Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter PRT-23 September 2012 TO: Prosthetic Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Prosthetics Manual (2012 HCPCS) This letter transmits revisions to service codes in the Prosthetics Manual. The Centers for Medicare & Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) codes for 2012. The revised Subchapter 6 is effective for dates of service on or after January 1, 2012. Providers may consult the CMS website at www.cms.gov for a full description of the service codes. Prior-authorization (PA) requirements, service limits, and place-of-service codes now appear in an updated version of the interactive MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool that has been posted on the MassHealth website. Revised Rates DHCFP has established new PRT service code rates for the above service codes, effective for dates of service beginning January 1, 2012. The DHCFP fee schedule and informational bulletins can be viewed on the DHCFP website at www.mass.gov/dhcfp. Fee Schedule The DHCFP fee schedule and informational bulletins can be viewed 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 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 title for Prostheses, Prosthetic Devices, and Orthotic Devices is 114.3 CMR 34.00. 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 PRT-23 September 2012 Page 2 PRT Service Code Additions The following service codes have been added to Subchapter 6 of the Prosthetic Manual and the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool, and are effective for dates of service on or after January 1, 2012. L5312 L6715 L6880 The following codes have been deleted from Subchapter 6 of the Prosthetic Manual and the MassHealth Orthotics and Prosthetic Payment and Coverage Guideline Tool without replacement. L7266 L7272 L7274 The following service code has been deleted from Subchapter 6 of the Prosthetic Manual and the MassHealth Orthotics and Prosthetic Payment and Coverage Guideline Tool and has been crosswalked to a new code as indicated below. L5311 has been deleted and crosswalked to L5312. Diagnosis Codes ICD-9-CM diagnosis codes are required on all claims. The ICD-9-CM diagnosis code on the claim must be directly related to the service code(s) billed on the claim. PA Requests for PRT Units in Excess of the Maximum Allowable Units MassHealth requires PA for any PRT service codes if the number of units requested exceeds the maximum allowable units specified in the MassHealth Orthotics and Prosthetic Payment and Coverage Guideline Tool. When requesting PA for services in excess of the maximum allowable units, the provider must . submit to MassHealth, in addition to the PA request that was submitted for units up to the maximum allowable, a separate PA request for the number of units that exceed the maximum allowed; and . include clinical documentation that supports the medical necessity of the additional units. Modifiers LT (Left Side) RT (Right Side) MassHealth has updated its Orthotics and Prosthetics Payment and Coverage Guidelines Tool to include modifiers LT and RT. If bilateral items are provided as a “purchase,” and the unit of service described in the service code description is “each,” bill for both items on the same line using the LT/RT modifiers and two units of service. If a single item is provided as a “purchase” for either the left or right side, bill on one claim line using the appropriate modifier (LT or RT) and one unit of service. MassHealth Transmittal Letter PRT-23 September 2012 Page 3 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. NEW MATERIAL (The pages listed here contain new or revised language.) Prosthetics Manual Pages vi, 6-1 and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Prosthetics Manual Page vi — transmitted by Transmittal Letter PRT-21 Pages 6-1 and 6-2 — transmitted by Transmittal Letter PRT-22 Commonwealth of Massachusetts MassHealth Provider Manual Series Prosthetics Manual Subchapter Number and Title Table of Contents Page vi Transmittal Letter PRT-23 Date 01/01/12 6. Service Codes Introduction.................................................................... ............................................................. 6-1 Service Codes........................................................................... ................................................... 6-1 Appendix A. Directory ................................................................................ ..................................... A-1 Appendix B. Enrollment Centers ................................................................................ ...................... B-1 Appendix C. Third-Party-Liability Codes ................................................................................ ........ C-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 Prosthetics Manual Subchapter Number and Title 6. Service Codes Page 6-1 Transmittal Letter PRT-23 Date 01/01/12 601 Introduction MassHealth pays for the services represented by the codes listed in Section 603 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 428.000 and 450.000. A prosthetics 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 Subchapter 6 of the Prosthetics Manual. Providers should refer to the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool for service descriptions, applicable modifiers, place- of-service codes, PA requirements, service limits, and pricing and markup information. For certain services that are payable on an individual- consideration (I.C.) basis, the tool will calculate the payable amount, based on information entered into certain fields on the tool. For service codes for which the Division of Health Care Finance and Policy (DHCFP) has established a rate, the provider can determine the payment by reviewing the DHCFP regulations at 114.3 CMR 34.00. The MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool also contains a link to DHCFP regulations. Error codes are available on the website at www.mass.gov/masshealthpubs. Click on Provider Library, then on List of Explanation of Benefits Codes Appearing on the Remittance Advice. To get to the MassHealth Orthotic and Prosthetic Payment and Coverage Guidelines Tool, go to www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, click on Provider Library, and go to MassHealth Payment and Coverage Guideline Tools. If you want a paper copy of the tool, you can print it from the website. See Appendix A of your provider manual for applicable contact information. 602 Modifiers Modifiers LT (left side) and RT (right side) have been added to certain service codes. Please refer to the Orthotics and Prosthetics Payment and Coverage Guidelines Tool. 603 Service Codes This section lists codes for services that are payable under MassHealth. Refer to the Centers for Medicare & Medicaid website at www.cms.gov for more detailed descriptions. L5000 L5230 L5430 L5580 L5620 L5638 L5651 L5010 L5250 L5450 L5585 L5622 L5639 L5652 L5020 L5270 L5460 L5590 L5624 L5640 L5653 L5050 L5280 L5500 L5595 L5626 L5642 L5654 L5060 L5301 L5505 L5600 L5628 L5643 L5655 L5100 L5312 L5510 L5610 L5629 L5644 L5656 L5105 L5321 L5520 L5611 L5630 L5645 L5658 L5150 L5331 L5530 L5613 L5631 L5646 L5661 L5160 L5341 L5535 L5614 L5632 L5647 L5665 L5200 L5400 L5540 L5616 L5634 L5648 L5666 L5210 L5410 L5560 L5617 L5636 L5649 L5668 L5220 L5420 L5570 L5618 L5637 L5650 L5670 Commonwealth of Massachusetts MassHealth Provider Manual Series Prosthetics Manual Subchapter Number and Title 6 Service Codes Page 6-2 Transmittal Letter PRT-23 Date 01/01/12 603 Service Codes (cont.) L5671 L5811 L5999 L6629 L6881 L7405 L5672 L5812 L6000 L6630 L6882 L7499 L5673 L5814 L6010 L6632 L6883 L7510 L5676 L5816 L6020 L6635 L6884 L7520 L5677 L5818 L6025 L6637 L6885 L7600 L5678 L5822 L6050 L6638 L6890 L8000 L5679 L5824 L6055 L6640 L6895 L8001 L5680 L5826 L6100 L6641 L6900 L8002 L5681 L5828 L6110 L6642 L6905 L8010 L5682 L5830 L6120 L6645 L6910 L8015 L5683 L5840 L6130 L6646 L6915 L8020 L5684 L5845 L6200 L6647 L6920 L8030 L5685 L5848 L6205 L6648 L6925 L8031 L5686 L5850 L6250 L6650 L6930 L8032 L5688 L5855 L6300 L6655 L6935 L8035 L5690 L5856 L6310 L6660 L6940 L8039 L5692 L5857 L6320 L6665 L6945 L8300 L5694 L5858 L6350 L6670 L6950 L8310 L5695 L5910 L6360 L6672 L6955 L8320 L5696 L5920 L6370 L6675 L6960 L8330 L5697 L5925 L6380 L6676 L6965 L8400 L5698 L5930 L6382 L6677 L6970 L8410 L5699 L5940 L6384 L6680 L6975 L8415 L5700 L5950 L6386 L6682 L7007 L8417 L5701 L5960 L6388 L6684 L7008 L8420 L5702 L5961 L6400 L6686 L7009 L8430 L5703 L5962 L6450 L6687 L7040 L8435 L5704 L5964 L6500 L6688 L7045 L8440 L5705 L5966 L6550 L6689 L7170 L8460 L5706 L5968 L6570 L6690 L7180 L8465 L5707 L5970 L6580 L6691 L7181 L8470 L5710 L5971 L6582 L6692 L7185 L8480 L5711 L5972 L6584 L6693 L7186 L8485 L5712 L5973 L6586 L6694 L7190 L8499 L5714 L5974 L6588 L6695 L7191 S1040 L5716 L5975 L6590 L6696 L7260 L5718 L5976 L6600 L6697 L7261 L5722 L5978 L6605 L6698 L7360 L5724 L5979 L6610 L6703 L7362 L5726 L5980 L6611 L6704 L7364 L5728 L5981 L6615 L6706 L7366 L5780 L5982 L6616 L6707 L7367 L5781 L5984 L6620 L6708 L7368 L5782 L5985 L6621 L6709 L7400 L5785 L5986 L6623 L6715 L7401 L5790 L5987 L6624 L6805 L7402 L5795 L5988 L6625 L6810 L7403 L5810 L5990 L6628 L6880 L7404