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 PRT-20 September 2007 TO: Prosthetic Providers Participating in MassHealth FROM: Thomas Dehner, Medicaid Director RE: Prosthetics Manual (2007 HCPCS Service Codes and Modifiers) This letter transmits revisions to service codes described in Subchapter 6 of the Prosthetics Manual to comply with federal coding mandates and to incorporate coding changes previously described in informational memoranda issued by the Division of Health Care Finance and Policy (DHCFP). This letter also reminds providers of certain existing MassHealth prosthetic policies and requirements. This letter also includes important information for prosthetic providers, including detailed instructions on service limitations, claims submission, prior authorization (PA), and rates for prosthetic products and services. Providers may consult the Centers for Medicare & Medicaid Services (CMS) Web site at www.cms.gov for a full description of the service codes. The revised Subchapter 6, instructions detailed in this transmittal letter, and the new MassHealth Orthotic and Prosthetic Payment and Coverage Guidelines tool (O&P Guidelines tool) described below, are effective for dates of service on or after June 1, 2007. New MassHealth Orthotic and Prosthetic Payment and Coverage Guidelines Tool MassHealth has posted a new Orthotic and Prosthetic Payment and Coverage Guidelines tool on its Web site. This interactive tool is designed to help providers understand the payment requirements and service limitations for each orthotic and prosthetic service code covered by MassHealth. The O&P Guidelines tool provides descriptions for all orthotic and prosthetic service codes covered by MassHealth, along with interpretive descriptions of each service code as written by the American Orthotic and Prosthetic Association (AOPA). It also identifies applicable modifiers, place-of-service codes, PA requirements, service limitations, and AAC mark up information. For certain services that are payable on an individual consideration (IC) basis, the O&P Guidelines tool helps providers calculate the payable amount based on information provided. To access the MassHealth O&P Guidelines tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, Provider Library, MassHealth Payment and Coverage Guidelines Tools, and the link for the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool. This tool also contains links to DHCFP regulations, the MassHealth Shoe Medical Necessity Form, Subchapter 4 of both the Orthotics Manual and Prosthetics Manual, as well as Part 6 of the Administrative and Billing Instructions, which lists the error codes and explanations for claims that have been denied or suspended by MassHealth. MassHealth Transmittal Letter PRT-20 September 2007 Page 2 Prescription Requirements for Services Provided to Members Residing in Nursing Facilities A prescription from a physician on a prescription pad or physician’s letterhead is no longer required when providing services to MassHealth members residing in a nursing facility. In lieu of this documentation, providers may submit a copy of the order from the member’s medical record along with any treatment plan written by the facility’s staff. Revised Fee Schedule DHCFP has promulgated new rate regulations for orthotics and prosthetics services and products. The new fees and rate methodologies are effective for dates of service on or after June 1, 2007. Providers can view the rates on the DHCFP Web site at www.mass.gov/dhcfp. Providers must submit an invoice with each PA request or with each claim for services, as applicable, for items that are paid on an individual-consideration (IC) basis. These services are listed as “AAC + % mark-up” in the DHCFP fee schedule and on the MassHealth O&P Guidelines tool. If you wish to obtain a paper copy of the DHCFP fee schedule, you may purchase DHCFP regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses and telephone numbers below). You must contact them first to find out the price of the publication. DHCFP also has the regulation available on disk. The regulation title for Prostheses, Prosthetic Devices, and Orthotic Devices is 114.3 CMR 34.00. Massachusetts State Bookstore Division of Health Care Finance and Policy State House, Room116 Two Boylston Street Boston, MA 02133 Boston, MA 02116 Telephone: 