Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter SHC-18 January 2012 TO: Speech and Hearing Centers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Revisions to Subchapter 6 (Service Codes and Descriptions) Section 6507 of the federal Patient Protection and Affordable Care Act (Public Laws 111-148 and 111-152), as implemented by the Centers for Medicare & Medicaid Services (CMS), requires state Medicaid agencies to incorporate compatible methodologies of the National Correct Coding Initiative (NCCI). NCCI was implemented by CMS to promote national correct coding methodologies and to control improper coding leading to inappropriate payment. This requirement is effective for claims for dates of service on or after October 1, 2010, that are processed by MassHealth on or after April 1, 2011. Medically Unlikely Edits (MUEs) MUEs are units-of-service edits that define for certain HCPCS/CPT codes the number of units of service beyond which the reported number of units of service is unlikely to be correct. Providers are advised to review All Provider Bulletin 209, issued in April 2011, which describes in greater detail NCCI MUE requirements and provides the link to the CMS Web site that providers may access to obtain a full list codes to which MUEs apply. To conform to NCCI coding edits, MassHealth has updated Subchapter 6 of the Speech and Hearing Center Manual to reflect revisions made to the maximum units allowed for service codes 92507 and 92508 from four units per visit to one unit per visit. These service codes were previously payable for MassHealth based on a 15-minute unit (maximum four units per visit), and are now payable based on a single unit (maximum one unit per visit) instead of on minutes. Consequently, the Division of Health Care Finance and Policy (DHCFP) has revised the rates for these two codes. The new rates for these codes take effect for dates of service beginning June 1, 2011. MassHealth had previously informed providers of these changes through message text issued in June, 2011. MassHealth Transmittal Letter SHC-18 January 2012 Page 2 Fee Schedule 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 39.00: Rehabilitation Clinic Services, Audiological Services, Restorative Services. 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 Procedure-to-Procedure Code Pair Editing In addition to implementing MUEs as described above, MassHealth has also implemented NCCI procedure-to-procedure code pair editing, which are automated prepayment edits that prevent improper payment when certain service codes are billed by the same provider for the same member on the same date of service. Speech and hearing center providers are again advised to review All Provider Bulletin 209, which describes in greater detail NCCI procedure-to-procedure edit requirements and provides the link to the CMS Web site that providers may access to obtain a full list of codes to which procedure-to-procedure edits apply. Claims Processing All speech and hearing center claims submitted to MassHealth for dates of service on or after October 1, 2010, that are processed on or after April 1, 2011, will be edited for NCCI procedure-to-procedure edits. With the exception of claims for Service Codes 92507 and 92508, speech and hearing center claims submitted to MassHealth for dates of service on or after October 1, 2010, that are processed on or after April1, 2011, will be edited for NCCI MUEs. Claims with Service Codes 92507 and 92508 with dates of service on or after October 1, 2010, that are processed on or after June 1, 2011, will be edited for MUEs. Any such claims using HCPCS/CPT codes that include code pairs on the NCCI edit list, or using codes billed with units of service greater than the MUE limit, will result in payment denials. Due to the timing of system updates, MassHealth may need to later reprocess and adjust claims to ensure proper NCCI editing. Please note that MUE limits and procedure-to-procedure code edits supersede any approved prior authorizations (PAs) in the system. Claims over the MUE limit or that include code pairs on the NCCI edit lists will be denied even if they have an approved PA that would otherwise allow coverage and payment of the service. If a claim with such an approved PA is denied solely due to NCCI editing, providers should request agency review of the denial. Consult All Provider Bulletin 209 for further information about NCCI editing, including Agency review and appeals of claims denials. MassHealth Transmittal Letter SHC-18 January 2012 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 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.) Speech and Hearing Center Manual Pages vi, vii, 6-1, and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Speech and Hearing Center Manual Page vi — transmitted by Transmittal Letter SHC-13 Page vii — transmitted by Transmittal Letter SHC-14 Pages 6-1 and 6-2 — transmitted by Transmittal Letter SHC-15 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Speech and Hearing Center Manual Transmittal Letter SHC-18 Date 06/01/11 6. Service Codes and Descriptions ................................................................................ ..................... 6-1 Appendix A. Directory ................................................................................ ..................................... A-1 Appendix B. Enrollment Centers ................................................................................ ...................... B-1 Appendix C. Third-Party-Liability Codes ................................................................................ ........ C-1 Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity Schedules............... W-1 Appendix X. Family Assistance Copayments and Deductibles......................................................... X-1 Appendix Y. EVS Codes/Messages.................................................................. .......................................... Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes ........................................................................ Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Preface Page vii Speech and Hearing Center Manual Transmittal Letter SHC-18 Date 06/01/11 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. Each manual in the series contains administrative regulations, billing regulations, program regulations, service codes and descriptions, 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. Regulations promulgated by MassHealth are assigned Title 130 of the Code. 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 provider manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For speech and hearing centers, those matters are covered in 130 CMR Chapter 413.000, reproduced as Subchapter 4 in the Speech and Hearing Center Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which provide instructions for 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 with MassHealth members. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-1 SPEECH AND HEARING CENTER MANUAL TRANSMITTAL LETTER SHC-18 DATE 06/01/11 601 Service Codes and Descriptions Note: (A) I.C. indicates that the claim will receive individual consideration to determine payment. See 130 CMR 413.407 for I.C. requirements. (B) Some service codes require prior authorization (P.A.). See 130 CMR 413.408 for prior authorization requirements. Service Code Modifier Service Description Audiological Services 92552 Pure tone audiometry (threshold); air only 92553 air and bone (S.P. to 92552) 92555 Speech audiometry threshold 92556 with speech recognition 92557 Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined) 92562 Loudness balance test, alternate binaural or monaural (S.P. to 92563 through 92565) 92563 Tone decay test (S.P. to 92562, 92564, and 92565) 92564 Short increment sensitivity index (SISI) (S.P. to 92562, 92563, and 92565) 92565 Stenger test, pure tone (S.P. to 92562 through 92564) 92567 Tympanometry (impedance testing) 92568 Acoustic reflex testing (S.P. to 92569) 92569 Acoustic reflex decay test (S.P. to 92568) 92572 Staggered spondaic word test (S.P. to 92576 and 92577) 92576 Synthetic sentence identification test (S.P. to 92571 and 92577) 92577 Stenger test, speech (S.P. to 92571 and 92576) 92582 Conditioning play audiometry 92583 Select picture audiometry (I.C.) 92584 Electrocochleography (I.C.) 92585 Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive 92586 limited 92587 Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) 92588 comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies) 92590 Hearing aid examination and selection; monaural 92591 binaural 92592 Hearing aid check, monaural (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 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-2 SPEECH AND HEARING CENTER MANUAL TRANSMITTAL LETTER SHC-18 DATE 06/01/11 601 Service Codes and Descriptions (cont.) Service Code Modifier Service Description 92594 Electroacoustical 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 92596 Ear protector attenuation measurements 92620 Evaluation of central auditory function, with report; initial 60 minutes 92621 Evaluation of central auditory function, with report, each additional 15 minutes (up to the maximum of eight units billed) Other Procedures 92700 Unlisted otorhinolaryngological service or procedure (I.C.) Speech and Language Services 92506 Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status (per hour, maximum of three hours) 92506 HA Evaluation of speech, language, voice, communication, auditory processing, and/or aural rehabilitation status, child/adolescent program (for children (age of 12 and younger); per hour, maximum of four hours) 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual (maximum one unit per visit) 92508 group, two or more individuals (but less than seven individuals) (each member)(maximum one unit per visit) This publication contains codes that are copyrighted by the American Medical Association.