Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA 02111
www.mass.gov/masshealth

MassHealth

MASSHEALTH
TRANSMITTAL LETTER REN-10
October 2004
TO:      Renal Dialysis Clinics Participating in MassHealth
FROM:      Beth Waldman, Medicaid Director
RE:      Renal Dialysis Clinic Manual (Revised Service Codes and Descriptions)
This letter transmits revisions to the service codes and descriptions in Subchapter 6 of the Renal Dialysis Clinic Manual. The Centers for Medicare and Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2004. These revisions to Subchapter 6 are being made in compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended. The revised Subchapter 6 is effective for dates of service on or after November 1, 2004.
If you wish to obtain a fee schedule, you may purchase 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 publication. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title is 114.3 CMR 37.00: Chronic Maintenance Dialysis Treatments and Home Dialysis Supplies.

Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr

Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp

Web Site Access and Questions
All of the information in this transmittal letter is available on MassHealth’s Web site at www.mass.gov/masshealth.
If you have any questions, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.

MASSHEALTH
TRANSMITTAL LETTER REN-10 October 2004 Page 2
NEW MATERIAL
(The pages listed here contain new or revised language.)
Renal Dialysis Clinic Manual
Pages vi, 6-1, and 6-2
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Renal Dialysis Clinic Manual
Pages vi, 6-1, and 6-2 — transmitted by Transmittal Letter REN-9

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

	TRANSMITTAL LETTER
REN-10	DATE
11/01/04	
6.   SERVICE CODES AND DESCRIPTIONS
Service Codes and Descriptions: All-Inclusive Dialysis Treatment 		6-1
Service Codes and Descriptions: Training for Home Dialysis 		6-1
Service Codes and Descriptions: Prescribed Drugs 		6-1
Appendix A. DIRECTORY 		A-1
Appendix B. ENROLLMENT CENTERS 		B-1
Appendix C. THIRD-PARTY-LIABILITY CODES 		C-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
RENAL DIALYSIS CLINIC MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-1	

	TRANSMITTAL LETTER
REN-10	DATE
11/01/04	
601	Service Codes and Descriptions: All-Inclusive Dialysis Treatment
Service
Code        Service Description
90935      Hemodialysis procedure with single physician evaluation
90937      Hemodialysis procedure requiring repeated evaluation(s) with or without substantial revision of
dialysis prescription 90945      Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other
continuous renal replacement therapies), with single physician evaluation 90947      Dialysis procedure other than hemodialysis (e.g., peritoneal dialysis, hemofiltration, or other
continuous renal replacement therapies) requiring repeated physician evaluations, with or
without substantial revision of dialysis prescription
602	Service Codes and Descriptions: Training for Home Dialysis
Service
Code        Service Description
90989       Dialysis training, patient, including helper where applicable, any mode, completed course 90993       Dialysis training, patient, including helper where applicable, any mode, course not completed, per training session
603	Service Codes and Descriptions: Prescribed Drugs
Service
Code        Service Description
Q4055      Injection, epoetin alpha, 1000 units (for ESRD on dialysis) J0895       Injection, deferoxamine mesylate, 500 mg (per 5 cc)

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

	TRANSMITTAL LETTER
REN-10	DATE
11/01/04	
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