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

MASSHEALTH
TRANSMITTAL LETTER POD-46
January 2004
TO:      Podiatrists Participating in MassHealth
FROM:      Beth Waldman, Acting Commissioner
RE:      Podiatrist Manual (Revisions to Service Codes and Reduction in Shoe Maximum)
Effective February 1, 2004, MassHealth has revised Subchapter 6 of the Podiatrist Manual to limit coverage of medically necessary orthotic shoes to one pair for a member within a 12-month period. The previous limit was two pairs within a 12-month period. The number of allowed service codes for shoe inserts and other accessories has also been reduced to reflect the new shoe maximum effective February 1, 2004.
Providers may request prior authorization for additional orthotic shoes within a 12-month period if the prescriber can show that additional orthotic shoes are medically necessary.
The revisions to Subchapter 6 are effective February 1, 2004.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Podiatry Manual
Pages vi and 6-1 through 6-6
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Podiatry Manual
Page vi — transmitted by Transmittal Letter POD-41
Pages 6-1 through 6-6 — transmitted by Transmittal Letter POD-45

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

	TRANSMITTAL LETTER
POD-46	DATE
02/01/04	
6. SERVICE CODES AND DESCRIPTIONS
Introduction 		6-1
Payable Codes 		6-1
Payable HCPCS Level II Service Codes for Injectable and Infusable
Drugs Administered in the Office 		6-3
Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services 		6-4
Modifiers    		6-6
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
6 SERVICE CODES	PAGE
6-1	

	TRANSMITTAL LETTER
POD-46	DATE
02/01/04	
601	Introduction
MassHealth pays for the services for codes listed in Sections 602 through 604 in effect at the time of service, subject to all conditions and limitations in MassHealth’s regulations at 130 CMR 424.000 and 450.000.
Podiatry services require a written referral from the member’s primary-care provider before the delivery of services. MassHealth pays only for podiatry services that are certified to be necessary for the life and safety of the member. The referral must be on the primary-care provider’s letterhead and must certify that such services are medically necessary for the life and safety of the member. A substantiating medical explanation must also be included in the written certification.
 •	Section 602 lists CPT service codes that are payable under MassHealth, some of which require individual consideration or prior authorization. Refer to the Centers for Medicare and Medicaid Web site at www.cms.gov/medicare/hcpcs for the descriptions of the service codes listed in Section 602.
 •	Sections 603 and 604 list Level II HCPCS codes that are payable under MassHealth. Refer to the Centers for Medicare and Medicaid Web site at www.cms.gov/medicare/hcpcs for the descriptions of the service codes listed in Section 603.
 •	Section 605 lists service code modifiers allowed under MassHealth.
Legend:
IC: Claim requires individual consideration. See 130 CMR 424.407 for more information. PA: Service requires prior authorization. See 130 CMR 450.303 for more information.
602	Payable CPT Codes
MassHealth pays for services billed using the following codes.

10060	11001	11057 (IC)	11308	11621	
10061	11040	11100	11420	11622	
10120	11041	11101	11421	11623	
10121	11042	11200	11422	11624	
10140	11043	11201	11423	11626	
10160	11044	11305	11424	11719	
10180	11055	11306	11426	11720	
11000	11056	11307	11620	11721	

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

	TRANSMITTAL LETTER
POD-46	DATE
02/01/04	
602 Payable CPT Codes (cont.)

11730	17000	27685	28092	28262	
11732	17003	27686	28100	28264	
11740	17004	27695	28102	28270	
11750	17110	27696	28103	28272	
11752	17111	27704	28104	28280	
11755	17250	27760	28106	28285	
11760	17270	27762	28107	28286	
11762	17271	27766	28108	28288	
11765	17272	27808	28110	28289	
12001	17273	27810	28111	28290	
12002	17274	27814	28112	28292	
12004	17276	27816	28113	28293	
12005	20000	27818	28114	28294	
12006	20005	27822	28116	28296	
12007	20200	27823	28118	28297	
12041	20205	27840	28119	28298	
12042	20206	27842	28120	28299	
12044	20520	27846	28122	28300	
12045	20525	27848	28124	28302	
13131	20550	27860	28126	28304	
13132	20600	27870	28130	28305	
13133	20605	28001	28140	28306	
14040	20612	28002	28150	28307	
14041	20615	28003	28153	28308	
14060	20650	28005	28160	28309	
14061	20670	28008	28171	28310	
14300	20680	28010	28173	28312	
14350	27603	28011	28175	28313	
15000	27604	28020	28190	28315	
15001	27605	28022	28192	28320	
15050	27606	28024	28193	28322	
15100	27607	28030	28200	28340	
15101	27610	28035	28202	28341	
15120	27612	28043	28208	28344	
15121	27613	28045	28210	28345	
15240	27614	28046	28220	28360 (IC)	
15241	27615	28050	28222	28400	
15350	27618	28052	28225	28405	
15351	27619	28054	28226	28406	
15400	27620	28060	28230	28415	
15401	27625	28062	28232	28420	
15574	27626	28070	28234	28430	
15620	27630	28072	28238	28435	
15850	27647	28080	28240	28436	
15851	27648	28086	28250	28445	
15852	27680	28088	28260	28450	
15999 (IC)	27681	28090	28261	28455	

