Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter AOH-25 January 2011 TO: Acute Outpatient Hospitals Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Acute Outpatient Hospital Manual (Revised Subchapter 6) This letter transmits revisions to the service codes in Subchapter 6 of the Acute Outpatient Hospital Manual. The revisions include deletions, additions, and updates of the payable HCPCS codes. The revised Subchapter 6 is effective for dates of service on or after January 1, 2011. This letter also updates billing information for acute outpatient hospitals (AOHs), including their hospital-licensed health centers and other provider-based satellites. Revised Service Codes for Subchapter 6 Providers should use the revised Subchapter 6 along with the American Medical Association Current Procedural Terminology (CPT) 2011 Healthcare Common Procedure Coding System (HCPCS) Level II code book. Subchapter 6 of the Acute Outpatient Hospital Manual contains the following information: . CPT codes that are not billable under the MassHealth acute outpatient hospital program (all other CPT codes in the CPT 2011 code book are billable, subject to all limitations and conditions of payment in MassHealth regulations at 130 CMR 410.000 and 450.000); and . Level II HCPCS that are billable under the MassHealth acute outpatient hospital program. An AOH 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 the Acute Outpatient Hospital Manual or other provider manuals referred to in this transmittal letter. The revised Subchapter 6 applies only when billing for services that are paid either according to the Payment Amount Per Episode (PAPE) methodology, or according to the Division of Health Care Finance and Policy (DHCFP) Clinical Laboratory Fee Schedule (114.3 CMR 20.00). MassHealth providers must refer to the official list of CPT and HCPCS codes with descriptions, as posted on the Centers for Medicare & Medicaid Services (CMS) Web site at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. Revised Subchapter 6 (Billing and Payment) For services provided by acute outpatient hospitals that are not paid according to the PAPE methodology, or according to the DHCFP Clinical Laboratory Fee Schedule, AOHs must refer to the MassHealth provider manuals listed below to determine which services are payable and which are not payable. These provider manuals are available on the MassHealth Web site at www.mass.gov/masshealth. Adult Day Health – AOHs billing for adult day health services must enroll in the Adult Day Health Program and refer to Subchapter 6 of the Adult Day Health Manual. Adult Foster Care – AOHs billing for adult foster care services must enroll in the Adult Foster Care Program and refer to Subchapter 6 of the Adult Foster Care Manual. Ambulance Services – AOHs billing for ambulance services must enroll in the Transportation Program and refer to Subchapter 6 of the Transportation Manual. Dental Services – AOHs billing for dental services must refer to Subchapter 6 of the Dental Manual except when the conditions in 130 CMR 420.430(A) or (D) apply. In those instances, AOHs should refer to Subchapter 6 of the Acute Outpatient Hospital Manual. Early Intervention Services – AOHs billing for early intervention program services must enroll in the Early Intervention Program and refer to Subchapter 6 of the Early Intervention Program Manual. Hearing Aid Dispensing – AOHs billing for the dispensing of hearing aids must refer to Subchapter 6 of the Hearing Instrument Specialist Manual. Home Health Services – AOHs billing for home health services must enroll in the Home Health Program and refer to Subchapter 6 of the Home Health Agency Manual. Physician Services –- AOHs billing for hospital-based physician or entity services must refer to Subchapter 6 of the Physician Manual. Psychiatric Day Treatment Services – AOHs billing for psychiatric day treatment services must enroll in the Psychiatric Day Treatment Program and refer to Subchapter 6 of the Psychiatric Day Treatment Program Manual. Vision Care Materials Dispensing – AOHs billing for the dispensing of ophthalmic materials must refer to Subchapter 6 of the Vision Care Manual. For more information on the reimbursement for AOH services, providers should refer to the Hospital Rate Year (HRY) 2010 Acute Hospital Request for Application (RFA). Hospitals can locate the HRY 2010 RFA at www.comm-pass.com. 