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 POD-54 August 2006 TO: Podiatrists Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Podiatrist Manual (2006 HCPCS Codes) This letter transmits revisions to the service codes and descriptions in the Podiatrist Manual. The Centers for Medicare and Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2006. Providers should refer to www.cms.hhs.gov for code descriptions. Subchapter 6 of the Podiatrist Manual lists CPT and Level II codes that: * are payable under MassHealth; and * have special limitations or requirements, such as prior authorization or individual consideration. In addition, pursuant to 130 CMR 450.144(A), a podiatrist may request prior authorization for any medically necessary service for a member under 21 years of age, even if it is not listed as payable in Subchapter 6 of the Podiatrist Manual. If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of Division of Health Care Finance and Policy regulations from either the Massachusetts State bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The specific regulation title(s) are: for medicine, 114.3 CMR 17.00: Medicine; for surgery and anesthesia, 114.3 CMR 16.00: Surgery and Related Anesthesia Care; for radiology, 114.3 CMR 18.00: Radiology; and for laboratory, 114.3 CMR 20.00: Laboratory. 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 Effective Date The changes to codes listed in Subchapter 6 are effective for dates of service on or after July 6, 2006. Code changes previously identified in Podiatrist Bulletin 15 and effective on or after January 1, 2006, have been incorporated within Subchapter 6. For claims you have already submitted for services furnished on or after these effective dates, you may request a payment adjustment. Follow the procedures in the Administrative and Billing Instructions in Subchapter 5 (Part 7) of your provider manual. 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.) Podiatrist Manual Pages 6-1 through 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Podiatrist Manual Pages 6-1 through 6-6 — transmitted by Transmittal Letter POD-53 601 Introduction MassHealth pays for the services for codes listed in Sections 602 through 604 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 424.000 and 450.000. Podiatry services require a written referral from the member’s primary-care provider before the delivery of services. MassHealth pays only for podiatry services that are certified to be necessary for the life and safety of the member. The referral must be on the primary-care provider’s letterhead and must certify that such services are medically necessary for the life and safety of the member. A substantiating medical explanation must also be included in the written certification. * Section 602 lists CPT service codes that are payable under MassHealth, some of which require individual consideration or prior authorization. Refer to the Centers for Medicare and Medicaid Web site at www.cms.gov/medicare/hcpcs for the descriptions of the service codes listed in Section 602. * Sections 603 and 604 list Level II HCPCS codes that are payable under MassHealth. Refer to the Centers for Medicare and Medicaid Web site at www.cms.gov/medicare/hcpcs for the descriptions of the service codes listed in Section 603. * Section 605 lists service code modifiers allowed under MassHealth. Legend: IC: Claim requires individual consideration. See 130 CMR 424.407 for more information. PA: Service requires prior authorization. See 130 CMR 450.303 for more information. 602 Payable CPT Codes MassHealth pays for services billed using the following codes. 