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 FAS-15 May 2006 TO: Freestanding Ambulatory Surgery Centers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Freestanding Ambulatory Surgery Center Manual (Revisions to Service Codes) This letter transmits revisions to the service codes and descriptions in the Freestanding Ambulatory Surgical Center Manual. The Centers for Medicare and Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2006. The revised Subchapter 6 is effective for dates of service on or after May 1, 2006. We will accept either the new or the old codes for dates of service through April 30, 2006. For dates of service on or after May 1, 2006, you must use the new codes in order to obtain reimbursement. Thirty-five codes have been added and 10 codes have been deleted. Replacement codes and their deleted counterparts are indicated on the following chart. New Codes New Codes New Codes Deleted Codes 15040 15157 16030 (replacing 16015) 15350 15110 15300 (replacing 15350) 19370 15351 15111 15301 (replacing 15351) 19371 16015 15115 15320 (replacing 15350) 37718 (replacing 37730) 21493 15116 15321 (replacing 15351) 37722 (replacing 37730) 21494 15130 15330 (replacing 15350) 45990 31585 15131 15331 (replacing 15351) 58565 37720 15135 15335 (replacing 15350) 37730 15136 15336 (replacing 15351) 42325 15150 15420 15151 15421 15152 15430 15155 15431 15156 16025 MASSHEALTH TRANSMITTAL LETTER FAS-15 May 2006 Page 2 If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (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 title is 114.3 CMR 16.00 Surgery and Related Anesthesia. 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 This letter also transmits a revised Appendix E. We have revised this appendix to update terminology. MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth. 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.) Freestanding Ambulatory Surgery Center Manual Pages vi, vii, 6-1 through 6-22, and E-1 through E-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Freestanding Ambulatory Surgery Center Manual Pages vi and vii – transmitted by Transmittal Letter FAS-13 Pages xii and 6-1 through 6-22 – transmitted by Transmittal Letter FAS-14 Pages E-1 through E-4 – transmitted by Transmittal Letter FAS-10 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title Table of Contents Page vi Transmittal Letter FAS-15 Date 05/01/06 6. Payable Service Codes 601 Payable Surgery Services 6-1 602 Periodontic Service Codes and Descriptions 6-21 603 Exodontic Service Codes and Descriptions 6-21 604 Dental Surgery Procedures 6-21 605 Prosthetic Service Codes and Descriptions 6-22 606 Modifiers 6-22 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix E Admission Guidelines E-1 Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule W-1 Appendix X. Family Assistance Copayments and Deductibles X-1 Appendix Y. REVS Codes/Messages Y-1 Appendix Z. EPSDT Services Laboratory Codes Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title Preface Page vii Transmittal Letter FAS-15 Date 05/01/06 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. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, billing instructions, and general information. MassHealth 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. MassHealth regulations are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. 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 manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For freestanding ambulatory surgery centers, those matters are covered in 130 CMR Chapter 423.000, reproduced as Subchapter 4 in the Freestanding Ambulatory Surgery Center Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("pen-and-ink" revisions), and by 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 its members. Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-1 Transmittal Letter FAS-15 Date 05/01/06 601 Payable Surgery Services MassHealth pays for the following services in a freestanding ambulatory surgery center, subject to all conditions and limitations in MassHealth regulations at 130 CMR423.000 and 130 CMR 450.000. Codes with additional text as shown in the legend below require specific attachments or prior authorization or have specific instructions or limitations. Legend: CPA-2: A completed Certification for Payable Abortion form is required. See 130 CMR 423.419 for additional information. CS-18: A completed Sterilization Consent Form (for members aged 18 through 20) is required. See 130 CMR 423.417 and 423.418 for additional information. CS-21: A completed Sterilization Consent Form (for members aged 21 and older) is required. See 130 CMR 423.417 and 423.418 for additional information. IC: Claim requires individual consideration. See 130 CMR 423.402 for more information. PA: Service requires prior authorization. See 130 CMR 423.406 for more information. Under 21 and S.C. only: Payable service for members who are under age 21 and adults who meet the special circumstances criteria as stated in the Dental Manual. See 130 CMR 420.432 in the Dental Manual for more information. Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-2 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 10121 12045 15155 10180 12046 15156 11010 12047 15157 11011 12054 15200 11012 12055 15201 11042 12056 15220 11043 12057 15221 11044 13100 15240 11404 13101 15241 11406 13120 15260 11424 13121 15261 11426 13131 15300 11444 13132 15301 11446 13150 15320 11450 13151 15321 11451 13152 15330 11462 13160 15331 11463 14000 15335 11470 14001 15336 11471 14020 15400 11604 14021 15401 11606 14040 15420 11624 14041 15421 11626 14060 15430 11644 14061 15431 11646 14300 15570 11770 14350 15572 11771 15000 15574 11772 15040 15576 11960 15050 15600 11970 15100 15610 11971 15101 15620 12005 15110 15630 12006 15111 15650 12007 15115 15732 12016 15116 15734 12017 15120 15736 12018 15121 15738 12020 15130 15740 12021 15131 15750 12034 15135 15760 12035 15136 15770 12036 15150 15820 (PA) 12037 15151 15821 (PA) 12044 15152 15822 (PA) Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-3 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 15823 (PA) 19290 21031 15831 (PA) 19291 21034 15832 (PA) 19318 (PA) 21040 15833 (PA) 19328 (PA) 21044 15834 (PA) 19330 (PA) 21046 15835 19340 (PA) 21047 15840 19342 (PA) 21050 15841 19350 (PA) 21060 15845 19357 (PA) 21070 15920 19366 (PA) 21100 15922 19370 (PA) 21181 15931 19371 (PA) 21206 (PA) 15933 19380 (PA) 21208 (PA) 15934 20005 21209 (PA) 15935 20200 21210 (PA) 15936 20205 21215 (PA) 15937 20206 21230 (PA) 15940 20220 21235 (PA) 15941 20225 21240 (PA) 15944 20240 21242 (PA) 15945 20245 21243 (PA) 15946 20250 21244 (PA) 15950 20251 21267 (PA) 15951 20525 21270 (PA) 15952 20650 21275 (PA) 15953 20670 21280 (PA) 15956 20680 21282 (PA) 15958 20690 21295 (PA) 16025 20692 21296 (PA) 16030 20693 21300 19020 20694 21310 19100 20900 21315 19101 20902 21320 19102 20910 21325 19103 20912 21330 19110 20920 21335 19112 20922 21336 19120 20924 21337 19125 20926 21338 19126 20975 21339 19140 (PA) 21010 21340 19160 21015 21345 19162 21025 21355 19180 21026 21400 19182 21029 21401 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-4 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 21421 23077 23491 21440 23100 23500 21445 23101 23505 21450 23105 23515 21451 23106 23520 21452 23107 23525 21453 23120 23530 21454 23125 23532 21461 23130 23540 21462 23140 23545 21465 23145 23550 21480 23146 23552 21485 23150 23570 21490 23155 23575 21497 23156 23585 21501 23170 23600 21502 23172 23605 21555 23174 23615 21556 23180 23616 21600 23182 23620 21610 23184 23625 21700 23190 23630 21720 23195 23650 21725 23330 23655 21800 23331 23660 21805 23395 23665 21820 23397 23670 21925 23400 23675 21930 23405 23680 21935 23406 23700 22305 23410 23800 22310 23412 23802 22315 23415 23921 22505 23420 23930 22900 23430 23931 23000 23440 23935 23020 23450 24000 23030 23455 24006 23031 23460 24066 23035 23462 24075 23040 23465 24076 23044 23466 24077 23066 23480 24100 23075 23485 24101 23076 23490 24102 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-5 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 24105 24495 25075 24110 24498 25076 24115 24500 25077 24116 24505 25085 24120 24515 25100 24125 24516 25101 24126 24530 25105 24130 24535 25107 24134 24538 25110 24136 24545 25111 24138 24546 25112 24140 24560 25115 24145 24565 25116 24147 24566 25118 24155 24575 25119 24160 24576 25120 24164 24577 25125 24201 24579 25126 24301 24582 25130 24305 24586 25135 24310 24587 25136 24320 24600 25145 24330 24605 25150 24331 24615 25151 24340 24620 25210 24341 24635 25215 24342 24655 25230 24345 24665 25240 24350 24666 25248 24351 24670 25250 24352 24675 