617-727-2834 Telephone: 617-988-3100 Billing and PA Requirements PA for Units in Excess of Specified Allowable Maximums For products that are listed on the MassHealth O&P Guidelines tool with a unit maximum and a designation that prior authorization is required “Sometimes,” providers may directly bill up to the allowable maximum units without requesting PA. If documentation is provided to support medical necessity for the member to receive more than the maximum allowable units, providers may request a PA for coverage of the additional units only. Providers must submit the request, along with supporting medical documentation, before providing the member with the additional units. Diagnosis Codes MassHealth updates ICD-9-CM codes on a regular basis. Current ICD-9-CM codes are required for all claims. The ICD-9-CM codes entered on the claim must be directly related to the service billed. MassHealth Transmittal Letter PRT-20 September 2007 Page 3 Repairs PA is required for all repairs (combined parts and labor) totaling over $1000 per repair in all settings. All PAs and claims submitted for repairs must be supported by an itemized work order indicating parts and labor. Payment for repairs will be a lump-sum payment and may not exceed the purchase price. PAs submitted for repairs must be billed in 15-minute increments, and must be supported by the following information: • a description of the problem; • the reason the repair is needed; • an itemization of parts and labor; and • invoices for all parts and products used that do not have an assigned HCPCS service code. Claims for Custom-Made Products Provided to Members Who Become Ineligible for MassHealth As stated in 130 CMR 450.231(B), the date of the service is the date on which a medical service is furnished or delivered to a member. If a provider delivers a product to a member that has been ordered, fitted, or altered for the member, and the member ceases to be eligible for such MassHealth services on a date before the final delivery of the products, MassHealth will pay the provider for the products. Providers must submit a paper claim for these services to the following address, with all applicable documentation outlined in 130 CMR 450.231(B). MassHealth Claims Operations ATTN: After Cancel Unit 600 Washington Street Boston, MA 02111 Billing for Members with Other Insurance When a member has other insurance, providers must bill MassHealth with the same HCPCS codes that were billed to the primary insurer. Medical Necessity Documentation Medical necessity determinations are based on specific clinical information and documentation that supports appropriate medical use of the services being requested. Providers must include all documentation of medical necessity as required in 130 CMR 428.000 when submitting requests for PA to MassHealth or its designee. MassHealth Transmittal Letter PRT-20 September 2007 Page 4 MassHealth Automated Prior Authorization System (APAS) MassHealth’s Automated Prior Authorization System (APAS) enables providers to submit PA requests and receive responses electronically. APAS also allows providers to attach additional documentation to their requests electronically when the attachments are needed to determine medical necessity. Providers may contact ACM at 1-866-378-3789 to request access to APAS. Providers are strongly encouraged to explore and utilize this new automated business solution. Case Management for Complex-Care Members MassHealth members under the age of 22 who are authorized to receive Continuous Nursing Services (CNS) are enrolled in Community Case Management (CCM). Some members aged 22 and older may also be enrolled in CCM. This program is administered for MassHealth by the University of Massachusetts Medical School. Each CCM enrollee is assigned a nurse case manager who performs a comprehensive needs assessment and authorizes all medically necessary home health and other community services, including prosthetics. The Recipient Eligibility Verification System (REVS) identifies members enrolled in CCM. Providers should consult Appendix A of the Prosthetics Manual on the MassHealth Web site at www.mass.gov/masshealth to determine where to send prior authorization requests for all members, including CCM members. 