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 POD-41
December 2002
TO:      Podiatrists Participating in MassHealth FROM:      Wendy E. Warring, Commissioner
RE:      Podiatrist Manual (Age Limitations for Orthotic Services)

Beginning January 1, 2003, MassHealth will no longer cover orthotic services for adult MassHealth members who are 21 years of age or older, except for members with severe diabetic foot disease. The Division’s current budget appropriation requires these changes, at a minimum, to cover expected deficiencies.
The attached regulations, which describe these changes, are effective January 1, 2003.
This letter also transmits revised pages to Subchapter 6 (Service Codes and Descriptions). The Division has added to Subchapter 6 service codes for diabetic shoes, fitting, and modifications. These codes are covered only for members who are under age 21, or for members with severe diabetic foot disease, regardless of their age.
Claims for Custom-Made Goods
As stated in 130 CMR 450.231(B), “the ‘date of service’ is the date on which a medical service is furnished to a member or, if the medical service consists principally of custom-made goods such as eyeglasses, dentures, or durable medical equipment, the date on which the goods are delivered to a member. If a provider delivers medical goods to a member, which goods had to be ordered, fitted, or altered for the member, and that member ceases to be eligible for such MassHealth services on a date prior to the final delivery of the goods, the Division will reimburse the provider for the goods...”
Providers must submit paper claims for these services with all applicable documentation outlined in 130 CMR 450.231(B) to the following address.
Division of Medical Assistance Claims Operations Unit Attention: After Cancel Unit 600 Washington Street Boston, MA 02111

MASSHEALTH
TRANSMITTAL LETTER POD-41 December 2002 Page 2
Billing Requirements and Reminders
These new age limitations present some new billing requirements. Below are billing requirements and reminders to ensure that your claims for covered services are processed appropriately.
 •	To ensure that your claims for orthotic services for members with severe diabetic foot disease are correctly identified, you must indicate the member’s diagnosis on the claim. Enter an ICD-9-CM diagnosis code that accurately describes the member’s condition in Item 21 of claim form no. 9, and the corresponding diagnosis name in Item 22. This diagnosis requirement is effective for dates of service on or after January 1, 2003.
 •	All claims for orthotic services, regardless of the member’s age, must be accompanied by a completed Shoe Medical Necessity Form. This form was revised in November 2002. Providers must begin using this revised Shoe Medical Necessity Form immediately. To obtain supplies of this form, send a request to the following address or fax number:
MassHealth Forms Distribution P.O. Box 9101 Somerville, MA 02145 Fax: 703-917-4937
When requesting forms, include your provider number, a contact name, and street address (no post office boxes, please). Also, indicate the desired quantity of forms.
 •	As a reminder, the Division pays for podiatry services only when a member’s primary care physician certifies on letterhead that such services are medically necessary for the life and safety of the member. This limitation extends to equipment and supplies prescribed or supplied by podiatrists.
 •	As always, it is important to enter the member’s primary care clinician’s (PCC) referral number in Item 8 on claim form no. 9, if the member is enrolled with a PCC.
DMA Web Site
This transmittal letter and attached regulations are available at the Division’s Web site at www.mass.gov/dma.
Questions
If you have any questions about this transmittal letter, 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.)
Podiatrist Manual
Pages vi, 4-1 through 4-4, 4-13, 4-14, 6-3, and 6-4

MASSHEALTH
TRANSMITTAL LETTER POD-41 December 2002 Page 3
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Podiatrist Manual
Pages 4-1 through 4-4 – transmitted by Transmittal Letter POD-39
Pages vi, 6-3, and 6-4 – transmitted by Transmittal Letter POD-40

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PODIATRIST MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
vi	

	TRANSMITTAL LETTER
POD-41	DATE
01/01/03	
6. SERVICE CODES AND DESCRIPTIONS
Explanation of Abbreviations 		6-1
Service Codes and Descriptions: Visits 		6-1
Service Codes and Descriptions: Surgery Procedures 		6-4
Service Codes and Descriptions: Special Shoes 		6-19
Service Codes and Descriptions: Podiatric X Rays 		6-22
Service Codes and Descriptions: Drugs and Medical Supplies 		6-23
Service Codes and Descriptions: Laboratory Services 		6-23
Appendix A. DIRECTORY 		A-1
Appendix B. ENROLLMENT CENTERS 		B-1
Appendix C. THIRD-PARTY-LIABILITY CODES 		C-1
Appendix D. (Reserved)
Appendix E. UTILIZATION MANAGEMENT PROGRAM 		E-1
Appendix F. ADMISSION GUIDELINES 		F-1
Appendix G. NONLEGEND DRUGS 		G-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
Division of Medical Assistance
Provider Manual Series
PODIATRIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 424.000)	PAGE
4-1	

