Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth School-Based Medicaid Bulletin 18 November 2009 To: School-Based Medicaid Providers Participating in MassHealth From: Terence G. Dougherty, Interim Medicaid Director RE: The School-Based Medicaid Program Background This bulletin provides additional information on the requirements of the School-Based Medicaid program. Trading Partner Agreements In order to participate in either the Direct Service Claiming (DSC) or the Administrative Activity Claiming (AAC) components of the School-Based Medicaid program, school-based Medicaid providers must have an executed trading partner agreement (TPA) with the Office of Medicaid. TPAs, which allow providers to conduct standard HIPAA transactions with MassHealth, were distributed to all providers in July 2002. School-based Medicaid providers must have an executed TPA in addition to an executed school-based Medicaid program provider contract. Clarification on Documentation Requirements for Per- Unit Service Claim Submission School-Based Medicaid Bulletin 17 indicated that school-based Medicaid providers may only submit interim claims only for services that are documented as described in Municipally Based Health Services Bulletin 9. School-based Medicaid providers should follow all requirements outlined in Municipally Based Health Services Bulletin 9 with the exception of supervision requirements. Providers should follow supervision requirements as outlined in the Provider Qualifications section of School-Based Medicaid Bulletin 17. (continued on next page) Update on Personal Care Services As stated in School-Based Medicaid Bulletin 17, dated April 2009, a personal care services provider must be able to perform personal care services and cannot be a family member of the individual receiving services. Please note that a family member is defined as “the spouse of the member, the parent of a minor member, including an adoptive parent, or any legally responsible relative” (MassHealth regulation 130 CMR 422.000). To be reimbursable as part of the School-Based Medicaid program, personal care services must be authorized by a physician or a nurse practitioner. This is an update from School-Based Medicaid Bulletin 17, dated April 2009, which stated that personal care services must be authorized only by a physician. Written Request for Service Agreements School-based Medicaid providers must retain documentation of a written request for services, when such a request is required for reimbursement. As indicated in the new School-Based Medicaid program provider contract, all documentation must be maintained for six years (see MassHealth regulation 130 CMR 422.000). This is an update from School-Based Medicaid Bulletin 17, dated April 2009, which stated that documentation must be kept on file for four years. Update on Per-Unit Service Claim Submission Codes School-based Medicaid providers must use the following codes when filing claims for services provided through DSC. The value of the interim rate for each code below and additional information for using the U1 modifier when submitting claims for students receiving services in a private residential school was distributed in a memo dated May 1, 2009. Service Code and Modifier Service Description Interim Rate Practitioner 97001-TM Physical therapy evaluation (related to an IEP) (per hour with a maximum of two hours) $13.04 Physical Therapist 97003-TM Occupational therapy evaluation (related to an IEP) (per hour with a maximum of two hours) $13.04 Occupational Therapist 97110-TM Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (provided pursuant to an IEP) (may bill multiple units) $3.26 Physical Therapist, Occupational Therapist Physical Therapy Assistant Occupational Therapy Assistant (continued on next page) Update on Per-Unit Service Claim Submission Codes (cont.) Service Code and Modifier Service Description Interim Rate Practitioner 97150-TM Therapeutic procedure(s) group (two or more individuals) (provided pursuant to an IEP) (per 15 minutes, may bill multiple units) $1.63 Physical Therapist Occupational Therapist Physical Therapy Assistant Occupational Therapy Assistant 92506-TM Evaluation of speech, language, voice, communication, and/or auditory processing , (pursuant to an IEP) (per hour with a maximum of four hours) $13.04 Speech-Language Therapist 92507-TM Treatment of speech, language, voice, communication, and/or auditory processing disorder (pursuant to an IEP) (per 15 minutes, may bill multiple units) $3.26 Speech-Language Therapist Speech-Language Pathology Assistant or Audiology Assistant 92508-TM Treatment of speech, language, voice, communication, and/or auditory processing disorder: group, two or more individuals (pursuant to an IEP) (per 15 minutes, may bill multiple units) $1.63 Speech-Language Therapist Speech-Language Pathology Assistant or Audiology Assistant T1002-TM RN Services up to 15 minutes (pursuant to an IEP), (may bill multiple units) $1.86 Nurse (RN) T1003-TM LPN/LVN Services, up to 15 minutes, (may bill multiple units) $1.40 Nurse (LPN) T1019-TM Personal care services per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) (may bill multiple units) (pursuant to an IEP) $0.85 Personal Care Services Provider 90801-TM Psychiatric diagnostic interview examination (pursuant to an IEP) (per 30-minutes, may bill multiple units) $10.73 Psychiatrist Psychologist Social Worker Counselor (continued on next page) Update on Per-Unit Service Claim Submission Codes (cont.) Service Code and Modifier Service Description Interim Rate Practitioner 96101-TM Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time with the administering