Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter CHC-90 August 2011 TO: Community Health Centers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Community Health Center Manual (Revised Service Codes and Descriptions) This letter transmits revisions to the service codes and descriptions in the Community Health Center Manual and informs providers about billing and payment rules that apply when community health center (CHC) physicians provide certain services at hospitals. These changes, including the revised Subchapter 6, are effective for dates of service on or after August 1, 2011. This letter also includes a reminder about the requirement to use the U-modifier for Service Code 96110, which is effective for dates of service on or after July 1, 2011. Please Note: MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 405.000 and 450.000. A community health center (CHC) may request prior authorization (PA) for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5), for a MassHealth Standard or CommonHealth member younger than 21 years of age even if it is not designated as covered or payable in the Community Health Center Manual. For more information about payment, you may download the Division of Health Care Finance and Policy (DHCFP) regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of the DHCFP regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The regulation titles are as follows: 114.3 CMR 18.00: Radiology, 114.3 CMR 20.00: Clinical Laboratory Services, 114.3 CMR 4.00: Rates for Community Health Centers, 114.3 CMR 16.00: Surgery and Anesthesia, and 114.3 CMR 17.00: Medicine. Massachusetts State Bookstore Division of Health Care Finance and Policy State House, Room 116 Two Boylston Street Boston, MA 02133 Boston, MA 02116 Telephone: 617-727-2834 Telephone: 617-988-3100 www.mass.gov/sec/spr www.mass.gov/dhcfp Expanded Obstetrics Services and Surgery Services Effective for dates of service on or after August 1, 2011, MassHealth is adding expanded obstetrics services and surgery services codes to Subchapter 6 of the Community Health Center Manual. (See Section 605 for obstetrics service codes and descriptions. See Section 606 for surgery service codes and descriptions.) When billing MassHealth for these services, CHCs must use the appropriate place-of-service-code. In order for the CHC to bill MassHealth for the expanded service codes, the services must be performed by a qualified physician who is an employee or contractor of the CHC, and is not receiving payment from a hospital or MassHealth for the same service. Claims submitted for payment by the CHC must clearly identify which services have been provided in the CHC and which services have been provided in a hospital setting. The CHC must maintain records that clearly account for the time a physician spends separately in the CHC and in a hospital setting. The CHC must make these records available for review by MassHealth staff upon request. For payment information applicable to obstetric services, refer to 130 CMR 405.423 and 405.426. MassHealth has recently developed new rules for the payment of surgical procedures that apply to the surgical procedures listed in Section 606 of Subchapter 6 of the Community Health Center Manual. Under the new policy, payment for a surgical procedure includes a standard package of preoperative, intraoperative, and postoperative services. The services included within the global surgical package are not payable separately, regardless of the setting in which those services are performed. The new rules appear in the Physician Manual at 130 CMR 433.451 and 433.452. In addition to a description of the global surgical package, the provisions in 130 CMR 433.451 and 433.452 describe payment for multiple surgeries and endoscopies, add-on surgical procedures, bilateral procedures, surgical assistants, team surgery, and co-surgery (two surgeons). Effective for dates of service on or after August 1, 2011, CHCs will be paid in accordance with the surgical services provisions in 130 CMR 433.451 and 433.452 when a CHC physician performs the surgical procedure in a hospital, subject to the following conditions. * The CHC, and not the physician, must bill for and receive payment from MassHealth. * In order for the CHC to bill for the service, the surgery services must be performed by a qualified physician who is an employee or contractor of the CHC and is not receiving payment from a hospital or MassHealth to perform the same service. The physician must be scrubbed and present in the operating room during the major portion of the operation. * MassHealth pays a CHC for a visit, treatment, or procedure. MassHealth does not pay for both a preoperative visit, and a treatment or procedure provided to a member on the same day when they are performed in the same location. For minor surgeries and endoscopies, MassHealth does not pay separately for a visit on the same day as the surgery or endoscopy. * The surgery service codes for which MassHealth pays CHCs are listed in Section 606 of Subchapter 6 of the Community Health Center Manual. MassHealth does not pay CHCs for other surgery service codes. * To receive payment for surgical assistants, the CHC must use the appropriate modifier, and the assistant surgeon must be an employee or contractor of the CHC, and not otherwise receiving a payment from the hospital or MassHealth for the same service. * To receive payment for team surgery, the CHC must use the team surgery modifier, and all physician members of the surgical team must be employees or contractors of the CHC, and not otherwise receiving a payment from the hospital or MassHealth for the same service. * To receive payment for two surgeons (co-surgery), the CHC must use the two surgeons modifier, and bill for both surgeons’ services. Both surgeons must be employees or contractors of the CHC, and not otherwise receiving a payment from the hospital or MassHealth for the same service. Modifiers applicable to the global surgical fee package and other rules referenced in 130 CMR 433.451 and 433.452 have been added to Section 614 of Subchapter 6 and are effective for dates of service on or after August 1, 2011. Vaccines Effective for dates of service on or after August 1, 2011, MassHealth is adding vaccine codes to Subchapter 6 of the Community Health Center Manual for: * HPV (90649 and 90650) – for adults aged 19 through 26; and * MMR (90707), IPV (90713), Tdap (90715), Varicella (90716), and PPV (90732) – for adults 19 years and older. The above referenced vaccines are