	TRANSMITTAL LETTER
POD-41	DATE
01/01/03	
424.401:  Introduction
All podiatrists participating in MassHealth must comply with the regulations of the Division governing MassHealth, including but not limited to Division regulations set forth in 130 CMR 424.000 and 450.000.
424.402:  Definitions
The following terms used in 130 CMR 424.000 have the meanings given in 130 CMR 424.402, unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 424.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 424.000 and in 130 CMR 450.000.
Controlled Substance — a drug listed in Schedule II, III, IV, V, or VI of the Massachusetts Controlled Substances Act (M.G.L. c. 94C).
Corrective Devices — orthotics, splints, inlays, appliances, and braces that support or accommodate part or all of the foot and serve to restore or improve functions of the foot.
Custom-Molded Shoe — an individually patterned shoe fabricated to meet the specific needs of an individual. A custom-molded shoe is not off-the-shelf, stock, or prefabricated. The shoe is individually constructed by a molded process over a modified positive model of the individual’s foot. It is made of leather or other suitable material of equal quality, has removable customized inserts that can be replaced if necessary according to the individual’s condition, and has some form of shoe closure.
Drug — a substance containing one or more active ingredients in a specified dosage form and strength. Each dosage form and strength is a separate drug.
Emergency — a sudden or unexpected illness or injury or traumatic injury or infection other than athlete's foot or chronic mycosis infecting the nail bed that must be treated promptly to prevent severe pain to the member.
Federal Upper-Limit Price (FULP) — a price established by the federal Centers for Medicare and Medicaid Services (CMS) pursuant to 42 CFR 447.332 and USC §1396r-8(e). The FULP is an amount equal to 150 percent of the published price for the least costly therapeutic equivalent (using all available national compendia of cost information on drugs) that can be purchased by pharmacists in quantities of 100 tablets or capsules (or, if the drug is not commonly available in quantities of 100, the package size most commonly listed) or, in the case of liquids, the most commonly listed size.
Flexible Adhesive Casting — the application of adhesive tape to orthopedically support or stabilize the foot, or to exert beneficial stress for a structural instability.
Hygienic Foot Care — the trimming of nonpathogenic nails; the cleansing or soaking of the feet; the use of skin creams to maintain skin tone of both ambulatory and bedridden patients; or such other foot care that can be performed by the member or by the nursing facility staff if the member resides in a nursing facility.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PODIATRIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 424.000)	PAGE
4-2	

	TRANSMITTAL LETTER
POD-41	DATE
01/01/03	
Interchangeable Drug Product — a product containing a drug in the same amounts of the same active ingredients in the same dosage form as another product with the same generic or chemical name, as listed in the current edition of the Massachusetts List of Interchangeable Drug Products (105 CMR 720.000) or any supplement thereof.
Last — a model that approximates the shape and size of the foot and over which a shoe is made. A last is usually made of wood, plastic, or plaster.
Moldable Shoes — off-the shelf, ready-made shoes formed from heat-activated materials. The shoes are molded by a thermo-forming process that first heats the material, then forms it over an individual’s foot or a positive model of the individual’s foot.
Nonstandard Size (Width or Length) — a shoe size made on a standard last pattern, but which is not part of a manufacturer’s regular inventory.
Orthopedic Shoes — shoes that are specially constructed to aid in the correction of a deformity of
the musculoskeletal structure of the foot and to preserve or restore the function of the
musculoskeletal system of the foot.
Legend Drug — any drug for which a prescription is required by applicable federal or state law or
regulation.
Massachusetts Upper-Limit Price (MULP) — for multiple-source drugs that do not appear on the federal upper-limit price (FULP) list, an amount equal to 150 percent of the published price for the least costly therapeutic equivalent as listed in national price compendia such as the Red Book and First Data Bank for the most frequently purchased package size.
Molded Shoe — a shoe made from a plaster cast of an individual foot and molded to the foot to accommodate an anatomical deformity that cannot be accommodated by an orthopedic or modified standard shoe.
Multiple-Source Drug — a drug marketed or sold by two or more manufacturers or labelers, or a drug marketed or sold by the same manufacturer or labeler under two or more different names.
Nonlegend Drug — any drug for which no prescription is required by federal or state law.
Orthotist — one who is skilled in the straightening or correction of a deformity or disability by use of a brace or orthopedic device.
Pharmacy On-Line Processing System (POPS) — the on-line, real-time computer network that adjudicates pharmacy claims, incorporating prospective drug utilization review, prior authorization, and member eligibility verification.
Split-Size Charge — an additional charge for dispensing an off-the-shelf, medical-grade pair of orthopedic shoes, where one shoe in the pair is a different size or width than the other shoe in the
pair.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PODIATRIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 424.000)	PAGE
4-3	