tests to the patient and time spent interpreting test results and preparing the report, (pursuant to an IEP) (may bill multiple units) $18.74 Psychiatrist Psychologist 90804-TM Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20-30-minutes face to face with the patient (pursuant to an IEP), (may bill multiple units) $8.71 Psychologist Social Worker Counselor 90847-TM Family psychotherapy (conjoint psychotherapy) (with patient present) (pursuant to an IEP) (per 30-minutes, may bill multiple units) $8.71 Psychologist Social Worker Counselor 90853-TM Group psychotherapy (other than of a multiple-family group) (pursuant to an IEP) (per 30- minutes, may bill multiple units) $2.09 Psychologist Social Worker Counselor 99499-TM Unlisted evaluation and management services (per 15- minutes, up to a maximum of six services per member per date of service) (related to an IEP) $3.26 Audiologist Hearing Instrument Specialist 97001-TM-U1 Physical therapy evaluation related to an IEP (per hour with a maximum of two hours) (in private residential school) $6.52 Physical Therapist 97003-TM-U1 Occupational therapy evaluation related to an IEP (per hour with a maximum of two hours) (in private residential school) $6.52 Occupational Therapist 97110-TM-U1 Therapeutic procedure, one or more areas, each 15minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (provided pursuant to an IEP) (may bill multiple units) (in private residential school) $1.63 Physical Therapist Occupational Therapist Physical Therapy Assistant Occupational Therapy Assistant (continued on next page) Update on Per-Unit Service Claim Submission Codes (cont.) Service Code and Modifier Service Description Interim Rate Practitioner 97150-TM-U1 Therapeutic procedure(s) group (two or more individuals) (provided pursuant to an IEP) (per 15 minutes, may bill multiple units) (in private residential school) $0.82 Physical Therapist Occupational Therapist Physical Therapy Assistant Occupational Therapy Assistant 92506-TM-U1 Evaluation of speech, language, voice, communication, and/or auditory processing, pursuant to an IEP (per hour with a maximum of four hours) (in private residential school) $6.52 Speech-Language Therapist 92507-TM-U1 Treatment of speech, language, voice, communication, and/or auditory processing disorder (pursuant to an IEP) (per 15 minutes, may bill multiple units) (in private residential school) $1.63 Speech-Language Therapist Speech-Language Pathology Assistant or Audiology Assistant 92508-TM-U1 Treatment of speech, language, voice, communication, and/or auditory processing disorder: group, two or more individuals (pursuant to an IEP) (per 15 minutes, may bill multiple units) (in private residential school) $0.82 Speech-Language Therapist Speech-Language Pathology Assistant or Audiology Assistant T1002-TM-U1 RN Services up to 15 minutes (pursuant to an IEP) (may bill multiple units) (in private residential school) $0.93 Nurse (RN) T1003-TM-U1 LPN/LVN Services, up to 15 minutes ( may bill multiple units) (in private residential school) $0.70 Nurse (LPN) T1019-TM-U1 Personal care services per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) (may bill multiple units) (pursuant to an IEP) (in private residential school) $0.43 Personal Care Services Provider (continued on next page) Update on Per-Unit Service Claim Submission Codes (cont.) Service Code and Modifier Service Description Interim Rate Practitioner 90801-TM-U1 Psychiatric diagnostic interview examination (pursuant to an IEP) (per 30-minutes, may bill multiple units) (in private residential school) $5.36 Psychiatrist Psychologist Social Worker Counselor 96101-TM-U1 Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, e.g., MMPI, Rorschach, WAIS), per hour of the psychologist’s or physician’s time, both face-to-face time with the administering tests to the patient and time spent interpreting test results and preparing the report (pursuant to an IEP) (may bill multiple units) (in private residential school) $9.37 Psychiatrist Psychologist 90804-TM-U1 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20-30-minutes face to face with the patient (pursuant to an IEP) (may bill multiple units) (in private residential school) $4.36 Psychologist Social Worker Counselor 90847-TM-U1 Family psychotherapy (conjoint psychotherapy) (with patient present) (pursuant to an IEP) (per 30-minutes, may bill multiple units) (in private residential school) $4.36 Psychologist Social Worker Counselor 90853-TM-U1 Group psychotherapy (other than of a multiple-family group) (pursuant to an IEP) (per 30- minutes, may bill multiple units) (in private residential school) $1.05 Psychologist Social Worker Counselor 99499-TM-U1 Unlisted evaluation and management services (per 15- minutes, up to a maximum of six services per member per date of service) (related to an IEP) (in private residential school) $1.63 Audiologist Hearing Instrument Specialist (continued on next page) Clarification on Definition of Unit For per-service billing, the following definitions apply for unit. * For services billed per 15-minute increment: 1-15 minutes = 1 unit, 16-30 minutes, = 2 units, etc. * For services billed per 30 minutes: 1-30 minutes = 1 unit, 31- 60 minutes = 2 units, etc. * For services billed per hour: 1-60 minutes = 1 unit, 61-120 minutes = 2 units, etc. * For services billed approximately 20-30 minutes: 1-30 minutes = 1unit, 31- 60 minutes = 2 units, etc. Questions If you have any questions about the information in this bulletin, please contact UMMS at 1-508-856-7640 or e-mail your inquiry to schoolbasedclaiming@umassmed.edu. 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