Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
www.mass.gov/masshealth
	MassHealth
School-Based Medicaid Bulletin 20
	December 2011




	TO:	School-Based Medicaid Providers Participating in MassHealth

	FROM:	Julian J. Harris, M.D., Medicaid Director

	RE:	HIPAA 5010 Diagnosis Code Requirement for School-Based Medicaid Providers


New Requirement	The Centers for Medicare & Medicaid Services (CMS) has mandated that, effective 
January 1, 2012, the standards for electronic health care transactions must change 
from version 4010/4010A1 to version 5010. (See All Provider Bulletin 210.) School-
Based Medicaid providers are not exempt from this new requirement. (See All 
Provider Bulletin 216.)

School-Based 	Effective January 1, 2012, all School-Based Medicaid providers submitting claims via
Medicaid Providers 	electronic, paper, or direct data entry (DDE) transactions must include a valid 
diagnosis code on the claim.
	
	Providers must use the ICD-9-CM diagnosis codes or, if applicable, the diagnosis 
codes from the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 
4th Edition Text Revision) to report student condition at the time of service.

	Providers may use diagnosis code 315.9 (Unspecified delay in development) for all 
claims to report student general condition.

All-Electronic Claims 	Please Note: Effective January 1, 2012, all providers must submit claims
Submission 	electronically unless MassHealth has approved the provider’s request for an
Effective	electronic claim submission waiver.
January 1, 2012	
	Please refer to the following documents and Web page for additional information.
*	All Provider Bulletin 212 (important claims submission policy changes)
*	All Provider Bulletin 217 (waiver policy for claim submissions)
*	www.mass.gov/masshealth/5010 (information about the 5010 implementation, 
testing, timelines, billing and companion guides, job aids, and other documents)

                                                     (continued on next page)



Effective Date	This change is effective January 1, 2012.
	
Questions	If you have any questions about the information in this bulletin, 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.



MassHealth
			School-Based Medicaid Bulletin 20
	December 2011
Page 2