25251 24354 24685 25260 24356 24800 25263 24360 24802 25265 24361 24925 25270 24362 25000 25272 24363 25020 25274 24365 25023 25275 24366 25024 25280 24400 25025 25290 24410 25028 25295 24420 25031 25300 24430 25035 25301 24435 25040 25310 24470 25066 25312 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-6 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 25315 25575 26123 25316 25605 26125 25320 25611 26130 25332 25620 26135 25335 25624 26140 25337 25628 26145 25350 25635 26160 25355 25645 26170 25360 25660 26180 25365 25670 26185 25370 25671 26200 25375 25675 26205 25390 25676 26210 25391 25680 26215 25392 25685 26230 25393 25690 26235 25400 25695 26236 25405 25800 26250 25415 25805 26255 25420 25810 26260 25425 25820 26261 25426 25825 26262 25440 25830 26320 25441 25907 26350 25442 25922 26352 25443 25929 26356 25444 26011 26357 25445 26020 26358 25446 26025 26370 25447 26030 26372 25449 26034 26373 25450 26040 26390 25455 26045 26392 25490 26055 26410 25491 26060 26412 25492 26070 26415 25505 26075 26416 25515 26080 26418 25520 26100 26420 25525 26105 26426 25526 26110 26428 25535 26115 26432 25545 26116 26433 25565 26117 26434 25574 26121 26437 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-7 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 26440 26555 26863 26442 26560 26910 26445 26561 26951 26449 26562 26952 26450 26565 26990 26455 26567 26991 26460 26568 27000 26471 26580 27001 26474 26587 27003 26476 26590 27033 26477 26591 27035 26478 26593 27040 26479 26596 27041 26480 26605 27047 26483 26607 27048 26485 26608 27049 26489 26615 27050 26490 26645 27052 26492 26650 27060 26494 26665 27062 26496 26675 27065 26497 26676 27066 26498 26685 27067 26499 26686 27080 26500 26705 27086 26502 26706 27087 26504 26715 27097 26508 26727 27098 26510 26735 27100 26516 26742 27105 26517 26746 27110 26518 26756 27111 26520 26765 27193 26525 26776 27194 26530 26785 27202 26531 26820 27230 26535 26841 27238 26536 26842 27246 26540 26843 27250 26541 26844 27252 26542 26850 27257 26545 26852 27265 26546 26860 27266 26548 26861 27275 26550 26862 27301 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-8 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 27305 27420 27607 27306 27422 27610 27307 27424 27612 27310 27425 27614 27315 27427 27615 27320 27428 27618 27323 27429 27619 27324 27430 27620 27327 27435 27625 27328 27437 27626 27329 27438 27630 27330 27441 27635 27331 27442 27637 27332 27443 27638 27333 27496 27640 27334 27497 27641 27335 27498 27647 27340 27499 27650 27345 27500 27652 27347 27501 27654 27350 27502 27656 27355 27503 27658 27356 27508 27659 27357 27509 27664 27358 27510 27665 27360 27516 27675 27372 27517 27676 27380 27520 27680 27381 27530 27681 27385 27532 27685 27386 27538 27686 27390 27550 27687 27391 27552 27690 27392 27560 27691 27393 27562 27692 27394 27566 27695 27395 27570 27696 27396 27594 27698 27397 27600 27700 27400 27601 27704 27403 27602 27705 27405 27603 27707 27407 27604 27709 27409 27605 27730 27418 27606 27732 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-9 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 27734 27894 28150 27740 28002 28153 27742 28003 28160 27745 28005 28171 27750 28008 28173 27752 28011 28175 27756 28020 28192 27758 28022 28193 27759 28024 28200 27760 28030 28202 27762 28035 28208 27766 28043 28210 27780 28045 28222 27781 28046 28225 27784 28050 28226 27786 28052 28234 27788 28054 28238 27792 28060 28240 27808 28062 28250 27810 28070 28260 27814 28072 28261 27816 28080 28262 27818 28086 28264 27822 28088 28270 27823 28090 28280 27824 28092 28285 27825 28100 28286 27826 28102 28288 27827 28103 28289 27828 28104 28290 27829 28106 28292 27830 28107 28293 27831 28110 28294 27832 28111 28296 27840 28112 28297 27842 28113 28298 27846 28114 28299 27848 28116 28300 27860 28118 28302 27870 28119 28304 27871 28120 28305 27884 28122 28306 27889 28126 28307 27892 28130 28308 27893 28140 28309 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-10 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 28310 28735 29871 28312 28737 29874 28313 28740 29875 28315 28750 29876 28320 28755 29877 28322 28760 29879 28340 28810 29880 28341 28820 29881 28344 28825 29882 28345 29800 (PA) 29883 28400 29804 (PA) 29884 28405 29805 29885 28406 29806 29886 28415 29807 29887 28420 29819 29888 28435 29820 29889 28436 