Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter ABR-15 June 2012 TO: Abortion Clinics Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Abortion Clinic Manual (New Modifiers for Provider Preventable Conditions That Are National Coverage Determinations) This letter transmits updates to Subchapter 6 of the Abortion Clinic Manual to add modifiers for Provider Preventable Conditions (PPCs) that are National Coverage Determinations. For more information about PPCs and related billing instructions, see Transmittal Letter ALL-195. These updates are effective for dates of service on or after July 1, 2012. MassHealth Website This transmittal letter and attached pages are available on the MassHealth website 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.) Abortion Clinic Manual Pages vi, vii, 6-1, and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Abortion Clinic Manual Pages vi, 6-1, and 6-2 — transmitted by Transmittal Letter ABR-13 Page vii — transmitted by Transmittal Letter ABR-12 MassHealth Transmittal Letter * * 2012 Page 2 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Abortion Clinic Manual Transmittal Letter ABR-15 Date 07/01/12 6. Service Codes and Descriptions Introduction 6-1 Service Codes and Descriptions 6-1 Modifiers for Provider Preventable Conditions That Are National Coverage Determinations 6-2 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party Liability- Codes C-1 Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider reventable Conditions U-1 Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions V-1 Appendix W. EPSDT Services: Medical 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 6. Service Codes and Descriptions Page 6-1 Abortion Clinic Manual Transmittal Letter ABR-15 Date 07/01/12 601 Introduction (A) The maximum allowable fee for an abortion service payable to licensed ambulatory abortion clinics is the fee listed in the applicable Division of Health Care Finance and Policy fee schedule or the provider's usual fee or charge, whichever is less. (B) The service codes for contraceptive supplies are in the MassHealth Family Planning Agency Manual. (C) All claims for induced abortions, except medically induced abortions, must have a completed Certification for Payable Abortion (CPA-2) form attached to the claim (see 130 CMR 484.008). (D) I.C. indicates that the claim will be paid on an individual-consideration basis. 602 Service Codes and Descriptions Service Code-Modifier Service Description 99213 Office or other outpatient visit for the evaluation and management of an established patient, that requires at least two of these three key components * an expanded problem-focused history * an expanded problem-focused examination * medical decisionmaking of low complexity J2790 Injection, Rho (D) immune globulin, human, one-dose package (when required only; reimbursed at the actual wholesale cost of the serum; a copy of the purchase invoice must be submitted with the claim form) (I.C.) S0190 Mifepristone, oral, 200 mg S0191 Misoprostol, oral, 200 mcg S0199 Medically induced abortion by oral ingestion of medication, including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by Hcg, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion), except drugs 59820 Treatment of missed abortion, completed surgically, first trimester (includes physician's charges and clinic services) 59840 Induced abortion, by dilation and curettage (first trimester) (includes physician's charges and clinic services with either intravenous sedation or general anesthesia; CPA-2 form required) 59840-TF Induced abortion, by dilation and curettage (second trimester—12.1 through 13.9 weeks; includes physician’s charges and clinic services with either intravenous sedation or general anesthesia; CPA-2 form required) 59840-TG Induced abortion by dilation and curettage (second trimester—14.0 through 18.9 weeks; includes physician’s charges and clinic services with either intravenous sedation or general anesthesia and insertion of cervical dilator, e.g., laminaria; CPA-2 form required) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Abortion Clinic Manual Transmittal Letter ABR-15 Date 07/01/12 602 Service Codes and Descriptions (cont.) Service Code-Modifier Service Description 59841 Induced abortion, by dilation and evacuation (first trimester) (includes physician's charges and clinic services; CPA-2 form required) 59841-TF Induced abortion, by dilation and evacuation (second trimester—12.1 through 13.9 weeks; includes physician’s charges and clinic services with either intravenous sedation or general anesthesia; CPA-2 form required) 59841-TG Induced abortion, by dilation and evacuation (second trimester—14.0 through 18.9 weeks; includes physician’s charges and clinic services with either intravenous sedation or general anesthesia, and insertion of cervical dilator, e.g., laminaria; CPA-2 form required) 76805 Ultrasound, pregnant uterus, B-scan and/or real time with image documentation; complete (complete fetal and maternal evaluation) 76815 limited (fetal size, heart beat, placental location, fetal position, or emergency in the delivery room) 603 Modifiers for Provider Preventable Conditions That Are National Coverage Determinations PA Surgical or other invasive procedure on wrong body part PB Surgical or other invasive procedure on wrong patient PC Wrong surgery or other invasive procedure on patient For more information on the use of these modifiers, see Appendix V of your provider manual. This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS codes are defined in the Physician’s Current Procedural Terminology (CPT) code book.