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 POD-60 October 2008 TO: Podiatrists Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Podiatrist Manual (Elimination of Life and Safety Requirement) With Podiatrist Bulletin 16 (June 2008), MassHealth eliminated the limitation on podiatry services to those necessary for the life and safety of the member, and the corresponding requirement that providers obtain and provide a life and safety certification with claims for payment for podiatry services. This letter transmits an amendment to the podiatrist regulations that codifies these changes. However, MassHealth covers only podiatry services that are medically necessary and, in addition, all other provisions of 130 CMR 424.000 and 450.000 continue to apply. For members who belong to the PCC Plan, podiatry services will continue to require a referral from the member’s primary-care (PCC) clinician before the delivery of services. This letter also transmits a revised Subchapter 6 of the Podiatrist Manual. Subchapter 6 lists the codes that are covered by MassHealth. For dates of service on or after January 1, 2008, Service Code J7345 has been discontinued by CMS and replaced with Service Code J7347. 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. This transmittal letter and other publications issued by MassHealth are available on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library. NEW MATERIAL (The pages listed here contain new or revised language.) Podiatrist Manual Pages iv, 4-3 through 4-6, 4-15, 4-16, and 6-1 through 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Podiatrist Manual Pages iv, 4-3, 4-4, 4-15, and 4-16 — transmitted by Transmittal Letter POD-59 Pages 4-5 and 4-6 — transmitted by Transmittal Letter POD-45 Pages 6-1 through 6-6 — transmitted by Transmittal Letter POD-57 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 4. Program Regulations 424.401: Introduction .......................................................................................................... 4-1 424.402: Definitions............................................................................................................. 4-1 424.403: Eligible Members.................................................................................................. 4-3 424.404: Provider Eligibility................................................................................................ 4-3 424.405: Noncovered Services............................................................................................. 4-4 424.406: Maximum Allowable Fees.................................................................................... 4-5 424.407: Individual Consideration....................................................................................... 4-5 424.408: Referral ................................................................................................................ 4-5 424.409: Recordkeeping (Medical Records) Requirements................................................. 4-6 424.410: Report Requirements............................................................................................. 4-6 424.411: Office Visits.......................................................................................................... 4-7 424.412: Out-of-Office Visits.............................................................................................. 4-7 424.413: Surgical Services and Utilization Management Program Requirements.............. 4-8 424.414: Surgical Assistants................................................................................................ 4-9 424.415: Radiology Services................................................................................................ 4-9 424.416: Clinical Laboratory Services................................................................................. 4-10 424.417: Pharmacy Services: Prescription Requirements .................................................. 4-10 424.418: Pharmacy Services: Covered Drugs .................................................................... 4-12 424.419: Pharmacy Services: Limitations on Coverage of Drugs ...................................... 4-12 424.420: Pharmacy Services: Insurance Coverage.............................................................. 4-13 424.421: Pharmacy Services: Prior Authorization ............................................................. 4-15 424.422: Pharmacy Services: Member Copayments .......................................................... 4-15 424.423: Drugs Dispensed in Provider’s Office .................................................................. 4-15 424.424: Shoes and Corrective Devices............................................................................... 4-16 410.425: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services........ 4-16 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 424.000) Page 4-3 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 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. 424.403: Eligible Members (A) (1) MassHealth Members. The MassHealth agency pays for podiatry services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. 130 CMR 450.105 specifically states, for each MassHealth coverage type, which services are covered and which members are eligible to receive those services. (2) Recipients of the 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. 