MASSHEALTH TRANSMITTAL LETTER POD 45 October 2003 TO: Podiatrists ...
Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street
Boston, MA 02111
www.mass.gov/dma
MASSHEALTH
TRANSMITTAL LETTER POD-45
October 2003
TO:
Podiatrists Participating in MassHealth
FROM:
Beth Waldman, Acting Commissioner
RE:
Podiatrist Manual (Revised Regulations and Service Codes and Descriptions)
Updated Podiatry Regulations
This letter transmits revised podiatry regulations. The regulation retains the life-and-safety
certification requirement but no longer requires the certification to be attached to the podiatrist claim
for payment with the exception of shoes and other corrective devices. However, the life-and-safety
certification must be retained as documentation in the member’s medical record. Additionally,
regulatory changes were made to sections about shoes and corrective devices.
Revised Subchapter 6 (Service Codes)
This letter transmits a revised Subchapter 6 of the Podiatrist Manual. 2003 HCPCS (Healthcare
Common Procedure Coding System) codes have been added to replace certain MassHealth local
codes. The local codes have been replaced so that the Division’s coding requirements are
compliant with the Health Insurance Portability and Accountability Act (HIPAA) of 1996).
Subchapter 6 of the Podiatrist Manual lists CPT and Level II codes that:
• are payable under MassHealth; and
• have special limitations or requirements, such as prior authorization or individual
consideration.
Providers should use this revised Subchapter 6 in conjunction with the American Medical
Association Current Procedural Terminology (CPT) 2003 code book and the Ingenix HCPCS Level II
2003 code book, as the Division is no longer including the service descriptions of payable codes.
Please find attached a crosswalk from the obsolete MassHealth local service codes and modifiers to
the new national service codes and modifiers for the revised Subchapter 6.
Effective Date
The revised regulations are effective for dates of service on or after October 16, 2003. The new
codes introduced in Subchapter 6 under the CPT 2003 code book and the 2003 HCPCS Level II
code book are effective for dates of service on or after October 16, 2003. We will accept either the
new or old codes for dates of service through November 15, 2003. For dates of service on or after
November 16, 2003, providers must use the new codes to receive payment.
MASSHEALTH
TRANSMITTAL LETTER POD-45
October
2003
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2
How to Obtain a Podiatry Fee Schedule
If you wish to obtain a fee schedule, you may purchase Division of Health Care Finance and Policy
regulations from either the Massachusetts State Bookstore or from the Division of Health Care
Finance and Policy. See addresses and telephone numbers below. You must contact them first to
find out the price of the publication. The Division of Health Care Finance and Policy also has the
regulations available on disk. The regulation title for Podiatric Care is 114.3 CMR 26.00: Podiatric
Care. The regulation title for surgery and anesthesia is 114.3 CMR 16.00: Surgery and Related
Anesthesia Care. The regulation title for radiology is 114.3 CMR 18.00: Radiology.
Massachusetts State Bookstore
Division of Health Care Finance and Policy
State House, Room 116
Two Boylston Street
Boston, MA 02133
Boston, MA 02116
Telephone: 617-727-2834
Telephone: 617-988-3100
www.mass.gov/sec/spr
www.mass.gov/dhcfp
Miscellaneous
The remainder of this transmittal letter contains information, clarifications, and instructions
relating to MassHealth billing.
A. Referrals for Podiatric Care
Podiatry services require a written referral from the member’s primary care provider prior to
the delivery of services. The Division pays only for podiatry services that are certified to be
necessary for the life and safety of the member. The referral must be on the primary-care
provider’s letterhead and must certify that such services are medically necessary for the life
and safety of the member. A substantiating medical explanation must be included in the
written certification. The life and safety referral must be retained in the member’s medical
record. See 130 CMR 424.405(A) and 424.409(B). The life and safety referral no longer
needs to be submitted with the claim.
For shoes and other corrective devices, providers must submit with their claim a copy of the
completed MassHealth Shoe Medical Necessity Form and a copy of the life and safety
documentation from the primary care provider. See 130 CMR 424.405.
Periodically, the Division may ask podiatry providers to verify the issuance of the life and
safety documentation. In cases where the Division reviews have revealed provider
noncompliance with 130 CMR 450.205(A) through (C), the Division may seek to pursue
recovery of overpayments and to impose sanctions in accordance with the provisions of 130
CMR 450.234 through 450.260.
B. Routine Drugs Dispensed in a Podiatrist’s Office (99070)
The Division does not pay separately for routine drugs dispensed in the office when they are
integral to the podiatrist’s professional services in the course of diagnosis and treatment.
Such drugs are commonly provided by the podiatrist without charge, and payment is
MASSHEALTH
TRANSMITTAL LETTER POD-45
October
2003
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3
included in the MassHealth payment for the professional service.
The Division considers certain drugs, including but not limited to those listed below, to be
routine drugs:
• Demerol
• Vistaril.
