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 PHY-120 December 2007 TO: Physicians Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Physician Manual (New Behavioral Health Screening Fee and 2008 HCPCS Coding Update) This letter transmits a revised Subchapter 6 (Service Codes) for the Physician Manual. The revised Subchapter 6 incorporates the new behavioral health screening fee and reflects the 2008 revisions to the Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedure Coding System (HCPCS). Please read below for a more detailed description of the new codes, including the new tobacco-cessation counseling codes. In addition, MassHealth has updated prior-authorization requirements for certain services. Behavioral Health Screening Effective for dates of service on or after December 31, 2007, all primary-care providers serving MassHealth-enrolled members under the age of 21 (except MassHealth Limited) must offer to use a standardized behavioral health screening tool when performing the behavioral health screening component of an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) or Pediatric Preventive Health-care Screening and Diagnosis (PPHSD) visit according to Appendix W of your MassHealth provider manual. Appendix W contains a menu of screening tools from which to choose. MassHealth will pay for the administration and scoring of the standardized behavioral health screening tool in addition to, and separately from, the office visit. MassHealth provided detailed information about the new requirements surrounding the standardized behavioral health screening tool in Transmittal Letter ALL-155, which communicated updates to the EPSDT/PPHSD regulations (130 CMR 450.140 through 450.150), Appendix W, and Appendix Z. To implement this new requirement, Subchapter 6 of the Physician Manual has been revised as follows. • Service Code 96110 has been removed from Section 602: Nonpayable CPT Codes, and has been added to Section 603: Codes That Have Special Requirements or Limitations. Its use is limited to the administration and scoring of a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual when delivered to members under the age of 21 as part of the EPSDT/PPHSD visit. Service Code 96110 must be billed with distinct modifiers that are provider-specific and that indicate whether the administration of the screen identified a behavioral health need or not. • The modifiers that must be billed with Service Code 96110 have been added to the list of modifiers in Section 605: Modifiers in a section entitled Behavioral Health Modifiers. Effective July 1, 2008, failure to include one of these modifiers will result in denial of the claim. For your convenience, the list of modifiers has been reproduced below. Behavioral Health Screening of Members < 21 Years Service Code 96110 and Modifier Servicing Provider When No Behavioral Health Need Identified* When Behavioral Health Need Identified* Physician, Independent Nurse Midwife, Independent Nurse Practitioner 96110 U1 96110 U2 Nurse Midwife employed by Physician 96110 U3 96110 U4 Nurse Practitioner employed by Physician 96110 U5 96110 U6 Physician Assistant employed by Physician 96110 U7 96110 U8 *Behavioral health need identified includes needs in the areas of behavioral health, social-emotional well-being, or mental health. If you wish to obtain a fee schedule for Service Code 96110, you may download the Division of Health Care Finance and Policy (DHCFP) regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of 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 paper copy of the publication. The regulation titles are 114.3 CMR 17.00: Medicine, 114.3 CMR 16.00: Surgery and Related Anesthesia Care, 114.3 CMR 18.00: Radiology, and 114.3 CMR 20.00: Laboratory. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp 2008 HCPCS For dates of service on or after January 1, 2008, service codes that have been discontinued by CMS and deleted by the American Medical Association Current Procedural Terminology (CPT) for 2008 are not payable by MassHealth. Services described by these codes may be billed with replacement codes. Replacement codes are Level I and Level II HCPCS codes from any year, including 2008, that replace the 2008 “deleted” codes. MassHealth will pay only for new 2008 HCPCS code additions that are replacing 2008 deleted codes. Prior-authorization requests may be submitted to MassHealth for any medically necessary service for a MassHealth Standard or CommonHealth member younger than 21 years of age. MassHealth is not adopting any other 2008 HCPCS code additions at this time. MassHealth will review the remainder of the 2008 HCPCS code additions and changes