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 PCA-13
October 2002
TO:      Personal Care Agencies and Personal Care Agencies’ Fiscal Intermediaries Participating in MassHealth
FROM:      Wendy E. Warring, Commissioner
RE:      Personal Care Manual (Revisions to Regulations and Service Codes and Descriptions; Revised Forms)

I.	Introduction
This letter transmits the following revisions to the Personal Care Manual:
•	PCA program regulations (Subchapter 4 of the Personal Care Manual), including changes in provider eligibility and implementation of personal care management (PCM) contracts;
•	PCA service codes and descriptions (Subchapter 6 of the Personal Care Manual);
•	the Application for Personal Care Attendant (PCA) Services form; and
•	the Evaluation for Personal Care Attendant (PCA) Services form.
The revisions to PCA service codes and descriptions (Subchapter 6) relate to new, national standard codes and descriptions for some of the services provided under the MassHealth PCA program, which have been issued by the Centers for Medicare and Medicaid Services (CMS). The Subchapter 6 revisions are further described below.
Also included in this letter are a crosswalk table describing changes from Local “X” codes to the new codes; instructions on how to request prior authorization using the new codes; and an example of a prior authorization request using the new service codes. Revisions to the billing instructions (Subchapter 5 of the Personal Care Manual) will be sent to providers under separate cover.
II.	Effective Dates of Revisions
The revisions to the MassHealth program regulations and forms are effective October 28, 2002. The effective dates for requesting prior authorization using the new MassHealth service codes and descriptions are described later in this letter. The effective dates for other service code changes are described in the attached crosswalk.

MASSHEALTH
TRANSMITTAL LETTER PCA-13 October 2002 Page 2
III.	Amendments to Division of Health Care Finance and Policy (DHCFP) Rate Regulation
In addition to MassHealth regulatory revisions, the Division of Health Care Finance and Policy (DHCFP) has adopted amendments to the rate regulation for the PCA program, effective for dates of service beginning October 6, 2002. These amendments include an increase in the PCA wage component of the PCA rate and the establishment of rates for the new codes assigned by the Centers for Medicare and Medicaid Services (CMS) in accordance with the Health Insurance Portability and Accountability Act (HIPAA). If you wish to obtain a fee schedule, you may purchase DHCFP regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses, telephone numbers, and URLs below). You must contact them first to find out the price of the publication. These regulations are also available on disk from DHCFP or you may visit its Web site. The DHCFP regulation title for the personal care attendant program is 114.3 CMR 9.00: Independent Living Services for the Personal Care Attendant Program.
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
IV.	New Personal Care Management Contracts
Effective October 11, 2002, the Division will begin to contract with qualified personal care management (PCM) agencies to provide PCM services in accordance with 130 CMR 422.419(A) and the PCM contract. Changes to the program regulations (130 CMR 422.000) reflect the new PCM contract provisions and requirements, and also include revisions intended to improve accessibility and accountability in the PCA program.

