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-14 November 2003
TO:      Personal Care Providers Participating in MassHealth
FROM:      Beth Waldman, Acting Commissioner!
RE:      Personal Care Manual (Changes to Service Codes and Service Descriptions)
This letter transmits revisions to the service codes and descriptions in the Personal Care Manual. These revisions are effective for dates of service on or after December 1, 2003.
The Centers for Medicare and Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS). New national service codes have been added, and all MassHealth local codes have been removed from the Personal Care Manual. Please note that you must use a modifier with some codes to accurately reflect the service provided. The attached Subchapter 6 contains codes with modifiers, where applicable.
Billing Guidelines
In addition to the revised Subchapter 6, you will find a table that crosswalks the obsolete MassHealth local service codes to the new national service codes and modifiers. The crosswalk provides a description of the old and new service codes as well as the new modifiers. Please note that providers must use these new codes and modifiers when billing MassHealth for personal care management services, fiscal intermediary services, or transitional living services provided on or after December 1, 2003.
Some of the new code descriptions are different than the previous local code descriptions, but the service itself has not changed. For example, the CMS code T2022 with the description “case management, per month” is used to bill for functional skills training. Please consult Subchapter 6 to determine which code to bill for services provided.
Modifiers
Please refer to the attached Subchapter 6 and crosswalk for instructions on when and how to use modifiers. Failure to use the appropriate modifier as required for a given service will result in a denied claim, or inappropriate payment for the claim. The attached crosswalk explains which modifiers must be used with each service code, and describes the function of the modifier.

MASSHEALTH
TRANSMITTAL LETTER PCA–14 November 2003 Page 2
Prior Authorization
Please refer to Subchapter 6 to determine which codes require prior authorization from the Division. Providers must continue to use the codes T1019 (personal care services) and 99054 (holiday) when submitting prior authorization requests for personal care services. Providers must use the new codes and modifiers for overtime (T1019-TU) and transitional living (T1020-U1) when requesting prior authorization for dates of service on or after December 1, 2003. Please note that service code X9798 (transitional living medical-absence day (P.A.)) has been deleted and a new code has not been issued at this time.
Fiscal Intermediary Administrative Charge
Effective for dates of service on or after December 1, 2003, the fiscal intermediary administrative charge has been changed from a per-member per-month rate to a per diem rate to reflect the unit of measurement under the new code, T1020 (personal care services, per diem). The new rate for T1020 is $1.72 per member per diem. Fiscal intermediaries should consult Section 4.1(A)(2) of the Fiscal Intermediary contract (amended July 1, 2003) for instructions on billing the per diem rate.
Fee Schedule for New Service Codes
If you wish to obtain a fee schedule with the new service codes, you may purchase Division of Health Care Finance and Policy (DHCFP) regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses and phone numbers below), or you can obtain the regulations from the DHCFP website at www.mass.gov/dhcfp. The regulation title is 114.3 CMR 9.00 Independent Living Services for the Personal Care Attendant Program.
Massachusetts State Bookstore       Division of Health Care
State House, Room 116	Finance and Policy
Boston, MA 02133	Two Boylston Street
Telephone: 617-727-2834	Boston, MA 02116
Error! Hyperlink reference not valid.	Telephone: 617-988-3100
www.mass.gov/dhcfp
Questions
If you have any questions about this information please 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 6-1 and 6-2
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Personal Care Manual
Pages 6-1 and 6-2 — transmitted by Transmittal Letter PCA-13

Transmittal Letter PCA-14
November 2003
Attachment
PCA Service Code Crosswalk
Effective December 1, 2003

