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 CHC-82 January 2009 TO: Community Health Centers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Community Health Center Manual (Application of Fluoride Varnish by Pediatricians and Other Qualified Health Care Professionals) This letter transmits revisions to the MassHealth community health center regulations at 130 CMR 405.000 effective October 1, 2008. The revised regulations allow pediatricians and other qualified health care professionals to apply medically necessary fluoride varnish to eligible MassHealth members under age 21. Covered Service Effective October 1, 2008, physicians and other qualified health care professionals at community health centers may apply fluoride varnish to eligible MassHealth members under age 21. In general, MassHealth expects that this will occur during a pediatric preventive care visit. The purpose of applying fluoride varnish during a well child visit is to increase access to preventive dental treatment in an effort to intercept and prevent early childhood caries in children at moderate to high risk for dental caries. Please note: This service does not require a referral for PCC Plan members. Eligible Members This service is primarily intended for children up to age 3; however, the service is allowed for children up to age 21 who are eligible for MassHealth. Qualified Providers In addition to dental practitioners, physicians, physician assistants, nurse practitioners, registered nurses, and licensed practical nurses who complete the required training as described below, are eligible to apply the fluoride varnish subject to the limitations of state law. Required Training Providers must complete a MassHealth-approved training program on how to apply fluoride varnish, maintain proof of completion of the training, and provide such documentation to MassHealth upon request. For a list of MassHealth-approved training programs and additional information and resources, please visit the MassHealth Web site page that will be available on Monday, February 2, 2009, www.mass.gov/masshealth/fluoridevarnish. Restrictions/Limitations Fluoride varnish application is not recommended to exceed one application every 180 days from first tooth eruption (usually at 6 months) to the third birthday. This service is recommended during a well child visit and will be delivered along with oral health anticipatory guidance that includes patient self-management goals as well as appropriate dental referral, if necessary. Communications Any member without a dental provider should be referred to an appropriate dental provider. MassHealth Dental Customer Service can assist members in locating a dental provider. MassHealth Dental Customer Service can be reached at 1-800-207-5019, or e-mail your inquiry to inquiries@masshealth-dental.net. Billing Requirements Community health centers must submit claims for fluoride varnish services by non-dental practitioners in accordance with applicable program regulations. Community health centers should bill MassHealth with Service Code D1206 on the MassHealth claim form no. 9 or transmitted through the 837P format. For MassHealth managed care organization (MCO) members, providers must contact the appropriate MCO customer service center listed below. Boston Medical Center HealthNet Plan: 1-888-900-1451 Fallon Community Health Plan: 1-866-275-3247 Network Health: 1-888-257-1985 Neighborhood Health Plan: 1-800-462-5449 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. NEW MATERIAL (The pages listed here contain new or revised language.) Community Health Center Manual Pages iv-a, 4-27, 4-28, and 6-59 through 6-62 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Community Health Center Manual Page iv-a — transmitted by Transmittal Letter CHC-81 Pages 4-27 and 4-28 — transmitted by Transmittal Letter CHC-74 Pages 6-59 through 6-62 — transmitted by Transmittal Letter CHC-80 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv-a Community Health Center Manual Transmittal Letter CHC-82 Date 10/01/08 4. Program Regulations (cont.) 405.451: Electrocardiogram (EKG) Services: Introduction ............................................. 4-23 405.452: Electrocardiogram (EKG) Services: Eligibility to Provide Services ................. 4-23 405.453: Electrocardiogram (EKG) Services: Payment Limitations ................................ 4-23 (130 CMR 405.454 through 405.460 Reserved) 405.461: Audiology Services: Introduction ...................................................................... 4-24 405.462: Audiology Services: Eligibility to Provide Services ......................................... 4-24 405.463: Audiology Services: Payment Limitations ........................................................ 4-24 (130 CMR 405.464 and 405.465 Reserved) 405.466: Pharmacy Services: Participation in the 340B Drug-Pricing Program for Outpatient CHC Pharmacies .......................................................................... 4-25 405.467: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services........ 4-25 (130 CMR 405.468 through 405.470 Reserved) 405.471: Optional Reimbursable Services ........................................................................ 4-26 405.472: Tobacco-Cessation Services ............................................................................. 4-26 405.473: Fluoride Varnish Services .................................................................................. 