29821 29891 28445 29822 29892 28456 29823 29893 28465 29824 29894 28476 29825 29895 28485 29826 29897 28496 29827 29898 28505 29830 29899 28525 29834 29900 28531 29835 29901 28545 29836 29902 28546 29837 30115 28555 29838 30117 28575 29840 30118 28576 29843 30120 28585 29844 30125 28605 29845 30130 28606 29846 30140 28615 29847 30150 28635 29848 30160 28636 29850 30310 28645 29851 30320 28665 29855 30400 (PA) 28666 29856 30410 (PA) 28675 29860 30420 (PA) 28705 29861 30430 (PA) 28715 29862 30435 (PA) 28725 29863 30450 (PA) 28730 29870 30460 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-11 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 30462 31276 31629 30465 31287 31630 30520 31288 31631 30540 31300 31635 30545 31320 31640 30560 31400 31641 30580 31420 31643 30600 31510 31645 30620 31511 31646 30630 31512 31656 30801 31513 31700 30802 31515 31717 30903 31525 31720 30905 31526 31730 30906 31527 31750 30915 31528 31755 30920 31529 31820 30930 31530 31825 31020 31531 31830 31030 31535 32000 31032 31536 32400 31050 31540 32405 31051 31541 32420 31070 31560 33010 31075 31561 33011 31080 31570 33222 31081 31571 33223 31084 31576 35188 31085 31577 35207 31086 31578 35875 31087 31580 35876 31090 31582 36260 31200 31588 36261 31201 31590 36262 31205 31595 36488 31233 31611 36489 31235 31612 36490 31237 31613 36491 31238 31614 36530 31239 31615 36531 31240 31622 36532 31254 31623 36533 31255 31624 36534 31256 31625 36535 31267 31628 36555 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-12 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 36556 37735 40843 (PA) 36557 37760 40844 (PA) 36558 37780 40845 (PA) 36560 37785 41005 36561 37790 41006 36563 38300 41007 36565 38305 41008 36566 38308 41009 36568 38500 41010 36569 38505 41015 36570 38510 41016 36571 38520 41017 36575 38525 41018 36576 38530 41112 36578 38542 41113 36580 38550 41114 36581 38555 41116 36582 38570 41120 36583 38571 41250 36584 38572 41251 36585 38740 41252 36589 38745 41500 36590 38760 41510 36640 40500 41520 36800 40510 41800 36810 40520 41827 36815 40525 42000 36819 40527 42107 36820 40530 42120 36821 40650 42140 (PA) 36825 40652 42145 36830 40654 42180 36831 40700 42182 36832 40701 42200 36833 40720 42205 36835 40761 42210 36860 40801 42215 36861 40806 42220 36870 40814 42226 37607 40816 42235 37609 40818 42260 37650 40819 42300 37700 40831 42305 37718 40840 (PA) 42310 37722 40842 (PA) 42320 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-13 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 42972 43271 42340 43200 43272 42405 43201 43450 42408 43202 43453 42409 43204 43456 42410 43205 43458 42415 43215 43600 42420 43216 43653 42425 43217 43750 42440 43219 43760 42450 43220 43870 42500 43226 44100 42505 43227 44312 42507 43228 44340 42508 43231 44360 42509 43232 44361 42510 43234 44363 42600 43235 44364 42700 43236 44365 42720 43239 44366 42725 43240 44369 42800 43241 44370 42802 43242 44372 42804 43243 44373 42806 43244 44376 42808 43245 44377 42810 43246 44378 42815 43247 44379 42820 43248 44380 42821 43249 44382 42825 43250 44383 42826 43251 44385 42830 43255 44386 42831 43256 44388 42835 43258 44389 42836 43259 44390 42860 43260 44391 42870 43261 44392 42890 43262 44393 42892 43263 44394 42900 43264 45000 42950 43265 45005 42955 43267 45020 42960 43268 45100 42962 43269 45108 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-14 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 45150 46200 47630 45160 46210 48102 45170 46211 49080 45190 46220 49081 45305 46250 49085 45307 46255 49180 45308 46257 49250 45309 46258 49320 45315 46260 49321 45317 46261 49322 45320 46262 49420 45321 46270 49421 45331 46275 49422 45332 46280 49426 45333 46285 49495 45334 46288 49496 45335 46608 49500 45337 46610 49501 45338 46611 49505 45339 46612 49507 45340 46615 49520 45355 46700 49521 45378 46750 49525 45379 46753 49540 45380 46754 49550 45381 46760 49553 45382 46761 49555 45383 46762 49557 45384 46917 49560 45385 46922 49561 45386 46924 49565 45500 46937 49566 45505 46938 49568 45560 47000 49570 45900 47510 49572 45905 47511 49580 45910 47525 49582 45915 47530 49585 46020 47552 49587 46030 47553 49590 46040 47554 49600 46045 47555 49650 46050 47556 49651 46060 47560 50200 46080 47561 50390 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-15 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 