MASSHEALTH
TRANSMITTAL LETTER PCA-13 October 2002 Page 3
V. Changes to the MassHealth PCA Program Regulations
PCM providers and fiscal intermediaries are responsible for complying with the PCA program regulations. Significant changes include, but are not limited to, the following:
•	eligibility criteria for receiving PCA services. (See 130 CMR 422.403(C).)
•	definition of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). (See 130 CMR 422.410.)
•	member utilization of PCA services. (See 130 CMR 422.416(E).)
•	allowing nurse practitioner or physician signoff on evaluations and reevaluations. (See 130 CMR 422.422(C).)
•	allowing verbal authorization from the member’s physician or nurse practitioner when submitting requests for prior authorization, providing all other conditions are met. (See 130 CMR 422.416(A).)
•	definition of “assessment” changed to specify assessment of a member’s ability to manage the PCA program independently. (See 130 CMR 422.402 and 130 CMR 422.422(A).)
•	member and agency responsibilities related to surrogates. (See 130 CMR 422.422(B).)
•	introduction of new service: “Intake and Orientation.” (See 130 CMR 422.421 (A).)
•	billing requirements for intake and orientation and skills training. (See 130 CMR 422.421(C).)
•	service agreement requirements (previously called “Personal Care Services Plan.” (See 130 CMR 422.423.)
•	provider notification to the Division when initial PCA services are being requested for a member who resides in a nursing home or other inpatient facility. The Division may, at its discretion, conduct the initial PCA evaluation and authorize PCA services, or coordinate other MassHealth services, as appropriate, for those members who are at imminent discharge from these facilities. (See 130 CMR 422.416(D)(2).) Until further notice, providers should contact the PCA program manager with this information, at 617-210-5329.
•	noncovered services. (See 130 CMR 422.412.)
•	member responsibilities. (See 130 CMR 422.420.)
•	
MASSHEALTH
TRANSMITTAL LETTER PCA-13 October 2002 Page 4
VI.	PCA Service Codes and Descriptions
As stated above, CMS has issued new, national standard codes and descriptions for some of the services provided under the MassHealth PCA program. These and other service code changes and requirements are described in Subchapter 6 and in the enclosed crosswalk table. In the future, CMS will assign additional codes to replace all remaining local (“X”) codes for services covered under the PCA program. The Division will inform providers of these changes as they develop. CMS expects all local (“X”) codes to be eliminated by no later than dates of service of October 16, 2003. The Division has therefore stopped issuing PAs with local “X” codes for more than one year’s duration.
NOTE: A new code for X9791 (functional skills training) has not yet been assigned by CMS. However, effective November 1, 2002, providers must bill MassHealth with Service Code X9791 only for those members for whom the PCM agency has obtained a prior authorization for PCA services (with the exception of consumer transfers, as noted in 130 CMR 422.421(C)(2).) The PCC requirement for Service Code X9791 will be lifted, beginning with dates of service of November 1, 2002 or later. The rate for Service Code X9791 continues to be paid on a single per-member, per-month basis. The Division has assigned a new local code, X9790 (intake and orientation services), for those members who have been referred to the provider for PCA services but do not yet have a PA. This code also takes effect on November 1, 2002. (See crosswalk for further description.) Please note that the PCC requirement for initial evaluations (99456 as of 10/6/02) and reevaluations (X9786) remains in place, and that there is a PCC requirement when billing for intake and orientation services (X9790).
Also, beginning October 6, 2002, and in accordance with the DHCFP regulations, the rate for Service Code X9806 (premium pay for overtime) changes to a 15-minute unit. Prior-authorization requests for overtime will be authorized in 15-minute units beginning with dates of service of October 6, 2002, and later. Prior-authorization requests and fiscal intermediary billing must therefore reflect this change.
VII.	Requests for Prior Authorization Using New Codes
Many of the new codes assigned by CMS are for codes that require prior authorization. To avoid issuing new prior authorizations to all members in the PCA program at one time due to coding changes, the Division will implement a transition period to facilitate the change from the existing set of local “X” codes that require prior authorization to the new HIPAA set of codes that require prior authorization. Until further notice from the Division, fiscal intermediaries must continue to bill for existing PAs (that is, PAs issued with “X” codes) using the local (“X”) codes and corresponding units (1 unit = 1 hour).

