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 PHY-124 January 2009 TO: Physicians Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Physician Manual (Implementation of the Child and Adolescent Needs and Strengths Tool) This letter transmits revisions to the physician regulations to implement the Child and Adolescent Needs and Strengths (CANS) tool. The CANS is a standardized behavioral-health assessment tool that MassHealth is implementing as part of the Children’s Behavioral Health Initiative (CBHI) for members under the age of 21. These regulations are effective December 26, 2008. Overview of the MassHealth CANS Requirement MassHealth providers who furnish behavioral-health services to MassHealth members under the age of 21 are required to ensure that certain clinicians are certified every two years, according to the process established by MassHealth, to use the CANS, and that those clinicians complete the CANS as part of any comprehensive evaluation before the member starts individual, group, or family therapy, and update the CANS at least every 90 days thereafter as part of the review of the member’s treatment plan. For each CANS conducted, these providers are required to document the data collected during the assessment in the member’s medical record and report it to MassHealth in a specified manner and format. Description of the CANS Tool MassHealth has developed two versions of the CANS tool: “CANS Birth through Four” and “CANS Five through Twenty.” In addition to the CANS assessment questions, both forms allow the clinician to record the determination of whether the member has a serious emotional disturbance (SED). Providers can access the two CANS forms, as well as frequently asked questions relating to them, on the MassHealth CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. Click on Information for Providers. The link for the CANS tool is under the first heading. The CBHI Web site also includes a bibliography of published papers and other resources on the CANS approach. CANS Requirements for Physicians Psychiatrists who provide individual, group, or family therapy to members under the age of 21 must complete the CANS during the initial behavioral-health assessment before the initiation of therapy and must update it every 90 days thereafter. The medical record of each member under the age of 21 who is being treated by a psychiatrist must include a CANS completed at the initial behavioral-health assessment and updated at least every 90 days thereafter. In addition, for each CANS conducted, psychiatrists must ensure that the data collected is reported to MassHealth in the format that is specified in the section entitled “CANS Reporting Requirements: “Paper CANS” and the Web-based Massachusetts CANS Application.” Completion of the CANS for Members Currently Receiving Therapy If a member has an ongoing relationship with a psychiatrist to receive individual, group, or family therapy before the effective date of these regulations, it is not necessary to perform another initial assessment, including the CANS, or to update the CANS every 90 days thereafter when the treatment plan is reviewed for that member. However, if the member leaves treatment and subsequently returns for a new course of treatment, it is necessary to perform a new initial assessment, using the CANS for that member, and to update the CANS every 90 days thereafter. CANS Certification and Training Requirements Psychiatrists who are required to use the CANS must be certified every two years by passing an online CANS certification examination. Certified psychiatrists can use both versions of the Massachusetts CANS: “CANS Birth through Four” and “CANS Five through Twenty.” MassHealth is offering online and in-person training opportunities to assist clinicians with the certification process. The in-person training is being conducted by the University of Massachusetts Medical School on various dates across the state. Participation in both the in-person and online training will be free of charge. Participation is voluntary, but encouraged. It is not necessary to participate in training in order to take the certification exam. Information about the CANS training and certification exam can be found on the Web at https://masscans.ehs.state.ma.us. This Web site provides access to the online training, the online certification exam, and the schedule of the in- person training sessions. For more information about CANS training or certification please contact the Massachusetts CANS Training Center by calling 508-856-1016 or e-mailing Mass.CANS@umassmed.edu. CANS Reporting Requirements: “Paper CANS” and the Web-based Massachusetts CANS Application MassHealth has developed a new Web-based application that permits providers to enter and view CANS data in a secure environment, subject to consent by the member, his or her custodial parent, or other authorized individual. The CANS application is accessible through the Executive Office of Health and Human Services (EOHHS) Virtual Gateway (VG) Web portal. MassHealth is rolling out the online CANS application in two stages. The first release was in December 2008. It allows users to develop familiarity with the application and asks users to document certain member demographic information and answer the questions that determine if the member has a serious emotional disturbance (SED). The second release, which is expected in the spring of 2009, will add the rest of the assessment questions from the two versions of the CANS tool. With the CANS application available online, psychiatrists are required to use this application each time the CANS is completed or updated to satisfy their CANS data reporting requirements. Until the second release of the online CANS application, which is expected in the spring of 2009, the CANS must be completed on paper and be included in the member’s medical record. Once the second release occurs, providers can choose to include a copy of the CANS in either an electronic or paper form in the member’s medical record. However, providers must be sure to exercise one of these options. At no point should a CANS form be mailed to EOHHS or MassHealth. The CANS forms are available at the MassHealth CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. Click on Information for Providers. The link for the CANS tool is under the first heading. This link will take you to PDF and RTF (for screen readers for the visually disabled) versions of the two CANS forms. Psychiatrists can obtain updated information about the release schedule for the CANS application on the CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. Providers should check this site regularly for updated information. In order to use the online CANS application, psychiatrists must ensure that the organization is enrolled with the VG and that each psychiatrist who will be entering and viewing data in the CANS application has his or her own VG user ID. In addition, the CANS application will allow data entry operators to perform certain functions on behalf of psychiatrists. Each data entry operator also needs his or her own VG user ID. Enrollment with the VG for other business applications, such as STARS or EIM/EIS, does not satisfy this requirement. For assistance in the process in obtaining access to the CANS application, psychiatrists should send the following information to VirtualGatewayCBHI@state.ma.us: * the name of the facility or organization; * the name, address, phone, and e-mail address for a CANS point-of-contact at the organization who is being identified to work with the