424.404: Provider Eligibility Payment for services described in 130 CMR 424.000 is made only to providers who are participating in MassHealth on the date the service was provided or who are otherwise eligible for such payment pursuant to 130 CMR 450.000 and meet the following requirements. (A) In State. A podiatrist practicing in Massachusetts must be licensed by the Massachusetts Board of Registration in Podiatry. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 424.000) Page 4-4 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 (B) Out of State. An out-of-state podiatrist must be licensed by that state's board of registration for podiatrists. The MassHealth agency pays an out-of-state podiatrist only when services are provided to an eligible Massachusetts member under the following circumstances: (1) the podiatrist practices outside the border of Massachusetts and provides emergency services to a member; (2) the podiatrist 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 state; or (3) the podiatrist provides services to a member who is authorized to reside out of state by the Massachusetts Department of Social Services. 424.405: Noncovered Services The MassHealth agency does not pay for the following: (1) hygienic foot care as a separate procedure, except when the member's medical record documents that the member cannot perform the care or risks harming himself or herself by performing it. The preceding sentence notwithstanding, payment for hygienic foot care performed on a resident of a nursing facility is included in the nursing facility's per diem rate and is not reimbursable in any case as a separate procedure; (2) canceled or missed appointments; (3) services provided by a podiatrist whose contractual arrangements with a state institution, acute, chronic, or rehabilitation hospital, medical school, or other medical institution involve a salary, compensation in kind, teaching, research, or payment from any other sources, if such payment would result in dual compensation for professional, supervisory, or administrative services related to member care; (4) telephone consultations; (5) in-service education; (6) research or experimental treatment; (7) cosmetic services or devices; (8) sneakers or athletic shoes; (9) an additional charge for nonstandard size (width or length) in custom-molded shoes; or (10) shoes when there is no diagnosis of associated foot deformities. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 424.000) Page 4-5 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 424.406: Maximum Allowable Fees The Massachusetts Division of Health Care Finance and Policy (DHCFP) determines the maximum allowable fees for podiatry services. Payment is always subject to the conditions, exclusions, and limitations set forth in 130 CMR 424.000, 442.000, and 450.000. Payment for a service is the lowest of the following: (A) the provider's usual and customary fee; (B) the provider's actual charge; or (C) the maximum allowable fee listed in the applicable DHCFP fee schedule. 424.407: Individual Consideration (A) Some services listed in Subchapter 6 of the Podiatrist Manual are designated "I.C.," an abbreviation for individual consideration. Individual consideration means that a fee could not be established. Payment for an individual-consideration service is determined by the MassHealth agency's professional advisors based on the podiatrist's descriptive report of the service furnished. (B) To receive payment for an individual-consideration service, the podiatrist must submit with the claim a report that contains the diagnosis, a description of the condition of the foot, and the length of time spent with the member. (C) Determination of the appropriate payment for an individual consideration service is in accordance with the following criteria: (1) the amount of time required to perform the service; (2) the degree of skill required to perform the service; (3) the severity and complexity of the member's disease, disorder, or disability; (4) the policies, procedures, and practices of other third-party insurers, both governmental and private; (5) prevailing professional ethics and accepted customs of the podiatric community; and (6) such other standards and criteria as may be adopted from time to time by DHCFP or the Division. (D) For shoes and corrective devices see 130 CMR 442.421 and 442.422. 424.408: Referral When, during an examination or as a result of laboratory tests, a podiatrist discovers a debilitating or systemic disease (such as diabetes mellitus or ischemia caused by circulatory deficiency), the podiatrist must inform the member that a physician evaluation is necessary and must document this referral in the member's medical record. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 424.000) Page 4-6 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 424.409: Recordkeeping (Medical Records) Requirements Payment for any service listed in 130 CMR 424.000 is conditioned upon its full and complete documentation in the member's medical record. (A) The medical record must contain sufficient data to fully document the nature, extent, and necessity of the care furnished to a member for each date of service claimed for payment, as well as any data that will update the member's medical course. The data maintained in the medical record must also be sufficient to justify any further diagnostic procedures, treatments, and recommendations for return visits or referrals. (B) Although 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, the medical records of each service provided by a podiatrist at any location must include, but not be limited to, the following: (1) the member's name and date of birth; (2) the date of each service; (3) the reason for the visit; (4) the name and title of the person performing the service; (5) the member's medical history; (6) the diagnosis or chief complaint; (7) a clear indication of all findings, whether positive or negative, on examination; (8) any medications administered or prescribed, including strength, dosage, route, regimen, and duration of use; (9) a description of any treatment given; (10) recommendations for additional treatments or consultations, when applicable; (11) any medical goods or supplies dispensed or prescribed; (12) any tests administered and their results; (13) documentation of a treatment plan if subsequent visits are expected; (14) documentation, when applicable, that the member was informed of the necessity of a physician evaluation; and (15) MassHealth Shoe Medical Necessity Form (if applicable). 