maximum is authorized by MassHealth, the provider must submit a separate claim with separate dates of service for the excess units that were provided, corresponding to the separate PA that was approved by MassHealth. Provider Eligibility An oxygen and respiratory therapy equipment provider located in Massachusetts must employ a minimum of one respiratory care practitioner with a current Massachusetts license in accordance with 130 CMR 427.404(B)(2) on a full-time or part-time basis. Oxygen and respiratory therapy equipment providers must have a Medicare provider number and must comply with Medicare requirements, including being open to the public a minimum of 30 hours per week. MassHealth Transmittal Letter OXY-30 June 2011 Page 3 An oxygen and respiratory therapy equipment provider that furnishes services to MassHealth members in Massachusetts must have a servicing facility in Massachusetts, in accordance with 130 CMR 427.404(B)3). MassHealth Web Site This transmittal letter is available on the MassHealth Web site at www.mass.gov/masshealth. Questions If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) 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 Pages vi, 6-1, and 6-2 — transmitted by Transmittal Letter OXY-29 Page vii — transmitted by Transmittal Letter OXY-27 Commonwealth of Massachusetts MassHealth Provider Manual Series Oxygen and Respiratory Therapy Equipment Manual Subchapter Number and Title Table of Contents Transmittal Letter OXY-30 Page vi Date 01/01/11 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 and Dental Protocols and Periodicity Schedules W-1 Appendix X. Family Assistance Copayments and Deductibles X-1 Appendix Y. EVS Codes/Messages Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Oxygen and Respiratory Therapy Equipment Manual Subchapter Number and Title Preface Transmittal Letter OXY-30 Page vii Date 01/01/11 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. 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 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 Oxygen and Respiratory Therapy Equipment Manual Subchapter Number and Title 6. Service Codes Transmittal Letter OXY-30 Page 6-1 Date 01/01/11 601 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 This section lists Level II HCPCS codes that are payable under MassHealth. Refer to the Centers for Medicare & Medicaid Services Web site at www.cms.gov/mcdicare/hcpcs for more detailed descriptions when billing for Level II HCPCS codes provided to MassHealth members. A4216 A4217 A4481 A4483 A4556 A4557 A4605 A4606 A4608 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 A7020 A7025 A7026 A7027 A7028 A7029 A7030 A7031 A7032 A7033 A7034 A7035 A7036 A7037 A7038 A7039 A7044 A7045 A7046 A7200 A7501 A7502 A7503 A7504 A7505 A7506 A7507 A7508 A7509 A7520 A7521 A7522 A7523 A7524 A7525 A7526 A7527 E0424 E0431 E0434 E0439 E0445 E0450 E0457 E0459 E0460 E0461 E0463 E0464 E0470 E0471 E0480 E0482 E0483 E0484 E0487 E0500 E0550 E0560 E0561 E0562 E0565 E0570 E0572 E0585 E0600 E0601 E0619 E1372 E1390 K0730 K0738 L8501 S8186 S8210 S8999 Commonwealth of Massachusetts MassHealth Provider Manual Series Oxygen and Respiratory Therapy Equipment Manual Subchapter Number and Title 6. Service Codes Transmittal Letter OXY-30 Page 6-2 Date 01/01/11 This page is reserved.