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

	TRANSMITTAL LETTER
POD-46	DATE
02/01/04	
602 Payable CPT Codes (cont.)

28456	28630	29425	73650	99231	
28465	28635	29440	73660	99232	
28470	28636	29445	76499 (IC)	99238	
28475	28645	29450	81000	99239	
28476	28660	29515	82947	99241	
28485	28665	29540	84550	99242	
28490	28666	29550	85007	99243	
28495	28675	29580	85014	99251	
28496	28705	29590	85018	99252	
28505	28715	29705	85032	99253	
28510	28725	29730	85041	99261	
28515	28730	29750	85048	99262	
28525	28735	29799 (IC)	87101	99281	
28530	28737	29891	87102	99282	
28531	28740	29892	87106	99283	
28540	28750	29893	99070 (IC)	99311	
28545	28755	29894	99202	99312	
28546	28760	29895	99203	99321	
28555	28800	29897	99204	99322	
28570	28805	29898	99211	99331	
28575	28810	29899	99212	99332	
28576	28820	73590	99213	99341	
28585	28825	73592	99214	99342	
28600	28899 (IC)	73600	99218	99343	
28605	29345	73610	99219	99347	
28606	29355	73620	99221	99348	
28615	29405	73630	99222	99349	
603 Payable HCPCS Level II Service Codes for Injectable and Infusable Drugs Administered in the Office
MassHealth pays for the services for codes listed in Section 603 in effect at the time of service, subject to all conditions and limitations in Subchapter 6 and in MassHealth’s regulations at 130 CMR 424.000 and 450.000. All services for codes listed in this section are paid on an individual-consideration (IC) basis. See 130 CMR 424.407 for more information.

J0170 (IC) J0702 (IC) J0704 (IC) J1020 (IC) J1030 (IC)	J1040 (IC) J1200 (IC) J1700 (IC) J1710 (IC) J2000 (IC)	J3301 (IC) J3302 (IC) J3303 (IC) J3490 (IC) (PA) S0020 (IC)	

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-46	DATE
02/01/04	
604 Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services
MassHealth pays for the services for codes listed in Section 604 in effect at the time of service, subject to all conditions and limitations in Subchapter 6 and in MassHealth’s regulations at 130 CMR 424.000 and 450.000. In addition, each code lists the age restriction and service limitations that apply. All service codes listed in this section are paid on an individual-consideration (IC) basis. See 130 CMR 424.407 for more information.
The provider may request prior authorization (PA) for eligible members, if additional units are medically necessary. In particular, for members under age 21, MassHealth regulations at 130 CMR 450.144(A) allow providers to seek coverage of units in excess of service limitations, when medically necessary, by requesting prior authorization.
HCPCS Code	Covered for Under Age 21	Covered for Age 21 and Older	Service Limits (PA s                  required for units in excess of limits.)	
A5500 (IC)	Yes	Yes	1 per 12 months	
A5501 (IC)	Yes	Yes	1 per 12 months	
A5503 (IC)	Yes	Yes	2 per 12 months	
A5504 (IC)	Yes	Yes	2per 12 months	
A5505 (IC)	Yes	Yes	2 per 12 months	
A5506 (IC)	Yes	Yes	2 per 12 months	
A5507 (IC)	Yes	Yes	2per 12 months	
A5508 (IC)	Yes	Yes	2 per 12 months	
A5509 (IC)	Yes	Yes	6 per 12 months	
A5511 (IC)	Yes	Yes	2 per 12 months	
L3000 (IC)	Yes	No	2 per 12 months	
L3001 (IC)	Yes	No	2 per 12 months	
L3002 (IC)	Yes	No	2 per 12 months	
L3003 (IC)	Yes	No	2 per 12 months	
L3010 (IC)	Yes	No	2 per 12 months	
L3020 (IC)	Yes	No	2 per 12 months	
L3030 (IC)	Yes	No	2 per 12 months	
L3040 (IC)	Yes	No	2 per 12 months	
L3050 (IC)	Yes	No	2 per 12 months	
L3060 (IC)	Yes	No	2 per 12 months	
L3070 (IC)	Yes	No	2 per 12 months	
L3080 (IC)	Yes	No	2 per 12 months	
L3090 (IC)	Yes	No	2 per 12 months	
L3100 (IC)	Yes	No	2per 12 months	
L3140 (IC)	Yes	No	1 per 12 months	
L3150 (IC)	Yes	No	1 per 12 months	
L3160 (IC)	Yes	No	1 per 12 months	
L3170 (IC)	Yes	No	1per 12 months	
L3201 (IC)	Yes	No	2 per 12 months	
L3202 (IC)	Yes	No	2 per 12 months	
L3203 (IC)	Yes	No	2 per 12 months	
L3204 (IC)	Yes	No	2 per 12 months	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PODIATRIST MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-5	