available free of charge through the Massachusetts Immunization Program for children under 19 years of age. MassHealth is also adding a vaccine code for Zoster (shingles) (90736). For additional information and PA requirements, see Section 604 of Subchapter 6 of the Community Health Center Manual. Critical Edit for Required Behavioral Health Screen Modifier This is a reminder that, in May 2011, MassHealth issued All Provider Bulletin 211 (Critical Edit for Required Behavioral Health Screen Modifier). It stated that effective for dates of service on or after July 1, 2011, MassHealth denies claims that do not include a “U” modifier (U1~U8) with a claim for Service Code 96110. The claim will deny for Edit 8156 “U” Modifier required for code 96110 – not present. Since December 31, 2007, MassHealth has required all CHCs serving MassHealth members under the age of 21 (except MassHealth Limited) to offer to use one of several standardized behavioral health screening tools when performing that component of an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) or Pediatric Preventive Health-care Screening and Diagnosis (PPHSD) visit. The EPSDT Medical and Dental Periodicity Protocols and Schedules (Appendix W) of the Community Health Center Manual contains the menu of approved, clinically appropriate, standardized screening tools from which to choose. MassHealth pays for the administration and scoring of the standardized behavioral health screening tool, separately from the office visit when using Service Code 96110 and the appropriate “U” modifier. MassHealth provided detailed information about these requirements in Transmittal Letter ALL-155, dated December 2007,which communicated updates to the EPSDT/PPHSD regulations (130 CMR 450.140 through 450.150), Appendix W, and Appendix Z. The specific billing modifier to use depends on the type of provider conducting the screen and the disposition of the screen, see Section 613 of Subchapter 6 of the Community Health Center Manual. The clinician must exercise his or her professional judgment as to whether or not the screen identifies a potential behavioral health need. CHCs must ensure that billing departments and fiscal intermediaries are aware of the implementation of and requirements for this critical edit in order to avoid denial of claims for a behavioral health screen using Service Code 96110. Please refer to All Provider Bulletin 211 for more information. All applicable provisions of 130 CMR 405.000 and 130 CMR 450.000 continue to govern CHC participation in 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) Community Health Center Manual Pages vi and 6-61 through 6-76 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Community Health Center Manual Pages vi and 6-61 through 6-74 — transmitted by Transmittal Letter CHC-89 MassHealth Transmittal Letter CHC-90 August 2011 Page 4 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page vi Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 6. Service Codes and Descriptions Introduction and Explanation of Abbreviations 6-1 Radiology Service Codes and Descriptions 6-1 Laboratory Service Codes and Descriptions 6-23 Visit Service Codes and Descriptions 6-61 Obstetrics Service Codes and Descriptions 6-69 Surgery Service Codes and Descriptions……………………………………………………….. 6-69 Nurse-Midwife Service Codes and Descriptions 6-71 Audiology Service Codes and Descriptions 6-71 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment Service Codes and Descriptions 6-72 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Tests Service Codes and Descriptions 6-72 Tobacco Cessation Service Codes and Descriptions 6-72 Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes and Descriptions 6-73 Behavioral Health Screening Tool Service Codes and Descriptions 6-74 Modifiers………………………………………………………………………………………... 6-75 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix D. Supplemental Instructions for TPL Exceptions D-1 Appendix E. Utilization Management Program E-1 Appendix F. Admission Guidelines F-1 Appendix W. EPSDT Services Medical and Dental Protocols and Periodicity Schedules W-1 Appendix X. Family Assistance Copayment 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 6. Service Codes and Descriptions Page 6-61 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 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 604 Visit Service Codes and Descriptions 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 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.) 90632 Hepatitis A vaccine, adult dosage, for intramuscular use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-62 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 90649 Human Papiloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use (Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90650 Human Papiloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use (Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90713 Poliovirus vaccine, inactivated (IPV), for subcutaneous or intramuscular use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use (Covered for adults > 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90716 Varicella virus vaccine, live, for subcutaneous use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90732 Pneumoccal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90736 Zoster (shingles) vaccine, live, for subcutaneous injection (I.C.) (P.A. is required for members < age 60) 90746 Hepatitis B vaccine, adult dosage, for intramuscular use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 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, or 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: - a detailed or comprehensive history; - a detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-63 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 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. 99460 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant 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. 99462 Subsequent hospital care, per day, for evaluation and management of normal newborn 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-64 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 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. Subsequent Observation Care 99224 Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - problem focused interval history; - problem focused examination; - medical decision making that is straightforward or of low complexity. 99225 Subsequent observation 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. 