C. Shoes and Corrective Devices
Shoes and corrective devices are paid on an individual consideration (I.C.) basis subject to
the regulations set forth in the Orthotics Manual at 130 CMR 442.420, 442.421, and
442.422. An Orthotics Manual may be obtained by contacting MassHealth Provider
Enrollment and Credentialing, P.O. Box 9101, Somerville, MA 02145. The Orthotics Manual
regulations are also located on the Division’s Web site at www.mass.gov/dma.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Podiatrist Manual
Pages 4-1 through 4-6, 4-13, 4-14, and 6-1 through 6-4
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Podiatrist Manual
Pages 4-1 through 4-4, 4-13, and 4-14 — transmitted by Transmittal Letter POD-43
Pages 4-5 and 4-6 — transmitted by Transmittal Letter POD-39
Pages 6-1 through 6-4 — transmitted by Transmittal Letter POD-42
Transmittal Letter POD-45
October 2003
Attachment
Page 1
Podiatrist
Service Code Crosswalk
Effective October 16, 2003
Obsolete
Obsolete Code Description
New Code
New Code Description
Code
X1705 Examination and treatment of the feet in a
99231
Subsequent hospital care, per day, for the evaluation and management of a
licensed hospital, successive members,
patient, which requires at least two of these three key components:
same day
• a problem focused interval history;
• a problem focused examination; and
• a medical decision making that is straightforward or of low complexity.
99232
Subsequent hospital care, per day, for the evaluation and management of a
patient, which requires at least two of these three key components:
• an expanded problem focused interval history; and
• a expanded problem focused examination;
• a medical decision making of moderate complexity.
X1707 Examination and treatment of the feet in the
99347
Home visit for the evaluation and management of an established patient,
member’s residence, successive members,
which requires at least two of these three key components:
same day
• a problem focused interval history;
• a problem focused examination; and
• straightforward medical decisionmaking.
99348
Home visit for the evaluation and management of an established patient,
which requires at least two of these three key components:
• an expanded problem focused interval history;
• an expanded problem focused examination; and
• medical decision making of low complexity.
99349
Home visit for the evaluation and management of an established patient,
which requires at least two of these three key components:
• a detailed interval history;
• a detailed examination; and
• medical decision making of moderate complexity.
X1709 Examination and treatment of the feet in a
99311
Subsequent nursing facility care, per day, for the evaluation and
licensed nursing facility, convalescent
management of a new or established patient, which requires at least two of
home, charitable home for the aged, or rest
these three key components:
home, successive members, same day
• a problem focused interval history;
• a problem focused examination; and
• medical decision making that is straightforward or of low complexity.
99312
Subsequent nursing facility care, per day for the evaluation and management
of a new or established patient, which requires at least two of these three key
components:
• an expanded problem focused interval history;
• an expanded problem focused examination; and
• medical decision making of moderate complexity.
99331
Domiciliary or rest home visit for the evaluation and management of an
established patient, which requires at least two of these three key
components:
• a problem focused interval history;
• a problem focused examination; and
• medical decision making that is straightforward or of low complexity.
99332
Domiciliary or rest home visit for the evaluation and management of an
established patient, which requires at least two of these three key
components:
• an expanded problem focused interval history;
• an expanded problem focused examination; and
• medical decision making of moderate complexity.
Transmittal Letter POD-45
October 2003
Attachment
Page 2
Podiatrist
Service Code Crosswalk
Effective October 16, 2003
Obsolete
Obsolete Code Description
New Code
New Code Description
Code
X1711 Visit to member living more than 10 miles
99347
Home visit for the evaluation and management of an established patient,
away from podiatrist’s place of business,
which requires at least two of these three key components:
and no podiatrist is practicing in the
• a problem focused interval history;
community in which the member lives
• a problem focused examination; and
• Straightforward medical decisionmaking.
99348
Home visit for the evaluation and management of an established patient,
which requires at least two of these three key components:
• an expanded problem focused interval history;
• an expanded problem focused examination; and
• medical decision making of low complexity.
99349
Home visit for the evaluation and management of an established patient,
which requires at least two of these three key components:
• a detailed interval history;
• a detailed examination; and
• medical decision making of moderate complexity.
X1720 Other X-ray (I.C.)
76499
Unlisted diagnostic radiographic procedure (I.C.)
X3333 Injectable and infusible drugs and devices
J3490
Unclassified drugs (Prior authorization required.) (I.C.) (P.A.)
supplied in a physician’s office that require
prior authorization (I.C.) (P.A.)
Modifier
Description
Comments
W8
Emergency treatment in a nursing facility
Modifier deleted, no longer in use
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
4 PROGRAM REGULATIONS
4-1
Provider Manual Series
(130 CMR 424.000)
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
424.401: Introduction
All podiatrists participating in MassHealth must comply with the regulations of the Division
governing MassHealth, including but not limited to Division regulations set forth in 130 CMR
424.000 and 450.000.
