Commonwealth of Massachusetts



601 Introduction and Explanation of Abbreviations MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) code book for the service codes and service descriptions when billing for services provided to MassHealth members. MassHealth pays for all medicine, radiology, laboratory, surgery, and anesthesia CPT codes in effect at the time of service, except for those codes listed in Section 602 of this Subchapter, including Category II codes ending in F and Category III codes ending in T as noted, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000.A chronic disease and rehabilitation outpatient hospital provider may request prior authorization (PA) for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. s 1396d(a) and 42 U.S.C. s 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Chronic Disease and Rehabilitation Outpatient Hospital Manual.Section 602 lists CPT service codes that are not payable under MassHealth.Section 603 lists Level II HCPCS codes that are payable under MassHealth.Section 604 lists service code Modifiers allowed under MassHealth.602 Nonpayable Evaluation and Management (E/M) Service Codes9921799218992199922099221992229922399224992259922699231992329923399234992359923699238992399925199252992539925499255992819928299283992849928599288992919929299304993059930699307993089930999310993159931699318993249932599326993279932899334993359933699337993399934099341993429934399344993459934799348993499935099354993559935699357993589935999360993749937599377993789937999380994019940299403994049940699408994099941199412994209942999441994429944399444994509945599456994649946599466994679946899469994719947299475994769947799478994799948099485994869948799488994899949599496994991004011004110051100611008119201192111922119501195111952119541196011970119711197611980119811198211983131001310113102131201312113122131311313213133131501315113152131531316014000140011402014021140401404114060140611430114302143501504015050151001510115110151111511515116151201512115130151311513515136151501515115152151551515615200152011522015221152401524115260152611527115272152731527415275152761527715278155701557215574155761560015610156201563015650157311573215734157361573815740-1603617000-19499201002010120102201032015020200202052020620220202252024020245202502025120252205522055320660206612066220663206642069020692206932069420802-2083820900-20999210102104521120-2129921310-2149921510215552155621557216002161021615216162162021627216302163221685-2193622010-22328225262252722532-22905232002321023220233322347223900239202392124065-24155242012490024920249302493124940258002580525810258202582525830259002590525907259092591525920259222592425927259292593126415264162643226449-2659626820-268632691026951269522699227000-270362704927054270592706627067270702707127075270762707727078270802709027091270982710027105271102711127120271222712527130-271872720227215272172721827222272262722727228272322723527236272442724527248272532725427258272592726927280272822728427286272902729527303273052730627307273242732527326273302733127332273332733427335273502735527356273602732927364273652738127386273902739127392273932739427395273962739727400-27495275062750727509275112751327514275192752427535275362754027556275572755827566275802759027591275922759427596275982759927600276012760227605276062761427625276162762027625276262763427635276372763827645276462764727650-27745277562775827759277662776927784277922781427822278232782627827278282782927832278462784827870278712788027881278822788427886278882788928010280112802228024280352804628047280522805428062280702807228080280862808828100-28175281922819328200-282802840628200-2828028406284152842028445284462846528485285052852528531285552858528615286452867528705-288253122531230312903129131360313653136731368313703137531380313823139031395315843158731725317603176631770317753178031781317853178631800318053203532036320953210032110321203212432140321413215032151321603220032225323103232032440-3254032650326513265232653326543265532656326583265932661326623266332664326653280032810328153282032850328513285232853328543285532856329003290532906329403299733015330203302533030330313305033120331303314033141332023320333206332073320833210332113321233213332143321533216