99226 Subsequent observation 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. 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 at the bedside and on the patient’s facility floor or unit. 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 at the bedside and on the patient’s facility floor or unit. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-65 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 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 at the bedside and on the patient’s facility floor or unit. 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 at the bedside and on the patient’s facility floor or unit. 99308 Subsequent nursing facility 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 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 patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 15 minutes at the bedside and on the patient’s facility floor or unit. 99309 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 detailed interval history; - a detailed examination; - 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 patient has developed a significant complication or a significant new problem. Physicians typically spend 25 minutes at the bedside and on the patient’s facility floor or unit. 99310 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 comprehensive interval history; - a comprehensive examination; - 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. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 35 minutes at the bedside and on the patient’s facility floor or unit. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-66 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description DOMICILIARY, REST HOME (E.G., BOARDING HOME), OR CUSTODIAL CARE SERVICES New Patient 99324 Domicillary or rest home visit for the evaluation and management of a new patient, which requires these three key components: - a problem-focused history; - a problem-focused examination; and - 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 presenting problem(s) are of low severity. Physicians typically spend 20 minutes with the patient and/or family or caregiver. 99325 Domicillary or rest home visit for the evaluation and management of a new patient, which requires these three components: - an expanded problem-focused history; - an expanded problem-focused examination; and - medical decision making 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 presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes with the patient and/or family or caregiver. 99326 Domicillary or rest home visit for the evaluation and management of a new patient, which requires these three key components: - a detailed history; - a detailed 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 presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver. 99327 Domicillary or rest home visit for the evaluation and management of a new 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 presenting problem(s) are of high severity. Physicians typically spend 60 minutes with the patient and/or family or caregiver. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-67 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description Established Patient 99334 Domicillary or rest home visit for the evaluation and management of an established patient, which requires at least two 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 presenting problem(s) are of self-limited or minor. Physicians typically spend 15 minutes with the patient and/or family or caregiver. 99335 Domicillary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three components: - an expanded problem-focused interval history; - an expanded problem-focused examination; - medical decision making 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 presenting problem(s) are of low to moderate severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver. 99336 Domicillary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three components: - a detailed interval history; - a detailed examination; - 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 presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes with the patient and/or family or caregiver. 99337 Domicillary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a comprehensive interval history; - a comprehensive examination; - medical decision making of moderate to 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 presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 60 minutes with the patient and/or family or caregiver. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-68 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description HOME SERVICES New Patient 99341 Home visit for the evaluation and management of a new patient, which requires these three key components: - a problem focused history; - a problem focused examination; and - straightforward medical decision making. 99342 Home visit for the evaluation and management of a new patient, which requires these three key components: - an expanded problem focused history; - an expanded problem focused examination; and - medical decision making of low complexity. 99343 Home visit for the evaluation and management of a new patient, which requires these three key components: - a detailed history; - a detailed examination; and - medical decision making of moderate complexity. 99345 Home visit for the evaluation and management of a new patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity. (I.C.) Established Patient 99347 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a problem focused interval history; - a problem focused examination; - straightforward medical decision making. 99348 Home visit for the evaluation and management of an established 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 low complexity. 99349 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a detailed interval history; - a detailed examination; - medical decision making of moderate complexity. 99350 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a comprehensive interval history; - a comprehensive examination; - medical decision making of moderate to high complexity. (I.C.