424.402: Definitions
The following terms used in 130 CMR 424.000 have the meanings given in 130 CMR
424.402, unless the context clearly requires a different meaning. The reimbursability of services
defined in 130 CMR 424.000 is not determined by these definitions, but by application of
regulations elsewhere in 130 CMR 424.000 and in 130 CMR 450.000.
Controlled Substance – a drug listed in Schedule II, III, IV, V, or VI of the Massachusetts
Controlled Substances Act (M.G.L. c. 94C).
Corrective Devices – orthotics, splints, inlays, appliances, and braces that support or
accommodate part or all of the foot and serve to restore or improve functions of the foot.
Custom-Molded Shoe – an individually patterned shoe fabricated to meet the specific needs of an
individual. A custom-molded shoe is not off-the-shelf, stock, or prefabricated. The shoe is
individually constructed by a molded process over a modified positive model of the individual’s
foot. It is made of leather or other suitable material of equal quality, has removable customized
inserts that can be replaced if necessary according to the individual’s condition, and has some
form of shoe closure.
Drug – a substance containing one or more active ingredients in a specified dosage form and
strength. Each dosage form and strength is a separate drug.
Emergency – a sudden or unexpected illness or injury or traumatic injury or infection other than
athlete's foot or chronic mycosis infecting the nail bed that must be treated promptly to prevent
severe pain to the member.
Flexible Adhesive Casting – the application of adhesive tape to orthopedically support or stabilize
the foot, or to exert beneficial stress for a structural instability.
Hygienic Foot Care – the trimming of nonpathogenic nails; the cleansing or soaking of the feet;
the use of skin creams to maintain skin tone of both ambulatory and bedridden patients; or such
other foot care that can be performed by the member or by the nursing facility staff if the member
resides in a nursing facility.
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
4 PROGRAM REGULATIONS
4-2
Provider Manual Series
(130 CMR 424.000)
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
Interchangeable Drug Product – a product containing a drug in the same amounts of the same
active ingredients in the same dosage form as another product with the same generic or chemical
name that has been determined to be therapeutically equivalent (that is, “A”-rated) by the Food
and Drug Administration for Drug Evaluation and Research (FDA CDER), or by the
Massachusetts Drug Formulary Commission.
Last – a model that approximates the shape and size of the foot and over which a shoe is made. A
last is usually made of wood, plastic, or plaster.
Legend Drug – any drug for which a prescription is required by applicable federal or state law or
regulation.
MassHealth Drug List – a list of commonly prescribed drugs and therapeutic class tables published
by the Division. The MassHealth Drug List specifies the drugs that are payable under
MassHealth. The list also specifies which drugs require prior authorization. Except for drugs and
drug therapies described in 130 CMR 424.419(B), any drug that does not appear on the
MassHealth Drug List requires prior authorization, as otherwise set forth in 130 CMR 424.000.
Moldable Shoes – off-the shelf, ready-made shoes formed from heat-activated materials. The
shoes are molded by a thermo-forming process that first heats the material, then forms it over an
individual’s foot or a positive model of the individual’s foot.
Multiple-Source Drug – a drug marketed or sold by two or more manufacturers or labelers, or a
drug marketed or sold by the same manufacturer or labeler under two or more different names.
Nonlegend Drug – any drug for which no prescription is required by federal or state law.
Nonstandard Size (Width or Length) – a shoe size made on a standard last pattern, but which is not
part of a manufacturer’s regular inventory.
Orthopedic Shoes – shoes that are specially constructed to aid in the correction of a deformity of
the musculoskeletal structure of the foot and to preserve or restore the function of the
musculoskeletal system of the foot.
Pharmacy On-Line Processing System (POPS) – the on-line, real-time computer network that
adjudicates pharmacy claims, incorporating prospective drug utilization review, prior
authorization, and member eligibility verification.
Split-Size Charge – an additional charge for dispensing an off-the-shelf, medical-grade pair of
orthopedic shoes, where one shoe in the pair is a different size or width than the other shoe in the
pair.
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
4 PROGRAM REGULATIONS
4-3
Provider Manual Series
(130 CMR 424.000)
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
Unit-Dose Distribution System – a means of packaging or distributing drugs, or both, devised by
the manufacturer, packager, wholesaler, or retail pharmacist. A unit dose contains an exact dosage
of medication and may also indicate the total daily dosage or the times when the medication
should be taken.
424.403: Eligible Members
(A) (1) MassHealth Members. The Division covers podiatry services only when provided to
eligible MassHealth members, subject to the restrictions and limitations described in the
Division’s regulations. The Division’s regulations at 130 CMR 450.105 specifically state, for
each MassHealth coverage type, which services are covered and which members are eligible to
receive those services.
(2) Age Limitations. In addition to any other restrictions and limitations set forth in 130 CMR
424.00 and 450.000, the Division covers shoes only when provided to eligible MassHealth
members under age 21. This age restriction does not apply to therapeutic, moldable, or custom-
molded shoes and shoe inserts for members who have severe diabetic foot disease.
(3) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For
information on covered services for recipients of the Emergency Aid to the Elderly, Disabled
and Children Program, see 130 CMR 450.106.