50392 52204 52606 50393 52214 52612 50395 52224 52614 50396 52234 52620 50398 52235 52630 50551 52240 52640 50553 52250 52647 50555 52260 52648 50557 52270 52700 50561 52275 53000 50590 52276 53010 50688 52277 53020 50947 52281 53040 50948 52282 53080 50951 52283 53200 50953 52285 53210 50955 52290 53215 50957 52300 53220 50961 52305 53230 50970 52310 53235 50972 52315 53240 50974 52317 53250 50976 52318 53260 50980 52320 53265 51010 52325 53270 51020 52327 (PA) 53275 51030 52330 53400 51040 52332 53405 51045 52334 53410 51050 52341 53420 51065 52342 53425 51080 52343 53430 51500 52344 53431 51520 52345 53440 51710 52346 53442 51715 (PA) 52351 53444 51726 52352 53445 51772 52353 53446 51785 52354 53447 51880 52355 53449 52000 52400 53450 52001 52450 53460 52005 52500 53502 52007 52510 53505 52010 52601 53510 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-16 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 53515 54401 (PA) 55535 53520 54405 (PA) 55540 53605 54406 55550 53665 54408 55680 53850 (PA) 54410 55700 54000 54415 55705 54001 54416 55720 54015 54420 55725 54057 54435 55859 54060 54440 56440 54065 54450 56441 54100 54500 56515 54105 54505 56620 54110 54512 56625 54111 54520 56700 54112 54522 56720 54115 54530 56740 54120 54550 56800 54150 54600 56810 54152 54620 57000 54160 54640 57010 54161 54660 57020 54162 54670 57023 54163 54680 57065 54164 54690 57105 54205 54700 57130 54220 54800 57135 54300 54820 57180 54304 54830 57200 54308 54840 57210 54312 54860 57220 54316 54861 57230 54318 55040 57240 54322 55041 57250 54324 55060 57260 54326 55100 57265 54328 55110 57268 54340 55120 57289 54344 55150 57291 54348 55175 57300 54352 55180 57400 54360 55250 (CS-18 or CS-21) 57410 54380 55500 57415 54385 55520 57513 54400 (PA) 55530 57520 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-17 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 57522 61020 64417 57530 61026 64420 57550 61050 64421 57555 61055 64430 57556 61070 64470 57700 61215 64472 57720 61790 64475 57820 61791 64476 58120 61885 64479 58145 61886 64480 58350 61888 64483 58353 62194 64484 58545 62225 64510 58546 62230 64520 58550 62263 64530 58555 62268 64553 58558 62269 64573 58559 62270 64575 58560 (CS-18 or CS-21) 62272 64577 58561 (CS-18 or CS- 21) 62273 64580 58562 62280 64585 58563 62281 64590 58565 (CS-18 or CS- 21) 62282 64595 58660 62287 64600 58661 (CS-18 or CS-21) 62294 64605 58662 62310 64610 58670 (CS-18 or CS-21) 62311 64620 58671 (CS-18 or CS-21) 62318 64622 58672 62319 64623 58673 62350 64626 58800 62355 64627 58820 62360 64630 58900 62361 64680 59160 62362 64702 59320 62365 64704 59812 63600 64708 59820 63610 64712 59821 63650 64713 59840 (CPA-2) 63660 64714 59841 (CPA-2) (first trimester) 63685 64716 59870 63688 64718 59871 63744 64719 60000 63746 64721 60200 64410 64722 60280 64415 64726 60281 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-18 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 64727 64886 65772 64732 64890 65775 64734 64891 65800 64736 64892 65805 64738 64893 65810 64740 64895 65815 64742 64896 65850 64744 64897 65865 64746 64898 65870 64771 64901 65875 64772 64902 65880 64774 64905 65900 64776 64907 65920 64778 65091 65930 64782 65093 66020 64783 65101 66030 64784 65103 66130 64786 65105 66150 64787 65110 66155 64788 65112 66160 64790 65114 66165 64792 65130 66170 64795 65135 66172 64802 65140 66180 64821 65150 66185 64831 65155 66220 64832 65175 66225 64834 65235 66250 64835 65260 66500 64836 65265 66505 64837 65270 66600 64840 65272 66605 64856 65275 66625 64857 65280 66630 64858 65285 66635 64859 65290 66680 64861 65400 66682 64862 65410 66700 64864 65420 66710 64865 65426 66720 64870 65710 66740 64872 65730 66821 64874 65750 66825 64876 65755 66830 64885 65770 66840 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-19 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 66850 67405 68330 66852 67412 68335 66920 67413 68340 66930 67415 68360 66940 67420 68362 66982 67430 68500 66983 67440 68505 66984 67450 68510 66985 67550 68520 66986 67560 68525 67005 67715 68540 67010 67808 68550 67015 67830 68700 67025 67835 68720 67027 67880 6874568750 67030 67882 68770 67031 67900 (PA) 68810 67036 67901 (PA) 68811 67038 67902 (PA) 68815 67039 67903 (PA) 69110 67040 67904 (PA) 69120 67107 67906 (PA) 69140 67108 67908 (PA) 69145 67112 67909 (PA) 69150 