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 HIS-21 April 2004 TO: Hearing Instrument Specialists Participating in MassHealth FROM: Beth Waldman, Director, Office of Medicaid RE: Hearing Instrument Specialist Manual (Changes to Program Regulations) This letter transmits revisions to the Hearing Instrument Specialist Manual program regulations. These revisions are effective for dates of service on or after May 1, 2004. If you wish to obtain a fee schedule, you may purchase 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 publication. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for hearing aid dispensing services is 114.3 CMR 23.00: Hearing Aid Dispensers. 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 Changes to the Hearing Instrument Specialist Regulations Effective October 1, 2003, MassHealth pays for office visits for evaluation and management services when certain procedures are required and provided as part of the office visit. These procedures include minor office repairs for which the provider customarily charges non-MassHealth patients, cleaning of the hearing aid, and the replacement of parts such as tubing and battery doors. These visits are billable under Service Code 99499, at one unit per service provided. For example, if two hearing aids are cleaned for one member during one visit, two units of Service Code 99499 may be billed. If one hearing aid cleaning and two battery door replacements are provided, three units of Service Code 99499 may be billed. Effective for dates of service beginning May 1, 2004, MassHealth will pay for a maximum of six units of service per member per date of service. These regulations are effective May 1, 2004. MASSHEALTH TRANSMITTAL LETTER HIS-21 April 2004 Page 2 NEW MATERIAL (The pages listed here contain new or revised language.) Hearing Instrument Specialist Manual Pages vii, 4-7, 4-8, 6-1, and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Hearing Instrument Specialist Manual Pages vii, 4-7, 4-8, 6-1 and 6-2 — transmitted by Transmittal Letter HIS-20 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE PREFACE PAGE vii HEARING INSTRUMENT SPECIALIST MANUAL TRANSMITTAL LETTER HIS-21 DATE 05/01/04 The regulations and instructions, governing provider participation in MassHealth are published in the Provider Manual Series. The Division 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’s regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. 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 hearing instrument specialists, those matters are covered in 130 CMR Chapter 416.000, reproduced as Subchapter 4 in the Hearing Instrument Specialist 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 Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 416.000) PAGE 4-7 HEARING INSTRUMENT SPECIALIST MANUAL TRANSMITTAL LETTER HIS-21 DATE 05/01/04 (G) Office Visits for Evaluation and Management Services. MassHealth pays for an office visit for evaluation and management services only when one or more of the following services is required and is provided as part of the visit: (1) minor adjustments to the hearing aid to assure a proper fitting, such as an earmold adjustment, when the provider is not the provider who initially fit the hearing aid, and the provider who initially fit the hearing aid is no longer a MassHealth provider; (2) minor office repairs for which the provider customarily charges non-MassHealth patients; (3) cleaning of the hearing aid; or (4) replacement of parts such as, but not limited to, tubing, hooks, battery doors, and recasing. (H) Refitting Services/Other Professional Services. MassHealth pays for additional fitting/refitting services only where the hearing aid was dispensed more than two years prior to the date of service of the refitting services. These professional services include refitting of the aid, orientation, counseling with the member or member’s family, contact with interpreters, fitting of a loaner aid, and similar services. Payment for these services must include a face-to-face encounter with the member. Payment is made for a maximum of three visits per year. 416.417: Nonreimbursable Services MassHealth does not pay for any of the following services: (A) the rental of hearing aids; (B) hearing aids that are completely in the ear canal (CIC); (C) personal FM systems; or (D) assistive technology devices provided under 34 CFR 300.308, where such devices are maintained at the school facility for the general use of disabled students, and assistive technology services provided under 34 CFR 300.308 relating to the use of such devices. 416.418: Service Limitations MassHealth does not pay for more than one hearing aid per ear per member in a 60-month period without prior authorization in accordance with 130 CMR 416.408. One hearing aid per ear consists of either one binaural hearing-aid fitting, or two monaural hearing aids dispensed more than six months apart, with one aid dispensed for the left ear and the other dispensed for the right ear. 416.419: Recordkeeping Requirements A hearing instrument specialist must maintain a medical record for each member for a period of at least six years following the date of service. The record must contain all pertinent information about the services provided, including the date of service and the dates on which Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 416.000) PAGE 4-8 HEARING INSTRUMENT SPECIALIST MANUAL TRANSMITTAL LETTER HIS-21 DATE 05/01/04 materials were ordered and dispensed. The recordkeeping requirements are specific to each type of service and are described as follows. (A) Earmolds. The hearing instrument specialist must maintain the manufacturer's invoice indicating the actual acquisition cost for the earmold. (B) Hearing Aids. The hearing instrument specialist must maintain the following information in the member's medical record: (1) a history of the member's hearing loss and use of hearing aids. The history must contain the following information: (a) the etiology and chronology of the member's hearing loss, including the member's age at the onset of the loss and an indication of whether the hearing loss