Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter PHY-135 February 2012 TO: Physicians Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Physician Manual (Coverage for Fluoride Varnish Applied by Medical Assistants) MassHealth has revised its regulations to allow payment to physicians for the application of fluoride varnish by medical assistants under the supervision of the physician. Previously, MassHealth regulations allowed payment for application of fluoride varnish only by physicians, nurse practitioners, registered nurses, licensed practical nurses, and physician assistants. To qualify to apply fluoride varnish, the individual must complete a MassHealth-approved training on the application of fluoride varnish, maintain proof of completion of the training, and provide such proof to MassHealth upon request. These amendments are effective for dates of service on or after March 15, 2012. 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 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.) Physician Manual Pages 4-41 and 4-42 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Physician Manual Pages 4-41 and 4-42 — transmitted by Transmittal Letter PHY-131 MassHealth Transmittal Letter * * 2012 Page 2 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-41 Physician Manual Transmittal Letter PHY-135 Date 03/15/12 433.449: Fluoride Varnish Services (A) Eligible Members. Members must be under 21 years of age to be eligible for the application of fluoride varnish. (B) Qualified Personnel. Physicians, nurse practitioners, registered nurses, licensed practical nurses, physician assistants, and medical assistants may apply fluoride varnish subject to the limitations of state law. To qualify to apply fluoride varnish, the individual must complete a MassHealth-approved training on the application of fluoride varnish, maintain proof of completion of the training, and provide such proof to the MassHealth agency upon request. (C) Billing for an Office Visit and Fluoride Varnish Treatment or Procedure. A physician may bill for fluoride varnish services provided by the physician or a qualified staff member as listed in 130 CMR 433.449(B) under the supervision of a physician. The physician may bill for an office visit, in addition to the fluoride varnish application, only if fluoride varnish was not the sole service, treatment, or procedure provided during the visit. (D) Claims Submission. Physicians and independent nurse practitioners may submit claims for fluoride varnish services when they provide those services directly to MassHealth members. These are the only MassHealth provider types who may bill for this service independently under 130 CMR 433.449. A physician may also submit claims for fluoride varnish services that are provided by nurse practitioners, registered nurses, licensed practical nurses, physician assistants, and medical assistants according to 130 CMR 433.449(C). See Subchapter 6 of the Physician Manual for service codes. (130 CMR 433.450 Reserved) Part 3. Surgery Services 433.451: Surgery Services: Introduction (A) Provider Eligibility. The MassHealth agency pays a physician for surgery only if the physician is scrubbed and present in the operating room during the major portion of the operation. (See 130 CMR 433.421(B)(2) for the single exception to this requirement.) (B) Nonpayable Services. The MassHealth agency does not pay for (1) any experimental, unproven, cosmetic, or otherwise medically unnecessary procedure or treatment. This specifically includes, but is not limited to, sex-reassignment surgery, thyroid cartilage reduction surgery, and any other related surgeries; (2) the treatment of male or female infertility (including, but not limited to, laboratory tests, drugs, and procedures associated with such treatment); (3) reconstructive surgery, unless the MassHealth agency determines, pursuant to a request for prior authorization, the service is medically necessary to correct, repair, or ameliorate the physical effects of physical disease or defect, or traumatic injury; (4) services billed under codes listed in Subchapter 6 of the Physician Manual as not payable; (5) services otherwise identified in MassHealth regulations at 130 CMR 433.000 or 450.000 as not payable; and (6) services billed with otherwise covered service codes when such codes are used to bill for nonpayable circumstances as described in 130 CMR 433.404. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-42 Physician Manual Transmittal Letter PHY-135 Date 03/15/12 (C) Definitions. The following terms have the meanings given for purposes of 130 CMR 433.451 and 433.452, unless otherwise indicated. (1) Complications Following Surgery – all additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room. (2) Evaluation and Management (E/M) Services – visits and consultations furnished by physicians in various settings and of various complexities as defined in the Evaluation and Management section of the American Medical Association’s Current Procedural Terminology (CPT) code book. (3) Intraoperative Services – intraoperative services that are normally a usual and necessary part of a surgical procedure. (4) Major Surgery – a surgery for which the Centers for Medicare & Medicaid Services (CMS) determines the preoperative period is one day and the postoperative period is 90 days. (5) Minor Surgery – a surgery for which CMS determines the preoperative period is zero days and the postoperative period is zero or 10 days. (6) Postoperative Period – (a) The postoperative period for major surgery is 90 days. (b) The postoperative period for minor surgery and endoscopies is zero or 10 days. (7) Postoperative Visits – follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery. (8) Postsurgical Pain Management – postsurgical pain management by the surgeon, including supplies. (9) Preoperative Period – (a) The preoperative period for major surgery is one day. (b) The preoperative period for minor surgery is zero days. (10) Preoperative Visits – preoperative visits after the decision is made to operate, beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures. 433.452: Surgery Services: Payment Surgical services and other invasive procedures are listed in the surgery and medicine section of the American Medical Association’s Current Procedural Terminology (CPT) code book. The MassHealth agency pays for all medicine and surgery CPT codes in effect at the time of service, except for those codes listed in Section 602 of Subchapter 6 of the Physician Manual, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 433.000 and 450.000. (A) Visit and Treatment/Procedure on Same Day in Same Location. The MassHealth agency pays a physician for either a visit or a treatment/procedure, whichever fee is greater. The MassHealth agency does not pay for both a preoperative evaluation and management visit, and a treatment/procedure provided to a member on the same day when they are performed in the same location. For minor surgeries and endoscopies, the MassHealth agency does not pay separately for an evaluation and management service on the same day as the surgery or endoscopy. For payment information about obstetrical care, refer to 130 CMR 433.421.