	TRANSMITTAL LETTER
POD-41	DATE
01/01/03	
Unit-Dose Distribution System — a means of packaging or distributing drugs, or both, devised by the manufacturer, packager, wholesaler, or retail pharmacist. A unit dose contains an exact dosage of medication and may also indicate the total daily dosage or the times when the medication should be taken.
424.403:  Eligible Members
(A)(1)MassHealth Members. The Division covers podiatry services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in the Division’s regulations. The Division’s regulations at 130 CMR 450.105 specifically state, for each MassHealth coverage type, which services are covered and which members are eligible to receive those services.
 (2)	Age Limitations. In addition to any other restrictions and limitations set forth in 130 CMR 424.00 and 450.000, the Division covers shoes only when provided to eligible MassHealth members under age 21. This age restriction does not apply to therapeutic, moldable, or custom-molded shoes and shoe inserts for members who have severe diabetic foot disease.
 (3)	Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106.
(B) Member Eligibility and Coverage Type. For information on verifying member eligibility and coverage type, see 130 CMR 450.107.
424.404:  Provider Eligibility
Payment for services described in 130 CMR 424.000 will be made only to providers who are participating in MassHealth on the date the service was provided or who are otherwise eligible for such payment pursuant to 130 CMR 450.000 and who meet the following requirements.
(A) In State. A podiatrist practicing in Massachusetts must be licensed by the Massachusetts Board of Registration in Podiatry.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PODIATRIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 424.000)	PAGE
4-4	

	TRANSMITTAL LETTER
POD-41	DATE
01/01/03	
(B) Out of State. An out-of-state podiatrist must be licensed by that state's board of registration for podiatrists. The Division pays an out-of-state podiatrist only when services are provided to an eligible Massachusetts member under the following circumstances:
 (1)	the podiatrist practices outside the border of Massachusetts and provides emergency services to a member;
 (2)	the podiatrist practices in a community of Connecticut, Maine, New Hampshire, New York, Rhode Island, or Vermont that is within 50 miles of the Massachusetts border and provides services to a member who resides in a Massachusetts community near the border of that state; or
 (3)	the podiatrist provides services to a member who is authorized to reside out of state by the Massachusetts Department of Social Services.
424.405:  Service Limitations and Noncovered Services
 (A)	Services Limited to Life and Safety. The Division pays only for podiatry services that are certified to be necessary for the life and safety of the member. The Division reimburses for podiatry services as long as the provider's claim has attached to it a written certification on letterhead from the member's primary care physician that attests that such services are medically necessary for the life and safety of the member and that contains a substantiating medical explanation.
 (B)	Noncovered Services. The Division does not pay for the following:

 (1)	hygienic foot care as a separate procedure, except when the member's medical record documents that the member cannot perform the care or risks harming himself or herself by performing it. The preceding sentence notwithstanding, payment for hygienic foot care performed on a resident of a nursing facility is included in the nursing facility's per diem rate and is not reimbursable in any case as a separate procedure;
 (2)	canceled or missed appointments;
 (3)	services provided by a podiatrist whose contractual arrangements with a state institution, acute, chronic, or rehabilitation hospital, medical school, or other medical institution involve a salary, compensation in kind, teaching, research, or payment from any other sources, if such payment would result in dual compensation for professional, supervisory, or administrative services related to member care;
 (4)	telephone consultations;
 (5)	standard or stock shoes unless they are attached to braces;
 (6)	in-service education;
 (7)	research or experimental treatment;
 (8)	cosmetic services or devices;
 (9)	sneakers or athletic shoes;

 (10)	an additional charge for nonstandard size (width or length) in custom-molded shoes; or
 (11)	shoes when there is no diagnosis of associated foot deformities.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PODIATRIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 424.000)	PAGE
4-13	

