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 POD-53 June 2006 TO: Podiatrists Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Podiatrist Manual (Coverage of Medically Necessary Orthotic Shoes for Members Aged 21 Years or Older) Due to a new state law, effective July 1, 2006, MassHealth will cover medically necessary orthotic shoes for eligible members aged 21 years or older. This letter transmits an amendment to the podiatrist regulations that reflects this change. All other conditions and limitations of 130 CMR 424.000 and 450.000 continue to apply. These regulations were filed as emergency regulations, effective July 1, 2006. This letter also transmits a revised Subchapter 6 of the Podiatrist Manual. Subchapter 6 lists the codes that are covered by MassHealth. The revisions reflect coverage of orthotic shoes for adult members, effective July 1, 2006. 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. This transmittal letter, including the attached pages, and other publications issued by MassHealth are available on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library. NEW MATERIAL (The pages listed here contain new or revised language.) Podiatrist Manual Pages iv, vii, 4-3, 4-4, and 6-1 through 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Podiatrist Manual Page iv — transmitted by Transmittal Letter POD-49 Page viii — transmitted by Transmittal Letter POD-39 Pages 4-3 and 4-4 — transmitted by Transmittal Letter POD-45 Pages 6-1 through 6-6 — transmitted by Transmittal Letter POD-46 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Podiatrist Manual Transmittal Letter POD-53 Date 07/01/06 4. Program Regulations 424.401: Introduction 4-1 424.402: Definitions 4-1 424.403: Eligible Members 4-3 424.404: Provider Eligibility 4-3 424.405: Service Limitations and Noncovered Services 4-4 424.406: Maximum Allowable Fees 4-5 424.407: Individual Consideration 4-5 424.408: Referral 4-5 424.409: Recordkeeping (Medical Records) Requirements 4-6 424.410: Report Requirements 4-6 424.411: Office Visits 4-7 424.412: OutofOffice Visits 4-7 424.413: Surgical Services and Utilization Management Program Requirements 4-8 424.414: Surgical Assistants 4-9 424.415: Radiology Services 4-9 424.416: Clinical Laboratory Services 4-10 424.417: Pharmacy Services: Prescription Requirements 4-10 424.418: Pharmacy Services: Covered Drugs 4-12 424.419: Pharmacy Services: Limitations on Coverage of Drugs 4-12 424.420: Pharmacy Services: Insurance Coverage 4-13 424.421: Pharmacy Services: Prior Authorization 4-14 424.422: Pharmacy Services: Member Copayments 4-14 424.423: Pharmacy Services: Drugs Dispensed in Provider’s Office 4-15 424.424: Shoes and Corrective Devices 4-15 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Preface Page vii Podiatrist Manual Transmittal Letter POD-53 Date 07/01/06 The regulations and instructions governing provider participation in MassHealth are published in the Provider Manual Series. MassHealth publishes a separate manual for each provider type. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, administrative and billing instructions, and general information. MassHealth regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. MassHealth regulations are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For podiatrists, those matters are covered in 130 CMR Chapter 424.000, reproduced as Subchapter 4 in the Podiatrist Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("penandink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead MassHealth’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with MassHealth and its members. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 424.000) Page 4-3 Podiatrist Manual Transmittal Letter POD-53 Date 07/01/06 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 MassHealth agency covers podiatry services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105 specifically states, for each MassHealth coverage type, which services are covered and which members are eligible to receive those services. (2) 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 is 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 MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 424.000) Page 4-4 Podiatrist Manual Transmittal Letter POD-53 Date 07/01/06 (B) Out of State. An outofstate podiatrist must be licensed by that state's board of registration for podiatrists. The MassHealth agency pays an outofstate 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 MassHealth agency pays only for podiatry services that are certified to be necessary for the life and safety of the member. The MassHealth agency pays for podiatry services as long as the podiatrist has 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 MassHealth agency 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) inservice education; (6) research or experimental treatment; (7) cosmetic services or devices; (8) sneakers or athletic shoes; (9) an additional charge for nonstandard size (width or length) in custom-molded shoes; or (10) shoes when there is no diagnosis of associated foot deformities. 10 601 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 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 10061 10120 10121 10140 10160 10180 11000 11001 11040 11041 11042 11043 11044 11055 11056 11057 (IC) 11100 11101 11200 11201 11305 11306 11307 11308 11420 11421 11422 11423 11424 11426 11620 11621 11622 11623 11624 11626 11719 11720 11721 602 Payable CPT Codes (cont.) 11730 11732 11740 11750 11752 11755 11760 11762 11765 12001 12002 12004 12005 12006 12007 12041 12042 12044 12045 13131 13132 13133 14040 14041 14060 14061 14300 14350 15000 15001 15050 15100 15101 15120 15121 15240 15241 15350 15351 15400 15401 15574 15620 15850 15851 15852 15999 (IC) 17000 17003 17004 17110 17111 17250 17270 17271 17272 17273 17274 17276 20000 20005 20200 20205 20206 20520 20525 20550 20600 20605 20612 20615 20650 20670 20680 27603 27604 27605 27606 27607 27610 27612 27613 27614 27615 27618 27619 27620 27625 27626 27630 27647 27648 27680 27681 27685 27686 27695 27696 27704 27760 27762 27766 27808 27810 27814 27816 27818 27822 27823 27840 27842 27846 27848 27860 27870 28001 28002 28003 28005 28008 28010 28011 28020 28022 28024 28030 28035 28043 28045 28046 28050 28052 28054 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100 28102 28103 28104 28106 28107 28108 28110 28111 28112 28113 28114 28116 28118 28119 28120 28122 28124 28126 28130 28140 28150 28153 28160 28171 28173 28175 28190 28192 28193 28200 28202 28208 28210 28220 28222 28225 28226 28230 28232 28234 28238 28240 28250 28260 28261 28262 28264 28270 28272 28280 28285 28286 28288 28289 28290 28292 28293 28294 28296 28297 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322 28340 28341 28344 28345 28360 (IC) 28400 28405 28406 28415 28420 28430 28435 28436 28445 28450 28455 602 Payable CPT Codes (cont.) 28456 28465 28470 28475 28476 28485 28490 28495 28496 28505 28510 28515 28525 28530 28531 28540 28545 28546 28555 28570 28575 28576 28585 28600 28605 28606 28615 28630 28635 28636 28645 28660 28665 28666 28675 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760 28800 28805 28810 28820 28825 28899 (IC) 29345 29355 29405 29425 29440 29445 29450 29515 29540 29550 29580 29590 29705 29730 29750 29799 (IC) 29891 29892 29893 29894 29895 29897 29898 29899 73590 73592 73600 73610 73620 73630 73650 73660 76499 (IC) 81000 82947 84550 85007 85014 85018 85032 85041 85048 87101 87102 87106 99070 (IC) 99202 99203 99204 99211 99212 99213 99214 99218 99219 99221 99222 99231 99232 99238 99239 99241 99242 99243 99251 99252 99253 99261 99262 99281 99282 99283 99311 99312 99321 99322 99331 99332 99341 99342 99343 99347 99348 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) 604 Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services MassHealth pays for the services represented by the codes listed in Section 604 in effect at the time of service, subject to all the conditions and limitations in Subchapter 6 and in MassHealth regulations at 130 CMR 424.000 and 450.000. The provider may request prior authorization (PA) for orthotic services to eligible members, if additional units are medically necessary. Please Note: Service codes that require PA only when the number of units exceeds the limitations for the code in Section 602 are listed as requiring PA “Sometimes.” Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? A5500 No Sometimes 2 per 12 months RT LT Yes A5501 No Sometimes 2 per 12 months RT LT Yes A5503 No Sometimes 2 per 12 months RT LT Yes A5504 No Sometimes 2 per 12 months RT LT Yes A5506 No Sometimes 2 per 12 months RT LT Yes A5507 No Sometimes 2 per 12 months RT LT Yes A5508 No Sometimes 2 per 12 months RT LT Yes A5509 No Sometimes 12 per 12 months RT LT Yes A5511 No Sometimes 2 per 12 months RT LT Yes L3000 No Sometimes 4 per 12 months RT LT No L3001 No Sometimes 4 per 12 months RT LT No L3002 No Sometimes 4 per 12 months RT LT No L3003 No Sometimes 4 per 12 months RT LT No L3010 No Sometimes 4 per 12 months RT LT No L3020 No Sometimes 4 per 12 months RT LT No L3030 No Sometimes 4 per 12 months RT LT No L3040 No Sometimes 4 per 12 months RT LT No L3050 No Sometimes 4 per 12 months RT LT No L3060 No Sometimes 4 per 12 months RT LT No L3070 No Sometimes 4 per 12 months RT LT No L3080 No Sometimes 4 per 12 months RT LT No L3090 No Sometimes 4 per 12 months RT LT No L3100 No Sometimes 2 per 12 months RT LT No L3140 Yes Sometimes 2 per 12 months RT LT No L3150 Yes Sometimes 2 per 12 months RT LT No L3160 Yes Sometimes 2 per 12 months RT LT No L3170 No Sometimes 2 per 12 months RT LT No L3201 Yes Sometimes 4 per 12 months RT LT Yes L3202 Yes Sometimes 4 per 12 months RT LT Yes L3203 Yes Sometimes 4 per 12 months RT LT Yes L3204 Yes Sometimes 4 per 12 months RT LT Yes L3206 Yes Sometimes 4 per 12 months RT LT Yes L3207 Yes Sometimes 4 per 12 months RT LT Yes L3208 Yes Sometimes 4 per 12 months RT LT Yes L3209 Yes Sometimes 4 per 12 months RT LT Yes L3211 Yes Sometimes 4 per 12 months RT LT Yes Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L3212 Yes Sometimes 2 per 12 months RT LT Yes L3213 Yes Sometimes 2 per 12 months RT LT Yes L3214 Yes Sometimes 2 per 12 months RT LT Yes L3215 No Yes 2 per 12 months RT LT Yes L3216 No Yes 2 per 12 months RT LT Yes L3217 No Yes 2 per 12 months RT LT Yes L3219 No Yes 2 per 12 months RT LT Yes L3221 No Yes 2 per 12 months RT LT Yes L3222 No Yes 2 per 12 months RT LT Yes L3224 No Yes 4 per 12 months RT LT Yes L3225 No Yes 4 per 12 months RT LT Yes L3230 No Yes 4 per 12 months RT LT Yes L3250 No Yes 4 per 12 months RT LT Yes L3251 No Yes 4 per 12 months RT LT Yes L3252 No Yes 4 per 12 months RT LT Yes L3253 No Yes 4 per 12 months RT LT Yes L3524 No Yes 2 per 12 months RT LT Yes L3255 No Yes 2 per 12 months RT LT Yes L3257 No Yes 2 per 12 months RT LT Yes L3260 No Yes 4 per 12 months RT LT Yes L3265 No Yes 4 per 12 months RT LT Yes L3300 No Yes 4 per 12 months RT LT Yes L3310 No Yes 4 per 12 months RT LT Yes L3320 No Yes 4 per 12 months RT LT Yes L3332 No Yes 2 per 12 months RT LT Yes L3334 No Yes 4 per 12 months RT LT Yes L3350 No Yes 4 per 12 months RT LT Yes L3360 No Yes 4 per 12 months RT LT Yes L3370 No Yes 4 per 12 months RT LT Yes L3390 No Yes 4 per 12 months RT LT Yes L3400 No Yes 4 per 12 months RT LT Yes L3420 No Yes 4 per 12 months RT LT Yes L3450 No Yes 4 per 12 months RT LT No L3455 No Yes 4 per 12 months RT LT No L3460 No Sometimes 4 per 12 months RT LT No L3465 No Sometimes 4 per 12 months RT LT No L3470 No Sometimes 4 per 12 months RT LT No L3480 No Sometimes 4 per 12 months RT LT No L3485 No Sometimes 4 per 12 months RT LT No L3500 No Sometimes 4 per 12 months RT LT No L3510 No Sometimes 4 per 12 months RT LT No L3530 No Sometimes 4 per 12 months RT LT No L3530 No Sometimes 4 per 12 months RT LT No L3540 No Sometimes 4 per 12 months RT LT No L3570 No Sometimes 4 per 12 months RT LT Yes Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L3580 No Sometimes 4 per 12 months RT LT No L3590 No Sometimes 4 per 12 months RT LT No L3595 No Sometimes 4 per 12 months RT LT No T2003 No Sometimes -- -- No 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 LT Left side (for orthotic shoes only) RT Right side (for orthotic shoes only) TC Technical component