is progressive; (b) the make, model number, type, and date of purchase of each hearing aid previously worn by the member; (c) a description of any speech and hearing therapy received by the member; and (d) a description of any handicap that the member has that may impair vision or affect hearing aid use; (2) all audiological evaluations. The evaluations must have been performed no more than six months before the dispensing dates of the hearing aid; (3) a medical clearance from a physician that states that the member has no medical conditions that would prohibit the use of a hearing aid. The medical examination must have been performed no more than six months before the dispensing date of the hearing aid; and (4) the manufacturer's invoice indicating the actual acquisition cost of the hearing aid, including all discounts, and the warranty indicating the terms of repair or replacement in the event of loss of or damage to the hearing aid. (C) Replacement Hearing Aids. (1) If the member's hearing aid has been lost, the hearing instrument specialist must maintain in the member's medical record a statement from the member or someone acting on the member's behalf (for example, an immediate family member or other legal representative), that describes the circumstances of the loss of the hearing aid. (2) If the member's hearing aid has been irreparably damaged, the hearing instrument specialist must maintain in the member's medical record a statement from the manufacturer documenting that the hearing aid cannot be repaired. (D) Batteries and Accessories/Options. The hearing instrument specialist must maintain in the member's record the manufacturer's invoice indicating the actual acquisition cost of batteries or accessories/options, or both, if the cost of any item is more than $35.00. (E) Audiological Evaluation. The results of all audiological evaluations must be fully documented in the member’s record. REGULATORY AUTHORITY 130 CMR 416.000: M.G.L. c. 118E, §§ 7 and 12. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-1 HEARING INSTRUMENT SPECIALIST MANUAL TRANSMITTAL LETTER HIS-21 DATE 05/01/04 601 Service Codes and Descriptions Service Code Service Description HEARING AID SERVICES Instrument Testing 92592 Hearing aid check; monaural (provider was not the original dispenser and the instrument is older than one year) (listening check of the instrument plus sound field testing of the instrument on the patient; may or may not be performed together with a diagnostic evaluation) 92593 binaural 92594 Electroacoustic evaluation for hearing aid; monaural (real ear measurement (REM) objective test of hearing instrument performance in the patient's ear as compared to a target response and electroacoustical assessment of the performance evaluation of the hearing instrument as compared to its original factory specifications) 92595 binaural Office Visits for Evaluation and Management Services 99499 Unlisted evaluation and management service (up to a maximum of six services per member per date of service). Providers may submit a prior authorization request pursuant to 130 CMR 450.144(A) for members under 21 for units in excess of six per member per date of service. Refitting Services/Other Professional Services V5011 Fitting/orientation/checking of hearing aid Hearing Aid Purchases-Monaural V5030 Hearing aid, monaural, body worn, air conduction (P.A. if cost exceeds $500) (I.C.) V5040 Hearing aid, monaural, body worn, bone conduction (P.A. if cost exceeds $500) (I.C.) V5050 Hearing aid, monaural, in the ear (P.A. if cost exceeds $500) (I.C.) V5060 Hearing aid, monaural, behind the ear (P.A. if cost exceeds $500) (I.C.) V5246 Hearing aid, digitally programmable analog, monaural, ITE (in the ear) (P.A. if cost exceeds $500) (I.C.) V5247 Hearing aid, digitally programmable analog, monaural, BTE (behind the ear) (P.A. if cost exceeds $500) (I.C.) V5256 Hearing aid, digital, monaural, ITE (P.A. if cost exceeds $500) (I.C.) V5257 Hearing aid, digital, monaural, BTE (P.A. if cost exceeds $500) (I.C.) Hearing Aid Purchases-Binaural V5130 Binaural, in the ear (P.A. if cost exceeds $1,000) (I.C.) V5140 Binaural, behind the ear (P.A. if cost exceeds $1,000) (I.C.) V5150 Binaural, glasses (P.A. if cost exceeds $1,000) (I.C.) V5252 Hearing aid, digitally programmable, binaural, ITE (P.A. if cost exceeds $1,000) (I.C.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-2 HEARING INSTRUMENT SPECIALIST MANUAL TRANSMITTAL LETTER HIS-21 DATE 05/01/04 601 Service Codes and Descriptions (cont.) V5253 Hearing aid, digitally programmable, binaural, BTE (P.A. if cost exceeds $1,000) (I.C.) V5260 Hearing aid, digital, binaural, ITE (P.A. if cost exceeds $1,000) (I.C.) V5261 Hearing aid, digital, binaural, BTE (P.A. if cost exceeds $1,000) (I.C.) Service Code Service Description Hearing Aid Purchases-CROS and BICROS V5170 Hearing aid, CROS, in the ear (P.A. if cost exceeds $1,000) (I.C.) V5180 Hearing aid, CROS, behind the ear (P.A. if cost exceeds $1,000) (I.C.) V5190 Hearing aid, CROS, glasses (P.A. if cost exceeds $1,000) (I.C.) V5210 Hearing aid, BICROS, in the ear (P.A. if cost exceeds $1,000) (I.C.) V5220 Hearing aid, BICROS, behind the ear (P.A. if cost exceeds $1,000) (I.C.) V5230 Hearing aid, BICROS, glasses (P.A. if cost exceeds $1,000) (I.C.) Hearing Aid Purchases-Other V5070 Glasses, air conduction (I.C.) V5080 Glasses, bone conduction (I.C.) V5100 Hearing aid, bilateral, body worn (I.C.) V5274 Assistive listening device, not otherwise specified (I.C.) (Use this code only for pocket-talkers.) V5298 Hearing aid, not otherwise classified (P.A.) (I.C.) Hearing Aid Repairs, Accessories, and Related Services V5014 Repair/modification of a hearing aid (I.C.) V5264 Ear mold/insert, not disposable, any type (I.C.) V5265 Ear mold/insert, disposable, any type (I.C.) V5266 Battery for use in hearing device (per battery) V5267 Hearing aid supplies/accessories (I.C.) V5275 Ear impression, each V5299 Hearing service, miscellaneous (P.A.) (I.C.) Hearing Aid Dispensing Fees V5160 Dispensing fee, binaural V5200 Dispensing fee, CROS V5240 Dispensing fee, BICROS V5241 Dispensing fee, monaural hearing aid, any type