	TRANSMITTAL LETTER
POD-41	DATE
01/01/03	
(E) Specific Drug Limitations.
 (1)	Cosmetic Drugs. The Division does not pay for drugs used for cosmetic purposes or for hair growth.
 (2)	Cough and Cold Preparations. The Division does not pay for legend or nonlegend preparations that contain an antitussive or expectorant as a major ingredient, or any drug used for the symptomatic relief of coughs and colds, when they are dispensed to a noninstitutionalized member.
 (3)	Fertility Drugs. The Division does not pay for any drugs used to treat male or female infertility (specifically including, but not limited to, A.P.L., chorionic gonadotropins, Clomid, clomiphenes, HCG, menotropins, Milphene, Pergonal, Pregnyl, Profasi, Profasi HP, and Serophene).
 (4)	Immunizing Biologicals and Tubercular Drugs. Immunizing biologicals and tubercular (TB) drugs available free of charge through local boards of public health or through the Massachusetts Department of Public Health are not covered. If the member has a prescription, however, the Division pays for the following drugs for a nonambulatory member who cannot attend one of the Department of Public Health clinics: Isoniazid, Myambutal, and P.A.S. All other such drugs require prior authorization (see 130 CMR 424.420).
 (5)	Nongeneric Multiple-Source Drugs. Prescribers must obtain prior authorization from the Division for any nongeneric multiple-source drug identified by the Division in accordance with 130 CMR 450.303.
 (6)	Obesity Management. The Division does not pay for any drug used for the treatment of obesity.
 (7)	Sexual Dysfunction Therapy. The Division does not pay for the treatment of male or female sexual dysfunction.
 (8)	Sex-Reassignment Hormone Therapy. The Division does not pay for drugs related to sex-reassignment surgery. This specifically includes, but is not limited to, presurgery and postsurgery hormone therapy.  The Division, however, will continue to pay for post sex-reassignment surgery hormone therapy for which it had been paying immediately prior to May 15, 1993.
 (9)	Smoking Cessation. The Division does not pay for any drug used for smoking cessation.

 (10)	Topical Acne Drugs. The Division does pays only for topical acne products for members aged 25 years and under who have cases of acne documented to be Grade II or higher.
 (11)	Unit-Dose Distribution System. The Division does not pay any additional fees for dispensing drugs in a unit-dose distribution system.
424.420: Pharmacy Services: Prior Authorization
 (A)	Prescribers must obtain prior authorization from the Division for drugs identified by the Division in accordance with 130 CMR 450.303. In addition, if the limitations on payment specified in 130 CMR 424.418 and 424.419 would result in inadequate treatment for a diagnosed medical condition, the prescriber may submit a written request, including written documentation of medical necessity, to the Division for prior authorization for an otherwise noncovered drug or medical supply.
 (B)	All prior-authorization requests must be submitted in accordance with the instructions for requesting prior authorization in Subchapter 5 of the Podiatry Manual. If the Division approves the request, the Division will notify both the podiatrist and the member and assigns a prior-authorization number that must be written on the prescription.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PODIATRIST MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 424.000)	PAGE
4-14	

	TRANSMITTAL LETTER
POD-41	DATE
01/01/03	
(C) The Division will authorize at least a 72-hour supply of a prescription drug to the extent required by federal law. (See 42 U.S.C. 1396r-8(d)(5).) The Division acts on requests for prior authorization for a prescribed drug within a time period consistent with federal regulations.
(D) Prior authorization does not waive any other prerequisites to payment such as, but not limited to, member eligibility or requirements of other health insurers.
424.421: Pharmacy Services: Member Copayments
The Division requires under certain conditions that members make a copayment to the dispensing pharmacy for each original prescription and for each refill for all drugs (whether legend or nonlegend) covered by MassHealth. The copayment requirements are detailed in the Division's administrative and billing regulations at 130 CMR 450.130.
424.422: Pharmacy Services: Payment
Drugs dispensed in the office are reimbursable at the podiatrist's actual acquisition cost if this cost is more than $1.00. Claims for dispensing drugs must include the name of the drug or biological, the strength, and the dosage, and must have a copy of the invoice showing the actual acquisition cost attached to the claim form. Claims without this information will be denied.
424.423: Shoes and Corrective Devices
 (A)	The Division pays for only those shoes listed in Subchapter 6 of the Podiatrist Manual..
 (B)	For shoes, providers must submit with their claim a copy of the completed MassHealth Shoe Medical Necessity Form.
 (C)	The Division does not pay for casting materials used in the molding of orthotic shoes or corrective devices. The cost of these materials is included in the fee for prescribing and providing the shoe or corrective device.
(D) The Division does not pay a podiatrist for stock items prescribed or ordered.
REGULATORY AUTHORITY
130 CMR 424.000: M.G.L. c. 118E, §§7 and 12.