Obsolete Code	Obsolete Service Description	New Code	Modifier	New Service Description	Modifier Required?	Use the modifier to:	Guidelines	
Personal Care Agency Services	
X9786	Reevaluation of a member to determine the continuing need and extent of the need for PCA services (per reevaluation)	99456	TS	Work related or medical disability examination by other than the treating physician that includes:
•	completion of a medical history
commensurate with the patient's
condition;
•	performance of an examination
commensurate with the patient's
condition;
•	formulation of a diagnosis,
assessment of capabilities and
stability, and calculation of
impairment;
•	development of future medical
treatment plan; and
•	completion of necessary
documentation/certificates and
report.	Yes	denote follow-up service .	Use this code and modifier when billing for re-evaluation of a member to determine the need and extent of the need for personal care services, per evaluation.	
X9790	Intake and orientation services – per member, per month	T1023		Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol, per encounter	No		One encounter=a single per member per month charge. Use this code to bill for intake and orientation services provided to a member who does not yet have a PA for PCA services, maximum 3 consecutive months.	
X9791	Functional skills training – per member, per month (current P.A. for PCA services required for each member)	T2022		Case management, per month	No		Current P.A. for PCA services required for each member;, use this code to bill for functional skills training, per member per month	
Fiscal Intermediary Services	
X9806	Premium pay for overtime (P.A.) 1 unit = 15 minutes (NOTE: bill in 15-minute units for dates of service on or after October 6, 2002)	T1019	TU	Personal care services (P.A.), per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)	Yes	denote special payment rate, overtime	Use this code and modifier to bill for premium pay for overtime, requires prior authorization	
X9807	Fiscal intermediary administrative charge -per member, per month (current P.A. required for each member)	T1020		Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)	No		Use to bill for fiscal intermediary administrative charge; 1 unit per diem; current P.A. for PCA services required for each member.	
Transitional Living Services	
X9794	Transitional living service (P.A.)	T1020	U1	Personal care services, Personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)	Yes	denote that this is a transitional living service (Medicaid level of care 1)	Use this code and modifier to bill for transitional living services, requires prior authorization.	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PERSONAL CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-1	

	TRANSMITTAL LETTER
PCA-14	DATE
12/01/03	
601 Service Codes and Descriptions
Service
Code     Modifier Service Description
Personal Care Management (PCM) Services
99456	Work related or medical disability examination by other than the treating physician that
includes:
•	completion of a medical history commensurate with the patient’s condition;
•	performance of an examination commensurate with the patient’s condition;
•	formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment;
•	development of future medical treatment plan; and
•	completion of necessary documentation/certificates and report. (use this code when billing for initial evaluation of a member to determine the need and extent of the need for personal care services) (per evaluation)
99456    TS	Work related or medical disability examination by other than the treating physician that
includes:
•	completion of a medical history commensurate with the patient’s condition;
•	performance of an examination commensurate with the patient’s condition;
•	formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment;
•	development of future medical treatment plan; and
•	completion of necessary documentation/certificates and report. (follow-up service) (use this code and modifier when billing for reevaluation of a member to determine the need and extent of the need for personal care services.) (per evaluation)
T2022	Case management, per month (current P.A. for PCA services required for each member)
(Use this code to bill for functional skills training.) (per member per month)
T1023	Screening to determine the appropriateness of consideration of an individual for
participation in a specified program, project, or treatment protocol, per encounter (Use this code to bill a single per member per month charge for intake and orientation services provided to a member who does not yet have a PA for PCA services.) (maximum 3 consecutive months)
Fiscal Intermediary (FI) Services
T1019	Personal care services per 15 minutes, not for an inpatient or resident of a hospital,
nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) (P.A.), (Use this code to bill for PCA services provided during day or night.)
T1019   TU	Personal care services, per 15 minutes, not for an inpatient or resident of a hospital,
nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) special payment rate, overtime (P.A.) (Use this code and modifier to bill for premium pay for overtime.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PERSONAL CARE MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-2	

	TRANSMITTAL LETTER
PCA-14	DATE
12/01/03	
601 Personal Care: Service Codes (cont)
Service
Code     Modifier Service Description
99054	Services requested on Sundays and holidays in addition to basic service (P.A.) (premium
rate only, applies only to holidays) (per 15 minutes)
T1020	Personal care services, per diem, not for an inpatient or resident of a hospital, nursing
facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) (Use to bill for fiscal intermediary administrative charge; 1 unit per diem.) (current P.A. for PCA services required for each member)
Transitional Living Services
T1020   U1	Personal care services, per diem, not for an inpatient or resident of a hospital, nursing
facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) (Medicaid level of care 1) (P.A.) (Use this code and modifier to bill for transitional living services.)
This publication contains codes that are copyrighted by the American Medical Association.