(B) Member Eligibility and Coverage Type. For information on verifying member eligibility and
coverage type, see 130 CMR 450.107.
424.404: Provider Eligibility
Payment for services described in 130 CMR 424.000 is made only to providers who are
participating in MassHealth on the date the service was provided or who are otherwise eligible for
such payment pursuant to 130 CMR 450.000 and who meet the following requirements.
(A) In State. A podiatrist practicing in Massachusetts must be licensed by the Massachusetts
Board of Registration in Podiatry.
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
4 PROGRAM REGULATIONS
4-4
Provider Manual Series
(130 CMR 424.000)
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
(B) Out of State. An out-of-state podiatrist must be licensed by that state's board of registration
for podiatrists. The Division pays an out-of-state podiatrist only when services are provided to an
eligible Massachusetts member under the following circumstances:
(1) the podiatrist practices outside the border of Massachusetts and provides emergency
services to a member;
(2) the podiatrist practices in a community of Connecticut, Maine, New Hampshire, New
York, Rhode Island, or Vermont that is within 50 miles of the Massachusetts border and
provides services to a member who resides in a Massachusetts community near the border of
that state; or
(3) the podiatrist provides services to a member who is authorized to reside out of state by the
Massachusetts Department of Social Services.
424.405: Service Limitations and Noncovered Services
(A) Services Limited to Life and Safety. The Division pays only for podiatry services that are
certified to be necessary for the life and safety of the member. The Division pays for podiatry
services as long as the podiatrist has a written certification on letterhead from the member's
primary care physician that attests that such services are medically necessary for the life and safety
of the member and that contains a substantiating medical explanation.
(B) Noncovered Services. The Division does not pay for the following:
(1) hygienic foot care as a separate procedure, except when the member's medical record
documents that the member cannot perform the care or risks harming himself or herself by
performing it. The preceding sentence notwithstanding, payment for hygienic foot care
performed on a resident of a nursing facility is included in the nursing facility's per diem rate
and is not reimbursable in any case as a separate procedure;
(2) canceled or missed appointments;
(3) services provided by a podiatrist whose contractual arrangements with a state institution,
acute, chronic, or rehabilitation hospital, medical school, or other medical institution involve a
salary, compensation in kind, teaching, research, or payment from any other sources, if such
payment would result in dual compensation for professional, supervisory, or administrative
services related to member care;
(4) telephone consultations;
(5) in-service education;
(6) research or experimental treatment;
(7) cosmetic services or devices;
(8) sneakers or athletic shoes;
(9) an additional charge for nonstandard size (width or length) in custom-molded shoes; or
(10) shoes when there is no diagnosis of associated foot deformities.
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
4 PROGRAM REGULATIONS
4-5
Provider Manual Series
(130 CMR 424.000)
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
424.406: Maximum Allowable Fees
The Massachusetts Division of Health Care Finance and Policy (DHCFP) determines the
maximum allowable fees for podiatry services. Payment is always subject to the conditions,
exclusions, and limitations set forth in 130 CMR 424.000, 442.000, and 450.000. Payment for a
service is the lowest of the following:
(A) the provider's usual and customary fee;
(B) the provider's actual charge; or
(C) the maximum allowable fee listed in the applicable DHCFP fee schedule.
424.407: Individual Consideration
(A) Some services listed in Subchapter 6 of the Podiatrist Manual are designated "I.C.," an
abbreviation for individual consideration. Individual consideration means that a fee could not be
established. Payment for an individual-consideration service is determined by the Division's
professional advisors based on the podiatrist's descriptive report of the service furnished.
(B) To receive payment for an individual-consideration service, the podiatrist must submit with
the claim a report that contains the diagnosis, a description of the condition of the foot, and the
length of time spent with the member.
(C) Determination of the appropriate payment for an individual consideration service is in
accordance with the following criteria:
(1) the amount of time required to perform the service;
(2) the degree of skill required to perform the service;
(3) the severity and complexity of the member's disease, disorder, or disability;
(4) the policies, procedures, and practices of other third-party insurers, both governmental
and private;
(5) prevailing professional ethics and accepted customs of the podiatric community; and
(6) such other standards and criteria as may be adopted from time to time by DHCFP or the
Division.
(D) For shoes and corrective devices see 130 CMR 442.421 and 442.422
424.408: Referral
When, during an examination or as a result of laboratory tests, a podiatrist discovers a
debilitating or systemic disease (such as diabetes mellitus or ischemia caused by circulatory
deficiency), the podiatrist must inform the member that a physician evaluation is necessary and
must document this referral in the member's medical record.
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
4 PROGRAM REGULATIONS
4-6
Provider Manual Series
(130 CMR 424.000)
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
424.409: Recordkeeping (Medical Records) Requirements
Payment for any service listed in 130 CMR 424.000 is conditioned upon its full and complete
documentation in the member's medical record.
