Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter CRP-23 November 2010 TO: Chiropractors Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Chiropractor Manual (Elimination of Primary Care Referral Requirement) This letter transmits revisions to the chiropractor regulations. Effective December 1, 2010, chiropractors will no longer need a referral from a MassHealth member’s primary care provider for chiropractor services. Payment for chiropractor services remains subject to all conditions and restrictions of MassHealth, including but not limited to regulations set forth in 130 CMR 441.000 and the scope of covered services for a member’s coverage type, service limitations, and prior-authorization requirements as set forth in 130 CMR 450.000. Even though this policy change eliminates the requirement to seek and receive primary care referrals for members, MassHealth continues to encourage chiropractors to communicate and coordinate care with the MassHealth members’ primary care clinician. Additionally, in accordance with 130 CMR 441.408, chiropractors must continue to report the results of these services to the member’s primary-care provider in writing. In addition, MassHealth has updated terminology throughout the regulations, has made clarifications to the payable services and nonpayable services sections of the chiropractor regulations, and has added standard provisions about coverage of all medically necessary services to members under 21 years of age. These clarifications do not constitute substantive changes. MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site 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 Transmittal Letter CRP-23 November 2010 Page 2 NEW MATERIAL (The pages listed here contain new or revised language.) Chiropractor Manual Pages iv, vi, vii, and 4-1 through 4-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect) Chiropractor Manual Pages iv, vii, 4-1, and 4-2 — transmitted by Transmittal Letter CRP-21 Page vi — transmitted by Transmittal Letter CRP-15 Pages 4-3 and 4-4 — transmitted by Transmittal Letter CRP-17 Pages 4-5 and 4-6 — transmitted by Transmittal Letter CRP-20 Commonwealth of Massachusetts MassHealth Provider Manual Series Chiropractor Manual Subchapter Number and Title Table of Contents Page iv Transmittal Letter CRP-23 Date 12-01/10 4. Program Regulations 441.401: Introduction ............................................................................................................ 4-1 441.402: Definitions ................................................................................................................ 4-1 441.403: Eligible Members .................................................................................................... 4-1 441.404: Provider Eligibility .................................................................................................. 4-2 441.405: Out-of-State Chiropractic Services .......................................................................... 4-2 441.406: Payable Services ..................................................................................................... 4-3 441.407: Service Limitations ................................................................................................. 4-3 441.408: Reporting Requirements ......................................................................................... 4-3 441.409: Radiology Services .................................................................................................. 4-3 441.410: Nonpayable Services .............................................................................................. 4-4 (130 CMR 441.411 Reserved) 441.412: Recordkeeping Requirements ................................................................................. 4-5 441.413: Rates of Payment .................................................................................................... 4-6 (130 CMR 441.414 through 441.419 Reserved) 441.420: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services ......... 4-6 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Chiropractor Manual Transmittal Letter CRP-23 Date 12/01/10 6. Service Codes and Descriptions Evaluation and Management Services................................................................................... 6-1 Chiropractic Manipulative Treatment ................................................................................... 6-1 Radiology Services................................................................................................................ 6-1 Appendix A. Directory ...................................................................................................................... A-1 Appendix B. Enrollment Centers....................................................................................................... B-1 Appendix C. Third-Party-Liability Codes......................................................................................... C-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 Preface Page vii Chiropractor Manual Transmittal Letter CRP-23 Date 12/01/10 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 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. 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 chiropractors, those matters are covered in 130 CMR Chapter 441.000, reproduced as Subchapter 4 in the Chiropractor Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for 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 Title4. Program Regulations (130 CMR 441.000) Page 4-1 Chiropractor Manual Transmittal Letter CRP-23 Date 12/01/10 441.401: Introduction 130 CMR 441.000 establishes the requirements for the provision and payment of chiropractor services under MassHealth. All chiropractors participating in MassHealth must comply with MassHealth regulations, including but not limited to 130 CMR 441.000 and 450.000. 441.402: Definitions The following terms used in 130 CMR 441.000 have the meanings given in 130 CMR 441.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 441.402 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 441.000 and 450.000. Chiropractic Manipulative Treatment – the correction of misalignments, subluxations, or segmental joint dysfunction of the bony articulations of the vertebral column, the pelvis, and adjacent areas. Chiropractor – one who is licensed to practice chiropractic manipulation to correct interference with spinal nerves by adjusting the spinal column. Office Visit – a visit by a MassHealth member to a chiropractor's office for evaluation and management services. These services do not include chiropractic manipulative treatment. Subluxation – a segmental joint dysfunction, misalignment, fixation, or abnormal spacing of the vertebrae. 441.403: Eligible Members (A) (1) MassHealth Members. The MassHealth agency pays for chiropractor 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 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) For information on verifying member eligibility and coverage type, see 130 CMR 450.107. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 441.000) Page 4-2 Chiropractor Manual Transmittal Letter CRP-23 Date 12/01/10 441.404: Provider Eligibility The MassHealth agency pays only chiropractors who are participating in MassHealth on the date of service. Chiropractors must meet the following eligibility requirements. (A) In-State Providers. To be eligible to participate in MassHealth, an in-state chiropractor must (1) be licensed by the Massachusetts Board of Registration of Chiropractors; (2) be an active MassHealth provider; and (3) participate in the Medicare program as a chiropractor. (B) Out-of-State-Providers. To be eligible to participate in MassHealth, an out-of-state chiropractor must (1) obtain a MassHealth provider number and maintain active provider status; (2) participate in his or her own state's Medicaid program; (3) be currently licensed as a chiropractor in his or her own state, or in a state that does not license chiropractors, be legally authorized to perform the services of a chiropractor in that state; and (4) participate in the Medicare program as a chiropractor. 441.405: Out-of-State Chiropractor Services (A) The MassHealth agency pays out-of-state chiropractors for covered services provided to an eligible MassHealth member when the chiropractor 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 he or she provides covered services to a member who resides in a Massachusetts community near the border of the chiropractor's state. The out-of-state chiropractor's office must be more accessible to the member than the office of an in-state chiropractor who participates in MassHealth. (B) Prior authorization is required from the MassHealth agency before a chiropractor whose office is located in a community more than 50 miles from the Massachusetts border may provide covered chiropractor services to a member. Prior authorization will not be granted if the MassHealth agency determines that the chiropractor's office is less accessible to the member than the office of any other chiropractor participating in MassHealth. All requests for prior authorization must be submitted in accordance with the instructions found in Subchapter 5 of the Chiropractor Manual. The MassHealth agency does not pay for covered services provided at a site more than 50 miles from the Massachusetts border unless the chiropractor obtains prior authorization from the MassHealth agency before the delivery of service. The MassHealth agency does not grant retroactive requests for prior authorization. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 441.000) Page 4-3 Chiropractor Manual Transmittal Letter CRP-23 Date 12/01/10 441.406: Payable Services The MassHealth agency pays chiropractors only for the following services subject to the restrictions and limitations specified in 130 CMR 441.000: chiropractic manipulative treatment, office visits, and radiology services. 441.407: Service Limitations (A) The MassHealth agency pays a chiropractor for medically necessary treatment related to a neuromusculoskeletal condition only. Services must be provided in a chiropractor's office and must have a direct therapeutic relation to the patient's condition. Conditions that may be considered to provide therapeutic grounds for chiropractic treatment include functional disabilities of the spine, nerve pains, and documented incidents that produce sprains and strains of the spinal axis. (B) The MassHealth agency does not pay for both an office visit and chiropractic manipulative treatment provided to a MassHealth member on the same day. (C) The MassHealth agency limits payment for chiropractor services to a total of 20 office visits or chiropractic manipulative treatments, or any combination of office visits and chiropractic manipulative treatments, up to a total of 20, per member per calendar year. (See 130 CMR 441.409 for limits on radiology services.) 441.408: Reporting Requirements Chiropractors who furnish services to MassHealth members must report the results of these services to the member’s primary-care provider or PCC in writing. The chiropractor may report the results of treatment initially by telephone, but he or she must then submit a written report. 