Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter POD-64 February 2011 TO: Podiatrists Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Podiatrist Manual (2011 HCPCS) This letter transmits revisions to the service codes in the Podiatrist Manual. The Centers for Medicare & Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2011. The revised Subchapter 6 is effective for dates of service on or after January 1, 2011. Providers should refer to www.cms.hhs.gov for code descriptions. Subchapter 6 of the Podiatrist Manual lists CPT and Level II codes that • are payable under MassHealth; and • have special limitations or requirements, such as prior authorization (PA) or individual consideration (IC). In addition, pursuant to 130 CMR 450.144(A), a podiatrist may request PA for any medically necessary service for a member under 21 years of age, even if it is not listed as payable in Subchapter 6 of the Podiatrist Manual. A podiatrist may request prior approval for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age even if it is not designated as covered or payable in the Podiatrist Manual. If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The specific regulation title(s) are, 114.3 CMR 17.00: Medicine, 114.3 CMR 16.00: Surgery and Related Anesthesia Care, 114.3 CMR 18.00: Radiology, 114.3 CMR 20.00: Laboratory, and 114.3 CMR 34.00: Prostheses, Prosthetic Devices, and Orthotic Devices. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/sprDivision of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp Consultation Codes Effective January 1, 2011, the consultation codes are no longer recognized by MassHealth for payment. Providers should bill patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs, and that identify the complexity of the visit performed. In the office or other outpatient setting where a consultation is performed, Podiatrists should use the appropriate service codes (99202–99204; 99211–99214), depending on the complexity of the visit and whether the patient is a new or established patient to that podiatrist. In an inpatient hospital or nursing facility setting, all podiatrists who perform an initial consultation may bill the initial hospital care service codes (99221–99222) or nursing facility care service codes (99307– 99309). Multiple Surgery Payment and Global Surgery Periods MassHealth is currently developing new regulations about multiple surgery payment and global surgery periods. These changes will be reflected in revised regulations to be issued within the coming months. MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth. Questions If you have any questions about 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.) Podiatrist Manual Pages vi, vii, and 6-1 through 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Podiatrist Manual Page vi — transmitted by Transmittal Letter POD-55 Page vii — transmitted by Transmittal Letter POD-53 Pages 6-1 through 6-6 — transmitted by Transmittal Letter POD-63 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Podiatrist Manual Transmittal Letter POD-64 Date 01/01/11 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................... 6-4 Modifiers ................................................................................................................................. 6-5 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 and Dental Protocols and Periodicity Schedules............. W-1 Appendix X. Family Assistance Copayments and Deductibles........................................................ X-1 Appendix Y. EVS Codes/Messages.................................................................................................. Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes.................................................................. Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Preface Page vii Podiatrist Manual Transmittal Letter POD-64 Date 01/01/11 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. 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 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. 601 Introduction MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2011 code book for the service codes and service descriptions when billing for services provided to MassHealth members. 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. In addition, a podiatrist may request prior authorization (PA) for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age even if it is not designated as covered or payable in Subchapter 6 of the Podiatrist Manual. For members who belong to the PCC Plan, podiatry services continue to require a referral from the member’s primary care clinician (PCC) before the delivery of services. Section 602 lists CPT codes that are generally payable under MassHealth, some of which require individual consideration (IC) or PA. Sections 603 and 604 list Level II HCPCS codes that are payable under MassHealth. Section 605 lists service code modifiers payable under MassHealth. Legend: IC: Claim requires individual consideration. See 130 CMR 424.407 and 450.271 for more information. PA: Service requires prior authorization. See 130 CMR 450.303 for more information. 