Virtual Gateway Deployment Unit; * a statement indicating whether or not the organization has access to the VG Web portal (yes or no); * the number of clinicians who need access to the CANS application; and * a statement indicating whether or not anyone in the organization has completed the CANS training. (If yes, provide the number of individuals who have completed the training.) If you have any comments or concerns about the VG enrollment process or technical questions about the CANS application, please send them to VirtualGatewayCBHI@state.ma.us. MassHealth is developing job aids and interactive flash files for the CANS application. There will be a job aid explaining how to log onto the application. Also, there will be separate job aids for clinicians, data entry operators, and provider organization staff to help them use and navigate the various functions that they have access to in the system. The job aids will be available on the CBHI Web site at www.mass.gov/masshealth/childbehavioralhealth. In addition, for clinicians registered on the VG, the job aids and flash files will be transmitted electronically from the VG Team to provide instruction on the application. Payment for CANS: Service Code 90801-HA For dates of service on or after November 30, 2008, psychiatrists should bill for the initial behavioral-health assessment that includes the CANS as a psychiatric diagnostic interview examination, using Service Code 90801 with the modifier HA. MassHealth will reimburse psychiatrists at an enhanced rate for billing Service Code 90801-HA. To implement this requirement, the modifier HA for Service Code 90801 has been added to Subchapter 6 of the physician manual, under “Modifiers.” Only pages 6- 19 and 6-20 of Subchapter 6 are being reissued at this time. The diagnostic examination that includes the CANS tool may require two sessions. Psychiatrists may bill according to the Subchapter 6 guidelines, which limit billing to two sessions. The review and updating of the CANS required every 90 days for members in ongoing individual, group, or family therapy is part of treatment planning and documentation. As such, it is not a separately billable service. If you wish to obtain a fee schedule for Service Code 90801-HA, 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 DHCFP regulations from either the Massachusetts Book Store or from DHCFP (see addresses and telephone numbers below). The regulation title is 114.3 CMR 17.00. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp Other Changes to the Regulations The following additional changes to the physician regulations are being made at this time: * clarify references to DHCFP regulations that apply to physicians; * add language about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services; and * eliminate outdated references to the emergency department screening fee. Contact Numbers If you need technical assistance with the VG, you may contact VG Customer Assistance at 1-800-421-0938, ext. 5. If you have questions about CANS training or certification, contact the Massachusetts CANS Training Center at 508-856-1016 or e-mail your questions to Mass.CANS@umassmed.edu. 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.) Physician Manual Pages iv, iv-a, 4-1, 4-2, 4-5 through 4-8, 4-11 through 4-16, 4-25, 4-26, 4-39, 4-40, 6-19, and 6-20 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Physician Manual Page iv — transmitted by Transmittal Letter PHY-116 Pages iv-a, 4-39, and 4-40 — transmitted by Transmittal Letter PHY-122 Pages 4-1, 4-2, 4-5 through 4-8, 4-11, 4-12, 4-25, and 4-26 — transmitted by Transmittal Letter PHY-109 Pages 4-13 through 4-16 — transmitted by Transmittal Letter PHY-117 Pages 6-19 and 6-20 — transmitted by Transmittal Letter PHY-121 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Physician Manual Transmittal Letter PHY-124 Date 12/26/08 4. Program Regulations Part 1. General Information 433.401: Definitions 4-1 433.402: Eligible Members 4-6 433.403: Provider Eligibility 4-6 433.404: Nonpayable Circumstances 4-7 433.405: Maximum Allowable Fees 4-8 433.406: Individual Consideration 4-8 433.407: Service Limitations: Medical and Radiology Services 4-9 433.408: Prior Authorization 4-10 433.409: Recordkeeping (Medical Records) Requirements 4-11 433.410: Report Requirements 4-13 433.411: Child and Adolescent Needs and Strengths (CANS) Data Reporting 4-13 433.412: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services 4-13 Part 2. Medical Services 433.413: Office Visits: Service Limitations 4-14 433.414: Hospital Emergency Department and Outpatient Department Visits 4-14 433.415: Hospital Services: Service Limitations and Screening Requirements 4-15 433.416: Nursing Facility Visits: Service Limitations 4-15 433.417: Home Visits: Service Limitations 4-15 433.418: Consultations: Service Limitations 4-16 433.419: Nurse Midwife Services 4-16 433.420: Obstetric Services: Introduction 4-17 433.421: Obstetric Services: Global-Fee Method of Payment 4-17 (130 CMR 433.422 and 433.423 Reserved) 433.424: Obstetric Services: Fee-for-Service Method of Payment 4-20 433.425: Ophthalmology Services 4-20 433.426: Audiology Services: Service Limitations 4-21 433.427: Allergy Testing: Service Limitations 4-21 433.428: Psychiatry Services: Introduction 4-22 433.429: Psychiatry Services: Scope of Services 4-23 433.430: Dialysis: Service Limitations 4-26 433.431: Physical Medicine: Service Limitations 4-26 433.432: Other Medical Procedures 4-26 433.433: Nurse Practitioner Services 4-27 433.434: Physician Assistant Services 4-28 433.435: Tobacco Cessation Services 4-30 433.436: Radiology Services: Introduction 4-32 433.437: Radiology Services: Service Limitations 4-32 433.438: Clinical Laboratory Services: Introduction 4-33 433.439: Clinical Laboratory Services: Service Limitations 4-34 (130 CMR 433.440 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv-a Physician Manual Transmittal Letter PHY-124 Date 12/26/08 4. Program Regulations (cont.) 433.441: Pharmacy Services: Prescription Requirements 4-35 433.442: Pharmacy Services: Covered Drugs and Medical Supplies 4-36 433.443: Pharmacy Services: Limitations on Coverage of Drugs 4-37 433.444: Pharmacy Services: Insurance Coverage 4-38 433.445: Pharmacy Services: Prior Authorization 4-39 433.446: Pharmacy Services: Member Copayments 4-40 433.447: Pharmacy Services: Payment 4-40 (130 CMR 433.448 and 433.450 Reserved) Part 3. Surgery Services 433.451: Surgery Services: Introduction 4-41 433.452: Surgery Services: Payment 4-41 (130 CMR 433.453 Reserved) 433.454: Anesthesia Services 4-44 433.455: Abortion Services 4-45 433.456: Sterilization Services: Introduction 4-46 433.457: Sterilization Services: Informed Consent 4-47 433.458: Sterilization Services: Consent Form Requirements 4-48 433.459: Hysterectomy Services 4-49 (130 CMR 433.460 through 433.465 Reserved) Part 4. Other Services 433.466: Durable Medical Equipment and Medical/Surgical Supplies: Introduction 4-51 433.467: Durable Medical Equipment and Medical/Surgical Supplies: Prescription Requirements 4-51 433.468: Durable Medical Equipment and Medical/Surgical Supplies: Prior- Authorization Requirements 4-52 433.469: Oxygen and Respiratory Therapy Equipment 4-52 433.470: Transportation Services 4-53 433.471: Therapy, Speech and Hearing Clinic, and Amputee Clinic Services 4-54 433.472: Mental Health Services 4-55 (130 CMR 433.473 through 433.475 Reserved) 433.476: Alternatives to Institutional Care: Introduction 4-58 433.477: Alternatives to Institutional Care: Adult Foster Care 4-58 433.478: Alternatives to Institutional Care: Home Health Services 4-58 433.479: Alternatives to Institutional Care: Private Duty Nursing Services 4-59 433.480: Alternatives to Institutional Care: Adult Day Health Services 4-59 433.481: Alternatives to Institutional Care: Independent Living Programs 4-60 433.482: Alternatives to Institutional Care: Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) 4-60 433.483: Alternatives to Institutional Care: Day Habilitation Centers 4-61 433.484: The Massachusetts Special Education Law (Chapter 766) 4-61 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-1 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 Part 1. General Information 433.401: Definitions The following terms used in 130 CMR 433.000 have the meanings given in 130 CMR 433.401 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 433.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 433.000 and in 130 CMR 450.000. Adult Office Visit – a medical visit by a member 21 years of age or older to a physician's office or to a hospital outpatient department. Child and Adolescent Needs and Strengths (CANS) – a tool that provides a standardized way to organize information gathered during behavioral-health clinical assessments. A Massachusetts version of the tool has been developed and is intended to be used as a treatment decision support tool for behavioral- health providers serving MassHealth members under the age of 21. Community-Based Physician – any physician, excluding interns, residents, fellows, and house officers, who is not a hospital-based physician. Consultant – a licensed physician whose practice is limited to a specialty and whose written advice or opinion is requested by another physician or agency in the evaluation or treatment of a member's illness or disability. Consultation – a visit made at the request of another physician. Controlled Substance – a drug listed in Schedule II, III, IV, V, or VI of the Massachusetts Controlled Substances Act (M.G.L. c. 94C). Cosmetic Surgery – a surgical procedure that is performed for the exclusive purpose of altering appearance and is unrelated to physical disease or defect, or traumatic injury. Couple Therapy – therapeutic services provided to a couple for whom the disruption of their marriage, family, or relationship is the primary reason for seeking treatment. Diagnostic Radiology Service – a radiology service intended to identify an injury or illness. Domiciliary – for use in the member's place of residence, including a long-term- care facility. Drug – a substance containing one or more active ingredients in a specified dosage form and strength. Each dosage form and strength is a separate drug. Emergency Admission Service – a complete history and physical examination by a physician of a member admitted to a hospital to treat an emergency medical condition, when definitive care of the member is assumed subsequently by another physician on the day of admission. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-2 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 Emergency Medical Condition – a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of the member or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in §1867(e)(1)(B) of the Social Security Act, 42 U.S.C. §1395dd(e)(1)(B). Emergency Services – medical services that are furnished by a provider that is qualified to furnish such services, and are needed to evaluate or stabilize an emergency medical condition. Family Planning – any medically approved means, including diagnosis, treatment, and related counseling, that helps individuals of childbearing age, including sexually active minors, to determine the number and spacing of their children. Family Therapy – a session for simultaneous treatment of two or more members of a family. Group Therapy – application of psychotherapeutic or counseling techniques to a group of persons, most of whom are not related by blood, marriage, or legal guardianship. High-Risk Newborn Care – care of a full-term newborn with a critical medical condition or of a premature newborn requiring intensive care. Home or Nursing Facility Visit – a visit by a physician to a member at a residence, nursing facility, extended care facility, or convalescent or rest home. Hospital-Based Entity – any entity that contracts with a hospital to provide medical services to members on the same site as the hospital's inpatient facility or hospital-licensed health center. Hospital-Based Physician – any physician, excluding interns, residents, fellows, and house officers, who contracts with a hospital to provide services to members on the same site as the hospital's inpatient facility or hospital-licensed health center. Hospital-Licensed Health Center – a facility that (1) operates under a hospital's license but is not physically attached to the hospital; (2) operates within the fiscal, administrative, and clinical management of the hospital; (3) provides services to patients solely on an outpatient basis; (4) meets all regulatory requirements for participation in MassHealth as a hospital-licensed health center; and (5) is enrolled with the MassHealth agency as a hospital-licensed health center with a separate hospital-licensed health center MassHealth provider number. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-5 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 Referral – the transfer of the total or specific care of a member from one physician to another. For the purposes of 130 CMR 433.000, a referral is not a consultation. Respiratory Therapy Equipment – a product that (1) is fabricated primarily and customarily for use in the domiciliary treatment of pulmonary insufficiencies for its therapeutic and remedial effect; (2) is of proven quality and dependability; and (3) conforms to all applicable federal and state product standards. Routine Study – a set of X rays of an extremity that includes two or more views taken at one sitting. Separate Procedure – a procedure that is commonly performed as an integral part of a total service and therefore does not warrant a separate fee, but commands a separate fee when performed as a separate entity not immediately related to other services. Speech/Language Therapy – therapy services, including diagnostic evaluation and therapeutic intervention, that are designed to improve, develop, correct, rehabilitate, or prevent the worsening of speech/language communication and swallowing disorders that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Speech and language disorders are those that affect articulation of speech, sounds, fluency, voice, swallowing (regardless of presence of a communication disability), and those that impair comprehension, spoken, written, or other symbol systems used for communication. Sterilization – any medical procedure, treatment, or operation performed to make an individual permanently incapable of reproducing. Therapeutic Radiology Service – a radiology service used to treat an injury or illness. Therapy Visit – a personal contact provided as an office visit or outpatient visit for the purpose of providing a covered physical or occupational therapy service by a physician or licensed physical or occupational therapist employed by the physician. Additionally, speech therapy services provided by a physician as an office or outpatient visit is considered a therapy visit. Trimester – one of three three-month terms in a normal pregnancy. If the pregnancy has existed for less than 12 weeks, the pregnancy is in its first trimester. If the pregnancy has existed for 12 or more weeks but less than 24 weeks, the pregnancy is in its second trimester. If the pregnancy has existed for 24 or more weeks, the pregnancy is in its third trimester. Unit-Dose Distribution System – a means of packaging or distributing drugs, or both, devised by the manufacturer, packager, wholesaler, or retail pharmacist. A unit dose contains an exact dosage of medication and may also indicate the total daily dosage or the times when the medication should be taken. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-6 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 433.402: Eligible Members (A) (1) MassHealth Members. The MassHealth agency pays for physician services provided to MassHealth members, subject to the restrictions and limitations described in the MassHealth regulations. 130 CMR 450.105 describes the services covered and the members covered under each coverage type. (2) Recipients of Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106. (B) Member Eligibility and Coverage Type. For information on verifying member eligibility and coverage type, see 130 CMR 450.107. 433.403: Provider Eligibility (A) Participating Providers. (1) 130 CMR 433.000 applies to medical, radiology, laboratory, anesthesia, and surgery services provided to members by physicians participating in MassHealth as of the date of service. (2) To be eligible for payment, a physician must be physically present and actively involved in the treatment of the member. Time periods specified in the service descriptions refer to the amount of time the physician personally spends with the member, except in the instances noted where the service can be performed under the direct supervision of the physician. For surgery, the physician must be scrubbed and present in the operating room during the major portion of an operation. (B) In State. An in-state physician is a physician who is licensed by the Massachusetts Board of Registration in Medicine. (C) Out of State. An out-of-state physician must be licensed to practice in his or her state. The MassHealth agency pays an out-of-state physician for providing covered services to a MassHealth member only under the following circumstances. (1) The physician practices in a community of Connecticut, Maine, New Hampshire, New York, Rhode Island, or Vermont that is within 50 miles of the Massachusetts border and provides services to a member who resides in a Massachusetts community near the border of that physician's state. (2) The physician provides services to a member who is authorized to reside out of state by the Massachusetts Department of Children and Families. (3) The physician practices outside a 50-mile radius of the Massachusetts border and provides emergency services to a member. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-7 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 (4) The physician practices outside a 50-mile radius of the Massachusetts border and obtains prior authorization from the MassHealth agency before providing a nonemergency service. Prior authorization will be granted only for services that are not available from comparable resources in Massachusetts, that are generally accepted medical practice, and that can be expected to benefit the member significantly. To request prior authorization, the out-of-state physician or the referring physician must send the MassHealth agency a written request detailing the proposed treatment and naming the treatment facility (see the instructions for requesting prior authorization in Subchapter 5 of the Physician Manual). The MassHealth agency will notify the member, the physician, and the proposed treatment facility of its decision. If the request is approved, the MassHealth agency will assist in any arrangements needed for transportation. 433.404: Nonpayable Circumstances (A) The MassHealth agency does not pay a physician for services provided under any of the following circumstances. (1) The services were provided by a physician who individually or through a group practice has contractual arrangements with an acute, chronic, or rehabilitation hospital, medical school, or other medical institution that involve a salary, compensation in kind, teaching, research, or payment from any other source, if such payment would result in dual compensation for professional, supervisory, or administrative services related to member care. (2) The services were provided by a physician who is an attending, visiting, or supervising physician in an acute, chronic, or rehabilitation hospital but who is not legally responsible for the management of the member's case with respect to medical, surgery, anesthesia, laboratory, or radiology services. (3) The services were provided by a physician who is a salaried intern, resident, fellow, or house officer. 130 CMR 433.404 does not apply to a salaried physician when the physician supplements his or her income by providing services during off-duty hours on premises other than those of the institution that pays the physician a salary, or through which the physician rotates as part of his or her training. (4) The services were provided in a state institution by a state-employed physician or physician consultant. (5) Under comparable circumstances, the physician does not customarily bill private patients who do not have health insurance. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-8 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 (B) The MassHealth agency does not pay a physician for performing, administering, or dispensing any experimental, unproven, cosmetic, or otherwise medically unnecessary procedure or treatment, specifically including, but not limited to, sex-reassignment surgery, thyroid cartilage reduction surgery, and any other related surgeries and treatments, including pre- and post-sex- reassignment surgery hormone therapy. Notwithstanding the preceding sentence, the MassHealth agency will continue to pay for post-sex-reassignment surgery hormone therapy for which it had been paying immediately prior to May 15, 1993. (C) The MassHealth agency does not pay a physician for the treatment of male or female infertility (including, but not limited to, laboratory tests, drugs, and procedures associated with such treatment). (D) The MassHealth agency does not pay a physician for otherwise payable service codes when those codes are used to bill for circumstances that are not payable pursuant to 130 CMR 433.404. 433.405: Maximum Allowable Fees The MassHealth agency pays for physician services with rates set by the Massachusetts Division of Health Care Finance and Policy (DHCFP), subject to the conditions, exclusions, and limitations set forth in 130 CMR 433.000. DHCFP fees for physician services are contained in the following chapters of the Code of Massachusetts Regulations: (A) 114.3 CMR 14.00: Dental Services (B) 114.3 CMR 15.00: Vision Care Services and Ophthalmic Services (C) 114.3 CMR 16.00: Surgery and Related Anesthesia Care (D) 114.3 CMR 17.00: Medicine (E) 114.3 CMR 18.00: Radiology (F) 114.3 CMR 20.00: Clinical Laboratory Services 433.406: Individual Consideration (A) The MassHealth agency has designated certain services in Subchapter 6 of the Physician Manual as requiring individual consideration. This means that the MassHealth agency will establish the appropriate rate for these services based on the standards and criteria set forth in 130 CMR 433.406(B). Providers claiming payment for any service requiring individual consideration must submit with such claim a report that includes a detailed description of the service, and is accompanied by supporting documentation that may include, but is not limited to, an operative report, pathology report, or in the case of a purchase, a copy of the supplier's invoice. The MassHealth agency does not pay claims for services requiring individual consideration unless it is satisfied that the report and documentation submitted by the provider are adequate to support the claim. See 130 CMR 433.410 for report requirements. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-11 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 (E) Therapy Services Requiring Prior Authorization. Prior authorization is required for the following therapy services provided by any MassHealth provider to eligible MassHealth members. (1) more than 20 occupational-therapy visits or 20 physical-therapy visits, including group-therapy visits, for a member within a 12-month period; and (2) more than 35 speech/language therapy visits, including group-therapy visits, for a member within a 12-month period. (F) Nonphysician Services Requiring Prior Authorization. Many nonphysician services require prior authorization, and must first be ordered, or have their need substantiated, by a physician before the MassHealth agency grants such authorization. These services include, but are not limited to, the following: (1) transportation; (2) selected drugs; (3) home health services; (4) nursing facility services; (5) durable medical equipment; and (6) therapy services. 433.409: Recordkeeping (Medical Records) Requirements (A) Payment for any service listed in 130 CMR 433.000 is conditioned upon its full and complete documentation in the member's medical record. Payment for maintaining the member's medical record is included in the fee for the service. (B) In order for a medical record to document completely a service or services to a member, that record must set forth the nature, extent, quality, and necessity of care provided to the member. When the information contained in a member's medical record is not sufficient to document the service for which payment is claimed by the provider, the MassHealth agency will disallow payment for the claimed service. (C) The MassHealth agency may at its discretion request, and upon such request the physician must provide, any and all medical records of members corresponding to or documenting the services claimed, in accordance with M.G.L. c. 118E, §38, and 130 CMR 450.205. The MassHealth agency may produce, or at its option may require the physician to produce, photocopies of medical records instead of actual records when compliance with 130 CMR 433.409(C) would otherwise result in removal of medical records from the physician's office or other place of practice. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-12 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 (D) (1) Medical records corresponding to office, home, nursing facility, hospital outpatient department, and emergency department services provided to members must include the reason for the visit and the data upon which the diagnostic impression or statement of the member's problem is based, and must be sufficient to justify any further diagnostic procedures, treatments, and recommendations for return visits or referrals. Specifically, these medical records must include, but may not be limited to, the following: (a) the member's name and date of birth; (b) the date of each service; (c) the name and title of the person performing the service, if the service is performed by someone other than the physician claiming payment for the service; (d) the member's medical history; (e) the diagnosis or chief complaint; (f) clear indication of all findings, whether positive or negative, on examination; (g) any medications administered or prescribed, including strength, dosage, and regimen; (h) a description of any treatment given; (i) recommendations for additional treatments or consultations, when applicable; (j) any medical goods or supplies dispensed or prescribed; (k) any tests administered and their results; and (l) for members under the age of 21 who are being treated by a psychiatrist, a CANS completed during the initial behavioral-health assessment and updated at least once every 90 days thereafter. (2) When additional information is necessary to document the reason for the visit, the basis for diagnosis, or the justification for future diagnostic procedures, treatments, or recommendations for return visits or materials, such information must also be contained in the medical record. Basic data collected during previous visits (for example, identifying data, chief complaint, or history) need not be repeated in the member's medical record for subsequent visits. However, data that fully document the nature, extent, quality, and necessity of care provided to a member must be included for each date of service or service code claimed for payment, along with any data that update the member's medical course. (E) For inpatient visit services provided in acute, chronic, or rehabilitation hospitals, there must be an entry in the hospital medical record corresponding to and substantiating each hospital visit claimed for payment. An inpatient medical record will be deemed to document services provided to members and billed to the MassHealth agency if it conforms to and satisfies the medical record requirements set forth in 105 CMR 130.000. The physician claiming payment for any hospital inpatient visit service is responsible for the adequacy of the medical record documenting such service. The physician claiming payment for an initial hospital visit must sign the entry in the hospital medical record that documents the findings of the comprehensive history and physical examination. (F) Additional medical record requirements for radiology, psychiatry, and other services can be found in the applicable sections of 130 CMR 433.000. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-13 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 (G) Compliance with the medical record requirements set forth in, referred to in, or deemed applicable to 130 CMR 433.000 will be determined by a peer-review group designated by the MassHealth agency as set forth in 130 CMR 450.206. The MassHealth agency will refuse to pay or, if payment has been made, will consider such payment to be an overpayment as defined in 130 CMR 450.234 subject to recovery, for any claim that does not comply with the medical record requirements established or referred to in 130 CMR 433.000. Such medical record requirements constitute the standard against which the adequacy of records will be measured for physician services, as set forth in 130 CMR 450.205(B). 433.410: Report Requirements (A) General Report. A general written report or a discharge summary must accompany the physician's claim for payment for any service that is listed in Subchapter 6 of the Physician Manual as requiring a report or individual consideration (I.C.), or if the code is for an unlisted service. This report must be sufficiently detailed to enable the MassHealth agency to assess the extent and nature of the service. (B) Operative Report. For surgery procedures designated in Subchapter 6 of the Physician Manual as requiring individual consideration, the provider must attach operative notes to the claim. An operative report must state the operation performed, the name of the member, the date of the operation, the preoperative diagnosis, the postoperative diagnosis, the names of the surgeon and surgical assistants, and the technical procedures performed. 