Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter STR-17 July 2012 TO: Sterilization Clinics Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Sterilization Clinic Manual (New Modifiers for Provider Preventable Conditions That Are National Coverage Determinations) This letter transmits updates to Subchapter 6 of the Sterilization Provider Manual to add modifiers for Provider Preventable Conditions (PPCs) that are National Coverage Determinations. For more information about PPCs and related billing instructions, see Transmittal Letter ALL-195. These updates are effective for dates of service on or after July 1, 2012. MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions 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.) Sterilization Clinic Manual Pages vi, vii, 6-1, and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Sterilization Clinic Manual Pages vi and vii — transmitted by Transmittal Letter STR-12 Pages 6-1 and 6-2 — transmitted by Transmittal Letter STR-14 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Sterilization Clinic Manual Transmittal Letter STR-17 Date 07/01/12 6. Service Codes Payable Surgery Services 6-1 Service Codes and Descriptions 6-1 Modifiers for Provider Preventable Conditions That Are National Coverage Determinations 6-1 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 U. DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditions U-1 Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions V-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 Sterilization Center Manual Transmittal Letter STR-17 Date 07/01/12 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. Each manual in the series contains administrative regulations, billing regulations, program regulations, service codes and descriptions, billing instructions, and general information. MassHealth’s 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. Regulations promulgated by MassHealth 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 provider manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For therapists, those matters are covered in 130 CMR Chapter 485.000, reproduced as Subchapter 4 in the Sterilization Center Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which provide 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 with MassHealth members. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-1 Sterilization Clinic Manual Transmittal Letter STR-17 Date 07/01/12 601 Introduction (A) The maximum allowable fee for a sterilization service payable to licensed ambulatory sterilization clinics is the fee listed in the applicable Division of Health Care Finance and Policy fee schedule or the provider’s usual fee or charge, whichever is less. (B) Sterilization services include at least the following: preoperative evaluation and counseling, laboratory services, anesthesia, and postoperative care. (C) All claims for sterilization services must have a completed Consent for Sterilization (CS-18 or CS-21) form attached to the claim (see 130 CMR 485.409). 602 Service Codes and Descriptions The following services include local anesthesia or intravenous sedation and all physician and clinic services. Service Code Service Description 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) (S.P.) 55450 Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) 58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants 58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671 with occlusion of oviducts by device (e.g., band, clip, or Falope ring) 603 Modifiers for Provider Preventable Conditions That Are National Coverage Determinations PA Surgical or other invasive procedure on wrong body part PB Surgical or other invasive procedure on wrong patient PC Wrong surgery or other invasive procedure on patient For more information on the use of these modifiers, see Appendix V of your provider manual. This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS codes are defined in the Current Procedural Terminology (CPT) code book. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Sterilization Clinic Manual Transmittal Letter STR-17 Date 07/01/12 This page is reserved.