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-108 November 2005 TO: Physicians Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Physician Manual (Changes to Program Regulations) This letter transmits revisions to the Physician Manual program regulations. These revisions are effective for dates of service on or after December 1, 2005. Effective December 1, 2005, audiologists providing services under 130 CMR 433.426 should refer to the regulations at 130 CMR 426.404 in the Audiologist Manual for provider eligibility requirements. This letter transmits a revision to Subchapter 6 (Service Codes and Descriptions) of the Physician Manual. Effective for dates of service on or after November 1, 2005, Service Code J7303, contraceptive supply, hormone containing vaginal ring, is payable on an individual consideration (I.C.) basis and requires a copy of the invoice to be submitted. This letter also transmits a revised Appendix I: Utilization Management Program and Appendix K: Teaching Physicians. In Appendix I, minor revisions are being made for consistency with other MassHealth publications. In Appendix K, two service codes, 99261 and 99262, have been deleted in the American Medical Association Current Procedural Terminology (CPT) 2006 book. 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 Physician Manual Pages 4-17, 4-18, 6-13, 6-14, I-1, I-2, K-1, and K-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Physician Manual Pages 4-17 and 4-18 - transmitted by Transmittal Letter PHY-93 Pages 6-13 and 6-14 - transmitted by Transmittal Letter PHY-105 Pages I-1 and I-2 - transmitted by Transmittal Letter PHY-85 Pages K-1 and K-2 - transmitted by Transmittal Letter PHY-88 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 433.000) PAGE 4-17 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-108 DATE 12/01/05 433.424: Obstetric Services: Fee-for-Service Method of Payment The fee-for-service method of payment is always available to a provider for obstetric services covered by the MassHealth agency. If the global-fee requirements in 130 CMR 433.421 are not met, the provider or providers may claim payment from the MassHealth agency only on a fee-for-service basis, as specified below. (A) When there is no primary provider for the obstetric services performed for the member, each provider may claim payment only on a fee-for-service basis. (B) If the pregnancy is terminated by an event other than a delivery, each provider involved in performing obstetric services for the member may claim payment only on a fee-for-service basis. (C) When an independent nurse midwife is the primary provider and the collaborating physician performs a cesarean section, the independent nurse midwife may claim payment for the prenatal visits only on a fee-for-service basis. The collaborating physician may claim payment for the cesarean section only on a fee-for-service basis. (D) When additional services (for example, ultrasound or special tests) are performed, the provider may claim payment for these only on a fee-for-service basis. 433.425: Ophthalmology Services: Service Limitations The MassHealth agency pays for eye examinations, subject to the following limitations. (A) The MassHealth agency requires prior authorization for a comprehensive eye examination if the service has been provided: (1) within the preceding 12 months, for a member under 21 years of age; or (2) within the preceding 24 months, for a member 21 years of age or older. (B) The MassHealth agency pays for ophthalmology services designated as separate procedures only if they are provided independently of a comprehensive eye examination. (C) The MassHealth agency pays for a titmus vision test or similar screening device only once per year per member. (D) (1) The MassHealth agency pays for eyeglasses and other ophthalmic materials, only when provided to members who are under the age of 21 as set out in 130 CMR 433.425(D)(2), except over-the-counter items such as magnifiers, only upon prescription, even if the prescriber dispensed the materials. The prescription must be based upon the results of a vision examination performed by the prescriber. The prescription must include all information that is necessary to enable a dispensing practitioner to fill the prescription. The prescriber must give the member a signed copy of the prescription without extra charge. The date or dates upon which the prescription is filled or refilled must be recorded on the member's copy of the prescription. (For further regulations about ophthalmic materials, see the MassHealth regulations governing vision care services at 130 CMR 402.000.) Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 433.000) PAGE 4-18 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-108 DATE 12/01/05 (2) Age Limitations. In addition to any other restrictions and limitations set forth in MassHealth regulations, the MassHealth agency covers the following services only when provided to eligible MassHealth members who are under age 21: ophthalmic materials, specifically including, but not limited to, complete eyeglasses or eyeglass parts; the dispensing of ophthalmic materials; contact lenses; and other visual aids, except that this age limitation does not apply to visual magnifying aids for use by members who are both diabetic and legally blind. Visual magnifying aids do not include eyeglasses or contact lenses. 