(A) The medical record must contain sufficient data to fully document the nature, extent, and
necessity of the care furnished to a member for each date of service claimed for payment, as well
as any data that will update the member's medical course. The data maintained in the medical
record must also be sufficient to justify any further diagnostic procedures, treatments, and
recommendations for return visits or referrals.
(B) Although basic data collected during previous visits (for example, identifying data, chief
complaint, or history) need not be repeated in the member's medical record for subsequent visits,
the medical records of each service provided by a podiatrist at any location must include, but not
be limited to, the following:
(1) the member's name and date of birth;
(2) the date of each service;
(3) the reason for the visit;
(4) the name and title of the person performing the service;
(5) the member's medical history;
(6) the diagnosis or chief complaint;
(7) a clear indication of all findings, whether positive or negative, on examination;
(8) any medications administered or prescribed, including strength, dosage, route, regimen,
and duration of use;
(9) a description of any treatment given;
(10) recommendations for additional treatments or consultations, when applicable;
(11) any medical goods or supplies dispensed or prescribed;
(12) any tests administered and their results;
(13) documentation of a treatment plan if subsequent visits are expected;
(14) documentation, when applicable, that the member was informed of the necessity of a
physician evaluation;
(15) Life and Safety Certification (see 130 CMR 424.405); and
(16) MassHealth Shoe Medical Necessity Form (if applicable).
424.410: Report Requirements
(A) General Report. A general written report or a discharge summary must accompany the
podiatrist's claim for payment when the service is designated "I.C." in Subchapter 6 of the
Podiatrist Manual or when a service code for an unlisted procedure is used. This report must be
sufficiently detailed to enable professional advisors to assess the extent and nature of the services.
(B) Operative Report. For surgery procedures designated "I.C." in Subchapter 6 of the Podiatrist
Manual, operative notes must accompany the podiatrist's claim. An operative report must state the
operation performed, the name of the member, the date of the operation, the preoperative
diagnosis, the postoperative diagnosis, the names of the podiatrist and his or her assistants, and the
technical procedures performed.
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
4 PROGRAM REGULATIONS
4-13
Provider Manual Series
(130 CMR 424.000)
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
(2) The Division does not pay for the following types of drugs or drug therapy without prior
authorization:
(a) immunizing biologicals and tubercular (TB) drugs that are available free of
chargethrough local boards of public health or through the Massachusetts Department
of Public Health (DPH);
(b) nongeneric multiple-source drugs;
(c) drugs used for the treatment of male or female sexual dysfunction;
drugs related to sex-reassignment surgery, specifically including but not limited to,
presurgery and postsurgery hormone therapy. The Division, however, will continue to
pay for post sex-reassignment surgery hormone therapy for which it had been paying
immediately prior to May 15, 1993; and
retinoids for members aged 26 or older. The Division pays for retinoids for members
under age 26, and all other topical acne products for members of all ages who have
cases of acne Grade II or higher, without prior authorization.
(3) The Division does not pay any additional fees for dispensing drugs in a unit-dose
distribution system.
(4) The Division does not pay for any drug prescribed for other than the FDA-approved
indications as listed in the package insert, except as the Division determines to be consistent
with current medical evidence.
424.420: Pharmacy Services: Insurance Coverage
(A) Managed Care Organizations. The Division does not pay pharmacy claims for services to
MassHealth members enrolled in a MassHealth managed care organization (MCO) that provides
pharmacy coverage through a pharmacy network or otherwise, except for family planning
pharmacy services provided by a non-network provider to a MassHealth Standard MCO enrollee
(where such provider otherwise meets all prerequisites for payment for such services). A
pharmacy that does not participate in the MassHealth member’s MCO must instruct the
MassHealth member to take his or her prescription to a pharmacy that does participate in such
MCO. To determine whether the MassHealth member belongs to an MCO, pharmacies must
verify member eligibility and scope of services through POPS before providing service in
accordance with 130 CMR 450.107 and 450.117.
(B) Other Health Insurance. When the member’s primary carrier has a preferred drug list, the
prescriber must follow the rules of the primary carrier first. The provider may bill the Division for
the primary insurer’s copayment for the primary carrier’s preferred drug without regard to whether
the Division generally requires prior authorization, except in cases where the drug is subject to a
pharmacy service limitation pursuant to 130 CMR 424.419(C)(2)(a), (c), (d), and (e). In such
cases, the prescriber must obtain prior authorization from the Division in order for the pharmacy to
bill the Division for the primary insurer’s copayment.
424.421: Pharmacy Services: Prior Authorization
(A) Prescribers must obtain prior authorization from the Division for drugs identified by the
Division in accordance with 130 CMR 450.303. If the limitations on covered drugs specified in 130
CMR 424.418(A)(1) and 424.419(A) and (C) would result in inadequate treatment for a diagnosed
medical condition, the prescriber may submit a written request, including written documentation of
medical necessity, to the Division for prior authorization for an otherwise noncovered drug.