MASSHEALTH
TRANSMITTAL LETTER PCA-13 October 2002 Page 5
However, all prior-authorization requests (for initial evaluations or reevaluations) with a “date sent” (Box 16 on the MassHealth Prior Authorization Request Form) of October 28, 2002, or later must be submitted by PCM agencies using the new services codes T1019 (personal care services) and 99054 (services provided on a holiday). These codes are described in Subchapter 6 and in the enclosed crosswalk table. Prior authorizations issued by the Division with the new service codes must be billed by the fiscal intermediary using the new codes and corresponding units (1 unit = 15 minutes; see below).
CMS has designated that units of service for Service Codes T1019 (personal care services) and 99054 (services provided on a holiday) must be billed in 15-minute increments. Accordingly, the number of units requested on a prior-authorization request with a date sent (Box 16 on the Prior Authorization Request form) of October 28, 2002, or later, and subsequently billed by the fiscal intermediary, must reflect this change.
VIII. Calculating Units When Requesting Prior Authorization
As stated above, CMS has designated that units of service for personal care services must be billed in 15-minute increments. Prior-authorization requests must therefore reflect this change. (An example of a prior-authorization request using the new codes is enclosed.)
PCA agencies must continue to use the Division’s standard MassHealth Application for PCA Services and the MassHealth Evaluation for PCA Services when evaluating the member’s need for PCA services and when requesting prior authorization. (Copies of these forms are attached.) MassHealth will continue to authorize PCA services based on “time for task” (that is, the number of hours per week or per night that a member requires physical assistance with ADLs or IADLs). Providers must round up activity time to the nearest 15-minute unit when calculating prior-authorization requests for PCA day/evening services (6:00 A.M. to midnight) using the new service codes. Calculation for activity time during the night (midnight to 6:00 A.M.) will not change and will continue to be rounded up to two billable hours when the request is for 120 minutes or less per night, and rounded up to the nearest billable hour for requests for activity time over 120 minutes. The following are examples of how to calculate units when requesting prior authorization for a one-year period using the new service codes:
>   Example 1 (where total day/evening activity time on the MassHealth standard evaluation form = 1746 minutes per week):
■	1746/60 minutes = 29.10 hours
■	round up 29.10 hours to the next 15-minute unit = 29.25 hours/week requested
■	29.25 x 4 (to derive the number of 15-minute units) = 117 15-minute units per week
■	117 units x 52.14 (weeks in a 365-day calendar year) = 6100.38 units/year
■	round up to next whole unit = 6101 units/year
■	request for Service Code T1019 (day only) (for a request of 29.25 hours/week of PCA) = 6101 units for a one-year period.
■	
MASSHEALTH
TRANSMITTAL LETTER PCA-13 October 2002 Page 6
Example 2 (where total day/evening activity time on the evaluation is the same as in Example 1, plus 54 minutes per night (midnight to 6:00 A.M.)):
■	round up 54 minutes per night to a minimum of two billable hours/night (round up to next hour for activity time over two hours):
■	2 hours/night x 4 (to derive the number of 15-minute units) = 8 15-minute units per night
■	8 units x 365 (days per year) = 2920 units/year for night services
■	2920 night units plus 6101 day units (from above example) = 9021 units for day and night services for one year
■	T1019 = 9021 units for a request for 29.25 day hours/week plus two hours/night for a one-year period.
>   Example 3 (requesting premium pay for holiday (Christmas day, New Year’s Day, July 4, and Thanksgiving) for a member requesting 29.25 day hours per week (from Example 1)):
■	total the number of hours per week being requested, and divide by seven: 29.25 hours per week/7 (days per week) = 4.18 hours per day
■	4.18 x 4 (holidays) = 16.72 hours
■	round up to nearest 15-minute unit = 16.75 hours
■	16.75 x 4 (to derive the number of 15-minute units) = 67 units
■	do not deduct holiday units from day units, as the holiday rate is a “premium” rate and will therefore not impact the number of day units being requested
■	request for 99054 = 67 units.
Important note:
■    Although Service Code T1019 combines the overall day and night PCA units for billing purposes, the Division will continue to provide written notification to members that specifies the number of PCA day hours per week (6:00 A.M. to midnight) and the number of PCA hours per night (midnight to 6:00 A.M.) that the Division determines to be medically necessary. Members must continue to submit activity forms indicating the number of day hours and night hours that the PCA worked, as they have done previously, and use their PCA hours in accordance with the authorized activity time specified on the evaluation, and in accordance with the number of PCA day hours per week and PCA night hours per night that are authorized by the Division as medically necessary.   Please refer to 130 CMR 422.416(E) about member utilization.

MASSHEALTH
TRANSMITTAL LETTER PCA-13 October 2002 Page 7
■	For prior authorizations using the new codes, fiscal intermediaries must round up activity time on the activity form for day/evening PCA services to the nearest 15-minute unit when calculating activity time for payroll purposes. For example, a PCA works 30.10 hours one week and 25.25. hours the next week. Total activity time = 55.35. Round up to 55.50. PCA is paid for 55.50 hours. DMA is billed 222 units.
■	For activity time performed by the PCA during the night, fiscal intermediaries must round up activity time to two hours per night (eight units) when the PCA works 120 minutes or less in one night, and to the next hour if greater than 120 minutes. For example, a PCA works 45 minutes each night for five nights. 45 minutes is rounded to two “billable hours” each night; 5 X 2 = 10 hours; 10 x4 = 40 units billed. PCA is paid 10 hours; DMA is billed 40 units. In no case may the number of units paid to the PCA exceed the number of authorized units per night.
IX.	Revised MassHealth PCA Application and PCA Evaluation Forms
The Division has revised the MassHealth PCA Application and PCA evaluation forms to reflect changes in program regulations and the PCM contract. PCM agencies must use these forms when evaluating a member’s need for PCA services, and must submit the completed forms to the Division when requesting prior authorization for PCA services.
A copy of each of these forms is enclosed; PCM agencies can also access these forms at the Division’s Web site, found at www.mass.gov/dma/providers/prov IDX.htm, or by mailing or faxing a written request to the following address or fax number.
Unisys
Attention: Forms Distribution P.O. Box 9101 Somerville, MA 02145 Fax: (617) 576-4087
X.	Updates to MassHealth PCA Consumer Handbook
The Division plans to update the consumer handbook to reflect changes in the regulations that affect members. The Division will forward copies of the updated handbook to the fiscal intermediaries when the revisions are complete.
The Division’s current PCA Consumer handbook should no longer be distributed after October 28, 2002.