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.) Acute Outpatient Hospital Manual Pages vi, vii, and 6-1 through 6-14 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Pages vi and 6-1 through 6-12 — transmitted by Transmittal Letter AOH-24 Page vii — transmitted by Transmittal Letter AOH-10 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Acute Outpatient Hospital Manual Transmittal Letter AOH-25 Date 01/01/11 6. Service Codes Introduction................................................................................................................................. 6-1 Nonpayable CPT Codes .............................................................................................................. 6-1 Payable Level II HCPCS Codes................................................................................................... 6-11 Modifiers .................................................................................................................................... 6-13 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 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 Subchapter Number and Title Preface Page vii Acute Outpatient Hospital Manual Transmittal Letter AOH-25 Date 01/01/11 The regulations and instructions governing provider participation in MassHealth are published in the Provider Manual Series. MassHealth publishes a separate manual for each provider type. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, administrative and billing instructions, and general information. MassHealth regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. MassHealth regulations are assigned Title 130 of the Code. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For acute outpatient hospitals, those matters are covered in 130 CMR Chapter 410.000, reproduced as Subchapter 4 in the Acute Outpatient Hospital Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead MassHealth’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with MassHealth and its members. 601 Introduction MassHealth providers must refer to the official list of HCPCS codes and descriptions posted on the Centers for Medicare & Medicaid Services Web site at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. For a list of billable revenue codes, please refer to Appendix F of the Acute Outpatient Hospital Manual. CPT Codes MassHealth pays for services billed using all medicine, radiology, laboratory, surgery, and anesthesia CPT codes in effect at the time of service, except for those codes listed in Section 602 of this subchapter, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. Level II HCPCS Codes MassHealth pays for services billed using only those Level II HCPCS codes listed in Section 603 of this subchapter that are in effect at the time of service, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. EPSDT An acute outpatient hospital 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 Acute Outpatient Hospital Manual. 602 Nonpayable CPT Codes MassHealth does not ordinarily pay for services billed under the following codes and code ranges. 0001F 0005F 0012F 0014F 0015F 4002F 4006F 4009F 4011F 0016T 0017T 0019T 0030T 0042T 0048T 0050T 0051T 0052T 0053T 0071T 0072T 0073T 0075T 0076T 0078T 0079T 0080T 0081T 0085T 0092T 0095T 0098T 0099T 0100T 0101T 0102T 0103T 0104T 0105T 0106T 0107T 0108T 0109T 0110T 0111T 0123T 0124T 0126T 0130T 0140T 0141T 0142T 0143T 0155T 0156T 0157T 0158T 0159T 0160T 0161T 0163T 0016T 0017T 0019T 0030T 0042T 0048T 0050T 0051T 0052T 0053T 0071T 0072T 0073T 0075T 0076T 0078T 0079T 0080T 0081T 0085T 0092T 0095T 0098T 0099T 0100T 0101T 0102T 0103T 0104T 0105T 0106T 0107T 0108T 0109T 0110T 0111T 0123T 0124T 0126T 0130T 0140T 0141T 0142T 0143T 0155T 0156T 0157T 0158T 0159T 0160T 0161T 0163T 0164T 0165T 0166T 0167T 0168T 0169T 0171T 0172T 0173T 0174T 0175T 0176T 0177T 0178T 0179T 0180T 0181T 0182T 0183T 0184T 0185T 0186T 0187T 0188T 0189T 0190T 0191T 0192T 0193T 0195T 0196T 0197T 0198T 0199T 0200T 0201T 0202T 0203T 0204T 0205T 0206T 0207T 00100 through 01999 10040 11004 11005 11006 11008 11922 11950 11951 11952 