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
4 PROGRAM REGULATIONS
4-14
Provider Manual Series
(130 CMR 424.000)
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
(B) All prior-authorization requests must be submitted in accordance with the instructions for
requesting prior authorization in Subchapter 5 of the Podiatrist Manual. If the Division approves
the request, the Division will notify both the podiatrist and the member.
(C) The Division authorizes at least a 72-hour emergency supply of a prescription drug to the
extent required by federal law. (See 42 U.S.C. 1396r-8(d)(5).) The Division acts on requests for
prior authorization for a prescribed drug within a time period consistent with federal regulations.
(D) Prior authorization does not waive any other prerequisites to payment such as, but not limited
to, member eligibility or requirements of other health insurers.
(E) The MassHealth Drug List specifies the drugs that are payable under MassHealth. Any drug
that does not appear on the MassHealth Drug List requires prior authorization, as set forth in 130
CMR 424.417 through 424.421. The Division will evaluate the prior-authorization status of drugs
on an ongoing basis, and update the MassHealth Drug List.
424.422: Pharmacy Services: Member Copayments
The Division requires under certain conditions that members make a copayment to the
dispensing pharmacy for each original prescription and for each refill for all drugs (whether
legend or nonlegend) covered by MassHealth. The copayment requirements are detailed in the
Division's administrative and billing regulations at 130 CMR 450.130.
424.423: Drugs Dispensed in Provider’s Office
Drugs dispensed in the office are payable at the podiatrist’s actual acquisition cost if this cost
is more than $1.00. Claims for dispensing drugs must include the name of the drug or biological,
the strength, and the dosage. A copy of the invoice showing the actual acquisition cost must be
attached to the claim form, and must include the National Drug Code (NDC). Claims without this
information will be denied.
424.424: Shoes and Corrective Devices
(A) The Division pays for only those shoes listed in Subchapter 6 of the Podiatrist Manual.
(B) For shoes, providers must submit with their claim a copy of the completed MassHealth Shoe
Medical Necessity Form and a copy of the Life and Safety Certification from the primary care
physician. (See 130 CMR 424.405.)
(C) The Division does not pay for casting materials used in the molding of orthotic shoes or
corrective devices. The cost of these materials is included in the fee for prescribing and providing
the shoe or corrective device.
REGULATORY AUTHORITY
130 CMR 424.000: M.G.L. c. 118E, §§7 and 12.
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
Provider Manual Series
6 SERVICE CODES
6-1
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
601 Introduction
The Division pays for the services for codes listed in Sections 602 through 604 in effect at the time of
service, subject to all conditions and limitations in the Division’s regulations at 130 CMR 424.000 and
450.000.
Podiatry services require a written referral from the member’s primary-care provider before the delivery
of services. The Division pays only for podiatry services that are certified to be necessary for the life
and safety of the member. The referral must be on the primary-care provider’s letterhead and must
certify that such services are medically necessary for the life and safety of the member. A
substantiating medical explanation must also be included in the written certification.
• Section 602 lists CPT service codes that are payable under MassHealth, some of which require
individual consideration or prior authorization. MassHealth providers must refer to the American
Medical Association’s Current Procedural Terminology (CPT) 2003 code book for the service codes
and descriptions when billing for CPT codes provided to MassHealth members.
• Sections 603 and 604 list Level II HCPCS codes that are payable under MassHealth. MassHealth
providers must refer to Ingenix’s HCPCS Level II 2003 code book for the descriptions of the codes
when billing for Level II HCPCS codes provided to MassHealth members.
• Section 605 lists service code modifiers allowed under MassHealth.
Legend:
I.C.: Claim requires individual consideration. See 130 CMR 424.407 for more information.
P.A.: Service requires prior authorization. See 130 CMR 450.303 for more information.
602 Payable
CPT
Codes
The Division pays for services billed using the following codes.
10060
11001
11057 (I.C.)
11308
11621
10061
11040
11100
11420
11622
10120
11041
11101
11421
11623
10121
11042
11200
11422
11624
10140
11043
11201
11423
11626
10160
11044
11305
11424
11719
10180
11055
11306
11426
11720
11000
11056
11307
11620
11721
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
Provider Manual Series
6 SERVICE CODES
6-2
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
602 Payable
CPT
Codes (cont.)
11730
17000
27685
28092
28262
11732
17003
27686
28100
28264
11740
17004
27695
28102
28270
11750
17110
27696
28103
28272
11752
17111
27704
28104
28280
11755
17250
27760
28106
28285
11760
17270
27762
28107
28286
11762
17271
27766
28108
28288
11765
17272
27808
28110
28289
12001
17273
27810
28111
28290
12002
17274
27814
28112
28292
12004
17276
27816
28113
28293
12005
20000
27818
28114
28294
12006
20005
27822
28116
28296
12007
20200
27823
28118
28297
12041
20205
27840
28119
28298
12042
20206
27842
28120
28299
12044
20520
27846
28122
28300
12045
20525
27848
28124
28302
13131
20550
27860
28126
28304
13132
20600
27870
28130
28305
13133
20605
28001
28140
28306
14040
20612
28002
28150
28307
14041
20615
28003
28153
28308
14060
20650
28005
28160
28309
14061
20670
28008
28171
28310
14300
20680
28010
28173
28312
14350
27603
28011
28175
28313
15000
27604
28020
28190
28315
15001
27605
28022
28192
28320
15050
27606
28024
28193
28322
15100
27607
28030
28200
28340
15101
27610
28035
28202
28341
15120
27612
28043
28208
28344
15121
27613
28045
28210
28345
15240
27614
28046
28220
28360 (I.C.)
