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 CHC-85 August 2009 TO: Community Health Centers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Community Health Center Manual (Revisions to Subchapter 6) This letter transmits revisions to the service codes and descriptions in Subchapter 6 of the Community Health Center Manual. These changes are included in the attached Subchapter 6 and are effective for dates of service on or after July 1, 2009. Service codes that have been deleted will no longer be separately payable by MassHealth for dates of service on or after July 1, 2009. The deleted codes are listed below in this letter. Please Note: MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 405.000 and 450.000. A CHC provider may request prior authorization (PA) 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 the Community Health Center Manual. For more information about payment, you may download the Division of Health Care Finance and Policy (DHCFP) regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of the DHCFP regulations from either the Massachusetts State Bookstore or from DHCFP (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 titles are as follows: 114.3 CMR 18.00: Radiology; 114.3 CMR 20.00: Clinical Laboratory Services; 114.3 CMR 4.00: Rates for Community Health Centers; 114.3 CMR 17.00: Medicine. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp MassHealth Transmittal Letter CHC-85 August 2009 Page 2 Vaccines Provided in a Community Health Center Vaccines supplied by the Massachusetts Department of Public Health (DPH) free of charge are not reimbursable by MassHealth. In addition, MassHealth does not separately reimburse community health centers for vaccine costs that have been factored into the CHC payment rates determined by DHCFP. Accordingly, MassHealth separately reimburses community health centers for vaccines not supplied by DPH, only as listed in Subchapter 6, Section 604, of the Community Health Center Manual. Information about the availability of DPH-supplied vaccines can be found on the following DPH Web sites. http://www.mass.gov/dph http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/vaccine_availability_childhood.pdf Deleted Vaccine Service Codes for Community Health Centers Costs of the following vaccine service codes have been factored into the CHC payment rates determined by DHCFP and are not separately payable by MassHealth for dates of service on or after July 1, 2009. 90632 90716 90746 90707 90732 Any CHC that claimed and received payment for any of the above codes for dates of service on or after July 1, 2009 should contact MassHealth Customer Service at 1-800-841-2900, or send an e-mail to providersupport@mahealth.net. 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 revised information.) Community Health Center Manual Pages vi, vii, 6-61, and 6-62 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Community Health Center Manual Page vii — transmitted by Transmittal Letter CHC-71 Pages vi, 6-61, and 6-62 — transmitted by Transmittal Letter CHC-8 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page vi Community Health Center Manual Transmittal Letter CHC-85 Date 07/01/09 6. Service Codes and Descriptions Introduction and Explanation of Abbreviations 6-1 Radiology Service Codes and Descriptions 6-1 Laboratory Service Codes and Descriptions 6-23 Visit Service Codes and Descriptions 6-61 Obstetrics and Surgery Service Codes and Descriptions 6-69 Nurse-Midwife Service Codes and Descriptions 6-70 Audiology Service Codes and Descriptions 6-70 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment Service Codes and Descriptions 6-71 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Tests Service Codes and Descriptions 6-71 Tobacco Cessation Service Codes and Descriptions 6-71 Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes and Descriptions 6-72 Behavioral Health Screening Tool Service Codes and Descriptions 6-73 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix D. Reserved Appendix E. Utilization Management Program E-1 Appendix F. Admission Guidelines F-1 Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule W-1 Appendix X. Family Assistance Copayment 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 vii Community Health Center Manual Transmittal Letter CHC-85 Date 07/01/09 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. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, administrative and 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. MassHealth regulations are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. 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 manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For community health centers, those matters are covered in 130 CMR Chapter 405.000, reproduced as Subchapter 4 in the Community Health Center Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("pen-and-ink" revisions), and by 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 its members. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-61 Community Health Center Manual Transmittal Letter CHC-85 Date 07/01/09 604 Visit Service Codes and Descriptions When claiming payment for visits, a CHC must bill according to the following service codes. A visit during which a member sees more than one professional for the same medical problem or general purpose must be claimed as only one visit. (See 130 CMR 405.421 for other requirements.) Service Code Modifier Service Description CHC Visits 90660 Influenza virus vaccine, live, for intranasal use (P.A.) D1206 Topical fluoride varnish; therapeutic application for moderate-to-high caries risk patients. D9450 Case presentation, detailed and extensive treatment planning (use only for dental enhancement fee. This code may only be billed once per date of service for each member receiving dental services on that date.) J3490 Unclassified drugs (Use for injectable and infusible drugs and devices supplied in the clinic. Do not use for medications and injectables related to family planning services.) (I.C.) T1015 Clinic visit/encounter, all-inclusive (Use for individual medical visit.) T1015 HQ Clinic visit/encounter, all-inclusive, group setting (Use for group clinic visit.) 90899 Unlisted psychiatric service or procedure (Use for individual mental health visit.) (I.C.) 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g.. holidays, Saturday, and Sunday), in addition to basic service (Use for urgent care Monday through Friday from 5:00 P.M. to 6:59 A.M., and Saturday 7:00 A.M. to Monday 6:59 A.M. This code may be billed in addition to the individual medical visit.) 99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes (Use for HIV counseling visits.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-62 Community Health Center Manual Transmittal Letter CHC-85 Date 07/01/09 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description Hospital Inpatient Services 99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - detailed or comprehensive history; - detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity. 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity. 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity. 99460 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant Subsequent Hospital Care 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a problem focused interval history; - a problem focused examination; - medical decision making that is straightforward or of low complexity. 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - an expanded problem focused interval history; - an expanded problem focused examination; - medical decision making of moderate complexity. 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a detailed interval history; - a detailed examination; - medical decision making of high complexity. 99462 Subsequent hospital care, per day, for evaluation and management of normal newborn