	TRANSMITTAL LETTER
POD-46	DATE
02/01/04	
604 Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services (cont.)

HCPCS Code	Covered for Under Age 21	Covered for Ages 21 and Older	Service Limits (PA required for units in excess of limits.)	
L3206 (IC)	Yes	No	2 per 12 months	
L3207 (IC)	Yes	No	2 per 12 months	
L3208 (IC)	Yes	No	2 per 12 months	
L3209 (IC)	Yes	No	2 per 12 months	
L3211 (IC)	Yes	No	2 per 12 months	
L3212 (IC)	Yes	No	1 per 12 months	
L3213 (IC)	Yes	No	1 per 12 months	
L3214 (IC)	Yes	No	1 per 12 months	
L3215 (IC)	Yes	No	1 per 12 months	
L3216 (IC)	Yes	No	1 per 12 months	
L3217 (IC)	Yes	No	1 per 12 months	
L3219 (IC)	Yes	No	1per 12 months	
L3221 (IC)	Yes	No	1 per 12 months	
L3222 (IC)	Yes	No	1 per 12 months	
L3224 (IC)	Yes	No	2 per 12 months	
L3225 (IC)	Yes	No	2per 12 months	
L3230 (IC)	Yes	No	2 per 12 months	
L3250 (IC)	Yes	No	2 per 12 months	
L3251 (IC)	Yes	No	2 per 12 months	
L3252 (IC)	Yes	No	2 per 12 months	
L3253 (IC)	Yes	No	2 per 12 months	
L3254 (IC)	Yes	No	1per 12 months	
L3255 (IC)	Yes	No	1per 12 months	
L3257 (IC)	Yes	No	1 per 12 months	
L3260 (IC)	Yes	No	2 per 12 months	
L3265 (IC)	Yes	No	2 per 12 months	
L3300 (IC)	Yes	No	2 per 12 months	
L3310 (IC)	Yes	No	2 per 12 months	
L3320 (IC)	Yes	No	2 per 12 months	
L3332 (IC)	Yes	No	1 per 12 months	
L3334 (IC)	Yes	No	2 per 12 months	
L3350 (IC)	Yes	No	2 per 12 months	
L3360 (IC)	Yes	No	2 per 12 months	
L3370 (IC)	Yes	No	2 per 12 months	
L3390 (IC)	Yes	No	2 per 12 months	
L3400 (IC)	Yes	No	2 per 12 months	
L3420 (IC)	Yes	No	2 per 12 months	
L3450 (IC)	Yes	No	2 per 12 months	
L3455 (IC)	Yes	No	2 per 12 months	
L3460 (IC)	Yes	No	2per 12 months	
L3465 (IC)	Yes	No	2 per 12 months	
L3470 (IC)	Yes	No	2 per 12 months	

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

	TRANSMITTAL LETTER
POD-46	DATE
02/01/04	
604 Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services (cont.)
HCPCS Code	Covered for Under Age 21	Covered for Ages 21 and Older	Service Limits (PA required for units in excess of limits.)	
L3480 (IC)	Yes	No	2 per 12 months	
L3485 (IC)	Yes	No	2 per 12 months	
L3500 (IC)	Yes	No	2 per 12 months	
L3510 (IC)	Yes	No	2 per 12 months	
L3530 (IC)	Yes	No	2 per 12 months	
L3540 (IC)	Yes	No	2per 12 months	
L3570 (IC)	Yes	No	2 per 12 months	
L3580 (IC)	Yes	No	2per 12 months	
L3590 (IC)	Yes	No	2 per 12 months	
L3595 (IC)	Yes	No	2 per 12 months	
L4210 (IC)	Yes	Yes	--	
605 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
99	Multiple modifiers
TC	Technical component