15241
27615
28050
28222
28400
15350
27618
28052
28225
28405
15351
27619
28054
28226
28406
15400
27620
28060
28230
28415
15401
27625
28062
28232
28420
15574
27626
28070
28234
28430
15620
27630
28072
28238
28435
15850
27647
28080
28240
28436
15851
27648
28086
28250
28445
15852
27680
28088
28260
28450
15999 (I.C.)
27681
28090
28261
28455
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
Provider Manual Series
6 SERVICE CODES
6-3
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
602 Payable
CPT
Codes (cont.)
28456
28630
29425
73650
99231
28465
28635
29440
73660
99232
28470
28636
29445
76499 (I.C.)
99238
28475
28645
29450
81000
99239
28476
28660
29515
82947
99241
28485
28665
29540
84550
99242
28490
28666
29550
85007
99243
28495
28675
29580
85014
99251
28496
28705
29590
85018
99252
28505
28715
29705
85032
99253
28510
28725
29730
85041
99261
28515
28730
29750
85048
99262
28525
28735
29799 (I.C.)
87101
99281
28530
28737
29891
87102
99282
28531
28740
29892
87106
99283
28540
28750
29893
99070 (I.C.)
99311
28545
28755
29894
99202
99312
28546
28760
29895
99203
99321
28555
28800
29897
99204
99322
28570
28805
29898
99211
99331
28575
28810
29899
99212
99332
28576
28820
73590
99213
99341
28585
28825
73592
99214
99342
28600
28899 (I.C.)
73600
99218
99343
28605
29345
73610
99219
99347
28606
29355
73620
99221
99348
28615
29405
73630
99222
99349
603 Payable HCPCS Level II Service Codes for Injectable and Infusable Drugs Administered in the Office
The Division pays for the services for codes listed in Section 603 in effect at the time of service, subject to all
conditions and limitations in Subchapter 6 and in the Division’s regulations at 130 CMR 424.000 and
450.000. All services for codes listed in this section are paid on an individual consideration (I.C.) basis. See
130 CMR 424.407 for more information.
J0170 (I.C.)
J0702 (I.C.)
J0704 (I.C.)
J1020 (I.C.)
J1030 (I.C.)
J1040 (I.C.)
J1200 (I.C.)
J1700 (I.C.)
J1710 (I.C.)
J2000 (I.C.)
J3301 (I.C.)
J3302 (I.C.)
J3303 (I.C.)
J3490 (I.C.) (P.A.)
S0020 (I.C.)
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
Provider Manual Series
6 SERVICE CODES
6-4
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
604 Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services
The Division pays for the services for codes listed in Section 604 in effect at the time of service, subject to
all conditions and limitations in Subchapter 6 and in the Division's regulations at 130 CMR 424.000 and
450.000. In addition, each code lists the age restriction and service limitations that apply. All service codes
listed in this section are paid on an individual consideration (I.C.) basis. See 130 CMR 424.407 for more
information.
HCPCS
Covered
Covered Ages 21
Service
Code
Under Age 21
and Older
Limitations
A5500 (I.C.)
Yes
Yes
4 per 12 months
A5501 (I.C.)
Yes
Yes
4 per 12 months
A5503 (I.C.)
Yes
Yes
4 per 12 months
A5504 (I.C.)
Yes
Yes
4 per 12 months
A5505 (I.C.)
Yes
Yes
4 per 12 months
A5506 (I.C.)
Yes
Yes
4 per 12 months
A5507 (I.C.)
Yes
Yes
4 per 12 months
A5508 (I.C.)
Yes
Yes
4 per 12 months
A5509 (I.C.)
Yes
Yes
12 per 12 months
A5511 (I.C.)
Yes
Yes
4 per 12 months
L3000 (I.C.)
Yes
No
4 per 12 months
L3001 (I.C.)
Yes
No
4 per 12 months
L3002 (I.C.)
Yes
No
4 per 12 months
L3003 (I.C.)
Yes
No
4 per 12 months
L3010 (I.C.)
Yes
No
4 per 12 months
L3020 (I.C.)
Yes
No
4 per 12 months
L3030 (I.C.)
Yes
No
4 per 12 months
L3040 (I.C.)
Yes
No
4 per 12 months
L3050 (I.C.)
Yes
No
4 per 12 months
L3060 (I.C.)
Yes
No
4 per 12 months
L3070 (I.C.)
Yes
No
4 per 12 months
L3080 (I.C.)
