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3751580254000Commonwealth of MassachusettsExecutive Office of Health and Human ServicesOffice of MedicaidmasshealthMassHealthTransmittal Letter PHY-156May 2019TO:Physicians Participating in MassHealthFROM:Daniel Tsai, Assistant Secretary for MassHealth [Signature of Dan Tsai]RE:Physician Manual (2019 HCPCS Code Revisions; New Drug Codes and Prior-Authorization Requirements for Treatment of Varicose Veins of the Lower Extremities)SummaryThis letter transmits revisions to Subchapter 6 of the Physician Manual to incorporate 2019 Healthcare Common Procedure Coding System (HCPCS) coding updates, and also transmits certain additional drug codes and new prior authorization (PA) requirements for additional codes used for the treatment of varicose veins of the lower extremities, as specified below. 2019 HCPCS/CPT Updates The Centers for Medicare & Medicaid Services (CMS) has revised the HCPCS codes for 2019. MassHealth has updated Subchapter 6 of the Physician Manual to incorporate those 2019 HCPCS/Current Procedural Terminology (CPT) service code updates, as applicable. These 2019 HCPCS/CPT coding updates are effective for dates of service on or after January 1, 2019. MassHealth has also updated Subchapter 6 to reflect changes to special requirements or limitations for applicable codes. New PA RequirementsPA Additions for Treatment of Varicose Veins of the Lower Extremities MassHealth has also updated Subchapter 6 to reflect that PA will be required for additional CPT codes used for the treatment of varicose veins of the lower extremities. This policy change does not affect CPT codes 36470 and 36471, which have both required PA for some time and will continue to require PA. However, MassHealth has expanded the list of CPT codes used for the treatment of varicose veins of the lower extremities for which physicians must obtain PA approval from MassHealth to also include the following additional codes. These additional codes will require PA, effective for dates of service on or after May 31, 2019. PA Additions for Treatment of Varicose Veins of the Lower Extremities (cont.)Endovenous Ablation Therapy ServicesAdditional codes requiring PA36465, 36466, 36473, 36474, 36475, 36476, 36478, and 36479. Ligation and Division of Long Saphenous VeinAdditional codes requiring PA 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766 and 37780.A PA request for these services must be accompanied by clinical documentation to support medical necessity, as referenced in the current MassHealth Guidelines for Medical Necessity Determination for Treatment of Varicose Veins of the Lower Extremities, which may be accessed on the MassHealth website (masshealth/guidelines). As a condition of payment, PA approval from MassHealth must be obtained prior to the date of service. PA Additions for Drug Codes Administered By a Practitioner in the Office SettingMassHealth has also updated the following additional drug codes in Subchapter 6. MassHealth will require PA approval from MassHealth for these codes when the services are practitioner-administered to a MassHealth Member in the office setting. These additional drug codes will require PA effective for dates of service on or after May 31, 2019.J0517, J0572, J0573, J0574 J0575 J0584, J0592, J0599, J0640, J0641, J0712, J0878, J1170, J1301, J1454, J1458, J1459, J1460, J1628, J1743, J1746, J1750, J1885, J1931, J2170, J2175, J2270, J2274, J2278, J2469, J2504, J2794, J2797, J2916, J3030, J3243, J3285, J3304, J3315, J3397, J3591, J7316, J7318, J7329, J7340, J7518, J7527, J7599, J7682, J7699, J7799, J7999, J8655, J9020, J9032, J9035, J9057, J9153, J9173, J9215, J9225, J9226, J9229, J9311, J9312, J9390, Q5103, Q5104, Q5105, Q5106, Q5108, Q5110, Q9991, Q9992.For dates of service on or after May 31, 2019, MassHealth will process PA requests for the above drug codes using MassHealth’s standard procedures and protocols, and will deny payment to the provider for the drug if a required PA approval has not been obtained from MassHealth before the date of service (i.e., before the date the that drug is administered). Providers are referred to the MassHealth Drug List (MHDL) for the MassHealth PA approval criteria that will apply to the drug. You can find the MHDL at . The PA criteria may be updated from time to time. PA Additions for Treatment of Varicose Veins of the Lower Extremities (cont.)Additionally, when billing unlisted codes J3490, J3590, or J9999, please follow the PA guidelines that apply when the drug in question is designated on the MHDL as requiring PA. MassHealth reviews requests for PA on the basis of medical necessity. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including member eligibility, other insurance, and program restrictions. MassHealth WebsiteThis transmittal letter and attached pages are available on the MassHealth website at masshealth-transmittal-letters. To sign up to receive email alerts when MassHealth issues new transmittal letters and provider bulletins, send a blank email to?join-masshealth-provider-pubs@listserv.state.ma.us. No text in the body or subject line is needed.QuestionsIf you have any questions about this transmittal letter, please contact the MassHealth Customer Service Center at (800) 841-2900, email your inquiry to providersupport@, or fax your inquiry to (617) 988-8974. NEW MATERIAL(The pages listed here contain new or revised language.)Physician ManualPages 6-1 through 6-26OBSOLETE MATERIAL(The pages listed here are no longer in effect.)Physician ManualPages 6-1 through 6-24 — transmitted by Transmittal Letter PHY-1556. Service CodesIntroduction 6-1Nonpayable CPT Codes ................................................................................................................6-1Codes That Have Special Requirements or Limitations ............................................................... 6-5Payable HCPCS Level II Service Codes 6-16Modifiers6-22Appendix A.DirectoryA-1Appendix C. Third-Party-Liability Codes C-1Appendix E. Admission Guidelines E-1Appendix I. Utilization Management Program I-1Appendix K.Teaching PhysiciansK-1Appendix T.CMSP Covered Codes T-1Appendix U.DPH-Designated Serious Reportable Events That Are Not ProviderPreventable Conditions U-1Appendix V. MassHealth Billing Instructions for Provider Preventable ConditionsV-1Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity Schedules W-1Appendix X. Family Assistance Copayments and DeductiblesX-1Appendix Y. EVS Codes/MessagesY-1Appendix Z.EPSDT/PPHSD Screening Services CodesZ-1601 IntroductionMassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2019 codebook for the service code descriptions when billing for services provided to MassHealth members. MassHealth pays for all medicine, radiology, surgery, and anesthesia CPT codes in effect at the time of service, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 433.000 and 450.000: Administrative and Billing Regulations, except for those codes listed in Section 602 of this subchapter, CPT Category II codes ending in F, and CPT Category III codes ending in T.A physician 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 Physician Manual.Section 602 lists CPT codes that are not payable under MassHealth.Section 603 lists CPT codes that have special requirements or limitations. Beside each service code in Section 603 is an explanation of the requirement or limitation.Section 604 lists Level II HCPCS codes that are payable under MassHealth. Section 605 lists service code modifiers allowed under MassHealth.Note: Rates paid by MassHealth for covered codes under this Subchapter 6 for drugs, vaccines, and immune globulins administered in a physician’s office are as specified in 101 CMR 317.00: Medicine. Subject to any other applicable provision in 101 CMR 317.00, the payment rates for these MassHealth-covered codes are equal to the fees listed in the Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File. (See 101 CMR 317.03(1)(c)2 and 317.04(1)(a).). For applicable codes for drugs, vaccines, and immune globulins administered in a physician’s office that are listed in Section 603 or Section 604, below, with “IC,” payment set by IC will apply until such time as the code is listed and a rate set in the Quarterly ASP Medicare Part B Drug Pricing File, consistent with 101 CMR 317.04(1)(a). 602 Nonpayable CPT CodesRegardless of nonpayable status, a physician may request PA for any medically necessary service for a MassHealth Standard or CommonHealth member younger than 21 years of age.MassHealth does not pay for services billed under the following codes.1004011922157761578015781157821578315786157871578815789157921579315824158251582615828158291584717340173601935519396209302093620985211212112221123212452124621248212492252622527228412285622858228612286432491328503285532856332743327533289339303393333940339443483936415364163646836482364833659136592365983778538204382073820838209382103821138212382133821438215418704187243206432524375243842438434384544132443814440344404444054440644407444084470544715453494535045390453934539847133471434714447145473834816048550485515030050323503255490054901552005530055400558705832158322583235834558350587505875258760589705897458976590705907259412598976163061635616406164161642622876304363044657606576565767657716909071552721597219873225742637557176140763907649676497764987708677336773707737177372773737738577386774017740277407774127741777423774247742577520775227752377525777907826778268783518032080321803228032380324803258032680327803288032980330803318033280333803348033580336803378033880339803408034180342803438034480345803468034780348803498035080351803528035380354803558035680357803588035980360803618036280363803648036580366803678036880369803708037180372803738037480375803768037780500805028110581106811078110881109811108111181167811718117281173811748117781178811798118081181811828118481183811858118681187811888118981190812008120181202812038120481205812068120781208812098121081216812208122181222812238122481225812268122781233812348123581236812378123981240812418124281243812448124581250812518125281253812548125581256812578126081261812628126381264812658126681267812708127181274812758128481285812868128981290812918129281293