332173321833220332223322533226332333323433235332363323733238332403324133243332503325133254332553325633257332583325933261332653326633300-3333533400-3349633500-3357233600-3369733702-3378833800-3389133910-3399934001-34490345013450234510345203453034800-3483434900350013500235005350113501335021350223504535081350823509135092351023510335111351123512135122351313513235141351423515135152351823518935211352163522135231352413524635251352613527135276352813530135302353033530435305353063531135321353313534135351353553536135363353713537235390354003545035452354583546035550-3558735600-35697357003570135721357413587035875358763587935881358833588435901359033590535907364153641636468364693659136592365983666036822368233714037145371603718037181371823718337184371853718637187371883719537197372003720237204372103721137212372133721437215372163761637617376183766037765377663778838100381013810238115383803838138382385623856438700-387803890039000-395994113041135411404114541150411534115541870418724242642845428924289442953429614297143100-4313543300-4342543460434964350043501435024352043605-4364143644436454375243770437714377243773437744377543800-4388844005-4416044187441884420244203442044420544210442114421244227443004431044314443164432044322443454434644602-446804470044701447054471544720447214480044820448504489944900449504495544960451104511145112451134511445116451194512045121451234512645130451354513645395453974540045402455404555045562455634580045805458204582546700-46947470104701547100-47147473004735047360473614736247380473814740047420474254746047480475504757047600-47900480004800148020481004810548120481404814548146481484815048152481534815448155481604840048500-48556490004900249010490204902149040490414906049061490624920349204492054921549220492504925549425494284960549606496104961149900499044990549906500105004050045500655007050075501005012050125501305013550205502205022550230502345023650240502505028050290503005032050323503255032750328503295034050360503655037050380504005040550500505205052650540505455054650547505485060050605506105062050630506505066050700-509405106051525515305155051555515655157051575515805158551590515955159651597517015170251800-5198053400-53520541155412054125541305413554300-544405453554600-546805490054901550605517555180552505540055450556055565055801-5586655970559805662056625566305663156632566335663456637566405670056740568005680556810570655710557106571075710957110571115711257200-573355753157540575455770057720581405814558146581505815258180582005821058240582605826258263582675827058275582805828558290582915829258293582945840058410585205854058541-585795860058605586115861558660-5867958700-52770588225882558925-589765903059070590725907659100-59160592005930059320593255935059400-5943059510-598996020060210602126022060225602406625260254602606027060271602806028160505605206052160522605406054560600606056065061105-6125361304-6187562005-6214862161621626216362164621656218062190621926220062201622206222362256622586228763043630446305063051630766307763078630816308263085630866308763088630906309163101-633086370063702637046370663707637096371063740637416475264755647606480964818648666486864885-6491165091-651756527365710-65782662206622566680666826682166825669826698366984669856698667101-67121672506725567311-6734567875678806788267900-67924678716797367974679756832068325683266832868330683356834068360683626837168500685056852068540685506870068705687206874568750687606876168770688156881669090691506915569300693106932069501-6955469601-696766995069955605 Nonpayable Radiology Service Codes715527215972198732257426375571759007595275953759547595675957759587595976140764967649776498782677826878351606 Nonpayable Pathology and Laboratory Service Codes8010080101801048050281200-8139381400-8140081401814028140381404814058140681407814088147981500815068150881509815108151181512815998207582962839878414584431860798630586352867808682586826868908689186910869118692786930869318693286960869858715087153874938790387904880008800588007880128801488016880208802588027880288802988036880378804088045880998812588333883348873888749892508925189253892548925589257892588925989260892618926489268892728928089281892908929189300893108932089321893228932589329893308933189335893428934389344893468935289353893548935689398607 Nonpayable