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-69 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 605 Obstetrics Service Codes and Descriptions See 130 CMR 405.422 through 405.426 for other requirements. Service Code Service Description Fee-for-Service Deliveries 59409 Vaginal delivery only (with or without episiotomy and/or forceps 59410 including postpartum care 59414 Delivery of placenta (separate procedure) 59514 Cesarean delivery only 59515 including postpartum care 59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to code for primary procedure)(Hysterectomy Information (HI-1) form required) 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59614 including postpartum care 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59622 including postpartum care Global Deliveries 59400 Routine obstetric care, including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery 59618 Routine obstetric care, including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery 606 Surgery Service Codes and Descriptions Service Code Service Description 44955 Appendectomy; when done for indicated purpose at time of other major procedure (not as separate procedure) (List separately in addition to code for primary procedure.) 49255 Omentectomy, epiploectomy, resection of omentum (separate procedure) 49320 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 54057 Destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery 54150 Circumcision, using clamp or other device with regional dorsal penile or ring block 54160 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less) 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) (Consent for Sterilization Form (CS-18 or CS-21) required) (S.P.) 55450 Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) (Consent for Sterilization Form (CS-18 or CS-21) required)(S.P.) 56420 Incision and drainage of Bartholin's gland abscess 56440 Marsupialization of Bartholin's gland cyst Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-70 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 606 Surgery Service Codes and Descriptions (cont.) Service Code Service Description 57240 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele 57250 Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy 57260 Combined anteroposterior colporrhaphy 57520 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser 57522 loop electrode excision 57700 Cerclage of uterine cervix, nonobstetrical 58120 Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) 58140 Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; abdominal approach 58146 Myomectomy, excision of fibroid tumor(s) of uterus, 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g, abdominal approach 58150 Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s) (Hysterectomy Information (HI-1) form required) 58180 Supracervical abdominal hysterectomy (subtotal hysterectomy), with or without removal of tube(s), with or without removal of ovary(s) (Hysterectomy Information (HI-1) form required) 58353 Endometrial ablation, thermal, without hysteroscopic guidance 58541 Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less (Hysterectomy Information (HI-1) form required) 58543 Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g (Hysterectomy Information (HI-1) form required) 58544 with removal of tube(s) and/or ovary(s) (Hysterectomy Information (HI-1) form required) 58555 Hysteroscopy, diagnostic (separate procedure) 58558 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C 58560 with division or resection of intrauterine septum (any method) 58561 with removal of leiomyomata 58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral (Consent for Sterilization Form (CS-18 or CS-21) required) 58605 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure) (Consent for Sterilization Form (CS-18 or CS-21) required) (S.P.) 58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean delivery or intra- abdominal surgery (not a separate procedure) (Consent for Sterilization Form (CS-18 or CS- 21) required) (List separately in addition to code for primary procedure.) 58615 Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring), vaginal or suprapubic approach (Consent for Sterilization Form (CS-18 or CS-21) required) 58660 Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) 58661 with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) (Consent for Sterilization Form (CS-18 or CS-21) required) 58670 with fulguration of oviducts (with or without transection) (Consent for Sterilization Form (CS- 18 or CS-21) required) 58671 with occlusion of oviducts by device (e.g., band, clip, or Falope ring) (Consent for Sterilization Form (CS-18 or CS-21) required) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-71 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 606 Surgery Service Codes and Descriptions (cont.) Service Code Service Description 58700 Salpingectomy, complete or partial, unilateral or bilateral (separate procedure) 58720 Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure) 58940 Oophorectomy, partial or total, unilateral or bilateral 59000 Amniocentesis, diagnostic 59012 Cordocentesis (intrauterine), any method 59015 Chorionic villus sampling, any method 59025 Fetal non-stress test 59870 Uterine evacuation and curettage for hydatidiform mole 607 Nurse-Midwife Service Codes and Descriptions See 130 CMR 405.427 for requirements. When billing for delivery services performed by a nurse midwife, the provider must use a modifier. Service Code Modifier Service Description T1015 TH Clinic visit/encounter, all-inclusive – obstetrical treatment/services, prenatal or postpartum (use for a medical visit with a nurse midwife for a prenatal or postpartum service) 59400 Routine obstetric care, including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59410 including postpartum care 59414 Delivery of placenta (separate procedure) 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59614 including postpartum care 608 Audiology Service Codes and Descriptions See 130 CMR 405.461 through 405.463 for other requirements. Service Code Service Description 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only 92553 air and bone 92567 Tympanometry (impedance testing) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-72 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 609 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment Service Codes and Descriptions See 130 CMR 450.140 through 450.149 for other requirements. Service Code Service Description New Patient 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient; infant (age younger than one year) 99382 early childhood (age one through four years) 99383 late childhood (age five through 11 years) 99384 adolescent (age 12 through 17 years) 99385 18 through 39 years Established Patient 99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; infant (age younger than one year) 99392 early childhood (age one through four years) 99393 late childhood (age five through 11 years) 99394 adolescent (age 12 through 17 years) 99395 18 through 39 years 610 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Tests Service Codes and Descriptions Service Code Service Description 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only 92587 Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) 99173 Screening test of visual acuity, quantitative, bilateral. 