11954 15756 15757 15758 15781 15782 15783 15786 15787 15788 15789 15792 15793 15819 15824 15825 15826 15828 15829 15847 15876 15877 15878 15879 16036 17340 17360 17380 19271 19272 19305 19306 19316 19324 19325 19355 19361 19364 19367 19368 19369 19396 20660 20661 20664 20802 20805 20808 20816 20824 20827 20838 20930 20931 20936 20937 20938 20955 20956 20957 20962 20969 20970 20985 21045 21120 21121 21122 21123 21125 21127 21141 21142 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99509 99510 99511 99512 99600 99601 99602 99605 99606 99607 603 Payable Level II HCPCS Codes The following Level II HCPCS codes represent services that are covered by MassHealth when provided by AOHs, including hospital-licensed health centers (HLHCs) and other satellite clinics. A4641 A9500 A9502 A9503 A9505 A9512 A9537 G0105 G0108 G0109 G0121 G0202 G0204 G0206 G0270 G0271 J0129 J0135 J0171 J0207 J0215 J0256 J0290 J0295 J0348 J0456 J0461 J0475 J0476 J0558 J0561 J0585 J0586 J0587 J0592 J0597 J0598 J0638 J0640 J0690 J0694 J0696 J0697 J0702 J0718 J0775 J0780 J0833 J0834 J0881 J0882 J0885 J0886 J0900 J1020 J1030 J1040 J1055 J1056 J1060 J1070 J1080 J1094 J1100 J1160 J1170 J1200 J1260 J1290 J1300 J1320 J1438 J1440 J1441 J1460 J1559 J1561 J1562 J1566 J1569 J1571 J1580 J1599 J1626 J1630 J1650 J1655 J1670 J1710 J1720 J1740 J1743 J1745 J1750 J1786 J1790 J1800 J1826 J1885 J1890 J1950 J1956 J1990 J2060 J2150 J2175 J2248 J2250 J2270 J2271 J2275 J2300 J2310 J2315 J2323 J2355 J2357 J2358 J2405 J2430 J2440 J2469 J2503 J2505 J2510 J2515 J2550 J2560 J2562 J2675 J2680 J2760 J2778 J2785 J2788 J2790 J2792 J2793 J2794 J2796 J2820 J2910 J2916 J2920 J2930 J2940 J2941 J3010 J3030 J3095 J3110 J3120 J3130 J3230 J3240 J3243 J3250 J3262 J3301 J3302 J3303 J3357 J3360 J3385 J3396 J3410 J3411 J3430 J3487 J3490 J3590 J7030 J7060 J7070 J7302 J7303 J7304 J7307 J7309 J7312 J7321 J7323 J7324 J7325 J7335 J7599 J7608 J7614 J7620 J7626 J7633 J7639 J7644 J7669 J7676 J7682 J7686 J7699 J7799 J8562 J9000 J9001 J9025 J9031 J9035 J9040 J9041 J9045 J9055 J9060 J9130 J9155 J9171 J9178 J9181 J9190 J9201 J9202 J9206 J9212 J9213 J9214 J9215 J9216 J9217 J9218 J9219 J9250 J9260 J9261 J9263 J9264 J9265 J9266 J9293 J9300 J9302 J9305 J9307 J9310 J9315 J9340 J9351 J9355 J9360 J9370 J9390 J9395 J9999 L8614 L8615 L8616 L8617 L8618 L8619 L8690 L8691 Q0081 Q0083 Q0084 Q4100 Q4101 Q4102 Q4103 Q4104 Q4105 Q4106 Q4107 Q4108 Q4110 Q4111 Q4112 Q4113 Q4114 Q4115 S0023 S0028 S0077 S0302 S2083 604 Modifiers Modifiers for Behavioral Health Screening The administration and scoring of standardized behavioral health screening tools selected from the approved menu of tools found in Appendix W of your MassHealth provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. Service Code 96110 must be accompanied by one of the modifiers listed below to indicate whether a behavioral health need was identified. “Behavioral health need identified” means the provider administering the screening tool, in her or his professional judgment, identified a child with a potential behavioral health services need. Modifier and Description U1 Completed behavioral-health screening using a standardized behavioral-health screening tool selected from the approved menu of tools found in Appendix W of your MassHealth provider manual with no behavioral health need identified. U2 Completed behavioral-health screening using a standardized behavioral-health screening tool selected from the approved menu of tools found in Appendix W of your MassHealth provider manual and behavioral-health need identified. Modifiers for Tobacco-Cessation Services The following modifiers are used in combination with Service Code 99407 to report tobacco- cessation counseling. Service Code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) may also be billed without a modifier to report an individual smoking and tobacco use cessation counseling visit of at least 30 minutes. Modifier and Description HQ Group counseling, at least 60-90 minutes TF Intermediate level of care, at least 45 minutes Modifier for Child and Adolescent Needs and Strengths (CANS) HA Service code 90801 must be accompanied by this modifier to indicate that the Child and Adolescent Needs and Strengths is included in the assessment. This page is reserved.