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 AOH-22 May 2009 TO: Acute Outpatient Hospitals Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Acute Outpatient Hospital Manual (Revised Appendix F) This letter transmits a revised Appendix F for the Acute Outpatient Hospital Manual. Revisions in the appendix are effective for all claims with dates of service on or after January 1, 2009. Appendix F consists of a list of acceptable revenue codes for MassHealth. There is no longer mapping between the revenue codes and the service codes. To determine appropriate HCPCS mapping, providers must now refer to the Ingenix Uniform Billing Editor. For more information on the reimbursement for AOH services, providers can refer to the Acute Hospital Request for Application (RFA) in effect on the date of service. The application is available at www.comm-pass.com. Regulatory and billing information is available on the MassHealth Web site at www.mass.gov/masshealth. 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.) Acute Outpatient Hospital Manual Pages vi and F-1 through F-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Pages vi and F-1 through F-8 — transmitted by Transmittal Letter AOH-17 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Acute Outpatient Hospital Transmittal Letter AOH-22 Date 05/26/09 6. Service Codes Introduction.................................................................................................................................. 6-1 Nonpayable Services - CPT......................................................................................................... 6-1 Payable Services - Level II HCPCS............................................................................................. 6-4 Modifiers ..................................................................................................................................... 6-5 Appendix A. Directory....................................................................................................................... A-1 Appendix B. Enrollment Centers........................................................................................................ B-1 Appendix C. Third-Party-Liability Codes.......................................................................................... C-1 Appendix D. Utilization Management Program................................................................................. D-1 Appendix E. Admission Guidelines................................................................................................... E-1 Appendix F. Revenue Codes.............................................................................................................. F-1 Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule................................... 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 MassHealth Revenue Codes The following table lists the revenue codes that may be used by acute outpatient hospitals (AOHs) including hospital-licensed health centers and other provider-based satellites, when billing for MassHealth-covered services. To determine the appropriate revenue-HCPCS code mappings, please refer to the current edition of the Ingenix Uniform Billing Editor. To purchase the application, go to http://www.shopingenix.com. Acute hospitals should refer to Subchapter 6 of the Acute Outpatient Hospital Manual to determine if HCPCS codes are covered by MassHealth. Revenue Code Description 025X Pharmacy 0250 General 0251 Generic drugs 0252 Non-generic drugs 0253 Take-home drugs 0254 Drugs incident to other diagnostic services 0255 Drugs incident to radiology 0257 Nonprescription drugs 0258 IV solutions 026X IV Therapy 0260 General 027X Medical/Surgical Supplies and Devices – General 0270 General 0271 Non-sterile supply 0272 Sterile supply 0273 Take-home supplies 0274 Prosthetic/orthotic devices 0275 Pacemaker 0276 Intraocular lens 0278 Other implants 028X Oncology 0280 General 029X DME 0290 General 0291 Rental 0292 Purchase of new DME 0293 Purchase of used DME 030X Laboratory 0300 General 0301 Chemistry 0302 Immunology 0304 Nonroutine dialysis 0305 Hematology 0306 Bacteriology and microbiology 0307 Urology 0309 Other 031X Laboratory Pathological – General 0310 Laboratory pathological – general 0311 Cytology 0312 Histology 0314 Biopsy 0319 Other 032X Radiology - Diagnostic 0320 General 0321 Angiocardiography 0322 Arthrography 0323 Arteriography 0324 Chest X ray 0329 Other 033X Radiology – Therapeutic and/or Chemotherapy Administration 0330 General 0331 Chemotherapy administration – injected 0332 Chemotherapy – oral 0333 Radiation therapy 0335 Chemotherapy administration – IV 034X Nuclear Medicine 0340 General 0341 Diagnostic 0342 Therapeutic 0343 Diagnostic radiopharmaceuticals 0349 Other 035X Computerized Tomographic (CT) Scans 0350 General 0351 Head scan 0352 Body scan 0359 Other 036X Operating Room Services 0360 General 0361 Minor surgery 037X Anesthesia 0370 General 0371 Anesthesia incident to radiology 0372 Anesthesia incident to other diagnostic services 038X Blood 0381 Packed red blood cells 0383 Plasma 0384 Platelets 0385 Leukocytes 0386 Other components 0387 Other derivatives 039X Blood Storage and Processing 0390 General 0391 Administration 040X Other Imaging Services 0400 General 0401 Diagnostic mammography 0402 Ultrasound 0403 Screening mammography 0404 Positron emission tomography (PET) 041X Respiratory Services 0410 General 0412 Inhalation services 0413 Hyperbaric oxygen therapy 0419 Other 042X Physical Therapy 0420 General 0421 Visit charge 0423 Group charge 0424 Evaluation or reevaluation 043X Occupational Therapy 0430 General 0431 Visit charge 0433 Group rate 0434 Evaluation or reevaluation 044X Speech-Language Pathology 0440 General 0441 Visit charge 0443 Group rate 0444 Evaluation or reevaluation 045X Emergency Room 0450 General 0456 Urgent care 0459 Other ER 046X Pulmonary Function 0460 General 0469 Other 047X Audiology 0470 General 0471 Diagnostic 0472 Treatment 0479 Other 048X Cardiology 0480 General 0481 Cardiac catheterization lab 0482 Stress test 0483 Echocardiology 0489 Other 049X Ambulatory Surgical Care 0490 General 0499 Other 051X Clinic 0510 General 0514 OB/GYN 0515 Pediatric clinic 0519 Other 053X Osteopathic Services 0530 General 061X Magnetic Resonance Technology 0610 General 0611 MRI – brain 0612 MRI – spinal cord 062X Medical/Surgical Supplies 0621 Supplies incident to radiology 0622 Supplies incident to other diagnostic services 063X Pharmacy 0634 EPO, less than 10,000 units 0635 EPO, 10,000 or more units 0636 Drugs requiring detail coding 0700 General 071X Recovery Room 0710 General 072X Labor Room/Delivery 0720 General 0721 Labor 0722 Delivery 073X EKG/ECG 0730 General 0731 Holter monitor 0732 Telemetry 074X EEG 0740 General 075X Gastroenterology 0750 General 760X Treatment/Observation Room 0761 Treatment room 0762 Observation room 077X Preventive Services 0771 Vaccine administration 082X Hemodialysis 0820 General 0821 Hemodialysis composite/other rate 0825 Support Services 083X Peritoneal Dialysis 0830 General 0831 Peritoneal composite/other rate 0835 Support Services 084X CAPD 0840 General 0841 CAPD composite/other rate 0845 Support Services 085X CCPD 0850 General 0851 CCPD composite/other rate 0855 Support Services 090X Behavioral Health Treatments/Services 0900 General 0901 Electroshock therapy 091X Behavioral Health Treatments/Services 0914 Individual therapy 0918 Testing 092X Other Diagnostic Services 0920 General 0921 Peripheral vascular lab 0922 Electromyelogram 0924 Allergy testing 0929 Other diagnostic service 094X Other Therapeutic Services 0940 General 0942 Education/training 0943 Cardiac rehabilitation 0944 Drug rehabilitation 0945 Alcohol rehabilitation