Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter PRT-22 July 2011 TO: Prosthetics Providers Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Prosthetics Manual (2011 HCPCS) This letter transmits revisions to the service codes in Subchapter 6 of the Prosthetics Manual to comply with federal coding mandates, incorporate coding and rate changes previously described in informational bulletins issued by the Division of Health Care Finance and Policy (DHCFP), and remind providers of certain existing prosthetic (PRT) policies and requirements. The Centers for Medicare & Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2011, and providers may consult the CMS Web site at www.cms.gov for a full description of the service codes. Prior-authorization (PA) requirements, service limits, and place-of-service codes now appear in an updated version of the interactive MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool that has been posted on the MassHealth Web site. New Prosthetics Service Code Addition Effective for Dates of Service Beginning January 1, 2011 The addition to the MassHealth service codes and descriptions included in this section is effective for dates of service on or after January 1, 2011. The following code has been added to Subchapter 6 of the Prosthetics Manual and the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool. L5961 Diagnosis Codes Providers are reminded that ICD-9-CM diagnosis codes are required on all claims. The ICD-9- CM diagnosis codes must be directly related to the service billed on the claim. Claims with Multiple Modifiers MMIS can now accept claims with multiple modifiers. Providers can now use one line instead of two. In MassHealth’s previous system, providers were required to put HCPCS service codes with different modifiers on two different lines on a claim, as follows. Claim Line 1— L5210 RT 1 unit Claim Line 2— L5210 LT 1 unit MMIS can now accept multiple modifiers, so claims would now be billed on one claim line as follows. L5210 RT LT 2 units MassHealth Transmittal Letter PRT-22 July 2011 Page 2 Signatures MassHealth has changed the requirements for who is required to sign the MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Therapeutic Shoes, Inserts, and Modifications (for diabetics) (ORT-D (8/10). The form must be signed by a doctor of medicine (MD), nurse practitioner (NP), doctor of osteopathic medicine (DO), doctor of podiatric medicine (DPM), or a physician’s assistant (PA). MassHealth’s Prescription and Medical Neccessity Review Form for Foot Orthoses, Footwear, and Modifications (for non-diabetics) (ORT-ND)(08/10) must be signed by a doctor of medicine (MD), doctor of osteopathic medicine (DO), nurse practitioner (NP), physician’s assistant (PA), or podiatrist (DPM). Invoices Service codes priced at AAC+ (adjusted acquisition cost plus markup) require current invoices. MassHealth will not accept a Web-printed invoice or order form from a manufacturer’s Web site. The invoice(s) must clearly identify which products are applicable to the HCPCS. Providers must circle the product on the invoice and annotate the applicable service code for the item to identify what is being billed. For minor part replacements and repairs that do not have invoices, if the total cost of the repair is less than $35.00, invoices are not required. However, the provider must include a work order with a summary of the description of parts repaired or replaced with a claim or a prior authorization (PA). Revised Rates DHCFP has established new rates for the new prosthetics service codes effective for dates of service beginning January 1, 2011. The DHCFP fee schedule and informational bulletins can be viewed on the DHCFP Web site at www.mass.gov/dhcfp. If you wish to obtain a fee schedule, you may download DHCFP regulations at no cost at www.mass.gov/dhcfp. If you wish to obtain a paper copy of the fee schedule, you may purchase DHCFP regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses and telephone numbers that follow). You must contact them first to find out the price of the publication. The regulation title for Prostheses, Prosthetic Devices, and Orthotic Devices is 114.3 CMR 34.00. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.goc/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp MassHealth Transmittal Letter PRT-22 July 2011 Page 3 MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth. Questions If you have any questions about 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.) Prosthetics Manual Pages 6-1 and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Prosthetics Manual Pages 6-1 and 6-2 — transmitted by Transmittal Letter PRT-21 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Prosthetics Manual Transmittal Letter PRT-22 Date 01/01/11 601 Introduction MassHealth pays for the services represented by the codes listed in Section 602 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 428.000 and 450.000. A prosthetics provider may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Prosthetics Manual. Providers should refer to the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool for service descriptions, applicable modifiers, place-of-service codes, PA requirements, service limits, and pricing and markup information. For certain services that are payable on an individual-consideration (I.C.) basis, the tool will calculate the payable amount, based on information entered into certain fields on the tool. For service codes for which the Division of Health Care Finance and Policy (DHCFP) has established a rate, the provider can determine the payment by reviewing the DHCFP regulations at 114.3 CMR 34.00. The MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool also contains links to DHCFP regulations and Part 6 of the administrative and billing instructions, which lists the error codes and explanations for claims that have been denied or suspended by MassHealth. To get to the MassHealth Orthotic and Prosthetic Payment and Coverage Guidelines Tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and other Publications, click on Provider Library, and go to MassHealth Payment and Coverage Guideline Tools. If you want a paper copy of the tool, you can print it from the Web site, or request a copy from MassHealth Customer Service. See Appendix A of your provider manual for applicable contact information. 602 Service Codes This section lists codes for services that are payable under MassHealth. Refer to the Centers for Medicare & Medicaid Web site at www.cms.gov for more detailed descriptions. L5000 L5010 L5020 L5050 L5060 L5100 L5105 L5150 L5160 L5200 L5210 L5220 L5230 L5250 L5270 L5280 L5301 L5311 L5321 L5331 L5341 L5400 L5410 L5420 L5430 L5450 L5460 L5500 L5505 L5510 L5520 L5530 L5535 L5540 L5560 L5570 L5580 L5585 L5590 L5595 L5600 L5610 L5611 L5613 L5614 L5616 L5617 L5618 L5620 L5622 L5624 L5626 L5628 L5629 L5630 L5631 L5632 L5634 L5636 L5637 L5638 L5639 L5640 L5642 L5643 L5644 L5645 L5646 L5647 L5648 L5649 L5650 L5651 L5652 L5653 L5654 L5655 L5656 L5658 L5661 L5665 L5666 L5668 L5670 L5671 L5672 L5673 L5676 L5677 L5678 L5679 L5680 L5681 L5682 L5683 L5684 L5685 L5686 L5688 L5690 L5692 L5694 L5695 L5696 L5697 L5698 L5699 L5700 L5701 L5702 L5703 L5704 L5705 L5706 L5707 L5710 L5711 L5712 L5714 L5716 L5718 L5722 L5724 L5726 L5728 L5780 L5781 L5782 L5785 L5790 L5795 L5810 L5811 L5812 L5814 L5816 L5818 L5822 L5824 L5826 L5828 L5830 L5840 L5845 L5848 L5850 L5855 L5856 L5857 L5858 L5910 L5920 L5925 L5930 L5940 L5950 L5960 L5961 L5962 L5964 L5966 L5968 L5970 L5971 L5972 L5973 L5974 L5975 L5976 L5978 L5979 L5980 L5981 L5982 L5984 L5985 L5986 L5987 L5988 L5990 L5999 L6000 L6010 L6020 L6025 L6050 L6055 L6100 L6110 L6120 L6130 L6200 L6205 L6250 L6300 L6310 L6320 L6350 L6360 L6370 L6380 L6382 L6384 L6386 L6388 L6400 L6450 L6500 L6550 L6570 L6580 L6582 L6584 L6586 L6588 L6590 L6600 L6605 L6610 L6611 L6615 L6616 L6620 L6621 L6623 L6624 L6625 L6628 L6629 L6630 L6632 L6635 L6637 L6638 L6640 L6641 L6642 L6645 L6646 L6647 L6648 L6650 L6655 L6660 L6665 L6670 L6672 L6675 L6676 L6677 L6680 L6682 L6684 L6686 L6687 L6688 L6689 L6690 L6691 L6692 L6693 L6694 L6695 L6696 L6697 L6698 L6703 L6704 L6706 L6707 L6708 L6709 L6805 L6810 L6881 L6882 L6883 L6884 L6885 L6890 L6895 L6900 L6905 L6910 L6915 L6920 L6925 L6930 L6935 L6940 L6945 L6950 L6955 L6960 L6965 L6970 L6975 L7007 L7008 L7009 L7040 L7045 L7170 L7180 L7181 L7185 L7186 L7190 L7191 L7260 L7261 L7266 L7272 L7274 L7360 L7362 L7364 L7366 L7367 L7368 L7400 L7401 L7402 L7403 L7404 L7405 L7499 L7510 L7520 L7600 L8000 L8001 L8002 L8010 L8015 L8020 L8030 L8031 L8032 L8035 L8039 L8300 L8310 L8320 L8330 L8400 L8410 L8415 L8417 L8420 L8430 L8435 L8440 L8460 L8465 L8470 L8480 L8485 L8499 S1040