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
PODIATRIST MANUAL	6 SE	RVICE CODES	6-3	

	TRANSMITTAL LETTER	DATE	
		POD	-41		01/01/03	
602 Payable Codes (cont.)					
28344	28546	28820		73630                            99332	
28525	28755	73590		99311                            28495	
28730	29893	99211		28470                            28666	
29730	87106	28445		28635                            29540	
85041	28415	28600		29425                            85007	
28345	28555	28825		73650                            99341	
28530	28760	73592		99312                            28496	
28735	29894	99212		28475                            28675	
29750	99070 (I.C.)	28450		28636                            29550	
85048	28420	28605		29440                            85014	
28360 (I.C.)	28570	28899 (I.C.)		73660                            99342	
28531	28800	73600		99321                            28505	
28737	29895	99213		28476                            28705	
29799 (I.C.)	99202	28455		28645                            29580	
85590	28430	28606		29445                            85018	
28400	28575	29345		81000                            99351	
28540	28805	73610		99322                            28510	
28740	29897	99214		28485                            28715	
29891	99203	28456		28660                            29590	
87101	28435	28615		29450                            85022	
28405	28576	29355		82947                            99352	
28545	28810	73620		99331                            28515	
28750	29898	99231		28490                            28725	
29892	99204	28465		28665                            29705	
87102	28436	28630		29515                            85031	
28406	28585	29405		84550	
603 HCPCS Level II and Locally Assigned Service Codes					
The locally assigned service codes and service descriptions are exclusive to MassHealth. These local codes describe services that are not recognized in the CPT. The local codes are intended only for services provided to MassHealth members.
Legend:
I.C.:     Claim requires individual consideration. See 130 CMR 424.407 for more information. P.A.:    Service requires prior authorization. See 130 CMR 450.303 for more information.
HCPCS Level II Service Codes
A5500	A5509	L3020	L3201	L3211	
A5501	A5510	L3030	L3202	L3212	
A5503	A5511	L3040	L3203	L3213	
A5504	L3000	L3050	L3204	L3214	
A5505	L3001	L3060	L3206	L3215	
A5506	L3002	L3070	L3207	L3216	
A5507	L3003	L3080	L3208	L3217	
A5508	L3010	L3090	L3209	L3218	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PODIATRIST MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-4	

	TRANSMITTAL LETTER
POD-41	DATE
01/01/03	
603 HCPCS Level II and Locally Assigned Service Codes (cont.

L3219	L3255	L3340	L3440	L3520	
L3221	L3257	L3350	L3450	L3530	
L3222	L3260	L3360	L3455	L3540	
L3223	L3265	L3370	L3460	L3550	
L3230	L3300	L3380	L3465	L3560	
L3250	L3310	L3390	L3470	L3570	
L3251	L3320	L3400	L3480	L3580	
L3252	L3330	L3410	L3485	L3590	
L3253	L3332	L3420	L3500	L3595	
L3254	L3334	L3430	L3510	L4210 (I.C.)	
Locally Assigned Service Codes
X1705     Examination and treatment of the feet in a licensed hospital, successive members, same day X1707     Examination and treatment of the feet in the member’s residence, successive members, same
day X1709     Examination and treatment of the feet in a licensed nursing facility, convalescent home,
charitable home for the aged, or rest home, successive members, same day X1711     Visit to member living more than 10 miles away from podiatrist’s place of business, and no
podiatrist is practicing in the community in which the member lives X1720     Other X ray (I.C.) X3333     Injectable and infusible drugs and devices supplied in a physician’s office that require prior
authorization (I.C., P.A.)
604 Modifiers
The following service code modifiers are allowed for billing under MassHealth. See Subchapter 5 of the Podiatrist Manual for billing instructions related to the use of modifiers.
26   Professional component
 50	Bilateral procedure
 51	Multiple procedures 54   Surgical care only 99   Multiple modifiers W8 Emergency treatment in a nursing facility. To identify a visit to a nursing facility for emergency
treatment, add the modifier W8 to the end of the nursing facility visit service code.