433.411: Child and Adolescent Needs and Strengths (CANS) Data Reporting For each Child and Adolescent Needs and Strengths (CANS) conducted as described in 130 CMR 433.429, the physician must report data collected during the assessment to the MassHealth agency, in the manner and format specified by the MassHealth agency. 433.412: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services The MassHealth agency pays for all medically necessary physician services for EPSDT-eligible members in accordance with 130 CMR 450.140 et seq., without regard to service limitations described in 130 CMR 433.000, and with prior authorization. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-14 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 Part 2. Medical Services 433.413: Office Visits: Service Limitations (A) Time Limit. Payment for office visits is limited to one visit per day per member per physician. (B) Office Visit and Treatment/Procedure. The physician may bill for either an office visit or a treatment/procedure, but may not bill for both an office visit and a treatment/procedure for the same member on the same date when the office visit and the treatment/procedure are performed in the same location. This limitation does not apply to tobacco cessation counseling services provided by a physician or a qualified staff member under the supervision of a physician on the same day as a visit. This limitation does not apply to a treatment/procedure that is performed as a result of an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) visit (see 130 CMR 450.140 et seq.); in such a case, the physician may bill for both an EPSDT visit and a treatment/procedure. Examples of treatment/procedures are suturing, suture removal, aspiration of a joint, and cast application or removal. X rays, laboratory tests, and certain diagnostic tests may be billed in addition to an office visit. (C) Immunization or Injection. When an immunization or injection is the primary purpose of an office or other outpatient visit, the physician may bill only for the injectable material and its administration. However, when the immunization or injection is not the primary purpose of the office or other outpatient visit, a physician may bill for both the visit and the injectable material, but not for its administration. (See 130 CMR 433.440 on drugs dispensed in a physician's office.) The MassHealth agency does not pay for the cost of the injectable material if (1) the Massachusetts Department of Public Health distributes the injectable material free of charge; or (2) its cost to the physician is $1.00 or less. (D) Family Planning Office Visits. The MassHealth agency pays for office visits provided for the purposes of family planning. The MassHealth agency pays for any family planning supplies and medications dispensed by the physician at the physician’s acquisition cost. To receive payment for the supplies and medications, the provider must attach to the claim a copy of the actual invoice from the supplier. 433.414: Hospital Emergency Department and Outpatient Department Visits (A) Emergency Department Treatment. The MassHealth agency pays a physician for medical care provided in a hospital emergency department only when the hospital's claim does not include a charge for the physician's services. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-15 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 (B) Outpatient Department Visits. The MassHealth agency pays either a physician or a hospital outpatient department, but not both, for physician services provided in an outpatient department. 433.415: Hospital Services: Service Limitations and Screening Requirements (A) Hospital inpatient visit fees apply to visits by physicians to members hospitalized in acute, chronic, or rehabilitation hospitals. Payment is limited to one visit per day per member for the length of the member's hospitalization. (B) The MassHealth agency does not routinely pay for visits to members who have undergone or who are expected to undergo surgery, since the allowable surgical fees include payment for the provision of routine inpatient preoperative and postoperative care. In unusual circumstances, however, the MassHealth agency does pay for such visits. (C) The MassHealth agency pays only the attending physician for hospital visits, with the following exceptions. (1) The MassHealth agency pays for consultations by a physician other than the attending physician. (See 130 CMR 433.418 for regulations about consultations.) (2) If it is necessary for a physician other than the attending physician to treat a hospitalized member, the other physician's services are payable. An explanation of the necessity of such visits must be attached to the claim. The MassHealth agency will review the claim and determine appropriate payment to the other physician. 433.416: Nursing Facility Visits: Service Limitations (A) Requirement for Approval of Admission. The MassHealth agency seeks to ensure that a MassHealth member receives nursing facility services only when available alternatives (see 130 CMR 433.476 through 433.483) do not meet the member's need, and that every member receiving nursing facility services is placed appropriately according to the medical eligibility criteria, in accordance with 130 CMR 456.409 through 456.411. (B) Service Limitations. Payment for a visit by a physician to members in nursing facilities or rest homes is limited to one visit per member per month, except in an emergency. Any medically necessary care required for the follow-up of a condition during the month must be billed as subsequent nursing facility care. 433.417: Home Visits: Service Limitations Payment for a visit by a physician to a member's home is limited to one visit per member per day. (For information on additional home health services covered by MassHealth, see 130 CMR 433.478.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-16 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 433.418: Consultations: Service Limitations The MassHealth agency pays for only one initial consultation per member per case episode. Additional consultation visits per episode are payable as follow-up consultations. 433.419: Nurse Midwife Services (A) General. 130 CMR 433.419 applies specifically to nurse midwives. In general, however, subject to the limitations of state law, the requirements elsewhere in 130 CMR 433.000 that apply to physicians also apply to nurse midwives, such as service limitations, recordkeeping, report requirements, and prior-authorization requirements. (B) Conditions of Payment. The MassHealth agency pays either an independent nurse midwife (in accordance with 130 CMR 433.419(C)) or the physician employer of a nonindependent nurse midwife (in accordance with 130 CMR 433.419(D)) for nurse midwife services provided by a nurse midwife when (1) the services are limited to the scope of practice authorized by state law or regulation (including but not limited to 244 CMR 4.00); (2) the nurse midwife has a current license to practice as a nurse midwife in Massachusetts from the Massachusetts Board of Registration in Nursing; and (3) the nurse midwife has a current collaborative arrangement with a physician or group of physicians, as required by state law or regulation (including but not limited to 244 CMR 4.00 and 130 CMR 433.419(C)(2)). The MassHealth agency deems this requirement to be met for nonindependent nurse midwives employed by a physician. (C) Independent Nurse Midwife Provider Eligibility. (1) Submission Requirements. Only an independent nurse midwife may enroll in MassHealth as a provider. Any nurse midwife applying to participate as a provider in MassHealth must submit documentation, satisfactory to the MassHealth agency, that he or she is (a) a member of a group practice comprising physicians and other practitioners and is compensated by the group practice in the same manner as the physicians and other practitioners in the group practice; (b) a member of a group practice that solely comprises nurse midwives; or (c) in a solo private practice. (2) Collaborative Arrangement Requirements. The independent nurse midwife’s collaborating physician must be a MassHealth provider who engages in the same type of clinical practice as the nurse midwife. The nurse midwife must practice in accordance with written guidelines developed in conjunction with the collaborating physician as set forth in 244 CMR 4.00. The nurse midwife must submit to the MassHealth agency thorough documentation of the collaborative arrangement, including guidelines and any written agreement signed by the nurse midwife and the collaborating physician or physicians. The guidelines must specify (a) the services the nurse midwife is authorized to perform under the collaborative arrangement; and (b) the established procedures for common medical problems. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-25 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 (N) Hospital Inpatient Visit. A visit to a hospitalized member is payable only as a hospital visit (see 130 CMR 433.415) unless at least 15 minutes of psychotherapy is provided. Payment will be made for only one visit per member per day. (O) Routine Inpatient Care. The MassHealth agency pays for a maximum of three weeks of routine inpatient care without prior authorization if the admission has received a preadmission screening number from the MassHealth agency or its agent in accordance with 130 CMR 433.415(A). Routine inpatient care includes the following services. The amounts of services listed are the maximum payable; fewer services may be provided. (1) During the first week of hospitalization, the MassHealth agency pays for the following: (a) for an initial evaluation: (i) up to three hours for a member under 19 years of age; and (ii) up to two hours for a member aged 19 or older; (b) for individual psychotherapy, regulation of medication, family therapy, family consultation, or case consultation: (i) up to five hours for a member under 19 years of age; and (ii) up to three hours for a member aged 19 or older; and (c) for daily psychiatric-related medical care, which includes a limited examination or evaluation, treatment, and follow-up visits: (i) up to one day for a member under 19 years of age; and (ii) up to three days for a member aged 19 or older. (2) During each of the second and third weeks of hospitalization, the MassHealth agency pays a psychiatrist for the following: (a) for individual psychotherapy, regulation of medication, family therapy, family consultation, or case consultation: (i) up to five hours for a member under 19 years of age; and (ii) up to three hours for a member aged 19 or older; and (b) for daily psychiatric-related medical care, which includes a limited examination or evaluation, treatment, and follow-up visits: (i) up to two days for a member under 19 years of age; and (ii) up to four days for a member aged 19 years or older. (3) The MassHealth agency pays for only one type of service a day. (4) In order to be payable, individual psychotherapy, regulation of medication, and daily medical care must involve face-to-face contact between the psychiatrist and the member. (5) For extended hospitalization, if the hospital has complied with the MassHealth agency's concurrent review process, the MassHealth agency pays a psychiatrist for the services described in 130 CMR 433.429(O)(2), that is, for the same amount of services payable in the second and third weeks. (P) Child and Adolescent Needs and Strengths (CANS). Any psychiatrist who provides individual, group, or family therapy to members under the age of 21 must be certified every two years according to the process established by the Executive Office of Health and Human Services (EOHHS) to administer the CANS, must use the CANS during initial behavioral-health assessments before the initiation of therapy, and must update the CANS at least every 90 days thereafter during the treatment review process. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-26 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 433.430: Dialysis: Service Limitations (A) Medicare Coverage. Medicare is the primary source of payment for medical care to persons of any age who have chronic renal disease and who require hemodialysis or a kidney transplant. Members being treated for chronic renal disease must be referred to a MassHealth Enrollment Center or their Social Security Administration office to determine Medicare eligibility. (B) Service Limitations. The MassHealth agency pays for hemodialysis only to hospitalized members who are (1) being dialyzed for acute renal failure; (2) receiving initial dialysis for chronic renal failure prior to continuing chronic maintenance dialysis; or (3) receiving dialysis for complications of chronic maintenance dialysis. 433.431: Physical Medicine: Service Limitations (A) The services listed in 130 CMR 433.431 are payable only when the physician prescribes the needed therapy, and the services are provided by the physician or by a licensed physical or occupational therapist employed by the physician, subject to all general conditions of payment, including the requirement to obtain prior authorization as described in 130 CMR 433.408. (B) Physical medicine services include, but are not limited to, superficial or deep-heat modalities, therapeutic exercise, traction, hydrotherapy, prosthetics and orthotics training, activities of daily living and ambulation training, range of motion, and manual muscle strength assessment. Other restorative services are covered by MassHealth upon referral by a physician (see 130 CMR 433.471). (C) (1) The MassHealth agency pays for the establishment of a maintenance program and the training of the member, member’s family, or other persons to carry it out, as part of a regular treatment visit, not as a separate service. The MassHealth agency does not pay for performance of a maintenance program, except as provided in 130 CMR 433.431(C)(2). (2) In certain instances, the specialized knowledge and judgment of a licensed physician or licensed therapist may be required to perform services that are part of a maintenance program, to ensure safety or effectiveness that may otherwise be compromised due to the member’s medical condition. At the time the decision is made that the services must be performed by a licensed physician or a licensed therapist, all information that supports the medical necessity for performance of such services by a licensed physician or licensed therapist, rather than a nonphysician or non-therapist, must be documented in the medical record. 433.432: Other Medical Procedures (A) Cardiovascular and Other Vascular Studies. Fees for cardiovascular services and other vascular studies include payment for laboratory procedures, interpretations, and physician services (except surgery and anesthesia services), unless otherwise stated. These services may be billed in addition to an office visit. (B) Cardiac Catheterization. Fees for cardiac catheterization are for the physician's services only and include payment for the usual preassessment of the cardiac problem and the recording of intracardiac pressure. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-39 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 MassHealth-covered medications. (2) Medicare Part D One-Time Supplies. The MassHealth agency pays for one-time supplies of prescribed medications, as described in 130 CMR 406.414(C)(2)(a) and (b), if the medication is a MassHealth-covered medication and the MassHealth member would otherwise be entitled to MassHealth pharmacy benefits but for being eligible for Medicare prescription drug coverage. MassHealth prior authorization does not apply to such one-time supplies. The MassHealth agency pays for the one-time supplies in all instances in which the pharmacist cannot bill a Medicare Part D prescription drug plan at the time the prescription is presented. The MassHealth agency pays for a one-time 72-hour supply of prescribed medications. (3) Cost-Sharing Assistance for MassHealth Members Enrolled in a Medicare Part D Prescription Drug Plan. For the purpose of 130 CMR 433.444(C)(3)(a) and (b), the “applicable MassHealth copayment” is the copayment the MassHealth member would pay for prescription drugs if the drugs were covered by MassHealth and not covered by Medicare Part D. MassHealth members who are enrolled in a Medicare Part D prescription drug plan and are charged a copayment or deductible in excess of the member’s applicable MassHealth copayment for a drug that MassHealth would otherwise cover, must pay the applicable MassHealth copayment and the MassHealth agency pays the difference between the applicable MassHealth copayment and the amount charged by the Medicare Part D prescription drug plan. 433.445: Pharmacy Services: Prior Authorization (A) Prescribers must obtain prior authorization from the MassHealth agency for drugs identified by the MassHealth agency in accordance with 130 CMR 450.303. If the limitations on covered drugs specified in 130 CMR 433.442(A) and 433.443(A) and (C) would result in inadequate treatment for a diagnosed medical condition, the prescriber may submit a written request, including written documentation of medical necessity, to the MassHealth agency for prior authorization for an otherwise noncovered drug. (B) All prior-authorization requests must be submitted in accordance with the instructions for requesting prior authorization in Subchapter 5 of the Physician Manual. If the MassHealth agency approves the request, it will notify the pharmacy and the member. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-40 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 (C) The MassHealth agency will authorize at least a 72-hour emergency supply of a prescription drug to the extent required by federal law. (See 42 U.S.C. 1396r- 8(d)(5).) The MassHealth agency acts on requests for prior authorization for a drug within a time period consistent with federal regulations. (D) Prior authorization does not waive any other prerequisites to payment such as, but not limited to, member eligibility or requirements of other health insurers. (E) The MassHealth Drug List specifies the drugs that are payable under MassHealth. Any drug that does not appear on the MassHealth Drug List requires prior authorization, as set forth in 130 CMR 406.000. MassHealth evaluates the prior-authorization status of drugs on an ongoing basis, and updates the MassHealth Drug List accordingly. 433.446: Pharmacy Services: Member Copayments Under certain conditions, the MassHealth agency requires that members make a copayment to the dispensing pharmacy for each original prescription and for each refill for all drugs (whether prescription or over-the-counter) covered by MassHealth. The copayment requirements are detailed in 130 CMR 450.130. 433.447: Pharmacy Services: Payment Drugs and biologicals dispensed in the office are payable, subject to the service limitations at 130 CMR 433.404, 433.406, and 433.443. The MassHealth agency does not pay a physician separately for drugs that are considered routine and integral to the delivery of a physician’s professional services in the course of diagnosis or treatment. Such drugs are commonly provided without charge or are included in the physician’s fee for the service. The MassHealth agency does not pay separately for any oral drugs dispensed in the office for which the physician has not requested and received prior authorization from the MassHealth agency, with the exception of oral vaccines and oral radiopharmaceuticals, which do not require prior authorization. Claims for drugs and biologicals that are listed in Subchapter 6 of the Physician Manual must include the name of the drug or biological, strength, dosage, and number of units dispensed. A copy of the invoice showing the actual acquisition cost must be attached to the claim form for drugs and/or biologicals that are listed as requiring individual consideration in Subchapter 6 of the Physician Manual, and must include the National Drug Code (NDC). Claims without this information are denied. The MassHealth agency does not pay for a biological if the Massachusetts Department of Public Health distributes the biological free of charge. Payment for drugs may be claimed in addition to an office visit. (130 CMR 433.448 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-19 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 605 Modifiers (cont.) Modifiers for Tobacco-Cessation Services (cont.) Modifier Modifer Description HQ Group counseling, at least 60-90 minutes in duration, provided by a physician TD Individual counseling provided by a registered nurse (RN) TF Individual counseling, intermediate level of care (intake/assessment counseling, at least 45 minutes in duration) provided by a physician U1 Individual counseling services provided by a tobacco-cessation counselor U2 Individual intake/assessment counseling, at least 45 minutes in duration, provided by a nurse practitioner, nurse midwife, physician assistant, registered nurse, or a tobacco-cessation counselor, under the supervision of a physician U3 Group counseling, at least 60-90 minutes in duration, provided by a nurse practitioner, nurse midwife, physician assistant, registered nurse, or a tobacco-cessation counselor, under the supervision of a physician Modifiers for Behavioral-Health Screening 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. Service Code 96110 must be accompanied by one of the modifiers listed below to indicate whether a behavioral-health need was identified. “Behavioral- health need identified” means the provider administering the screening tool, in his or her professional judgment, identified a child with a potential behavioral health services need. Modifier Modifier Description U1 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified U2 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified U3 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified U4 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified U5 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-20 Physician Manual Transmittal Letter PHY-124 Date 12/26/08 605 Modifiers (cont.) Modifiers for Behavioral-Health Screening (cont.) Modifier Modifier Description U6 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified U7 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified U8 Completed a behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified Modifier for Child and Adolescent Needs and Strengths (CANS) HA Service code 90801 must be accompanied by this modifier to indicate that the Child and Adolescent Needs and Strengths (CANS) is included in the psychiatric diagnostic interview examination. This modifier may only be billed by psychiatrists.