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 FAS-16 June 2006 TO: Freestanding Ambulatory Surgery Centers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Freestanding Ambulatory Surgery Center Manual (Coverage of Dental Services for Members Aged 21 Years or Older) Due to a new state law, effective July 1, 2006, MassHealth will cover dental services for eligible members aged 21 years or older (adults). This letter transmits a revised Subchapter 6 of the Freestanding Ambulatory Surgery Center Manual. The revisions reflect the new dental coverage for adults. Effective July 1, 2006, dental coverage will be available for all eligible adults, not just to members with demonstrated special circumstances or to members who are pregnant or a mother of a child under the age of three years. Accordingly, providers will no longer need to seek special circumstances designation for members. MassHealth will continue to process all requests for special circumstances designation for services that will be provided before July 1, 2006. All other conditions of 130 CMR 423.000 and 450.000 continue to apply. This transmittal letter, including the attached pages, and other publications issued by MassHealth are available on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth Regulations and Other Publications, then on Provider Library. 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.) Freestanding Ambulatory Surgery Center Manual Pages iv, 6-1, 6-2, 6-21, and 6-22 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Freestanding Ambulatory Surgery Center Manual Page iv — transmitted by Transmittal Letter FAS-9 Pages 6-1, 6-2, 6-21, and 6-22 — transmitted by Transmittal Letter FAS-15 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-16 Date 07/01/06 4. Program Regulations 423.401: Introduction 4-1 423.402: Definitions 4-1 423.403: Eligible Recipients 4-2 423.404: Provider Eligibility 4-2 423.405: Reimbursement 4-4 423.406: Prior Authorization 4-5 (130 CMR 423.407 through 423.412 Reserved) 423.413: Recordkeeping Requirements 4-7 423.414: Reimbursable Surgical Procedures 4-9 423.415: Service Limitations 4-9 423.416: Sterilization Services: Introduction 4-9 423.417: Sterilization Services: Informed Consent 4-11 423.418: Sterilization Services: Consent Form Requirements 4-12 423.419: Abortion Services 4-12 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-16 Date 07/01/06 601 Payable Surgery Services MassHealth pays for the following services in a freestanding ambulatory surgery center, subject to all conditions and limitations in MassHealth regulations at 130 CMR 423.000 and 450.000. Codes with additional text as shown in the legend below require specific attachments or prior authorization or have specific instructions or limitations. Legend: CPA-2: A completed Certification for Payable Abortion form is required. See 130 CMR 423.419 for additional information. CS-18: A completed Sterilization Consent Form (for members aged 18 through 20) is required. See 130 CMR 423.417 and 423.418 for additional information. CS-21: A completed Sterilization Consent Form (for members aged 21 and older) is required. See 130 CMR 423.417 and 423.418 for additional information. IC: Claim requires individual consideration. See 130 CMR 423.402 for more information. PA: Service requires prior authorization. See 130 CMR 423.406 or 420.410 in the Dental Manual for more information. 10121 10180 11010 11011 11012 11042 11043 11044 11404 11406 11424 11426 11444 11446 11450 11451 11462 11463 11470 11471 11604 11606 11624 11626 11644 11646 11770 11771 11772 11960 11970 11971 12005 12006 12007 12016 12017 12018 12020 12021 12034 12035 12036 12037 12044 12045 12046 12047 12054 12055 12056 12057 13100 13101 13120 13121 13131 13132 13150 13151 13152 13160 14000 14001 14020 14021 14040 14041 14060 14061 14300 14350 15000 15040 15050 15100 15101 15110 15111 15115 15116 15120 15121 15130 15131 15135 15136 15150 15151 15152 15155 15156 15157 15200 15201 15220 15221 15240 15241 15260 15261 15300 15301 15320 15321 15330 15331 15335 15336 15400 15401 15420 15421 15430 15431 15570 15572 15574 15576 15600 15610 15620 15630 15650 15732 15734 15736 15738 15740 15750 15760 15770 15820 (PA) 15821 (PA) 15822 (PA) 602 Periodontic Service Codes and Descriptions Service Code Description Surgical Services (Includes Usual Postoperative Services) D4210 Gingivectomy or gingivoplasty—four or more contiguous teeth or bounded teeth spaces per quadrant (once per quadrant per three-year period) (PA) D4341 Periodontal scaling and root planing—four or more contiguous teeth or bounded teeth spaces per quadrant (includes curettage) (once per quadrant per three-year period) (PA) 603 Exodontic Service Codes and Descriptions Service Code Description Extractions (Includes Local Anesthesia and Routine Postoperative Care) D7111 Coronal remnants – deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth D7220 Removal of impacted tooth—soft tissue (PA) D7230 Removal of impacted tooth—partially bony (PA) D7240 Removal of impacted tooth—completely bony (PA) D7283 Placement of device to facilitate eruption of impacted tooth (under 21 only) (PA) 604 Dental Surgery Procedures Service Code Description D7310 Alveoloplasty in conjunction with extactions—per quadrant D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions—per quadrant D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant D7340 Vestibuloplasty—ridge extension (second epithelialization) (PA) D7960 Frenulectomy (frenectomy or frenotomy)—separate procedure D7963 Frenuloplasty D7970 Excision of hyperplastic tissue—per arch (PA) D7999 Unspecified oral surgery procedure, by report (PA) (IC) D9930 Treatment of complications (postsurgical) – unusual circumstances, by report (IC) 605 Prosthetic Service Codes and Descriptions Service Code Description Integumentary System L8500 Artificial larynx, any type (IC) L8501 Tracheostomy speaking valve (IC) L8510 Voice amplifier (IC) L8600 Implantable breast prosthesis, silicone or equal (IC) L8603 Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies (IC) L8606 Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies (IC) Head: Skull, Facial Bones, and Temporomandibular Joint L8610 Ocular implant (IC) L8612 Aqueous shunt (IC) L8613 Ossicular implant (IC) L8614 Cochlear device/system (IC) L8619 Cochlear implant external speech processor, replacement (IC) Upper Extremity L8630 Metacarpophalangeal joint implant (IC) Lower Extremity — Joint: Knee, Ankle, Toe L8641 Metatarsal joint implant (IC) L8642 Hallux implant (IC) L8658 Interphalangeal joint spacer, silicone or equal, each (IC) Cardiovascular System L8670 Vascular graft material, synthetic, implant (IC) 606 Modifiers 50 Bilateral procedure 51 Multiple procedures 73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia 74 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia