Connection supplemental articles and policies - November 2007

Download the print version

Connection - November 2007 (pdf, 302 KB)

supplemental articles

• masshealth: providing comprehensive well-child care visits
• understanding modifier -25 and modifier -57

policies and forms

These policies have substantial changes. For more details, please see “policy changes” below.

• Infertility/assisted reproductive technology (ART) services payment policy
• Inpatient medical review and payment policy
• Procedure code review policy
• Radiology payment policy
• Vaccine medical payment policy

   The following policies have only minor changes.

• Medical nutrition therapy payment policy
• Observation status payment policy
• Physician standby service policy

masshealth: providing comprehensive well-child care visits

In the summer 2007 issue of the PCC Plan Quarterly,MassHealth introduced a new requirement related to the behavioral health screening component of well-child care visits for children between birth and age 21. It is being implemented in response to a court case against MassHealth, called Rosie D. v. Patrick.

The following information can assist you in providing comprehensive well-child care while maximizing your reimbursement for those services. Primary care physicians must follow the Early and Periodic Screening, Diagnosis and Treatment Medical Protocol and Periodicity Schedule, which sets the timing and required components of well-child care visits. The EPSDT Schedule can be found in Appendix W of your MassHealth Provider Manual.

covered well-child care services
All FCHP MassHealth members under 21 years old are eligible for well-child checkups. These checkups include:

• initial or interval health history
• comprehensive physical examination
• nutritional assessment
• developmental screening
• behavioral health screening
• hearing screening
• vision screening
• dental assessment and referral
• cancer screening and examination
• health education and anticipatory guidance
• immunization assessment and administration
• lead toxicity screening
• tuberculin testing and other lab tests

schedule for well-care visits
The ages at which PCPs must conduct well-child visits are:

• 1 to 2 weeks old
• 1 month old
• 2 months old
• 4 months old
• 6 months old
• 9 months old
• 12 months old
• 15 months old
• 18 months old
• Once a year between ages 2 and 20

PCPs also must perform a checkup any time one is medically necessary, even if it’s not time for a regular checkup. This means that whenever you have a concern about a child’s health or when a parent, guardian or other clinician brings one to your attention, you must screen the child in accordance with the EPSDT Schedule.
 
Please note that regulations becoming effective later this year will require PCPs to use a MassHealth-approved, standardized behavioral health screening tool when conducting behavioral health screens. These tools, which will be listed in the EPSDT Schedule, will help you decide if a child needs further assessment by a behavioral health provider or other medical professional. You‘ll be required to provide or refer any child who requires behavioral health treatment services. MassHealth will notify you by transmittal letter when the updated EPSDT regulations and the EPSDT Schedule become effective.

enhanced and additional payments for well-child visits
Whenever a PCP (except for community health center providers) provides all of the age-appropriate services required by the EPSDT Schedule during a child’s visit, the PCP is eligible to receive an enhanced payment for the visit. Be sure to include the add-on code (S0302) in addition to the well-child visit code when you bill for the visit. Reimbursement is based on contractual agreements.

PCPs also are eligible to receive additional payments for providing the hearing and vision screening tests and laboratory services required by the EPSDT Schedule. Be sure to bill the codes listed in Appendix Z of your MassHealth Provider Manual when you provide these services as part of a well-child visit. Appendix Z will be updated to include the appropriate code. MassHealth will notify you by transmittal letter when the updated EPSDT regulations and Appendix Z become effective.

follow-up diagnostic and treatment services
The FCHP MassHealth contract covers diagnostic and treatment services that are medically necessary and included in a child’s coverage type. In addition, members under 21 years old enrolled in the FCHP MassHealth Standard and CommonHealth are entitled to all medically necessary diagnosis and treatment services required by federal Medicaid law even if they are not a covered service for that member. To get these services, a provider who is qualified and willing to provide the service can ask FCHP for prior authorization for the service. The PA request must include a letter and documentation supporting the medical necessity of the requested service. 
  
additional information
Materials regarding well-child health services are available through the PCC Plan Health Education Materials Catalog. These materials will help PCPs:

• Understand what services are covered by MassHealth.
• Maximize reimbursement when you deliver well-care services.(continued)
• Educate families about pediatric health care and remind them about recommended visits. 

