Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter AOH-29 June 2012 TO: Acute Outpatient Hospital Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Acute Outpatient Hospital Manual (New Modifiers for Provider Preventable Conditions That Are National Coverage Determinations) This letter transmits updates to Subchapter 6 of the Acute Outpatient Hospital 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 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. MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. NEW MATERIAL (The pages listed here contain new or revised language.) Acute Outpatient Hospital Manual Pages vi, 6-13 and 6-14 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Page vi — transmitted by Transmittal Letter AOH-26 Pages 6-13 and 6-14 — transmitted by Transmittal Letter AOH-28 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Acute Outpatient Hospital Manual Transmittal Letter AOH-29 Date 07/01/12 6. Service Codes Introduction 6-1 Nonpayable CPT Codes 6-1 Payable Level II HCPCS Codes 6-11 Modifiers 6-12 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix D. Utilization Management Program D-1 Appendix E. Admission Guidelines E-1 Appendix F. Revenue Codes F-1 Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditions……………………………………………………………………………… U-1 Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions………………. V-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 6. Service Codes Page 6-13 Acute Outpatient Hospital Manual Transmittal Letter AOH-29 Date 07/01/12 604 Modifiers Modifiers for Behavioral Health Screening The administration and scoring of standardized behavioral health screening tools selected from the approved menu of tools found in Appendix W of your MassHealth provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. Service Code 96110 must be accompanied by one of the modifiers listed below to indicate whether a behavioral health need was identified. “Behavioral health need identified” means the provider administering the screening tool, in her or his professional judgment, identified a child with a potential behavioral health services need. U1 Completed behavioral-health screening using a standardized behavioral-health screening tool selected from the approved menu of tools found in Appendix W of your MassHealth provider manual with no behavioral health need identified. U2 Completed behavioral-health screening using a standardized behavioral-health screening tool selected from the approved menu of tools found in Appendix W of your MassHealth provider manual and behavioral-health need identified. Modifiers for Tobacco-Cessation Services The following modifiers are used in combination with Service Code 99407 to report tobacco-cessation counseling. Service Code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) may also be billed without a modifier to report an individual smoking and tobacco use cessation counseling visit of at least 30 minutes. HQ Group counseling, at least 60-90 minutes TF Intermediate level of care, at least 45 minutes Modifier for Child and Adolescent Needs and Strengths (CANS) HA Service code 90801 must be accompanied by this modifier to indicate that the Child and Adolescent Needs and Strengths is included in the assessment. 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 are defined in the Current Procedural Terminology (CPT) code book. This page is reserved. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-14 Acute Outpatient Hospital Manual Transmittal Letter AOH-29 Date 07/01/12