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-55 January 2007 TO: Podiatrists Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Podiatry Manual (2007 HCPCS Coding Update) This letter transmits revisions to Subchapter 6 (Service Codes) of the Podiatry Manual. The Centers for Medicare and Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2007. For dates of service on or after January 1, 2007, service codes that have been discontinued by CMS and deleted by the American Medical Association Current Procedural Terminology (CPT) for 2007 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 2007, that replace the 2007 deleted codes. MassHealth will pay only for new 2007 HCPCS code additions that are replacing 2007 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 2007 HCPCS code additions for podiatrists at this time. MassHealth will review the remainder of the 2007 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 Podiatry Manual when the final review of 2007 HCPCS code additions has been completed. The 2007 HCPCS deleted codes and 2007 HCPCS code additions that are payable for dates of service on or after January 1, 2007, are found in Subchapter 6, Section 602 of the Podiatry Manual. In accordance with MassHealth regulations, payment is subject to the terms and conditions of 130 CMR 424.000 and 450.000. Payment Payment for most of the new 2007 codes will be determined through individual consideration (I.C.), until the Division of Health Care Finance and Policy (DHCFP) establishes specific rates and these rates are incorporated into the appropriate regulation. However, 2007 HCPCS codes that can be directly crosswalked to a deleted 2006 HCPCS code will be paid the same rate as the 2006 deleted code in accordance with the DHCFP regulation. For more information about payment, you may download the DHCFP informational bulletins at www.mass.gov/dhcfp. Reminders About Submitting Claims for I.C. Services Since payment for most of the new 2007 codes will be determined through I.C., we are providing the following reminders. MASSHEALTH TRANSMITTAL LETTER POD-55 January 2007 Page 2 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. 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. 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. 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. The revisions to Subchapter 6 are effective for dates of service on or after January 1, 2007. 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.) 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-51 Pages 6-1 through 6-6 — transmitted by Transmittal Letter POD-54 Commonwealth of Massachusetts MassHealth Provider Manual Series Podiatrist Manual Subchapter Number and Title Table of Contents Page vi Transmittal Letter POD-55 Date 01/01/07 6. Service Codes and Descriptions Introduction 6-1 Payable CPT 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- 3 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 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 MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Podiatrist Manual Transmittal Letter POD-55 Date 01/01/07 601 Introduction MassHealth pays for the services represented by the 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. 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. 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 (I.C.) 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 (CMS) Web site at www.cms.gov/medicare/hcpcs for the descriptions of the service codes listed in Sections 603 and 604. • 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 11101 11626 12007 15101 10061 11200 11719 12041 15110 10120 11201 11720 12042 15111 10121 11305 11721 12044 15115 10140 11306 11730 12045 15116 10160 11307 11732 13131 15120 10180 11308 11740 13132 15121 11000 11420 11750 13133 15130 11001 11421 11752 14040 15131 11040 11422 11755 14041 15135 11041 11423 11760 14060 15136 11042 11424 11762 14061 15150 11043 11426 11765 14300 15151 11044 11620 12001 14350 15152 11055 11621 12002 15002 (IC) 15155 11056 11622 12004 15003 (IC) 15156 11057 11623 12005 15050 15157 11100 11624 12006 15100 15170 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-2 Podiatrist Manual Transmittal Letter POD-55 Date 01/01/07 602 Payable CPT Codes (cont.) 15171 20525 27870 28150 28309 15175 20550 28001 28153 28310 15176 20600 28002 28160 28312 15240 20605 28003 28171 28313 15241 20612 28005 28173 28315 15300 20615 28008 28175 28320 15301 20650 28010 28190 28322 15320 20670 28011 28192 28340 15321 20680 28020 28193 28341 15330 27603 28022 28200 28344 15331 27604 28024 28202 28345 15335 27605 28035 28208 28360 15336 27606 28043 28210 28400 15340 27607 28045 28220 28405 15341 27610 28046 28222 28406 15360 27612 28050 28225 28415 15361 27613 28052 28226 28420 15365 27614 28054 28230 28430 15366 27615 28055 28232 28435 15400 27618 28060 28234 28436 15401 27619 28062 28238 28445 15420 27620 28070 28240 28450 15421 27625 28072 28250 28455 15430 27626 28080 28260 28456 15431 (IC) 27630 28086 28261 28465 15574 27647 28088 28262 28470 15620 27648 28090 28264 28475 15850 27680 28092 28270 28476 15851 27681 28100 28272 28485 15852 27685 28102 28280 28490 15999 (IC) 27686 28103 28285 28495 17000 27695 28104 28286 28496 17003 27696 28106 28288 28505 17004 27704 28107 28289 28510 17110 27760 28108 28290 28515 17111 27762 28110 28292 28525 17250 27766 28111 28293 28530 17270 27808 28112 28294 28531 17271 27810 28113 28296 28540 17272 27814 28114 28297 28545 17273 27816 28116 28298 28546 17274 27818 28118 28299 28555 17276 27822 28119 28300 28570 20000 27823 28120 28302 28575 20005 27840 28122 28304 28576 20200 27842 28124 28305 28585 20205 27846 28126 28306 28600 20206 27848 28130 28307 28605 20520 27860 28140 28308 28606 Commonwealth of Massachusetts MassHealth Provider Manual Series Podiatrist Manual Subchapter Number and Title 6. Service Codes Page 6-3 Transmittal Letter POD-55 Date 01/01/07 602 Payable CPT Codes (cont.) 28615 28825 28630 28890 (PA) 28635 28899 (IC) 28636 29345 28645 29355 28660 29405 28665 29425 28666 29440 28675 29445 28705 29450 28715 29515 28725 29540 28730 29550 28735 29580 28737 29590 28740 29705 28750 29730 28755 29750 28760 29799 (IC) 28800 29891 28805 29892 28810 29893 28820 29894 29895 87102 99253 29897 87106 99281 29898 99070 (IC) 99282 29899 99202 99283 73590 99203 99307 73592 99204 99308 73600 99211 99309 73610 99212 99324 73620 99213 99325 73630 99214 99326 73650 99218 99334 73660 99219 99335 76499 (IC) 99221 99336 81000 99222 99341 82947 99231 99342 84550 99232 99343 85007 99238 99347 85014 99239 99348 85018 99241 99349 85032 99242 85041 99243 85048 99251 87101 99252 603 Payable HCPCS Level II Service Codes for Injectable and Infusable Drugs Administered in the Office MassHealth pays for the services represented by the codes listed in Section 603 in effect at the time of service, subject to all conditions and limitations in Subchapter 6 and in MassHealth regulations at 130 CMR 424.000 and 450.000. J0702 J1720 J7341 J0704 J3301 J7342 J1020 J3302 J7343 J1030 J3303 J7344 J1040 J3490 (IC) J7346 (IC) J1710 (IC) J7340 S0020 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 for 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 described in Section 604 are listed as requiring PA “Sometimes.” Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-4 Podiatrist Manual Transmittal Letter POD-55 Date 01/01/07 604 Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services (cont.) Service Age Limitations and Required Shoe Prescription Code Limitation? PA Required? Requirements Modifiers 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 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-5 Podiatrist Manual Transmittal Letter POD-55 Date 01/01/07 604 Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services (cont.) Service Age Limitations and Required Shoe Prescription Code Limitation? PA Required? Requirements Modifiers Form Required? 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 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-6 Podiatrist Manual Transmittal Letter POD-55 Date 01/01/07 605 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