Commonwealth of Massachusetts Executive Office of Health and Human Services



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Commonwealth of Massachusetts

Executive Office of Health and Human Services

Office of Medicaid


www.mass.gov/masshealth

MassHealth

Transmittal Letter CHC-104

July 2015





TO: Community Health Centers Participating in MassHealth
FROM: Daniel Tsai, Assistant Secretary and Director of MassHealth
RE: Community Health Center Manual (2015 HCPCS)

This letter transmits revisions to the service codes in Subchapter 6 of the Community Health Center Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) codes for 2015. The revised Subchapter 6 is effective for dates of service on or after January 1, 2015.


In addition to revising for 2015 HCPCS updates, the revised Subchapter 6 reflects a code change when billing for the application of fluoride varnish as well as code changes for drug testing. Section 615 (Modifiers) also includes updates to clarify and define the distinct procedural services that are included under Modifier 59.

Community Health Centers (CHCs) must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2015 code book or the Healthcare Procedure Coding System (HCPCS) Level II code book for the service descriptions of the codes listed in Subchapter 6 of the Community Health Center Manual.



Please Note: MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 405.000 and 450.000. A CHC 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 Community Health Center Manual.

If you wish to obtain a fee schedule, you may download the Executive Office of Health and Human Services regulations, as applicable, at no cost at www.mass.gov/eohhs/gov/laws-regs/hhs/community-health-care-providers-ambulatory-care.html.The specific regulation titles are 101 CMR 304.00: Rates for Community Health Centers; 101 CMR 317.00: Medicine; 114.3 CMR 16.00: Surgery and Anesthesia Services; 114.3 CMR 18.00: Radiology; and 101 CMR 320.00: Clinical Laboratory Services.



Fluoride Varnish Billing Code Change

Effective for dates of service on or after January 1, 2015, MassHealth has adopted the Current Procedure Terminology (CPT) Service Code 99188 (application of topical fluoride varnish by a physician or other qualified health care professional) with ICD-9 diagnosis code V07.31 to replace Current Dental Terminology (CDT) Service code D1206.


MassHealth

Transmittal Letter CHC-104

July 2015

Page 2


Community Health Centers that submit claims for the application of fluoride varnish by CHC-based pediatricians or other qualified health care professionals to eligible MassHealth members younger than 21 years of age, must use CPT Service Code 99188 with diagnosis code V07.31 beginning with dates of service on or after January 1, 2015.
Effective July 1, 2015, D1206 will no longer be covered for claims submitted by CHCs for the application of fluoride varnish performed by CHC-based pediatricians and other qualified health care professionals. All claims submitted with D1206 for dates of service on or before June 30, 2015, will be paid. Any claim submitted with D1206 for dates of service on or after July 1, 2015, will be denied.
Fluoride Varnish Billing Requirements for CPT Service Code 99188
CHCs must submit claims for fluoride varnish services in accordance with applicable program regulations. CHCs should bill MassHealth with Service Code 99188 with diagnosis code V07.31 transmitted through the 837P format or the CMS 1500 claim form. For MassHealth managed care organization (MCO) members, CHCs must contact the appropriate MCO customer service center listed below.
Boston Medical Center HealthNet Plan: 1- 888-566-0010

Fallon Health:   1-800-868-5200

Tufts Health Plan -- Network Health: 1-888-257-1985

Neighborhood Health Plan: 1-866-414-5533

Health New England: 1-800-310-2835

CeltiCare Health: 1-855-678-6975


Code Changes for Drug Testing
The American Medical Association adopted new code sections for Presumptive Drug Class Screening (CPT 80300–80304) and Definitive Drug testing (CPT 80320-80377). MassHealth is following the CMS coverage determination for these code sections and has determined that these codes initially would not be included as covered service codes.
Drug Screening should continue to be billed using codes G0431 (Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter) and G0434 (Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter). Codes for quantitative and confirmatory testing that have been deleted have been mapped to the codes listed in the following table.
MassHealth