441.409: Radiology Services (A) The MassHealth agency pays for radiology services when the services are needed to confirm the existence of a neuromusculoskeletal condition requiring treatment. (B) Payment for radiology services is not included in the fees for office visits or chiropractic manipulative treatment and must be claimed separately. (C) All equipment used in providing radiology services must be inspected and approved by the Massachusetts Department of Public Health. (D) The MassHealth agency pays chiropractors for only those radiology services provided in the chiropractor's office and only when the films are developed and read in the chiropractor's office. (E) All X rays must be labeled with the member's name, date of the exam, and the nature of the exam and must be maintained in the member’s medical record in accordance with 130 CMR 441.412. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title4. Program Regulations (130 CMR 441.000) Page 4-4 Chiropractor Manual Transmittal Letter CRP-23 Date 12/01/10 441.410: Nonpayable Services Nonpayable services include, but are not limited to, the following: (A) the chiropractic treatment of diseases and pathological disorders other than those related to a neuromusculoskeletal condition (including, but not limited to, rheumatoid arthritis, muscular dystrophy, multiple sclerosis, pneumonia, and emphysema); (B) chiropractic manipulative treatment, office visits, and radiology services not personally provided by the chiropractor, in accordance with 130 CMR 450.301; (C) chiropractor services provided in settings other than the chiropractor's office. Such settings include, but are not limited to, inpatient or outpatient hospitals, nursing facilities, rest homes, and the member's home; (D) laboratory services; (E) orthotic devices, corrective devices, and orthopedic appliances; (F) research, or experimental, unproven, or medically unnecessary procedures or treatment; (G) maintenance therapy, that is, chiropractic manipulative treatment to maintain health or prevent regression when the member is no longer suffering or presenting symptoms; (H) supportive services such as, but not limited to, nutritional counseling, educational services, and printed materials; (I) physiotherapy, physical therapy, muscular stimulation, heat packs, or massage; and (J) vitamins, minerals, food supplements, or other such supplies. (130 CMR 441.411 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title4. Program Regulations (130 CMR 441.000) Page 4-5 Chiropractor Manual Transmittal Letter CRP-23 Date 12/01/10 441.412: Recordkeeping Requirements (A) Federal and state regulations require that all MassHealth providers maintain complete written medical records of all patients who are MassHealth members. Medical records must comply with the provisions of 233 CMR 4.04. All records must be kept for a minimum of six years after the date of service. Payment for maintaining the member's medical record is included in the fee for chiropractic services. Each medical record must contain sufficient information to document fully the nature, extent, quality, and necessity of the care furnished to the member for each date of service claimed for payment. If the documentation is not sufficient to justify the service for which payment is claimed by the provider, the MassHealth agency will not pay for the service or, if payment has been made, may consider such payment to be an overpayment subject to recovery in accordance with MassHealth’s administrative and billing regulations at 130 CMR 450.000. (B) The medical records must contain the following: (1) MassHealth member identification, including name, address, telephone number, date of birth, and the MassHealth member’s identification number; (2) a complete medical history; (3) examination results, including a description of the chief complaint and diagnosis; (4) a written referral from the member's primary-care provider or PCC; (5) copies of X rays, with interpretations; (6) copies of all prior-authorization requests for out-of-state services; (7) the date and nature of each visit, including a complete description of services furnished, written and signed by the chiropractor; (8) when more than one visit is indicated, a treatment plan for future visits written and signed by the chiropractor, which is updated on an ongoing basis to reflect changes in the member's presenting symptoms; (9) upon completion of treatment, a summary of the treatment and the member's current condition; (10) recommendations for additional treatment, signed and dated by the chiropractor; and (11) if the medical record or any component included therein is released for use by another party, the medical record must also contain a release form signed by the member. Release of the medical record to MassHealth for authorized use does not require the member's consent. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title4. Program Regulations (130 CMR 441.000) Page 4-6 Chiropractor Manual Transmittal Letter CRP-23 Date 12/01/10 441.413: Rates of Payment (A) The Massachusetts Division of Health Care Finance and Policy determines the maximum allowable fees for chiropractor services. Payment is subject to the conditions, exclusions, and limitations set forth in 130 CMR 441.000. Payment for a service will be the lower of the following: (1) the provider’s usual and customary fee; or (2) the maximum allowable fee listed in the applicable Division of Health Care Finance and Policy fee schedule and the applicable sections of 130 CMR 450.000. (B) Maximum allowable fees for chiropractor services include payment for all aspects of service delivery including administrative costs. Providers may not bill separately for services such as, but not limited to, the following: (1) telephone contacts; (2) information and referral services; and (3) recordkeeping. (130 CMR 441.414 through 441.419 Reserved) 441.420: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services The MassHealth agency pays for all medically necessary chiropractor services for EPSDT- eligible members in accordance with 130 CMR 450.140 et seq., without regard to service limitations described in 130 CMR 441.000, and with prior authorization. REGULATORY AUTHORITY 130 CMR 441.000: M.G.L. c 118E, §§ 7 and 12.