You can order these materials by calling the PCC Plan Hotline at 1-800-495-0086, online at the Massachusetts Behavioral Health Partnership Web site (http://www.masspartnership.com/pcccc) under “Support Materials,” by faxing the form from the catalog to 1-617-790-4138 or mailing it to:

PCC Plan PIMS
Massachusetts Behavioral Health Partnership
150 Federal St., 3rd Floor
Boston, MA  02110

For questions about the EPSDT Schedule, covered services, submitting PA requests or billing, call MassHealth Customer Services at 1-800-841-2900, or FCHP Customer Service at 1-800-868-5200 (TDD/TTY: 1-877-608-7677), Monday through Friday from 8 a.m. to 6 p.m.

understanding modifier -25 and modifier -57

Both modifiers -25 and -57 are used with evaluation and management (E/M) codes only, but each modifier may be used only under the specific circumstances detailed in its definition.

Modifier -25 is used to indicate that on the day a procedure or service was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided, or beyond the usual preoperative and postoperative care associated with the procedure that was performed. CPT codes for use with modifier -25 are 92002 to 92014 and 99201 to 99499.

It is not appropriate to use modifier -25 on the E/M code on the same day a minor procedure was performed when the patient’s trip to the office was strictly for the minor procedure.

Routine or automatic use of modifier -25 should be avoided, especially for established patients. It is the policy of Fallon Community Health Plan to analyze provider claims coding patterns. See FCHP’s Medical Payment Policy titled Coding Analysis Policy.

Important: If submitting multiple modifiers, please submit modifier -25 first as it affects reimbursement. 

Modifier -57 is used to identify an E/M service, provided on the day before or day of surgery, in which the initial decision is made to perform major surgery. Major surgery includes all surgical procedures assigned a 90-day global surgery period. The global surgery policy includes the E/M service provided on the day before or the day of the major surgical procedures unless the E/M service resulted in the decision to perform surgery. CPT codes for use with modifier -57 are 92002 to 92014 and 99201 to 99499.

FCHP may require medical notes for review of decision for surgery claims. If you have seen this patient during the month prior to the decision for surgery, please submit medical notes with your claim. See FCHP’s medical payment policy titled Global Surgical Policy for further information.

Reference guide to the use of modifiers -25 and -57

(Source: CPT Assistant, November and December 2004)

policy changes

The following policies available with this issue of Connection have substantial changes.

• Infertility/assisted reproductive technology (ART) services payment policy
  • The following services are not covered: Infertility/ART services for a partner who is not a plan member, except for sperm, egg and/or inseminated egg procurement and processing, and banking of sperm or inseminated eggs, to the extent that such costs are not covered by the donor’s insurer, if any (p. 2).
  • Microsurgical Epididymal Sperm Aspiration (MESA) and Testicular Sperm Extraction (TESE) will be reimbursed at a separate global rate—Code S4028 (pp. 11-12).
    
    
• Inpatient medical review and payment policy
  • Fallon Community Health Plan began adherence to the Diagnosis Related Grouping (DRG) methodology as devised by the Centers for Medicare & Medicaid Services when processing claims as of June 2007.
  • For providers who are reimbursed by FCHP according to the DRG methodology, FCHP will deny reimbursement for readmission to the same facility for inpatient services occurring within seven days of discharge for the same or related conditions for which the member was treated at the time of the original discharge.
  • The FCHP Inpatient Nurse Care Specialists (NCS) will be reviewing any re-admissions within seven days of discharge from the same facility for treatment of the same or related condition. The denial process will be initiated by the NCS. This will be considered a vendor-liable denial and the members may not be billed.
  • Payment under this methodology to the providers will be part of the original DRG from the first admission, and the second admission will not be separately reimbursed (pp. 2-3).
    
    

• Procedure code review policy
  • Title changed from “annual code review policy” to “procedure code review policy”.
  • FCHP recognizes that new codes can be published on a quarterly basis. We will review these codes within 30 days of the effective date and notify providers of all determinations via the next published Connection newsletter (p. 1).
    
    

• Radiology payment policy
  • In addition to FCHP’s MassHealth product, the FCHP Commonwealth Care product has been added as a product that will be exempt from member financial liability for non-covered services (p. 1).
    
    

• Vaccine medical payment policy
  • FCHP does not reimburse for state-supplied vaccines—therefore, you must append the -SL modifier to the appropriate code. Because of this revised payment policy, Modifier -22 should no longer be appended to vaccine codes (p.4).
  • Beginning January 1, 2008, FCHP will follow the new requirements released by the Center for Medicare & Medicaid for Part D vaccines (p. 9).