Transmittal Letter CHC-104

July 2015

Page 3




Deleted Code

2015 Replacement Code

Replacement Code Service Description

80102

G6058

Drug confirmation, each procedure

80152

G6030

Assay of amitriptyline

80154

G6031

Assay of benzodiazepines

80160

G6032

Assay of desipramine

80166

G6034

Assay of doxepin

80172

G6035

Assay of gold

80174

G6036

Assay of imipramine

80182

G6037

Assay of nortriptyline

80196

G6038

Assay of salicylate

82003

G6039

Assay of acetaminophen

82055

G6040

Assay of alcohol (ethanol); any specimen except breath

82101

G6041

Alkaloids, urine, quantitative

82145

G6042

Assay of amphetamine or methamphetamine

82205

G6043

Assay of barbiturates, not elsewhere specified

82520

G6044

Assay of cocaine or metabolite

82646

G6045

Assay of dihydrocodeinone

82649

G6046

Assay of dihydromorphinone

82651

G6047

Assay of dihydrotestosterone

82654

G6048

Assay of dimethadione

82666

G6049

Assay of epiandrosterone

82690

G6050

Assay of etchlorvynol

82742

G6051

Assay of flurazepam

83805

G6052

Assay of meprobamate

83840

G6053

Assay of methadone

83858

G6054

Assay of methsuximide

83887

G6055

Assay of nicotine

83925

G6056

Opiate(s), drug and metabolites, each procedure

84022

G6057

Assay of phenothiazine

84600

82441

Chlorinated hydrocarbons,screen

MassHealth

Transmittal Letter CHC-104

July 2015

Page 4

Quantitative Drug Test Edit
As transmitted through Independent Clinical Laboratory Provider Bulletin 9, MassHealth established claim edits for quantitative drug test codes billed on the same date of service as drug screen service codes. Effective January 1, 2015, this edit has been updated to reflect the code changes made for quantitative drug test codes.


Primary Procedure Codes

Secondary Procedure Codes

EOB Code/ Description

G0431 – Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter
and/or
G0434 – Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter

80299 – Quantitation of therapeutic drug, not elsewhere specified
82570 – Creatinine; other source
82575 – Creatinine; clearance
83992 – Phencyclidine
G6031 - Assay of benzodiazepines
G6040 - Assay of alcohol (ethanol); any specimen except breath
G6042 - Assay of amphetamine or methamphetamine
G6043 - Assay of barbiturates, not elsewhere specified
G6044 - Assay of cocaine or metabolite
G6052 - Assay of meprobamate
G6053 - Assay of methadone
G6055- Assay of nicotine
G6056 - Opiate(s), drug and metabolites, each procedure

8304 – Lab conflict w/ each other on the same day

MassHealth

Transmittal Letter CHC-104

July 2015

Page 5


MassHealth Web Site
This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth.
Questions
If you have any questions about the information in this transmittal letter, please contact the MassHealth Customer Service Center 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.)


Community Health Center Manual
Pages vi and 6-1 through 6-18
OBSOLETE MATERIAL

(The pages listed here are no longer in effect.)


Community Health Center Manual
Page vi — transmitted by Transmittal Letter CHC 102
Pages 6-1 through 6-20 — transmitted by Transmittal Letter CHC 102


Commonwealth of Massachusetts

MassHealth

Provider Manual Series

Subchapter Number and Title

6. Service Codes and Descriptions



Page

vi


Community Health Center Manual

Transmittal Letter

CHC-104


Date

01/01/15

6. Service Codes and Descriptions
Introduction and Explanation of Abbreviations 6-1

Payable Radiology Service Codes 6-1

Payable Laboratory Service Codes 6-4

Payable Visit and Vaccine Service Codes 6-9

Payable Obstetrics Service Codes 6-12

Payable Surgery Service Codes 6-12

Payable Nurse-Midwife Service Codes 6-13

Payable Audiology Service Codes 6-13

Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health

Assessment Service Codes 6-13

Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric

Hearing and Vision Test Service Codes 6-14

Payable Tobacco Cessation Service Codes 6-14

Payable Medical Nutrition Therapy and Diabetes Self-Management Training

Service Codes 6-15

Payable Behavioral Health Screening Tool Service Codes 6-15

Payable Acupuncture Service Codes 6-16

Modifiers 6-16


Appendix A. Directory A-1
Appendix C. Third-Party-Liability Codes C-1
Appendix D. Supplemental Instructions for TPL Exceptions D-1
Appendix E. Utilization Management Program E-1
Appendix F. Admission Guidelines F-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