67115 67911 (PA) 69205 67120 67914 69300 (PA) 67121 67916 (PA) 69310 67141 67917 (PA) 69320 67218 67921 69421 67227 67923 (PA) 69436 67250 67924 (PA) 69440 67255 67935 69450 67311 67950 69501 67312 67961 (PA) 69502 67314 67966 (PA) 69505 67316 67971 (PA) 69511 67318 67973 (PA) 69530 67320 67974 (PA) 69550 67331 67975 (PA) 69552 67332 68115 69601 67334 68130 69602 67335 68320 69603 67340 68325 69604 67350 68326 69605 67400 68328 69620 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-20 Transmittal Letter FAS-15 Date 05/01/06 601 Surgery Service Codes (cont.) Service Code 69631 69632 69633 69635 69636 69637 69641 69642 69643 69644 69645 69646 69650 69660 69661 69662 69666 69667 69670 69676 69700 69711 69714 69715 69717 69718 69720 69725 69740 69745 69801 69802 69805 69806 69820 69840 69905 69910 69915 69930 (PA) Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-21 Transmittal Letter FAS-15 Date 05/01/06 602 Periodontic Service Codes and Descriptions Service Code Description Surgical Services (Includes Usual Postoperative Services) D4210 Gingivectomy or gingivoplasty—four or more contiguous teeth or bounded teeth spaces per quadrant (once per quadrant per three-year period) (under 21 and S.C. only) (PA) D4341 Periodontal scaling and root planing—four or more contiguous teeth or bounded teeth spaces per quadrant (includes curettage) (once per quadrant per three-year period) (under 21 and S.C. only (P.A) 603 Exodontic Service Codes and Descriptions Service Code Description Extractions (Includes Local Anesthesia and Routine Postoperative Care) D7111 Coronal remnants – deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth D7220 Removal of impacted tooth—soft tissue (PA) D7230 Removal of impacted tooth—partially bony (PA) D7240 Removal of impacted tooth—completely bony (PA) D7283 Placement of device to facilitate eruption of impacted tooth (under 21 only) (PA) 604 Dental Surgery Procedures Service Code Description D7310 Alveoloplasty in conjunction with extactions—per quadrant D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions—per quadrant D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant D7340 Vestibuloplasty—ridge extension (second epithelialization) (PA) D7960 Frenulectomy (frenectomy or frenotomy)—separate procedure D7963 Frenuloplasty D7970 Excision of hyperplastic tissue—per arch (PA) D7999 Unspecified oral surgery procedure, by report (P.A) (IC) D9930 Treatment of complications (postsurgical) – unusual circumstances, by report (IC) Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6 Service Codes Page 6-22 Transmittal Letter FAS-15 Date 05/01/06 605 Prosthetic Service Codes and Descriptions Service Code Description Integumentary System L8500 Artificial larynx, any type (IC) L8501 Tracheostomy speaking valve (IC) L8510 Voice amplifier (IC) L8600 Implantable breast prosthesis, silicone or equal (IC) L8603 Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies (IC) L8606 Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies (IC) Head: Skull, Facial Bones, and Temporomandibular Joint L8610 Ocular implant (IC) L8612 Aqueous shunt (IC) L8613 Ossicular implant (IC) L8614 Cochlear device/system (IC) L8619 Cochlear implant external speech processor, replacement (IC) Upper Extremity L8630 Metacarpophalangeal joint implant (IC) Lower Extremity — Joint: Knee, Ankle, Toe L8641 Metatarsal joint implant (IC) L8642 Hallux implant (IC) L8658 Interphalangeal joint spacer, silicone or equal, each (IC) Cardiovascular System L8670 Vascular graft material, synthetic, implant (IC) 606 Modifiers 50 Bilateral procedure 51 Multiple procedures 73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia 74 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title Appendix E. Admission Guidelines Page E-1 Transmittal Letter FAS-15 Date 05/01/06 Acute Inpatient Hospital Admission Guidelines A. Introduction This appendix is intended to help providers make appropriate decisions about the medical necessity of acute inpatient hospital admissions. If the admission is medically necessary in accordance with 130 CMR 450.204, payment is still subject to all general conditions of MassHealth payment, including member eligibility, other insurance, and program restrictions, including but not limited to 130 CMR 423.000, 130 CMR 410.414 (see Section E of this appendix) and 130 CMR 415.414 (see Section C of this appendix). B. Definitions The reimbursability of services defined below is not determined by these definitions, but by application of MassHealth regulations referenced in 130 CMR 450.000 and in section A above. Inpatient Services — medical services provided to a member admitted to an acute inpatient hospital. Observation Services — outpatient hospital services provided anywhere in an acute inpatient hospital, to evaluate a member’s condition and determine the need for admission to an acute inpatient hospital. Observation services are provided under the order of a physician, consist of the use of a bed and intermittent monitoring by professional licensed clinical staff, and may be provided for more than 24 hours. Outpatient Hospital Services — medical services provided to a member in a hospital outpatient department. Such services include, but are not limited to, emergency services, primary-care services, observation services, ancillary services, day-surgery services, and recovery-room services. Outpatient Services — medical services provided to a member in an outpatient setting including but not limited to hospital outpatient departments, hospital- licensed health centers, physicians’ offices, nurse practitioners’ offices, freestanding ambulatory surgery centers, day treatment centers, or the member’s home. C. Medical Determination [excerpted from MassHealth acute inpatient hospital regulations at 130 CMR 415.414] To support the medical necessity of an inpatient admission, the provider must adequately document in the member’s medical record that a provider with applicable expertise expressly determined that the member required services involving a greater intensity of care than could be provided safely and effectively in an outpatient setting. Such a determination may take into account the amount of time the member is expected to require inpatient services, but must not be based solely on this factor. The decision to admit is a medical determination that is based on factors, including but not limited to the: (1) member’s medical history; (2) member’s current medical needs; (3) severity of the signs and symptoms exhibited by the member; (4) medical predictability of an adverse clinical event occurring with the member; (5) results of outpatient diagnostic studies; (6) types of facilities available to inpatients and outpatients; and (7) MassHealth Acute Inpatient Hospital Admission Guidelines (in section D of this appendix). Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title Appendix E. Admission Guidelines Page E-2 Transmittal Letter FAS-15 Date 05/01/06 D. Acute Inpatient Hospital Admission Guidelines What follows is a list of examples of admissions that are not medically necessary. This is not an all-inclusive list. MassHealth or its agent may also determine that other inpatient admissions not characterized in this list are medically unnecessary and that MassHealth will not pay the inpatient claim. 1. The admission occurs following observation services, and the admitting provider has not documented at least one of the following in the medical record at the time the decision to admit is made: • Failure to respond to outpatient treatment and a clear deterioration of the patient’s clinical status; • a significant probability that the treatment plan will continue to need frequent clinical modifications and what specific modifications are necessary; • instability of the patient that is a deviation from either normal clinical parameters or the patient’s baseline; or • a requirement for more intensive services than were already being delivered while the patient was on observation status, and a physician’s order for each specific new service. 2. The admission occurs when the member’s condition had improved significantly in response to outpatient treatment with a progression toward either normal clinical parameters or the member’s baseline. 3. The admission is for further monitoring or observing for potential complications when the member undergoes a procedure that is appropriately performed in an outpatient setting according to the current standards of care, the procedure is performed without complications, and the member’s clinical status is approaching either normal clinical parameters or his or her baseline. 