Yes
No
4 per 12 months
L3090 (I.C.)
Yes
No
4 per 12 months
L3100 (I.C.)
Yes
No
2 per 12 months
L3140 (I.C.)
Yes
No
2 per 12 months
L3150 (I.C.)
Yes
No
2 per 12 months
L3160 (I.C.)
Yes
No
2 per 12 months
L3170 (I.C.)
Yes
No
2 per 12 months
L3201 (I.C.)
Yes
No
4 per 12 months
L3202 (I.C.)
Yes
No
4 per 12 months
L3203 (I.C.)
Yes
No
4 per 12 months
L3204 (I.C.)
Yes
No
4 per 12 months
L3206 (I.C.)
Yes
No
4 per 12 months
L3207 (I.C.)
Yes
No
4 per 12 months
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
Provider Manual Series
6 SERVICE CODES
6-5
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
604 Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services (cont.)
HCPCS
Covered
Covered Ages 21
Service
Code
Under Age 21
and Older
Limitations
L3208 (I.C.)
Yes
No
4 per 12 months
L3209 (I.C.)
Yes
No
4 per 12 months
L3211 (I.C.)
Yes
No
4 per 12 months
L3212 (I.C.)
Yes
No
2 per 12 months
L3213 (I.C.)
Yes
No
2 per 12 months
L3214 (I.C.)
Yes
No
2 per 12 months
L3215 (I.C.)
Yes
No
2 per 12 months
L3216 (I.C.)
Yes
No
2 per 12 months
L3217 (I.C.)
Yes
No
2 per 12 months
L3219 (I.C.)
Yes
No
2 per 12 months
L3221 (I.C.)
Yes
No
2 per 12 months
L3222 (I.C.)
Yes
No
2 per 12 months
L3224 (I.C.)
Yes
No
4 per 12 months
L3225 (I.C.)
Yes
No
4 per 12 months
L3230 (I.C.)
Yes
No
4 per 12 months
L3250 (I.C.)
Yes
No
4 per 12 months
L3251 (I.C.)
Yes
No
4 per 12 months
L3252 (I.C.)
Yes
No
4 per 12 months
L3253 (I.C.)
Yes
No
4 per 12 months
L3254 (I.C.)
Yes
No
2 per 12 months
L3255 (I.C.)
Yes
No
2 per 12 months
L3257 (I.C.)
Yes
No
2 per 12 months
L3260 (I.C.)
Yes
No
4 per 12 months
L3265 (I.C.)
Yes
No
4 per 12 months
L3300 (I.C.)
Yes
No
4 per 12 months
L3310 (I.C.)
Yes
No
4 per 12 months
L3320 (I.C.)
Yes
No
4 per 12 months
L3332 (I.C.)
Yes
No
2 per 12 months
L3334 (I.C.)
Yes
No
4 per 12 months
L3350 (I.C.)
Yes
No
4 per 12 months
L3360 (I.C.)
Yes
No
4 per 12 months
L3370 (I.C.)
Yes
No
4 per 12 months
L3390 (I.C.)
Yes
No
4 per 12 months
L3400 (I.C.)
Yes
No
4 per 12 months
L3420 (I.C.)
Yes
No
4 per 12 months
L3450 (I.C.)
Yes
No
4 per 12 months
L3455 (I.C.)
Yes
No
4 per 12 months
L3460 (I.C.)
Yes
No
4 per 12 months
L3465 (I.C.)
Yes
No
4 per 12 months
L3470 (I.C.)
Yes
No
4 per 12 months
Commonwealth of Massachusetts
SUBCHAPTER NUMBER AND TITLE
PAGE
Division of Medical Assistance
Provider Manual Series
6 SERVICE CODES
6-6
TRANSMITTAL LETTER
DATE
PODIATRIST MANUAL
POD-45
10/16/03
604 Payable HCPCS Level II Service Codes for Diabetic Shoes and Orthotic Services (cont.)
HCPCS
Covered
Covered Ages 21
Service
Code
Under Age 21
and Older
Limitations
L3480 (I.C.)
Yes
No
4 per 12 months
L3485 (I.C.)
Yes
No
4 per 12 months
L3500 (I.C.)
Yes
No
4 per 12 months
L3510 (I.C.)
Yes
No
4 per 12 months
L3530 (I.C.)
Yes
No
4 per 12 months
L3540 (I.C.)
Yes
No
4 per 12 months
L3570 (I.C.)
Yes
No
4 per 12 months
L3580 (I.C.)
Yes
No
4 per 12 months
L3590 (I.C.)
Yes
No
4 per 12 months
L3595 (I.C.)
Yes
No
4 per 12 months
L4210 (I.C.)
Yes
Yes
--
605 Modifiers
The following service code modifiers are allowed for billing under MassHealth. See Subchapter 5 of the
Podiatrist Manual for billing instructions related to the use of modifiers.
26 Professional
component
50 Bilateral
procedure
51 Multiple
procedures
99 Multiple
modifiers
TC Technical
component