602 Payable CPT Codes 10060 10061 10120 10121 10140 10160 10180 11000 11001 11042 11043 11044 11045 11046 11047 11055 11056 11057 11100 11101 11200 11201 11305 11306 11307 11308 11420 11421 11422 11423 11424 11426 11620 11621 11622 11623 11624 11626 11719 11720 11721 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 14301 14302 14350 15002 15003 15004 15005 15050 15100 15101 15110 15111 15115 15116 15120 15121 15130 15131 15135 15136 15150 15151 15152 15155 15156 15157 15170 15171 15175 15176 15240 15241 15300 15301 15320 15321 15330 15331 15335 15336 15340 15341 15360 15361 15365 15366 15400 15401 15420 15421 15430 15431 ( 15574 15620 15850 15851 15852 15999 ( 17000 17003 17004 17110 17111 17250 17270 17271 17272 17273 17274 17276 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 28035 28043 28045 28046 28050 28052 28054 28055 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 28400 28405 28406 28415 28420 28430 28435 28436 28445 28450 28455 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 28740 28750 28755 28760 28800 28805 28810 28820 28825 28890 ( 28899 ( 29345 29355 29405 29425 29440 29445 29450 29515 29540 29550 29705 29730 29750 29799 ( 29891 29892 29893 29894 29895 29897 29898 29899 73590 73592 73600 73610 73620 73630 73650 73660 76499 ( 84550 85007 85014 85018 85032 85041 85048 87101 87102 87106 99070 ( 99202 99203 99204 99211 99212 99213 99214 99218 99219 99221 99232 99238 99239 99281 99282 99283 99307 99308 99309 99324 99325 99326 99334 99335 99336 99341 99342 99343 99347 28737 29590 82947 99231 Payable HCPCS Level II Service Codes for Injectable Drugs Administered in the Office MassHealth pays for the services represented by the codes listed in Section 603 in effect at the timservice, subject to all conditions and limitations in Subchapter 6 and in MassHealth regulations at 130CMR 424.000 and 450.000. Refer to the Cen services J0702 J1020 assHealth m J1710 ( J1720 J3303 J3490 (ICQ4103 Q4104 Q4108 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 conditions and limitations in MassHealth regulations at 130 CMR 424.000 and 450.000. In addition, a provider may request PA for any medically necessary orthotic services. Providers should refer to the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool for service descriptions, applicable modifiers, place-of-service codes, PA requirements, service limits, American Orthotic and Prosthetic Association (AOPA) interpretive language (if applicable), pricing and markup information, and MassHealth Shoe Prescription Form requirement. For certain services that are payable on an individual-consideration (I.C.) basis, the tool will calculate the payable amount, based on information entered into certain fields on the tool. For service codes for which the Division of Health Care Finance and Policy (DHCFP) has established a rate, the provider can determine the payment by reviewing the DHCFP regulations at 114.3 CMR 34.00. The MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool also contains links to DHCFP regulations, the MassHealth Shoe Prescription Form, the orthotics regulations, the prosthetics regulations, and the administrative and billing instructions, which lists the error codes and explanations for claims that have been denied or suspended by MassHealth. Providers should note that in the upper left corner of the Payment and Coverage Guidelines Tool, above the words Program Link, there is a date. Providers should make sure that if they download a printed copy the dates are the same. This will ensure that the providers use the current tool. To get to the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then Provider Library, and then MassHealth Payment and Coverage Guidelines Tools. If you want a paper copy of the tool, you can print it from the Web site, or request a copy from MassHealth Customer Service. See Appendix A of your provider manual for applicable contact information. A5500 A5501 A5503 A5504 A5505 A5506 A5507 A5508 A5510 A5512 A5513 L3000 L3001 L3002 L3003 L3010 L3020 L3030 L3031 L3040 L3050 L3060 L3070 L3080 L3090 L3100 L3140 L3150 L3160 L3170 L3201 L3202 L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L3224 L3225 L3230 L3250 L3251 L3252 L3253 L3254 L3255 L3257 L3260 L3265 L3300 L3310 L3320 L3330 L3332 L3334 L3340 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 L3520 L3530 L3540 L3550 L3560 L3570 L3580 L3590 L3595 The following service code modifiers are allowed for billing under MassHealth. See Subchapter 5 of the Podiatrist Manual for administrative and 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 This page is reserved.