424.410: Report Requirements (A) General Report. A general written report or a discharge summary must accompany the podiatrist's claim for payment when the service is designated "I.C." in Subchapter 6 of the Podiatrist Manual or when a service code for an unlisted procedure is used. This report must be sufficiently detailed to enable professional advisors to assess the extent and nature of the services. (B) Operative Report. For surgery procedures designated "I.C." in Subchapter 6 of the Podiatrist Manual, operative notes must accompany the podiatrist's 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 podiatrist and his or her assistants, and the technical procedures performed. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 424.000) Page 4-15 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 424.421: 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 424.418 and 424.419(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 Podiatrist Manual. If the MassHealth agency approves the request, it will notify both the podiatrist and the member. (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 prescribed 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 424.417 through 424.421. The MassHealth agency will evaluate the prior-authorization status of drugs on an ongoing basis, and update the MassHealth Drug List. 424.422: Pharmacy Services: Member Copayments The MassHealth agency requires under certain conditions that members make a copayment to the dispensing pharmacy for each original prescription and for each refill for all drugs (whether legend or nonlegend) covered by MassHealth. The copayment requirements are detailed in 130 CMR 450.130. 424.423: Drugs Dispensed in Provider’s Office Drugs dispensed in the office are payable at the podiatrist’s actual acquisition cost if this cost is more than $1.00. Claims for dispensing drugs must include the name of the drug or biological, the strength, and the dosage. A copy of the invoice showing the actual acquisition cost must be attached to the claim form, and must include the National Drug Code (NDC). Claims without this information will be denied. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 424.000) Page 4-16 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 424.424: Shoes and Corrective Devices (A) The MassHealth agency pays for only those shoes listed in Subchapter 6 of the Podiatrist Manual. (B) For shoes, providers must submit with their claim a copy of the completed MassHealth Shoe Medical Necessity Form. (C) The MassHealth agency does not pay for casting materials used in the molding of orthotic shoes or corrective devices. The cost of these materials is included in the fee for prescribing and providing the shoe or corrective device. 424.425: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services The MassHealth agency pays for all medically necessary podiatry services for EPSDT-eligible members in accordance with 130 CMR 450.140 et seq., without regard to service limitations described in 130 CMR 424.000, and with prior authorization. REGULATORY AUTHORITY 130 CMR 424.000: M.G.L. c. 118E, §§7 and 12. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes (130 CMR 424.000) Page 6-1 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 601 Introduction MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) code book for the service codes and service descriptions when billing for services provided to MassHealth members. MassHealth pays for the services represented by the codes listed in Sections 602 through 604 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 424.000 and 450.000. In addition, a podiatrist 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 Podiatrist Manual. For members who belong to the PCC Plan, podiatry services continue to require a referral from the member’s primary-care (PCC) clinician before the delivery of services. Section 602 lists CPT service codes that are generally payable under MassHealth, some of which require individual consideration (IC) or prior authorization (PA). Sections 603 and 604 list Level II HCPCS codes that are payable under MassHealth. Section 605 lists service code modifiers allowed under MassHealth. Legend: IC: Claim requires individual consideration. See 130 CMR 424.407 for more information. PA: Service requires prior authorization. See 130 CMR 450.303 for more information. 