and will determine coverage policies and other requirements at a later date. Providers will receive another transmittal letter and updated Subchapter 6 of the Physician Manual when the final review of 2008 HCPCS code additions has been completed. The 2008 HCPCS deleted codes and 2008 HCPCS code additions that are payable for dates of service on or after January 1, 2008, are found in Section 606 of Subchapter 6 of the Physician Manual. In accordance with MassHealth regulations, payment is subject to the terms and conditions of 130 CMR 433.000 and 450.000. Payment Payment for 2008 HCPCS codes that can be directly crosswalked to a deleted 2007 HCPCS code will be paid the same rate as the deleted code in accordance with DHCFP regulation. When relative value units are not available, DHCFP will apply individual consideration (IC) in reimbursing for these new codes until appropriate rates can be developed. For more information about payment, you may download the DHCFP informational bulletins at www.mass.gov/dhcfp. Reminders for Submitting Claims for I.C. Services Since payment for some of the new 2008 codes will be determined through I.C., we are providing the following reminders. A. Claim Attachments - All claims with service codes designated in Subchapter 6 as I.C. must be submitted with documentation suitable for MassHealth to price and evaluate the claim, including but not limited to, invoices, operative notes, and other reports. Providers submitting claims electronically will receive a Claim Attachment Form (CAF). When you receive a CAF, you must attach the necessary documentation and return the CAF to the address designated on the form. B. Operative Reports - Operative reports must be submitted in their entirety and must identify all procedures performed, including technical procedures, the name of the member, the date of the procedures, the preoperative diagnosis, the postoperative diagnosis, and the names of the surgeon and assistants. For procedures performed in settings that do not issue formal operative reports, the accompanying documentation must be legible and contain the same information required on an operative report. C. Drugs Administered in an Office - For drugs administered in an office, a supplier’s invoice must be submitted for each drug billed. Providers must indicate the name, strength, dose, units administered, and NDC (National Drug Code) for the drug. When more than one drug is listed on an invoice, providers must indicate which drug is being billed. This information must be submitted as a separate attachment in addition to the invoice. D. Legibility and Completeness - If the documentation is illegible or incomplete, or if no report has been submitted, MassHealth will deny the claim with the applicable error code. Other Revisions to Subchapter 6 MassHealth has also updated prior-authorization requirements for certain services. Providers should review Section 603 in Subchapter 6 to determine which codes have special requirements or limitations. Tobacco Cessation The MassHealth tobacco-cessation benefit covers both pharmacotherapy and counseling services. Effective January 1, 2008, the code for counseling used in combination with provider- specific modifiers is changing from Service Code G0376 to Service Code 99407. Please see the chart below for the modifier definitions. Because Service Code 99407 represents distinct services for tobacco cessation, it can be reported in addition to other evaluation-and-management service codes. Tobacco Cessation Counseling Services Individual tobacco cessation counseling visit, at least 30 minutes Individual tobacco cessation intake/assessment counseling visit, at least 45 minutes Group tobacco cessation counseling visit, at least 60-90 minutes Servicing Provider Service Code + Modifier Service Code + Modifier Service Code + Modifier Physician, Independent NP, Independent Nurse Midwife 99407 (no required modifier) 99407 TF 99407 HQ Nurse Practitioner 99407 SA 99407 U2 99407 U3 Nurse Midwife 99407 SB 99407 U2 99407 U3 Physician Assistant 99407 HN 99407 U2 99407 U3 Registered Nurse 99407 TD 99407 U2 99407 U3 Tobacco Cessation Counselor 99407 U1 99407 U2 99407 U3 Effective Date The revisions to Subchapter 6 are effective for dates of service on or after January 1, 2008, with the exception of the change to Service Code 96110 for behavioral health. This change is effective for dates of service on or after December 31, 2007. 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.) Physician Manual Pages vi and 6-1 through 6-22 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Physician Manual Pages vi and 6-1 through 6-18 — transmitted by Transmittal Letter PHY-119