812948129581296812978129881299813008130181302813038130481305813068131081312813158131681317813188131981320813218132281323813248132581326813278132981330813318133281333813368133781340813418134281343813448134581350813558137081371813728137381374813758137681377813788137981380813818138281383814008140181402814038140481405814068140781408814138141481422814398144381500815038150681508815098151081511815128151881521815398154181551815968159982075829628398784145844318441084830860798630586890868918691086911869278693086931869328694586950869608696586985871508715387493880008800588007880128801488016880208802588027880288802988036880378804088045880998812588333883348873888749892508925189253892548925589257892588925989260892618926489268892728928089281892908929189321893228932589329893308933189335893428934389344893468935289353893548935689398905869058790634906449064790648906499065090653906559065790680906819068590687906899069790698907009070290723907439074490748908459086390865908759087690880908859088990901909119094090989909939099790999911129113291133923149231592316923179232592352923539235492355923589237192531925329253392534925489255992560925619256292564925979260592606926139261592617926309263393264936609366893702937709378693895940059401594644946459501295052951209512595130951319513295133951349582495965959669596795992960009600496040961059611296113961169612196125961279613096131961329613396136961379613896139961469615096151961529615396154961559616096161963769656796570965719657396574969029690497014971519715297153971549715597156971579715897169971709717197172975379754597546977559894098941989429894398960989619896298966989679896898969990009900199002990249902699027990539905699058990609907199075990789908099082990919910099116991359914099151991529915399155991569915799172991749917799190991919919299241992429924399244992459925199252992539925499255992889931599316993399934099354993559935699357993589935999360993669936799368993749937599377993789937999380994019940299403994049940699408994099941199412994299944199442994439944499446994479944899449994509945199452994539945499455994569945799484994859948699487994899949099491994959949699497994989950099501995029950399504995059950699507995099951099511995129960199602996059960699607The service codes in this section are payable by MassHealth, subject to all conditions and limitations in MassHealth regulations at 130 CMR 433.000 and 450.000: Administrative and Billing Regulations, but require specific attachments or PA, or have other specific instructions or limitations. Refer to Section 604 for specific requirements or limitations for HCPCS Level II codes.LegendCDMassHealth-specified clinical documentation must be submitted. Covered for members birth to age 21This code is payable only for members aged birth to 21 years; used to claim for the administration and scoring of a standardized, behavioral health-screening tool from the approved menu of tools found in Appendix W of your provider manual; and must be accompanied by modifiers found in Section 605 under Modifiers for Behavioral Health Screening. Covered for members ≥ 19. This code is payable only for members age 19 or older; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age.CPA-2A completed Certification of Payable Abortion Formmust be completed for all induced abortions, except medically induced abortions. CS-18 or CS-21A completed Sterilization Consent Form (CS-18 for members aged 18 through 20 years; CS-21 form for members aged 21 and older) must be submitted. See 130 CMR 433.456 through 433.458 for more information.CS-18* or CS-21*A completed Sterilization Consent Form (CS-18 form for members aged 18 through 20; CS-21 for members aged 21 and older) must be submitted, except if the conditions of 130 CMR 433.458(D)(2) and (3) are met. See 130 CMR 433.456 through 433.458 for more information and other submission requirements.HI-1A completed Hysterectomy Information Form must be completed. See 130 CMR 450.235: Overpayments through 450.260: Monies Owed by Providers and 130 CMR 433.459 for more information.ICClaim requires individual consideration. See 130 CMR433.406 for more information.PAService requires prior authorization. See 130 CMR 433.408 for more information.PA for OMT > 20Prior authorization is required for more than 20 osteopathic manipulative therapy visits in a 12-month period.Legend (cont.)PA for OT > 20Prior authorization is required for more than 20 occupational therapy visits in a 12-month period.PA for PT > 20Prior authorization is required for more than 20 physical therapy visits, regardless of modality, in a 12-month period.PA for ST > 35Prior authorization is required for more than 35 speech/language therapy visits in a 12-month period.PA for Units > 8Prior authorization is required for claims submitted with greater than 8 units on a given date of service. Urgent Care Only: Service Codes 99050 and 99051 may be used only for urgent care provided in the office after hours, in addition to the basic service.ServiceCodeRequirement or Limitation01999IC11920PA11921PA11950CD (covered with diagnosis of lipodystrophy associated with, or secondary to, HIV only)11951CD (covered with diagnosis of lipodystrophy associated with, or secondary to, HIV only)11952CD (covered with diagnosis of lipodystrophy associated with, or secondary to, HIV only)11954CD (covered with diagnosis of lipodystrophy associated with, or secondary to, HIV only)11970PA (for gender dysphoria-related services only)11971PA (for gender dysphoria-related services only)15820PA15821PA15822PA15823PA15830PA15832PA15833PA15834PA15835PA15836PA15837PA15838PA15839PA15876CD; IC (covered with diagnosis of lipodystrophy associated with, or secondary to,HIV only)15877CD; IC (covered with diagnosis of lipodystrophy associated with, or secondary to,HIV only)ServiceCodeRequirement or Limitation 15878CD; IC (covered with diagnosis of lipodystrophy associated with, or secondary to, HIV only)15879CD; IC (covered with diagnosis of lipodystrophy associated with, or secondary to,HIV only)15999IC17380PA (covered in preparation for gender affirming surgery only)17999PA; IC19300PA19303PA (for gender dysphoria-related services only)19304PA (for gender dysphoria-related services only)19316PA19318PA19324PA19325PAServiceCodeReq. or Limit19328PA19340PA19350PA19499IC20999IC21088IC21089IC21137PA21138PA21139PA21146PA21147PA21150PA21151PA21154PA21155PA21159PA21160PA21172PA21175PA21188PA21193PA21194PA21195PAServiceCodeReq. or Limit21196PA21198PA21199PA21206PA21208PA21209PA21210PA21215PA21230PA21235PA21240PA21242PA21243PA21244PA21247PA21255PA21256PA21299PA; IC21499IC21742IC21743IC21899IC22857PA22862PAServiceCodeReq. or Limit22865PA22899IC22999IC23929IC24940IC24999IC25999IC26989IC27299IC27445PA27446PA27447PA27486PA27487PA27488PA27599IC27899IC28890PA28899IC29799IC29800PA29804PA29870PA29873PAServiceCodeReq. or Limit29874PA29875PA29876PA29877PA29879PA29880PA29881PA29882PA29883PA29884PA29885PA29886PA29887PA29888PA29889PA29999IC30400PA29888PA30410PA30420PA30430PA30435PA30450PA30999IC31299IC31599IC31899IC32851PA32852PA32853PA32854PA32999IC33935PA33945PA33981IC33982IC33983IC33999IC34841IC34842IC34843IC34844ICServiceCodeReq. or Limit34845IC34846IC34847IC34848IC36299IC36465PA136466PA136470PA36471PA36473PA136474PA136475PA136476PA136478PA136479PA137195IC37216IC37501IC37700PA137718PA137722PA137735PA137760PA137761PA137765PA137766PA137780PA137799PA; IC38129IC38230PA38240PA38241PA38242PA38589IC38999IC39499IC39599IC40799IC40840PA40842PA40843PA40844PAServiceCodeReq. or Limit40845PA40899IC41599IC41820PA; IC41821IC41850IC41899IC42280PA42281PA42299IC42699IC42999IC43289IC43496IC43499IC43644PA43645PA43647PA; IC43648IC43659IC43770PA43771PA43772PA43773PA43774PA43775PA43846PA43847PA43848PA43881PA; IC43882IC43886PA43887PA43888PA43999IC44135PA; IC44136PA; IC44137PA; IC44238IC44799IC44899IC44979ICServiceCodeRequirement or Limitation45399IC45499IC45999IC46999IC47135PA47379IC47399IC47579IC47999IC48554PA48999IC49329IC49659IC49906IC49999IC50549IC50949IC51925HI-151999IC53430PA (for gender dysphoria-related services only)53899IC54125PA (for gender dysphoria-related services only)54400PA54401PA54405PA54440IC54520PA (for gender dysphoria-related services only)54660PA (for gender dysphoria-related services only)54690PA (for gender dysphoria-related services only)54699IC55175PA (for gender dysphoria-related services only)55180PA (for gender dysphoria-related services only)55250CS-18 or CS-2155559IC55899PA; IC (for gender dysphoria-related services only)55970PA; IC55980PA; IC56620PA (for gender dysphoria- related services only)56625PA (for gender dysphoria-related services only)56800PAServiceCodeRequirement or Limitation56805IC57110PA (for gender dysphoria-related services only)57291PA (for gender dysphoria-related services only)57292PA (for gender dysphoria-related services only)57335IC58150HI-1; PA (for gender dysphoria-related services only)58152HI-158180HI-1; PA (for gender dysphoria-related services only)58200HI-158210HI-158240HI-158260HI-1; PA (for gender dysphoria-related services only)58262HI-1; PA (for gender dysphoria-related services only)58263HI-158267HI-158270HI-158275HI-158280HI-158285HI-158290HI-1; PA (for gender dysphoria-related services only) 58291HI-1; PA (for gender dysphoria-related services only)58292HI-158293HI-158294HI-158541HI-1; PA (for gender dysphoria-related services only)58542HI-1; PA (for gender dysphoria-related services only)58543HI-1; PA (for gender dysphoria-related services only)58544HI-1; PA (for gender dysphoria-related services only)58548HI-158550HI-1; PA (for gender dysphoria-related services only)58552HI-1; PA (for gender dysphoria-related services only58553HI-1; PA (for gender dysphoria-related services only)58554HI-1; PA (for gender dysphoria-related services only)58565CS-18 or CS-2158570HI-1; PA (for gender dysphoria-related services only)58571HI-1; PA (for gender dysphoria-related services only)58572HI-1; PA (for gender dysphoria-related services only)58573HI-1; PA (for gender dysphoria-related services only)58575HI-1; PA (for gender dysphoria-related services only)58578IC58579IC58600CS-18 or CS-21ServiceCodeRequirement or Limitation58605CS-18 or CS-2158611CS-18 or CS-2158615CS-18 or CS-2158661CS-18* or CS-21*; PA (for gender dysphoria-related services