4. The admission is primarily for providing or monitoring the services and treatment of a member with multiple or complex medical needs whose needs were adequately being met in a setting other than an acute inpatient hospital prior to that admission. 5. The admission of a member whose baseline clinical status is outside of the normal clinical parameters and whose condition has been managed successfully on an outpatient basis, when the admission is based primarily on the member’s abnormal status, unless that status has significantly deteriorated. 6. The admission is primarily to observe for the possible progression of labor when examination and monitoring does not indicate definite progression of active labor leading to delivery. 7. The admission is primarily for education, teaching, minor medication changes and/or monitoring, or adjustment of therapies associated with a medically stable condition(s). 8. The admission is primarily because the member requires sedation or anesthesia in order to conduct diagnostic tests that are appropriately performed in an outpatient setting according to the current standards of care, when there are no serious complications requiring inpatient services. 9. The admission of a member whose baseline condition requires the use of complex medical technology, when the admission is primarily due to the need for such technology or other maintenance services related to the pre-existing medical condition(s), unless the member’s condition is significantly deteriorating. Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title Appendix E. Admission Guidelines Page E-3 Transmittal Letter FAS-15 Date 05/01/06 10. The admission is primarily for a continuation of treatment or monitoring that has already been delivered effectively in the home, hospital outpatient department, or other institutional setting. 11. The admission of a member who is a patient or resident in another institutional setting, and is admitted primarily for diagnostic or treatment services that could have been provided in the member’s current institutional setting or by using outpatient services. 12. The admission of a member who has simple, uncomplicated, outpatient surgery and is being admitted primarily because of the time of day or the need for postoperative observation. 13. The admission is primarily due to the: • amount of time a member has spent as an outpatient in a hospital or other outpatient setting; • time of day a member recovers from outpatient surgery; • need for education of the member, parent, or primary caretaker; • need for diagnostic testing or obtaining consultations; • need to obtain medical devices or equipment or arrange home care or other noninstitutional services; • age of the member; • convenience of the physician, hospital, member, family, or other medical provider; • type of unit within the hospital in which the member is placed; or • need for respite care. E. Observation Services [excerpted from the MassHealth outpatient hospital regulations at 130 CMR 410.414] Reimbursable Services. MassHealth covers medically necessary observation services provided by acute inpatient hospitals. Reimbursable observation services may exceed 24 hours, and do not need to be provided in a distinct observation unit. To qualify for reimbursement of observation services, the medical record must specifically document when those services began and ended, the purpose of observation, and the name of the physician who ordered it. Acute inpatient hospitals will be reimbursed for these observation services on an outpatient basis in accordance with the signed provider agreement with MassHealth. Nonreimbursable Services. (1) Nonreimbursable observation services include but are not limited to: (a) services that are not reasonable or necessary for the diagnosis or treatment of the member; and (b) routine preparation and recovery services associated with diagnostic testing or outpatient surgery. (2) The following services are not reimbursable as a separate service: (a) postoperative monitoring during a standard recovery period that should be characterized as recovery-room services; and (b) observation services provided concurrently with therapeutic services such as chemotherapy. Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title Appendix E. Admission Guidelines Page E-4 Transmittal Letter FAS-15 Date 05/01/06 This page is reserved.