433.426: Audiology Services: Service Limitations The MassHealth agency pays for audiology services only when they are provided either by a physician, or by an audiologist licensed or certified in accordance with 130 CMR 426.404 who is employed by a physician. This limitation does not apply to an audiometric hearing test, pure-tone, air only. 433.427: Allergy Testing: Service Limitations (A) The MassHealth agency pays for allergy testing only when performed by a physician or under a physician's direct supervision. All fees include payment for physician observation and interpretation of the tests in relation to the member's history and physical examination. A physician may bill for an initial consultation in addition to allergy testing. (B) The MassHealth agency does not pay for more than three blood tests and pulmonary function tests (such as spirometry and expirogram) used only for diagnosis and periodic evaluation per member per year. (C) Immunotherapy and desensitization (extracts) are covered services. The provider must indicate the amount and anticipated duration of the supply for immunotherapy and desensitization (extracts) on the claim form. (D) The MassHealth agency pays for follow-up office visits for injections and reevaluation as office visits. (E) The MassHealth agency pays for sensitivity tests only once per member per year regardless of the type of tests performed or the number of visits required. 433.428: Psychiatry Services: Introduction (A) Covered Services. The MassHealth agency pays for the psychiatry services described in 130 CMR 433.429. (B) Noncovered Services. (1) Nonphysician Services. The MassHealth agency does not pay a physician for services provided by a social worker, psychologist, or other nonphysician mental health professional employed or supervised by the physician. (2) Research and Experimental Treatment. The MassHealth agency does not pay for research or experimental treatment. This includes, but is not limited to, any method not generally accepted or widely used in the field, or any session conducted for research rather than for a member's clinical need. 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-13 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-108 DATE 11/01/05 604 HCPCS Level II Service Codes (cont.) Service Code Service Description J1800 Injection, propranolol HCl, up to 1 mg J1885 Injection, ketorolac, tromethamine, per 15 mg J1890 Injection, cephalothin sodium, up to 1 g J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg (PA) J1956 Injection, levofloxacin, 250 mg J1990 Injection, chlordiazepoxide HCl, up to 100 mg J2060 Injection, lorazepam, 2 mg J2150 Injection, mannitol, 25% in 50 ml J2175 Injection, meperidine HCl, per 100 mg J2250 Injection, midazolam HCl, per 1 mg J2270 Injection, morphine sulfate, up to 10 mg J2271 Injection, morphine sulfate, 100 mg J2275 Injection, morphine sulfate (preservative-free sterile solution), per 10 mg J2300 Injection, nalbuphine HCl, per 10 mg J2310 Injection, naloxone HCl, per 1 mg J2357 Injection, omalizumab, 5 mg (PA) J2405 Injection, ondansetron HCl, per 1 mg J2430 Injection, pamidronate disodium, per 30 mg J2440 Injection, papaverine HC1, up to 60 mg J2469 Injection, palonosetron, HCl, 25 mcg J2505 Injection, pegfilgrastim, 6 mg (PA) J2510 Injection, penicillin G procaine, aqueous, up to 600,000 units J2515 Injection, pentobarbital sodium, per 50 mg J2550 Injection, promethazine HCl, up to 50 mg J2560 Injection, phenobarbital sodium, up to 120 mg J2675 Injection, progesterone, per 50 mg J2760 Injection, phentolamine mesylate, up to 5 mg J2765 Injection, metoclopramide HCl, up to 10 mg J2780 Injection, ranitidine HCl, 25 mg J2788 Injection, Rho D immune globulin, human, minidose, 50 mcg J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg J2792 Injection, Rho D immune globulin, intravenous, human, solvent detergent, 100 IU J2820 Injection, sargramostim (GM-CSF), 50 mcg (PA) J2910 Injection, aurothioglucose, up to 50 mg J2916 Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg J2920 Injection, methylprednisolone sodium succinate, up to 40 mg J2930 Injection, methylprednisolone sodium succinate, up to 125 mg J2940 Injection, somatrem, 1 mg (PA) J2941 Injection, somatropin, 1 mg (PA) J3030 Injection, sumatriptan succinate, 6 mg J3110 Injection, teriparatide, 10 mcg (PA) J3120 Injection, testosterone enanthate, up to 100 mg J3130 Injection, testosterone enanthate, up to 200 mg J3230 Injection, chlorpromazine HCl, up to 50 mg 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-14 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-108 DATE 11/01/05 604 HCPCS Level II Service Codes (cont.) Service Code Service Description J3250 Injection, trimethobenzamide HCl, up to 200 mg J3301 Injection, triamcinolone acetonide, per 10 mg J3302 Injection, triamcinolone diacetate, per 5 mg J3303 Injection, triamcinolone hexacetonide, per 5 mg J3396 Injection, verteporfin, 