only)58670CS-18 or CS-2158671CS-18 or CS-2158679IC58720CS-18* or CS-21*; PA (for gender dysphoria-related services only)58951HI-158956HI-158999IC; PA (for gender dysphoria-related services only) ServiceCodeRequirement or Limitation 59525HI-159135HI-159840CPA-2 59841CPA-259850CPA-259851CPA-259852CPA-259855CPA-259856CPA-259857CPA-259898IC59899IC60659IC60699IC62380IC64650PA64653PA64999IC65757IC65785PA66999IC67299ICServiceCodeRequirement or Limitation 67399IC67599IC67900PA67901PA67902PA67903PA67904PA67906PA67908PA67999IC68399IC68899IC69300PA69399IC69710IC69799IC69930PA69949IC69979IC74261PA74262PA76499ICServiceCodeRequirement or Limitation76999IC77046PA77047PA77048PA77049PA77061IC77062IC77299IC77387IC77399IC77499IC77799IC78099IC78199IC78299IC78399IC78499IC78599IC78699IC78799IC78999IC79999IC81099IC81162PA81163PA81164PA81212PA81215PA81217PA81220IC81228PA; IC81229PA; IC81420PA; IC81479IC81507PA; IC81508ICServiceCodeRequirement or Limitation 81509IC81510IC81511IC81512IC81519PA; IC84999IC88199IC85999IC86849IC86999IC87999PA; IC88299IC81266PA88399IC81265PA89240IC90281IC90283IC90284IC90287IC90288IC90296IC90378PA; IC90384IC90385IC90386IC90389IC90393PA; IC90396IC90399IC90476IC90477IC90581IC90620IC90621IC90625ICServiceCodeRequirement or Limitation 90630Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age90632Covered for adults ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90633IC; Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90636Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90651IC; Covered for members aged 19 to 45 years; available free of charge through theMassachusetts Immunization Program for children younger than 19 years of age90654IC; Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90658IC; Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90660IC; Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age90661IC; Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age90664IC90666IC90667IC90668IC90670Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age90672Covered for members > 19 < 49; available free of charge through theMassachusetts Immunization Program for children younger than 19 years of age90673Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age90676IC90682Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age 90686Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90688Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age90690IC90696IC90707IC; Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of ageServiceCodeRequirement or Limitation90710IC; Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90713IC; Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90715Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90716IC; Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age 90717IC; Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age 90732Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90733IC; Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90734IC; Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age90736IC; PA is required for members younger than age 5090738IC90739 Covered for members ≥1990749IC90750IC; PA required for members younger than age 5090756Covered for members ≥ 19; available free of charge through the MassachusettsImmunization Program for children younger than 19 years of age 90867IC90868PA for >30 sessions per course of treatment; IC90869IC90899IC90935For hospitalized members only; not for chronic maintenance90937For hospitalized members only; not for chronic maintenance90945For hospitalized members only; not for chronic maintenance90947For hospitalized members only; not for chronic maintenance90952IC90953IC91110PA91111PA91299IC92065PA92310PA; includes supply of lenses92311PA; includes supply of lenses92312 PA; includes supply of lenses ServiceCodeRequirement or Limitation92313PA; includes supply of lenses92326PA92499IC92507PA for ST >3592508PA for ST >3592521PA for ST >3592522PA for ST >3592523PA for ST >3592524PA for ST >3592526PA for ST >3592558IC92610PA for ST >3592700IC92925IC92934IC92938IC92944IC92992IC92993IC93229IC93299IC93745IC93799IC93998IC94669PA94772IC94774IC94775IC94776IC94777IC94799IC95199IC95941IC95943IC95999ICServiceCodeRequirement or Limitation96110Developmental screening,with interpretation andreport, per standardized instrument form. Covered for members birth to age 21 for the administration and scoring of a standardized behavioral health-screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; must be accompanied by modifiers found in Section 605 under Behavioral Health Screening Modifiers to indicate whether a behavioral health need was identified.96377IC96379IC96549IC96931IC96932IC96933IC96934IC96935IC96936IC96999IC97010PA for PT >2097012PA for PT >2097016PA for PT >2097018PA for PT >2097022PA for PT >2097024PA for PT >2097026PA for PT >2097028PA for PT >20ServiceCodeRequirement or Limitation 97032PA for PT >2097033PA for PT >2097034PA for PT >2097035PA for PT >2097036PA for PT >2097039PA for PT >20; IC97110PA for PT >2097112PA for PT >2097113PA for PT >2097116PA for PT >2097124PA for PT >2097127 PA for PT >2097139PA for PT >20; IC97161 PA for PT >2097162PA for PT >2097164 PA for PT >2097165 PA for PT >2097166 PA for PT >2097167 PA for PT >2097168 PA for PT >2097530PA for OT >2097533PA for OT >2097535PA for OT >2097542PA for OT >2097602IC97607IC97608ICServiceCodeRequirement or Limitation97760PA for OT >2097761PA for OT >2097763PA for OT >2097799IC97810PA >2097811PA>2097813PA >2097814PA>2098925PA for OMT >2098926PA for OMT >2098927PA for OMT >2098928PA for OMT >20 98929PA for OMT >2099050Urgent care only99051Urgent care only99070IC; excluding family planning supplies, such as trays used in used in the collection of specimens99188Once per three-month period99195For hematologic disorders only99199IC99499IC99600IC604 Payable HCPCS Level II Service CodesThis section lists Level II HCPCS codes that are payable under MassHealth. For more detailed descriptions when billing for these codes provided to MassHealth members, refer to the Centers for Medicare & Medicaid Services website at Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html.ServiceCodeReq. or LimitA4261ICA4266A4267A4268A4269A4641ICA4648ICServiceCodeReq. or LimitA9500ICA9502ICA9503ICA9505ICA9512ICA9537ICA9575ServiceCodeReq. or LimitA9576A9577A9578A9579A9581A9585A9606PA; ICServiceCodeReq. or LimitG0027G0105G0108G0109G0121G0270G0271G0279G0297G0480G0455ICG0481G0482G0483J0129PAJ0131IC J0135PA; ICJ0153J0171J0178J0185J0202PAJ0215PA; ICJ0221PAJ0256J0257J0285J0287J0289 J0290J0295J0348J0364ICJ0400ICJ0401J0456J0461J0470J0475J0476J0485PAJ0490PAJ0517PA1J0558ServiceCodeReq. or LimitJ0561J0565PAJ0570PAJ0571PA; ICJ0572PA1 >10.7 units; IC J0573PA1 >5.4 units; IC J0574PA1 >3.2 units;J0575PA1 >4 units; IC J0584PA1; IC J0585PAJ0586PAJ0587PAJ0588PAJ0592PA1J0594J0596PA J0598PAJ0599PA1; ICJ0604ICJ0636J0637J0638PAJ0640PA1J0641PA1J0670J0690J0692J0694J0696J0697J0702J0712PA1J0713J0715ICJ0716ICJ0717PAJ0720J0740J0743J0770J0775PAJ0780J0834J0840ServiceCodeReq. or LimitJ0850J0875PAJ0878PA1J0881PAJ0882PAJ0883ICJ0884ICJ0885PAJ0890PA; ICJ0894J0895J0897PAJ1000J1020J1030J1040J1050J1071PAJ1094ICJ1100J1130PA; ICJ1160J1170PA1 >8 unitsJ1190J1200J1212J1240J1260ICJ1290J1300PAJ1301PA1; ICJ1320ICJ1322PA; ICJ1428PA; ICJ1438PA; ICJ1439PAJ1442PAJ1447J1453J1454PA1 >2 unitsJ1455ICJ1458PA1J1459PA1J1460PA1ServiceCodeReq. or LimitJ1555PAJ1556PAJ1557PAJ1559PAJ1560PAJ1561PAJ1562PA; ICJ1566PAJ1568PAJ1569PAJ1571J1572J1573ICJ1575J1580J1599PA; ICJ1602PA J1626J1627PA > 10 units; IC J1628PA1; ICJ1630J1642J1644J1645J1650J1652J1655ICJ1670J1700ICJ1710ICJ1720J1726PA; ICJ1729PA; ICJ1740PAJ1743PA1J1744PA; ICJ1745PAJ1746PA1; ICJ1750PA1J1786PAJ1756PAJ1790ICJ1800J1815ServiceCodeReq. or LimitJ1826ICJ1830PA; ICJ1840ICJ1850ICJ1885 PA1 >4 unitsJ1890ICJ1930J1931PA1J1942PA >1064 unitsJ1950PAJ1956J1990ICJ2060J2150J2170PA1; ICJ2175PA1J2182PAJ2212PA; ICJ2248J2250J2265ICJ2270PA1 >12 unitsJ2274PA1 >12 unitsJ2278PA1J2300J2310J2315J2323J2326PA; ICJ2350PA J2353J2354J2355ICJ2357PAJ2358PA >1 unitJ2400J2405J2407PAJ2426PA >819 unitsJ2430J2440ICJ2460ICJ2469PA1 >250 unitsServiceCodeReq. or LimitJ2502PA; ICJ2503J2504PA1J2505J2507PAJ2510J2515J2540J2543J2545J2550J2560J2562J2675J2680J2700J2704J2760ICJ2778J2785J2786PAJ2788J2790J2791J2792J2793PA; ICJ2794PA1 >100 unitsJ2795J2796PAJ2797PA1 >166.5 units; IC J2820J2840PA; ICJ2910ICJ2916PA1J2920J2930J2940PA; ICJ2941PA; ICJ2997J3000J3010J3030PA1; ICJ3060PAServiceCodeReq. or LimitJ3090PAJ3095PAJ3110PA; ICJ3121PAJ3145PAJ3230J3240J3243PA1J3250J3262PAJ3285PA1J3300J3301J3302ICJ3303ICJ3304PA1J3315PA1J3357PAJ3360J3370J3380PAJ3385PAJ3396J3397PA1; ICJ3410J3411J3430J3465J3471J3472ICJ3473J3475J3486J3489PAJ3490ICJ3490-FP; ICJ3590ICJ3591PA1; ICJ7030J7040J7050J7060J7070ServiceCodeReq. or LimitJ7120J7131ICJ7170J7177ICJ7203ICJ7205J7296ICJ7297ICJ7298ICJ7300ICJ7301ICJ7303ICJ7304ICJ7307IC J7309ICJ7310ICJ7311ICJ7312J7313J7315ICJ7316PA1J7318PA1; ICJ7320PA; ICJ7321PAJ7322PA; ICJ7323PAJ7324PAJ7325PAJ7326PA; ICJ7327PAJ7328PA; ICJ7329PA1; ICJ7336PAJ7340PA1; ICJ7342ICJ7345ICJ7500J7502J7503J7504J7507J7508J7509ServiceCodeReq. or LimitJ7510J7511J7512J7515J7517J7518PA1J7520J7527PA1J7599PA1J7608J7614PAJ7620J7626J7633ICJ7639J7644J7665ICJ7669ICJ7676ICJ7682PA1J7686PAJ7699PA1; ICJ7799PA1; ICJ7999PA1J8562ICJ8655PA1 >1 unitJ8670PA >180 unitsJ9000J9015ICJ9017J9019PAJ9020PA1; ICJ9022PAJ9023PAJ9025J9031J9032PA1J9033J9034J9035PA1J9039PAJ9040J9041ServiceCodeReq. or LimitJ9042PAJ9043PAJ9044J9045J9047PAJ9050J9055J9057PA1; ICJ9060J9065J9070J9098J9100J9120J9130J9145PAJ9153PA1J9155PAJ9160ICJ9171J9173PA1; ICJ9176PAJ9178J9179PAJ9181J9185J9190J9200J9201J9202PAJ9205PAJ9206J9207J9208J9209J9211J9212ICJ9213ICJ9214J9215PA; ICJ9216ICJ9217PAJ9215PA1ServiceCodeReq. or LimitJ9218PAJ9219PA; ICJ9225PA1J9226PA1J9228J9229PA1; ICJ9230J9250J9260J9261PAJ9262PA; ICJ9263J9264J9266J9267J9268J9271PAJ9280J9293J9295PAJ9299PAJ9301PAJ9302PAJ9303J9305J9306PAJ9307J9308PAJ9311PA1J9312PA1J9315PAJ9320J9325PAJ9328J9330J9340ICJ9351J9352J9354PAJ9355J9357J9360J9370ServiceCodeReq. or LimitJ9371PAJ9390PA1J9395PAJ9400PAJ9999ICQ0138Q0139Q0162Q2009ICQ2017ICQ2028IC; CD (covered with diagnosis of lipodystrophyassociated with,or secondary to,HIV