MASSHEALTH
TRANSMITTAL LETTER PCA-13 October 2002 Page 8
XI. Provider Training
The Division, in conjunction with Unisys, will conduct training for providers related to billing instructions, service code changes, regulation changes, and contracts in the near future.
In the interim, if you have any questions related to billing, service codes, or claims submissions, you 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.)
Personal Care Manual
Pages iv, 4-1 through 4-38, 6-1, and 6-2
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Personal Care Manual
Pages iv, 4-1, 4-2, and 4-7 through 4-16 — transmitted by Transmittal Letter PCA-11
Pages 4-3, 4-4, 4-17 through 4-24, 6-1, and 6-2 — transmitted by Transmittal Letter PCA-8
Pages 4-5 and 4-6 — transmitted by Transmittal Letter PCA-12

Example of Approved Prior Authorization Request for PCA Services

PRIOR AUTHORIZATION REQUEST
MassHealth
The Division reviews requests for prior outnoriaition on the basis of medical necessity only. If the Division approves the retjrest,
EiecuBve Office of Health
and Human Services
C^ision or Medical Assignee
payment is still subject to all general conditions of MassHealth, including current member eligibility, other insurance, and program
restrictions. The Division will notify the provider and memher of its decision.
Complete Items 1 -17 only. See Subchorjter 5 of your provider monuol for detailed instructions on completing this form.
PROVIDER INFORMATION SECTION	MEMBER INFORMATION SECTION
5. PLACE OF RESIDENCE
I  I'Hyvim ■■!:, \,v.!i fl\ii:./.in>Hi ss
4. MEMBER S NAME AND ADDRESS

ABC Agenc
123 Main Street
Anytown, MA 02199

James Sawyer
10 Pleasant Street
Anytown, MA 02199

X n°me
| Nuising facility | | Rehab, facility |   | Olher

2. PROVDEFTS TELEPHONE NO.

7. OTHER INSURANCE   S. NAME OF INSURANCE CARRIER

| 61 1 17 )| 5 15   15 -I1 I 213 14

XU QF     I  I Yes  [X No

3. PROVIDER NO.

S. DATE OF BIRTH

10. RECIPIENT ID NO.

0|1|2|3|4|5|6

0 I 2 I 1 I  21 5    3     2   2    2   2    2 I 2 I 2 12  12  I 2

11. EXPLAIN WHY THIS SERVICE IS MEOICALLY NECESSARY. INCLUDE THE DIAGNOSIS AND A DESCRIPTION Of THE PROPOSED TREATMENT. ATTACH SUPPORTING DOCUMENTATION IF REQUIRED BY DIVISION REGULATIONS.
Requesting 44 hours per week of personal care day/evening services, and' 2 hours per night of personal care night services (midnight to 6 A.M.)

SERVICES REQUESTED

DIVISION USE ONLY

12.SERVICECGDE                                                13. NO-OF     14.PURATK5N 16-REVIEWER'S 19- REVVED SERVICE COOE
(USE A SEPARATE LINE FOR EACH CODE)          UNITS                (DAYS)               DECfSCN                {OR RANGE)	20. NO. OF
UNITS	21.miE.LJMn
(days)	22. UNIT FEE                 23. DENIAL
REASON NO.	
A	T1019	12097	365	X_APPROVEO
MODIFIED □ DENIEO	T1019	12097	365		6000	
B	99054	101	4	X AppB0VEB
□	MODIFIED
□	DENIEO	99054	101	4			
C				7 APPROVED
MOO FIED _ DENIEO						
D				APPROVED
Zmootied
;   ; DENIED						
E			'_ APPROVED ;' IMCOFED □ DENIEO						
15. PROVIDER'S SIGNATURE                                                                                                            24. DATE OF RECEIPT                                 25. EXPIRATION DATE                                26. DATE OUT	
Paula Doe		1   1   1  1 [2 10   12	1    1   1    9    0   3	1         1        2        0      0   12	
16	. DATE PA REQUESTED                     17. ATTACt	MENTS			57. a	dnsultant'sono.	2R.CONS	LILTANfs INn	1ALS		29. DATE OF DECISION		

111     1     0     0   2    XI Yes U No

0

6

3

BMC

1   1    1    9 10   12

30- COMMENTS OR REASONS FOR DENIAL h MODIFICATION, OR DEFERRAL

31, DATE OUT - CLERICAL

32. DATE RETURNED

6000 - Approved for 44 hours per week of personal care day/' evening services and 2 hours per night of personal care night services, 11/20/02 through 11/19/03.

33. DATE OUT - CONSULTANT

35. PRIOR AUTHORIZATION NO.

SA. DATE RETURNED

36.PA TYPE

1      2

3       4

5

6

0    1

For personol emergency iKponse systems, see Appendix D of the Durable Medkallquipmenl Manual \m moiling instructions. For Mossachusetts Commission fnilhe Blind clienls, see ippeniiixiolyouipioviiiermnnunlfoimnilinoinsliiictions.

Mail completed form with attachments to:
Division of Medical Assistance, Attention: Prior Authorization Unit 600 Washington Street, Boston, MA02111.
PA-1 (Rev. 10/01)