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.) Prosthetics Manual Pages 6-1 and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Prosthetic Manual Pages 6-1 through 6-10 — transmitted by Transmittal Letter PRT-18 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Prosthetics Manual Transmittal Letter PRT-20 Date 06/01/07 601 Introduction MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 442.000 and 450.000. A prosthetics provider may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 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 Prosthetics Manual. Providers should refer to the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines tool (O&P Guidelines) for service descriptions, applicable modifiers, place-of-service codes, PA requirements, service limits, American Orthotic and Prosthetic Association (AOPA) interpretive language (if applicable), and AAC markup information. For certain services that are payable on an individual-consideration (I.C.) basis, the tool will calculate the payable amount, based on the information provided. 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 Orthotic and Prosthetic Payment and Coverage tool also contains links to DHCFP regulations, MassHealth Shoe Prescription Form, Subchapter 4 of the Orthotics Manual, Subchapter 4 of the Prosthetics Manual, and Part 6 of the Administrative and Billing Instructions, which lists the error codes and explanations for claims that have been denied or suspended by MassHealth. Please note that the online O & P Guidelines tool is updated frequently. To ensure that you are using the most updated version, check the date in the upper-left corner above the word Program Link. 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, Provider Library, and MassHealth Payment and Coverage Guideline Tools, and Orthotics and Prosthetics Payment and Coverage Guidelines tool. 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. 602 Service Codes This section lists codes for services that are payable under MassHealth. Refer to the Centers for Medicare & Medicaid Web site at www.cms.gov for more detailed descriptions. L5000 L5230 L5430 L5580 L5620 L5638 L5651 L5010 L5250 L5450 L5585 L5622 L5639 L5652 L5020 L5270 L5460 L5590 L5624 L5640 L5653 L5050 L5280 L5500 L5595 L5626 L5642 L5654 L5060 L5301 L5505 L5600 L5628 L5643 L5655 L5100 L5311 L5510 L5610 L5629 L5644 L5656 L5105 L5321 L5520 L5611 L5630 L5645 L5658 L5150 L5331 L5530 L5613 L5631 L5646 L5661 L5160 L5341 L5535 L5614 L5632 L5647 L5665 L5200 L5400 L5540 L5616 L5634 L5648 L5666 L5210 L5410 L5560 L5617 L5636 L5649 L5668 L5220 L5420 L5570 L5618 L5637 L5650 L5670 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-2 Prosthetics Manual Transmittal Letter PRT-20 Date 06/01/07 602 Service Codes (cont.) L5671 L5790 L5986 L6610 L6695 L7190 L8460 L5672 L5795 L5987 L6611 L6696 L7191 L8465 L5673 L5810 L5988 L6615 L6697 L7260 L8470 L5676 L5811 L5990 L6616 L6698 L7261 L8480 L5677 L5812 L5993 L6620 L6703 L7266 L8485 L5678 L5814 L5994 L6621 L6704 L7272 L8499 L5679 L5816 L5995 L6623 L6706 L7274 S1040 L5680 L5818 L5999 L6624 L6707 L7360 L5681 L5822 L6000 L6625 L6708 L7362 L5682 L5824 L6010 L6628 L6709 L7364 L5683 L5826 L6020 L6629 L6805 L7366 L5684 L5828 L6025 L6630 L6810 L7367 L5685 L5830 L6050 L6632 L6881 L7368 L5686 L5840 L6055 L6635 L6882 L7400 L5688 L5845 L6100 L6637 L6883 L7401 L5690 L5848 L6110 L6638 L6884 L7402 L5692 L5850 L6120 L6639 L6885 L7403 L5694 L5855 L6130 L6640 L6890 L7404 L5695 L5856 L6200 L6641 L6895 L7405 L5696 L5857 L6205 L6642 L6900 L7499 L5697 L5858 L6250 L6645 L6905 L7500 L5698 L5910 L6300 L6646 L6910 L7510 L5699 L5920 L6310 L6647 L6915 L7520 L5700 L5925 L6320 L6648 L6920 L7600 L5701 L5930 L6350 L6650 L6925 L8000 L5702 L5940 L6360 L6655 L6930 L8001 L5703 L5950 L6370 L6660 L6935 L8002 L5704 L5960 L6380 L6665 L6940 L8010 L5705 L5962 L6382 L6670 L6945 L8015 L5706 L5964 L6384 L6672 L6950 L8020 L5707 L5966 L6386 L6675 L6955 L8030 L5710 L5968 L6388 L6676 L6960 L8035 L5711 L5970 L6400 L6677 L6965 L8039 L5712 L5971 L6450 L6680 L6970 L8300 L5714 L5972 L6500 L6682 L6975 L8310 L5716 L5974 L6550 L6684 L7007 L8320 L5718 L5975 L6570 L6686 L7008 L8330 L5722 L5976 L6580 L6687 L7009 L8400 L5724 L5978 L6582 L6688 L7040 L8410 L5726 L5979 L6584 L6689 L7045 L8415 L5728 L5980 L6586 L6690 L7170 L8417 L5780 L5981 L6588 L6691 L7180 L8420 L5781 L5982 L6590 L6692 L7181 L8430 L5782 L5984 L6600 L6693 L7185 L8435 L5785 L5985 L6605 L6694 L7186 L8440