only)Q2035Q2036ICQ2037ICQ2038ICQ2043PAQ2049ICQ2050Q4074Q4081Q4101Q4102Q4103ICQ4104ICQ4106Q4107Q4108ICQ4110ICQ4121Q4132Q4133Q4161ICQ4162ICQ4163ICQ4164ICQ4165ICQ4186 Q4187ICServiceCodeReq. or LimitQ5101PAQ5103PA1Q5104PA1Q5105PA1Q5106PA1Q5108PA1Q5110PA1Q9950Q9991PA1Q9992PA1ServiceCodeReq. or LimitS0020ICS0021ICS0077ICS0190ICS0023ICS0199S0191ICS0302S2260CPA-2; ICServiceCodeReq. or LimitS3005S4989ICS4993T1023V2600PA; ICV2610PA; ICV2615PA; ICV2799PA; ICThe following service code modifiers are allowed for billing under MassHealth. See the MassHealth Billing Guide for Paper Claim Submitters for billing instructions on the use of modifiers.ModifierModifier Description22Increased Procedural Services24Unrelated evaluation and management service by the same physician or otherqualified health care professional during a postoperative period25Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service26Professional component50Bilateral procedure51Multiple procedures 52 Reduced services53Discontinued procedure54Surgical care only57Decision for surgery58Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period59Distinct procedural service62Two surgeons66Surgical team78Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period79Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period80Assistant surgeon82Assistant surgeon (when qualified resident surgeon not available)91Repeat clinical diagnostic laboratory test99Multiple modifiersAAAnesthesia services performed personally by an anesthesiologist. (This allows payment of 100% of the Total Anesthesia Fee for the anesthesiologist’s services.)ASPhysician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery. E1Upper left, eyelidE2Lower left, eyelidE3Upper right, eyelidE4Lower right eyelidF1Left hand, second digitF2Left hand, third digitF3Left hand, fourth digitF4Left hand, fifth digitModifierModifier DescriptionF5Right hand, thumbF6Right hand, second digitF7Right hand, third digit F8 Right hand, fourth digitF9Right hand, fifth digitFALeft hand, thumbFPService provided as part of family planning program LCLeft circumflex coronary artery LDLeft anterior descending coronary artery LMLeft main coronary arteryLTLeft side (used to identify procedures performed on the left side of the body)QKMedical direction by a physician of two, three, or four concurrent anesthesia procedures.(Use to indicate physician medical direction of multiple CRNAs. This allows payment of 50% of the Total Anesthesia Fee for the physician’s services.)QYMedical direction of one CRNA by a physician. (Use to indicate physician medical direction of one CRNA. This allows payment of 50% of the Total Anesthesia Fee for the physician’s services.)QXCRNA anesthesia services with medical direction by a physician. (Use to indicate CRNA anesthesia services with medical direction by a physician. This allows payment of 50% of the Total Anesthesia Fee for the CRNA’s services. Not for use if CRNA is employed by the facility in which the anesthesia services were performed.)QZCRNA anesthesia services without medical direction by a physician. (This allows payment of 100% of the Total Anesthesia Fee for the CRNA’s services. Not for use if CRNA is employed by the facility in which the anesthesia services were performed.)RBReplacement of a part of a DME, orthotic, or prosthetic item furnished as part of a repair (This modifier should only be used with 92340, 92341, and 92342 to bill for the dispensing of replacement lenses.)RCRight coronary arteryRIRamus intermedius coronary arteryRTRight side (used to identify procedures performed on the right side of the body) SANurse practitioner rendering service in collaboration with a physician. (This modifier is to be applied to service codes billed by a physician that were performed by a certified nurse practitioner employed by the physician (the physician employer must be practicing as an individual and not practicing as a professional corporation or as a member of a group practice). A certified nurse practitioner billing under his/her own individual provider number, or a group practice, should not use this modifier.)ModifierModifier DescriptionSLState supplied vaccine (This modifier should only be applied to codes 90460, 90461, 90471, 90472, 90473, and 90474 to identify administration of vaccines provided at no cost by the Massachusetts Department of Public Health for individuals aged 18 years and younger, including those administered under the Vaccine for Children Program (VFC).)T1Left foot, second digitT2Left foot, third digitT3Left foot, fourth digitT4Left foot, fifth digitT5Right foot, great toeT6Right foot, second digitT7Right foot, third digitT8Right foot, fourth digitT9Right foot, fifth digitTALeft foot, great toeTCTechnical component. Under certain circumstances, a charge may be made for the technical component alone. Under those circumstances, the technical component charge is identified by adding modifier ‘TC’ to the usual procedure number. Technical component charges are institutional charges and not billed separately by physicians. However, portable x-ray suppliers only bill for technical component and should utilize modifier TC. The charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles. XESeparate encounter, a service that is distinct because it occurred during a separate encounterXPSeparate practitioner, a service that is distinct because it was performed by a different practitionerXSSeparate structure, a service that is distinct because it was performed on a separate organ/structureXUUnusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main serviceModifiers for Tobacco-Cessation ServicesThe 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.ModifierModifier Description HQGroup counseling, at least 60-90 minutes in duration, provided by a physician,physician assistant, certified nurse practitioner, clinical nurse specialist, psychiatric clinical nurse specialist or certified nurse midwife. TDIndividual counseling provided by a registered nurse (RN) under the supervision of a physician.TFIndividual counseling, intensive (intake/assessment counseling, at least 45 minutes in duration) provided by a physician, physician assistant, certified nurse practitioner, clinical nurse specialist, psychiatric clinical nurse specialist or certified nurse midwifeU1Individual counseling services provided by a tobacco-cessation counselor under the supervision of a physicianU2Individual counseling; intensive (intake/assessment counseling, at least 45 minutes in duration), provided by a registered nurse or a tobacco-cessation counselor, under the supervision of a physicianU3Group counseling, at least 6090 minutes in duration, provided by a registered nurse, or a tobacco-cessation counselor, under the supervision of a physicianModifiers for Behavioral Health ScreeningThe administration and scoring of standardized behavioral health-screening tools selected from the approved menu of tools found in Appendix W of your 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 his or her professional judgment, identified a child with a potential behavioral health services need.ModifierModifier DescriptionU1Completed behavioral health screening using a standardized behavioral health-screening tool selected from the approved menu of tools found in Appendix W of your provider manual with “no behavioral health need identified” when administered by a physician, certified nurse midwife, certified nurse practitioner or physician assistant.U2Completed behavioral health screening using a standardized behavioral health-screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified when administered by a physician, certified nurse midwife, certified nurse practitioner or physician assistant.U5Completed behavioral health screening using a standardized behavioral health-screening tool selected from the approved menu of tools found in Appendix W of your provider manual with “no behavioral health need identified” when administered by a certified nurse practitioner employed by a physician.ModifierModifier DescriptionU6Completed behavioral health screening using a standardized behavioral health-screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified when administered by a certified nurse practitioner employed by a physician.UDCovered for members birth to 6 months for the administration and scoring of the Edinburgh Postnatal Depression Scale. UD must be used together with one of the above modifiers, U1, U2, U5, or U6.Modifiers for Administration of MassHealth-Approved Screening ToolsService Code S3005, used for the performance measurement and evaluation of patient self-assessment and depression, must be accompanied by one of the modifiers below to indicate whether a behavioral health need was identified.ModifierModifier DescriptionU1Perinatal Care Provider – Positive Screen: completed prenatal or postpartumdepression screening and behavioral health need identified. U2Perinatal Care Provider – Negative Screen: completed prenatal or postpartumdepression screening with no behavioral health need identified.Please refer to the Massachusetts Department of Public Health’s (DPH) postpartum depression (PPD) screening-tool grid for any revisions to the list of MassHealth-approved screening tools at eohhs/gov/departments/dph/programs/family-health/postpartum-depression/postpartum-depression-tools.html.Modifier for Child and Adolescent Needs and Strengths (CANS)ModifierModifier DescriptionHAService Code 90791 must be accompanied by this modifier to indicate that the Child and Adolescent Needs and Strengths (CANS) is included in the psychiatric diagnostic interview examination. This modifier may be billed only by psychiatrists or psychiatric clinical nurse specialists.Modifiers for Provider Preventable ConditionsThat Are National Coverage DeterminationsModifierModifier DescriptionPASurgical or other invasive procedure on wrong body partPBSurgical or other invasive procedure on wrong patientPCWrong surgery or other invasive procedure on patientFor more information on the use of these modifiers, see Appendix V of your provider manual.This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS are defined in the Current Procedural Terminology (CPT) codebook. ................
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