4-27 (130 CMR 405.474 through 405.495 Reserved) 405.496: Utilization Management Program....................................................................... 4-28 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 405.000) Page 4-27 Community Health Center Manual Transmittal Letter CHC-82 Date 10/01/08 biological, psychological, and social causes of tobacco dependence; and (iii) a review of evidence-based treatment strategies and the advantages and disadvantages of each strategy; (b) collaborative development of a treatment plan that uses evidence-based strategies to assist the member to attempt to quit, to continue to abstain from tobacco, and to prevent relapse, including: (i) identification of personal risk factors for relapse and incorporation into the treatment plan; (ii) strategies and coping skills to reduce relapse risk; and (iii) a plan for continued aftercare following initial treatment; and (c) information and advice on the benefits of nicotine replacement therapy or other proven pharmaceutical or behavioral adjuncts to quitting smoking, including: (i) the correct use, efficacy, adverse events, contraindications, known side effects, and exclusions for all tobacco dependence medications; and (ii) the possible adverse reactions and complications related to the use of pharmacotherapy for tobacco dependence. (C) Provider Qualifications for Tobacco Cessation Counseling Services. (1) Qualified Providers. (a) Physicians, registered nurses, nurse practitioners, nurse midwives, and physician assistants may provide tobacco cessation counseling services without additional experience or training in tobacco cessation counseling services. (b) All other providers of tobacco cessation counseling services must be under the supervision of a physician, and must complete a course of training in tobacco cessation counseling by a degree-granting institution of higher education with a minimum of eight hours of instruction. (2) Supervision of Tobacco Cessation Counseling Services. A physician must supervise all non-physician providers of tobacco cessation counseling services. (D) Tobacco Cessation Services: Claims Submission. A CHC may submit claims for tobacco cessation counseling services that are provided by physicians, nurse practitioners, registered nurses, nurse midwives, physician assistants, and MassHealth-qualified tobacco cessation counselors according to 130 CMR 405.472(B) and (C). See Subchapter 6 of the Community Health Center Manual for service codes and descriptions. 405.473: Flouride Varnish Services (A) Eligible Members Members must be under the age of 21 to be eligible for the application of fluoride varnish. (B) Qualified Providers Physicians, nurse practitioners, registered nurses, licensed practical nurses and physician assistants may apply fluoride varnish subject to the limitation of state law. These non-dental providers must complete a MassHealth-approved training on the application of fluoride varnish, maintain proof of completion of the training, and provide such proof to the MassHealth agency upon request. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 405.000) Page 4-28 Community Health Center Manual Transmittal Letter CHC-82 Date 10/01/08 (C) Billing for a Medical Visit and Fluoride Treatment Procedure. The CHC may bill for fluoride varnish services provided by a physician or a qualified staff member as listed in 130 CMR 405.473(B) under the supervision of a physician. The CHC may bill for a medical visit in addition to the fluoride varnish application only if fluoride varnish was not the sole service, treatment, or procedure provided during the visit. (D) Claims Submission A CHC may submit claims for fluoride varnish services that are provided by physicians, nurse practitioners, registered nurses, licensed practical nurses and physician assistants according to 130 CMR 405.473(C). See Subchapter 6 of the Community Health Center Manual for service codes and descriptions. (130 CMR 405.474 through 405.495 Reserved) 405.496: Utilization Management Program The MassHealth agency pays for procedures and hospital stays that are subject to the Utilization Management Program only if the applicable requirements of the program as described in 130 CMR 450.207 through 450.211 are satisfied. Appendix E of the Community Health Center Manual contains the name, address, and telephone number of the contact organization for the screening program and describes the information that must be provided as part of the review process. REGULATORY AUTHORITY 130 CMR 405.000: M.G.L. c. 118E, §§ 7 and 12. Service Code Service Description 94400 Breathing response to CO2 (CO2 response curve) 94450 Breathing response to hypoxia (hypoxia response curve) 94620 Pulmonary stress testing; simple (e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry) 94621 complex (including measurements of CO2 production, O2 uptake, and electrocardiographic recordings) 94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) 94642 Aerosol inhalation of pentamidine for pneumocystis carinii pneumonia treatment or prophylaxis 94660 Continuous positive airway pressure ventilation (CPAP), initiation and management 94662 Continuous negative pressure ventilation (CNP), initiation and management 94664 Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device 94667 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation 94668 subsequent 94680 Oxygen uptake, expired gas analysis; rest and exercise, direct, simple (S.P. to 94620) 94681 including CO2 output, percentage oxygen extracted (S.P. to 94620 and 94680) 94690 rest, indirect (separate procedure) (S.P. to 94620) 94720 Carbon monoxide diffusing capacity (e.g., single breath, steady state) (S.P. to 94725) 94725 Membrane diffusion capacity 94750 Pulmonary compliance study (e.g., plethysmography, volume and pressure measurements) (with report only) (S.P. to 94010, 94060, 94070, and 94620) 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination (no professional component) (S.P. to 94620) 94761 multiple determinations (e.g., during exercise) (no professional component) (S.P. to 94620) 94762 by continuous overnight monitoring (separate procedure) (no professional component) (S.P. to 94620) 94770 Carbon dioxide, expired gas determination by infrared analyzer (with report only) (S.P. to 94620) 94772 Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour continuous recording, infant (I.C.) 94774 Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; includes monitor attachment, download of data, physician review, interpretation, and preparation of a report (I.C.) 94775 monitor attachment only (includes hook-up, initiation of recording and disconnection) (I.C.) 94776 monitoring, download of information, receipt of transmission(s) and analyses by computer only (I.C.) 94777 physician review, interpretation, and preparation of report only (I.C.) 94799 Unlisted pulmonary service or procedure (I.C.) SUPPLEMENTARY 99000 Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory – centrifuging required When claiming payment for visits, a CHC must bill according to the following service codes. A visit during which a member sees more than one professional for the same medical problem or general purpose must be claimed as only one visit. (See 130 CMR 405.421 for other requirements.) Service Code Modifier Service Description CHC Visits 90660 Influenza virus vaccine, live, for intranasal use (P.A.) D1206 Topical fluoride varnish; therapeutic application for moderate-to-high caries risk patients D9450 Case presentation, detailed and extensive treatment planning (Use only for dental enhancement fee. This code may only be billed once per date of service for each member receiving dental services on that date.) J3490 Unclassified drugs (Use for injectable and infusible drugs and devices supplied in the clinic. Do not use for medications and injectables related to family planning services.) (I.C.) T1015 Clinic visit/encounter, all-inclusive (Use for individual medical visit.) T1015 HQ Clinic visit/encounter, all-inclusive, group setting (Use for group clinic visit.) 90899 Unlisted psychiatric service or procedure (Use for individual mental health visit.) (I.C.) 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g.. holidays, Saturday, and Sunday), in addition to basic service (Use for urgent care Monday through Friday from 5:00 P.M. to 6:59 A.M., and Saturday 7:00 A.M. to Monday 6:59 A.M. This code may be billed in addition to the individual medical visit.) 99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes (Use for HIV counseling visits.) Hospital Inpatient Services 99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - detailed or comprehensive history; - detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity. 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity. 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity. Service Code Modifier Service Description 99431 History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records (This code should also be used for birthing room deliveries.) Subsequent Hospital Care 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a problem focused interval history; - a problem focused examination; - medical decision making that is straightforward or of low complexity. 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - an expanded problem focused interval history; - an expanded problem focused examination; - medical decision making of moderate complexity. 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a detailed interval history; - a detailed examination; - medical decision making of high complexity. 99433 Subsequent hospital care, for the evaluation and management of a normal newborn, per day HOSPITAL OBSERVATION SERVICES Initial Observation Care (New or Established Patient) 99218 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: - a detailed or comprehensive history; - a detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity. 99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity. 99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity. Service Code Modifier Service Description Nursing Facility Services 99304 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components: - a detailed or comprehensive history - a detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components: - a comprehensive history - a comprehensive examination; and - medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 35 minutes with the patient and/or family or caregiver. 99306 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components: - a comprehensive history - a comprehensive examination; and - medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver. Subsequent Nursing Facility Care 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: -a problem focused interval history; -a problem focused examination; -straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the patient is stable, recovering, or improving. Physicians typically spend 10 minutes with the patient and/or family or caregiver.