611 Tobacco Cessation Service Codes and Descriptions Service Code Modifier Service Description 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes) (Eligible providers are physicians employed by community health centers.) 99407 HN Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes) (Eligible providers are physicians employed by community health centers.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-73 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 611 Tobacco Cessation Service Codes and Descriptions (cont) Service Code Modifier Service Description 99407 HQ Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (for an individual in a group setting, 60-90 minutes) (Eligible providers are physicians employed by community health centers.) 99407 SA Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes) (Eligible providers are nurse practitioners employed by community health centers.) 99407 SB Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes) (Eligible providers are nurse midwives employed by community health centers.) 99407 TD Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes) (Eligible providers are registered nurses employed by community health centers.) 99407 TF Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (intake assessment for an individual, at least 45 minutes) (Eligible providers are physicians employed by community health centers.) 99407 U1 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes) Eligible providers are tobacco cessation counselors employed by community health centers.) 99407 U2 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (intake assessment for an individual, at least 45 minutes) (Eligible providers are nurse practitioner, nurse midwife, physician assistant, registered nurse, and tobacco cessation counselor.) 99407 U3 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (for an individual in a group setting, 60-90 minutes) (Eligible providers are nurse practitioners, nurse midwives, physician assistants, registered nurses, and tobacco cessation counselors.) 612 Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes and Descriptions Service Code Service Description G0108 Diabetes outpatient self-management training services, individual, per 30 minutes G0109 Diabetes outpatient self-management training services, group session (two or more), per 30 minutes G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes G0271 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (two or more individuals), each 30 minutes 97802 Medical nutrition therapy, initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-74 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 612 Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes and Descriptions (cont) Service Code Service Description 97803 reassessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 group (two or more individuals), each 30 minutes 613 Behavioral Health Screening Tool Service Codes and Descriptions Service Code Modifier Service Description The administration and scoring of standardized behavioral-health screening tools selected from the approved menu of tools found in Appendix W of your provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. 96110 U1 Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report; Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; with no behavioral need identified* (eligible providers are physicians employed by community health centers) 96110 U2 Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report; Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; and behavioral need identified* (eligible providers are physicians employed by community health centers) 96110 U3 Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report; Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; with no behavioral need identified* (eligible providers are nurse midwives employed by community health centers) 96110 U4 Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report; Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; and behavioral need identified* (eligible providers are nurse midwives employed by community health centers) 96110 U5 Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report; Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; with no behavioral need identified* (eligible providers are nurse practitioners employed by community health centers) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-75 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 613 Behavioral Health Screening Tool Service Codes and Descriptions Service Code Modifier Service Description 96110 U6 Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report; Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; and behavioral need identified* (eligible providers are nurse practitioners employed by community health centers) 96110 U7 Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report; Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; with no behavioral need identified* (eligible providers are physician assistants employed by community health centers) 96110 U8 Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report; Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; and behavioral need identified* (eligible providers are physician assistants employed by community health centers) * "Behavioral health need identified" means the provider administering the screening tool, in his or her professional judgment identifies a child with a potential behavioral health services need. 614 Modifiers The following service code modifiers are allowed for billing under MassHealth for CHCs in conjunction with Surgery Services. Modifier Modifer Description 50 Bilateral procedure 51 Multiple procedures 54 Surgical care only 62 Two surgeons 66 Surgical team 80 Assistant surgeon 82 Assistant surgeon (when qualified resident surgeon not available) 99 Multiple modifiers 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 6-76 Community Health Center Manual Transmittal Letter CHC-90 Date 08/01/11 This page is reserved.