601 Introduction and Explanation of Abbreviations


MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 405.000 and 450.000: Administrative and Billing Regulations. A community health center 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 Community Health Center Manual.
For complete descriptions of the service codes listed in Subchapter 6, MassHealth providers must refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).
The following abbreviations are used in Subchapter 6.

  1. PA indicates that service-specific prior authorization is required (see 130 CMR 450.303).

  2. IC indicates that the claim will receive individual consideration to determine payment. A descriptive report must accompany the claim (see 130 CMR 450.271).

  3. SP indicates that the procedure is commonly performed as part of a total service and does not usually warrant a separate fee. The procedure must be performed separately to receive the separate fee.

  4. CS-18 or CS-21 indicates that a completed Sterilization Consent Form (CS-18 for members aged 18 through 20; CS-21 form for members aged 21 and older) must be submitted. See 130 CMR 405.428 through 405.430 for more information.

  5. CS-18* or CS-21* indicates that a completed Sterilization Consent Form (CS-18 for members aged 18 through 20; CS -21 form for members aged 21 and older) must be submitted except if the conditions of 130 CMR 405.430(D)(2) and (3) are met. See 130 CMR 405.428 through 405.430 for more information and other submission requirements.

(F) HI-1: A completed Hysterectomy Information Form must be submitted. See 130 CMR 405.424for more information..
602 Payable Radiology Service Codes
This section lists radiology service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).



70030

70100


70110

70120


70130

70134


70140

70150


70160

70190


70200

70210


70220

70240


70250

70260


70300

70310


70320

70328


70330

70332


70336

70350


70355

70360


70370

70371


70373

70380


70390

70450


70460

70470


70480

70481


70482

70486


70487

70488


70490

70491


70492

70540


70542

70543


70544

70545


70546

70547


70548

70549


70551

70552


70553

70554


70555

71010


71015

71020


71021

71022


71023

71030


71034

71035


71100

71101


71110

71111


71120

71130


71550

71551


71555

72010


72020

72040


72050

72052


72069

72070


72072

72074


72080

72090


72100

72110


72114

72120


72125

72126


72127

72128


72129

72130


72131

72132


72133

72141


72142

72146


72147

72148


72149

72156


72157

72158


72170

72190


72192

72193


72194

72195


72196

72197


72200

72202


72220

72240


72255

72265


72270

72275


72285

72295


73000

73010


73020

73030


73040

73050


73060

73070


73080

73085


73090

73092


73100

73110


73115

73120


73130

73140


73200

73201


73202

73218


73219

73220


73221

73222


73223

73500


73510

73520


73525

73530


73540

73550


73560

73562


73564

73565


73580

73590


73592

73600


73610

73615


73620

73630


73650

73660


73700

73701


73702

73718


73719

73720


73721

73722


73723

73725


74000

74010


74020

74022


74150

74160


74170

74174


74176

74177


74178

74181


74182

74183


74185

74190


74210

74220


74230

74235


74240

74245


74246

74247


74249

74250


74251

74260


74261 (PA)

74262 (PA)

74270

74280


74283

74290


74300

74301


74305

74320


74327

74330


74340

74355


74400

74410


74415

74420


74425

74430


74440

74445


74450

74455


74470

74475


74480

74485


74710

74740


74742

74775


75557

75559


75561

75563


75565

75572


75573

75574


75600

75605


75625

75630


75658

75705


75710

75716


75726

75731


75733

75736


75741

75743


75746

75756


75774

75791


75801

75803


75805

75807


75809

75810


75820

75822


75825

75827


75831

75833


75840

75842


75860

75870


75872

75880


75885

75887


75889

75891


75893

75898


75901

75902


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