0.1 mg J3410 Injection, hydroxyzine HCl, up to 25 mg J3487 Injection, zoledronic acid, 1 mg J3490 Unclassified drugs (IC) J3490-FP Unclassified drugs (service provided as part of Medicaid family planning program) (Use for medications and injectibles related to family planning services, with the exception of Rho(D) human immune globulin, and contraceptive injectables such as Depo-Provera, items for which MassHealth will pay the provider's costs.) (IC) J3590 Unclassified biologics (IC) J7030 Infusion, normal saline solution, 1,000 cc J7070 Infusion, D-5-W, 1,000 cc J7303 Contraceptive supply, hormone containing vaginal ring, each (IC) J7304 Contraceptive supply, hormone containing patch, each (IC) J7317 Sodium hyaluronate, per 20 to 25 mg dose for intra-articular injection (PA) J7320 Hylan G-F 20, 16 mg, for intra-articular injection (PA) J7599 Immunosuppressive drug, NOC (IC) J9000 Doxorubicin HCl, 10 mg J9001 Doxorubicin HCl, all lipid formulations, 10 mg J9031 BCG live (intravesical), per instillation J9035 Injection, bevacizumab, 10 mg J9040 Bleomycin sulfate, 15 units J9041 Injection, bortezomib, 0.1 mg J9045 Carboplatin, 50 mg J9055 Injection, cetuximab, 10 mg J9060 Cisplatin, powder or solution, per 10 mg J9062 Cisplatin, 50 mg J9070 Cyclophosphamide, 100 mg J9080 Cyclophosphamide, 200 mg J9090 Cyclophosphamide, 500 mg J9091 Cyclophosphamide, 1 g J9092 Cyclophosphamide, 2 g J9093 Cyclophosphamide, lyophilized, 100 mg J9094 Cyclophosphamide, lyophilized, 200 mg J9095 Cyclophosphamide, lyophilized, 500 mg J9096 Cyclophosphamide, lyophilized, 1 g J9097 Cyclophosphamide, lyophilized, 2 g J9130 Dacarbazine, 100 mg J9140 Dacarbazine, 200 mg J9170 Docetaxel, 20 mg Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX I: UTILIZATION MANAGEMENT PROGRAM PAGE I-1 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-108 DATE 12/01/05 Information Required for Admission Screening The following is a list of information the admitting provider or designee must give the MassHealth Utilization Management contractor when proposing an elective admission. MassHealth may request additional information at any time to clarify the details of any admission. See 130 CMR 450.208 for regulations about admission screening. * the member's name and address * the member's sex * the member's date of birth * the member's MassHealth identification number * the guardian's name and address, if applicable * if applicable, the name of the member's primary care clinician (PCC) and one of the following:* * the telephone number of the PCC; * the provider number of the PCC; or * the address of the PCC. * if applicable, whether the PCC has been notified of the proposed admission * other health-insurance information * whether the member is being treated as a result of an accident, and if available, the date and type of accident * the expected or actual dates of admission and discharge * the name and provider number of the attending physician * the name of the hospital * the primary and secondary diagnoses * the primary and secondary procedures, if applicable * the ICD-9-CM codes for both the diagnoses and procedures, if available * clinical information that supports the medical necessity of the proposed admission and/or procedure * other pertinent information the admitting provider has considered in deciding to admit the member *Please note: Information about the member's PCC is not required if the admission is for dental, oral-surgery, family-planning, or abortion services. Contact for Utilization Management Program Contact information for the MassHealth Utilization Management Program contractor is given below. (See 130 CMR 450.207 through 450.209 for the Utilization Management Program regulations.) MassPRO, Inc. 235 Wyman Street Waltham, MA 02451-1231 Telephone: 1-800-732-7337 Fax: 1-800-752-6334 Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX I: UTILIZATION MANAGEMENT PROGRAM PAGE I-2 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-108 DATE 12/01/05 This page is reserved. Commonwealth of Massachusetts Medical Assistance Program Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX K: TEACHING PHYSICIANS PAGE K-1 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-108 DATE 12/01/05 Physician Service Codes Exempted from the Physical-Presence Requirement This appendix contains service codes for which a teaching physician may bill MassHealth even though he or she is not physically present for the key portions of the service. Note: This exception does not apply in certain circumstances if the teaching physician is also a primary care clinician in the Primary Care Clinician Plan. (See 130 CMR 450.275.) 99201 99202 99203 99211 99212 99213 99214 99232 99234 99235 99241 99242 99243 99251 99392 99393 99394 99395 99396 99397 99431 90807 90808 90809 90816 90817 90818 90819 99218 99219 99221 99222 99231 99252 99253 99281 99282 99391 99433 99435 90804 90805 90806 90821 90822 90847 90849 90853 Commonwealth of Massachusetts Medical Assistance Program Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX K: TEACHING PHYSICIANS PAGE K-2 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-108 DATE 12/01/05 This page is reserved.