10060 10061 10120 10121 10140 10160 10180 11000 11001 11040 11041 11042 11043 11044 11055 11056 11057 11100 11101 11200 11201 11305 11306 11307 11308 11420 11421 11422 11423 11424 11426 11620 11621 11622 11623 11624 11626 11719 11720 11721 11730 11732 11740 11750 11752 11755 11760 11762 11765 12001 12002 12004 12005 12006 12007 12041 12042 12044 12045 13131 13132 13133 14040 14041 14060 14061 14300 14350 15000 15001 15050 15100 15101 15110 15111 15115 15116 15120 15121 15130 15131 15135 15136 15150 15151 15152 15155 15156 15157 15170 15171 15175 15176 15240 15241 15300 15301 15320 15321 15330 15331 15335 15336 15340 15341 15360 15361 15365 15366 15400 15401 15420 15421 15430 15431 (IC) 15574 15620 15850 15851 15852 15999 (IC) 17000 17003 17004 17110 17111 17250 17270 17271 17272 17273 17274 17276 20000 20005 20200 20205 20206 20520 20525 20550 20600 20605 20612 20615 20650 20670 20680 27603 27604 27605 27606 27607 27610 27612 27613 27614 27615 27618 27619 27620 27625 27626 27630 27647 27648 27680 27681 27685 27686 27695 27696 27704 27760 27762 27766 27808 27810 27814 27816 27818 27822 27823 27840 27842 27846 27848 27860 27870 28001 28002 28003 28005 28008 28010 28011 28020 28022 28024 28030 28035 28043 28045 28046 28050 28052 28054 28060 28062 28070 28072 28080 28086 28088 28090 28092 28100 28102 28103 28104 28106 28107 28108 28110 28111 28112 28113 28114 28116 28118 28119 28120 28122 28124 28126 28130 28140 28150 28153 28160 28171 28173 28175 28190 28192 28193 28200 28202 28208 28210 28220 28222 28225 28226 28230 28232 28234 28238 28240 28250 28260 28261 28262 28264 28270 28272 28280 28285 28286 28288 28289 28290 28292 28293 28294 28296 28297 28298 28299 28300 28302 28304 28305 28306 28307 28308 28309 28310 28312 28313 28315 28320 28322 28340 28341 28344 28345 28360 28400 28405 28406 28415 28420 28430 28435 28436 28445 28450 28455 28456 28465 28470 28475 28476 28485 28490 28495 28496 28505 28510 28515 28525 28530 28531 28540 28545 28546 28555 28570 28575 28576 28585 28600 28605 28606 28615 28630 28635 28636 28645 28660 28665 28666 28675 28705 28715 28725 28730 28735 28737 28740 28750 28755 28760 28800 28805 28810 28820 28825 28890 (PA) 28899 (IC) 29345 29355 29405 29425 29440 29445 29450 29515 29540 29550 29580 29590 29705 29730 29750 29799 (IC) 29891 29892 29893 29894 29895 29897 29898 29899 73590 73592 73600 73610 73620 73630 73650 73660 76499 (IC) 81000 82947 84550 85007 85014 85018 85032 85041 85048 87101 87102 87106 99070 (IC) 99202 99203 99204 99211 99212 99213 99214 99218 99219 99221 99222 99231 99232 99238 99239 99241 99242 99243 99251 99252 99253 99281 99282 99283 99307 99308 99309 99324 99325 99326 99334 99335 99336 99341 99342 99343 99347 99348 99349 603 Payable HCPCS Level II Service Codes for Injectable and Infusable Drugs Administered in the Office MassHealth pays for the services for codes listed in Section 603 in effect at the time of service, subject to all conditions and limitations in Subchapter 6 and in MassHealth’s regulations at 130 CMR 424.000 and 450.000. J0702 J0704 J1020 J1030 J1040 J1710 (IC) J1720 J3301 J3302 J3303 J3490 (IC) J7340 J7341 J7342 J7343 J7344 J7350 S0020 604 Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services MassHealth pays for the services represented by the codes listed in Section 604 in effect at the time of service, subject to all the conditions and limitations in Subchapter 6 and in MassHealth regulations at 130 CMR 424.000 and 450.000. The provider may request prior authorization (PA) for orthotic services to eligible members, if additional units are medically necessary. Please Note: Service codes that require PA only when the number of units exceeds the limitations for the code in Section 602 are listed as requiring PA “Sometimes.” Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? A5500 No Sometimes 2 per 12 months RT LT Yes A5501 No Sometimes 2 per 12 months RT LT Yes A5503 No Sometimes 2 per 12 months RT LT Yes A5504 No Sometimes 2 per 12 months RT LT Yes A5506 No Sometimes 2 per 12 months RT LT Yes A5507 No Sometimes 2 per 12 months RT LT Yes A5508 No Sometimes 2 per 12 months RT LT Yes A5509 No Sometimes 12 per 12 months RT LT Yes A5511 No Sometimes 2 per 12 months RT LT Yes L3000 No Sometimes 4 per 12 months RT LT No L3001 No Sometimes 4 per 12 months RT LT No L3002 No Sometimes 4 per 12 months RT LT No L3003 No Sometimes 4 per 12 months RT LT No L3010 No Sometimes 4 per 12 months RT LT No L3020 No Sometimes 4 per 12 months RT LT No L3030 No Sometimes 4 per 12 months RT LT No L3040 No Sometimes 4 per 12 months RT LT No L3050 No Sometimes 4 per 12 months RT LT No L3060 No Sometimes 4 per 12 months RT LT No L3070 No Sometimes 4 per 12 months RT LT No L3080 No Sometimes 4 per 12 months RT LT No L3090 No Sometimes 4 per 12 months RT LT No L3100 No Sometimes 2 per 12 months RT LT No L3140 Yes Sometimes 2 per 12 months RT LT No L3150 Yes Sometimes 2 per 12 months RT LT No L3160 Yes Sometimes 2 per 12 months RT LT No L3170 No Sometimes 2 per 12 months RT LT No L3201 Yes Sometimes 4 per 12 months RT LT Yes L3202 Yes Sometimes 4 per 12 months RT LT Yes L3203 Yes Sometimes 4 per 12 months RT LT Yes L3204 Yes Sometimes 4 per 12 months RT LT Yes L3206 Yes Sometimes 4 per 12 months RT LT Yes L3207 Yes Sometimes 4 per 12 months RT LT Yes L3208 Yes Sometimes 4 per 12 months RT LT Yes L3209 Yes Sometimes 4 per 12 months RT LT Yes L3211 Yes Sometimes 4 per 12 months RT LT Yes Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L3212 Yes Sometimes 2 per 12 months RT LT Yes L3213 Yes Sometimes 2 per 12 months RT LT Yes L3214 Yes Sometimes 2 per 12 months RT LT Yes L3215 No Yes 2 per 12 months RT LT Yes L3216 No Yes 2 per 12 months RT LT Yes L3217 No Yes 2 per 12 months RT LT Yes L3219 No Yes 2 per 12 months RT LT Yes L3221 No Yes 2 per 12 months RT LT Yes L3222 No Yes 2 per 12 months RT LT Yes L3224 No Yes 4 per 12 months RT LT Yes L3225 No Yes 4 per 12 months RT LT Yes L3230 No Yes 4 per 12 months RT LT Yes L3250 No Yes 4 per 12 months RT LT Yes L3251 No Yes 4 per 12 months RT LT Yes L3252 No Yes 4 per 12 months RT LT Yes L3253 No Yes 4 per 12 months RT LT Yes L3524 No Yes 2 per 12 months RT LT Yes L3255 No Yes 2 per 12 months RT LT Yes L3257 No Yes 2 per 12 months RT LT Yes L3260 No Yes 4 per 12 months RT LT Yes L3265 No Yes 4 per 12 months RT LT Yes L3300 No Yes 4 per 12 months RT LT Yes L3310 No Yes 4 per 12 months RT LT Yes L3320 No Yes 4 per 12 months RT LT Yes L3332 No Yes 2 per 12 months RT LT Yes L3334 No Yes 4 per 12 months RT LT Yes L3350 No Yes 4 per 12 months RT LT Yes L3360 No Yes 4 per 12 months RT LT Yes L3370 No Yes 4 per 12 months RT LT Yes L3390 No Yes 4 per 12 months RT LT Yes L3400 No Yes 4 per 12 months RT LT Yes L3420 No Yes 4 per 12 months RT LT Yes L3450 No Yes 4 per 12 months RT LT No L3455 No Yes 4 per 12 months RT LT No L3460 No Sometimes 4 per 12 months RT LT No L3465 No Sometimes 4 per 12 months RT LT No L3470 No Sometimes 4 per 12 months RT LT No L3480 No Sometimes 4 per 12 months RT LT No L3485 No Sometimes 4 per 12 months RT LT No L3500 No Sometimes 4 per 12 months RT LT No L3510 No Sometimes 4 per 12 months RT LT No L3530 No Sometimes 4 per 12 months RT LT No L3530 No Sometimes 4 per 12 months RT LT No L3540 No Sometimes 4 per 12 months RT LT No L3570 No Sometimes 4 per 12 months RT LT Yes Service Code Age Limitation? PA Required? Limitations and Requirements Required Modifiers Shoe Prescription Form Required? L3580 No Sometimes 4 per 12 months RT LT No L3590 No Sometimes 4 per 12 months RT LT No L3595 No Sometimes 4 per 12 months RT LT No T2003 No Sometimes -- -- No 605 Modifiers The following service code modifiers are allowed for billing under MassHealth. See Subchapter 5 of the Podiatrist Manual for billing instructions related to the use of modifiers. 26 Professional component 50 Bilateral procedure 51 Multiple procedures 99 Multiple modifiers LT Left side (for orthotic shoes only) RT Right side (for orthotic shoes only) TC Technical component