602 Payable CPT Codes 10060 10061 10120 10121 10140 10160 10180 11000 11001 11040 11041 11042 11043 11044 11055 11056 11057 11100 11101 11200 11201 11305 11306 11307 11308 11420 11421 11422 11423 11424 11426 11620 11621 11622 11623 11624 11626 11719 11720 11721 11730 11732 11740 11750 11752 11755 11760 11762 11765 12001 12002 12004 12005 12006 12007 12041 12042 12044 12045 13131 13132 13133 14040 14041 14060 14061 14300 14350 15002 15003 15004 15005 15050 15100 15101 15110 15111 15115 15116 15120 15121 15130 15131 15135 15136 15150 15151 15152 15155 15156 15157 15170 15171 15175 15176 15240 15241 15300 15301 15320 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes (130 CMR 424.000) Page 6-2 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 15321 15330 15331 15335 15336 15340 15341 15360 15361 15365 15366 15400 15401 15420 15421 15430 15431(IC) 15574 15620 15850 15851 15852 15999(IC) 17000 17003 17004 17110 17111 17250 17270 17271 17272 17273 17274 17276 20000 20005 20200 20205 20206 20520 20525 20550 20600 20605 20612 20615 20650 20670 20680 27603 27604 27605 27606 27607 27610 27612 27613 27614 27615 27618 27619 27620 27625 27626 27630 27647 27648 27680 27681 27685 27686 27695 27696 27704 27760 27762 27766 27808 27810 27814 27816 27818 27822 27823 27840 27842 27846 27848 27860 27870 28001 28002 28003 28005 28008 28010 28011 28020 28022 28024 28035 28043 28045 28046 28050 28052 28054 28055 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100 28102 28103 28104 28106 28107 28108 28110 28111 28112 28113 28114 28116 28118 28119 28120 28122 28124 28126 28130 28140 28150 28153 28160 28171 28173 28175 28190 28192 28193 28200 28202 28208 28210 28220 28222 28225 28226 28230 28232 28234 28238 28240 28250 28260 28261 28262 28264 28270 28272 28280 28285 28286 28288 28289 28290 28292 28293 28294 28296 28297 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322 28340 28341 28344 28345 28360 28400 28405 28406 28415 28420 28430 28435 28436 28445 28450 28455 28456 28465 28470 28475 28476 28485 28490 28495 28496 28505 28510 28515 28525 28530 28531 28540 28545 28546 28555 28570 28575 28576 28585 28600 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes (130 CMR 424.000) Page 6-3 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 28605 28606 28615 28630 28635 28636 28645 28660 28665 28666 28675 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760 28800 28805 28810 28820 28825 28890(PA) 28899(IC) 29345 29355 29405 29425 29440 29445 29450 29515 29540 29550 29580 29590 29705 29730 29750 29799(IC) 29891 29892 29893 29894 29895 29897 29898 29899 73590 73592 73600 73610 73620 73630 73650 73660 76499(IC) 81000 82947 84550 85007 85014 85018 85032 85041 85048 87101 87102 87106 99070(IC) 99202 99203 99204 99211 99212 99213 99214 99218 99219 99221 99222 99231 99232 99238 99239 99241 99242 99243 99251 99252 99253 99281 99282 99283 99307 99308 99309 99324 99325 99326 99334 99335 99336 99341 99342 99343 99347 99348 99349 603 Payable HCPCS Level II Service Codes for Injectable Drugs Administered in the Office MassHealth pays for the services represented by the codes listed in Section 603 in effect at the time of service, subject to all conditions and limitations in Subchapter 6 and in MassHealth regulations at 130 CMR 424.000 and 450.000. Refer to the Centers for Medicare & Medicaid Services Web site at www.cms.gov/medicare/hcpcs for detailed descriptions when billing with Level II HCPCS codes for services provided to MassHealth members. J0702 J0704 J1020 J1030 J1040 J1710IC) J1720 J3301 J3302 J3303 J3490IC) J7340 J7341 J7342 J7343 J7344 J7346 J7347 S0020 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes (130 CMR 424.000) Page 6-4 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 604 Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services MassHealth pays for the services represented by the codes listed in Section 604 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 442.000 and 450.000. In addition, a provider may request PA for any medically necessary orthotic services. 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, American Orthotic and Prosthetic Association (AOPA) interpretive language (if applicable), pricing and markup information, and MassHealth Shoe Prescription Form requirement. 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, the MassHealth Shoe Prescription Form, Subchapter 4 of the orthotics regulations, Subchapter 4 of the prosthetics 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. Providers should note that in the upper left corner of the Payment and Coverage Guidelines tool, above the words Program Link, there is a date. Providers should make sure if they download a printed copy that the dates are the same. This will ensure that the providers use the current tool. To get to the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then Provider Library, and then MassHealth Payment and Coverage Guidelines 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. A5500 A5501 A5503 A5504 A5505 A5506 A5507 A5508 A5512 A5513 L3000 L3001 L3002 L3003 L3010 L3020 L3030 L3031 L3040 L3050 L3060 L3070 L3080 L3090 L3100 L3140 L3150 L3160 L3170 L3201 L3202 L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L3224 L3225 L3230 L3250 L3251 L3252 L3253 L3254 L3255 L3257 L3260 L3265 L3300 L3310 L3320 L3330 L3332 L3334 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 L3520 L3530 L3540 L3550 L3560 L3570 L3580 L3590 L3595 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes (130 CMR 424.000) Page 6-5 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 605 Modifiers The following service code modifiers are allowed for billing under MassHealth. See Subchapter 5 of the Podiatrist Manual for billing instructions related to the use of modifiers. 26 Professional component 50 Bilateral procedure 51 Multiple procedures 99 Multiple modifiers LT Left side (for orthotic shoes only) RT Right side (for orthotic shoes only) TC Technical component Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes (130 CMR 424.000) Page 6-6 Podiatrist Manual Transmittal Letter POD-60 Date 11/15/08 This page is reserved.