Medicine Services Codes902819028390284902879038490386903899039690634906449064590646906479064890654906699067090696906989070090702907089071090712907209072190723907439074490748907919079290832908339083490836908379083890839908409084590865908759087690880908859088990901909119094090989909939099790999911329113392265922709227592283922849228592286922879231492315923169231792325923529235392354923589237192531925329253392534925409254892550925599256092561925629256492570926309263392970929719297592992929939366093770937869400594011940129401394015947749477594776947779505295120951259513095131951329513495824959659596795992960009600196002960039600496150961519615296153961549615596376965679690296904970059700697537975459754697597975989760297605976069775597810978119781397814989409894198942989439896098961989629896698967989689896999000990019900299024990269902799050990519905399056990589906099071990759907899080990829909099091991009911699135991409914399144991459914899149991509917299190991919919299199995009950199502995039950499505995069950799509995109951199512996009960199602996059960699607608 Nonpayable CPT Category I and III Codes0001F0005F0012F0014F0015F0500F0501F0502F0503F0505F0507F0509F0513F0514F0516F0517F0518F0519F0520F0521F0001F0005F0012F0014F0015F0500F0501F0502F0503F0505F0507F0509F0513F0514F0516F0517F0518F0519F0520F0521F0525F0526F0528F0529F0535F0540F0550F0551F0556F0557F0575F1000F1002F1003F1004F1005F1006F1007F1008F1010F1011F1012F1015F1018F1019F1022F1026F1030F1034F1035F1036F1050F1052F1060F1061F1065F1066F1070F1071F1110F1111F1116F1118F1119F1121F1125F1126F1127F1128F1150F1151F1153F1157F1159F1160F2019F2020F2021F2022F2024F2026F3014F3015F3016F3017F3018F3019F3020F3021F3022F3023F3025F3027F3073F3100F3110F3111F3112F3125F3150F3155F3160F3250F3260F3265F3266F3267F3268F3269F3270F3271F3272F3273F3274F3278F3279F3280F3281F3284F3285F3292F3294F3315F3316F3317F3318F3321F3322F3323F3325F3328F3340F3341F3343F3344F3345F3350F3370F3372F3374F3376F3378F3380F3382F3384F3386F3388F3390F3450F3451F3452F3455F3490F3491F3492F3493F3494F3496F3497F3498F3500F3502F3503F3511F3512F3513F3514F3515F3550F3551F3552F3555F4000F4001F4003F4004F4005F4006F4009F4011F4012F4014F4017F4041F4042F4043F4044F4046F4047F4048F4049F4051F4052F4053F4054F4055F4056F4066F4070F4073F4075F4077F4084F4090F4095F4100F4115F4120F4124F4131F4132F4148F4149F4150F4151F4153F4155F4157F4159F4163F4164F4165F4167F4168F4169F4171F4172F4175F4178F4179F4181F4182F4191F4192F4193F4194F4200F4201F4250F4255F4256F4260F4261F4275F4276F4279F4280F4290F4293F4300F4301F4306F4320F4325F5005F5010F5060F6040F6045F7020F7025F0019T0030T0042T0048T0050T0051T0052T0053T0071T0072T0073T0075T0076T0078T0079T0080T0081T0085T0092T0095T0098T0099T0100T0101T0102T0103T0104T0105T0106T0107T0108T0109T0110T0111T0123T0124T0126T0141T0142T0143T0155T0156T0157T0158T0159T0163T0164T0165T0166T0167T0168T0169T0171T0172T0173T0174T0175T0178T0179T0180T0181T0182T0183T0184T0185T0186T0188T0189T0190T0191T0192T0195T0196T0197T0198T0199T0200T0201T0202T0205T0206T0207T0208T0209T0210T0211T0212T0213T0214T0215T0216T0217T0218T0219T0220T0221T0222T0223T0224T0225T0226T0227T0228T0229T0230T0231T0232T0233T0234T0235T0236T0237T0238T0239T0240T0241T0242T0243T0244T0245T0246T0247T0248T0249T0250T0251T0252T0253T0254T0255T0256T0257T0258T0259TCommonwealth of MassachusettsMassHealthProvider Manual SeriesSubchapter Number and Title6. Service Codes and DescriptionsPage6-10Chronic Disease and Rehabilitation Outpatient Hospital ManualTransmittal LetterCOH-8Date07/01/13609 Payable HCPCS Level II CodesThis section lists Level II HCPCS codes that are payable under MassHealth when provided by CDR outpatient hospitals. A4641A9500A9502A9503A9505A9512A9537G0105G0108G0109G0121G0202G0206G0270G0271J0129J0135J0171J0207J0215J0256J0290J0295J0348J0456J0461J0475J0476J0558J0561J0585J0586J0587J0592J0597J0598J0638J0640J0690J0694J0696J0697J0702J0715J0718J0775J0780J0833J0834J0840J0881J0882J0885J0886J0897J0900J1020J1030J1040J1055J1056J1060J1070J1080J1094J1100J1160J1170J1200J1260J1290J1300J1320J1438J1440J1441J1460J1557J1559J1561J1562J1566J1569J1571J1580J1599J1626J1630J1650J1655J1670J1710J1720J1725J1740J1743J1745J1750J1786J1790J1800J1826J1885J1890J1950J1956J1990J2060J2150J2175J2248J2250J2270J2271J2275J2300J2310J2315J2323J2355J2357J2358J2405J2426J2430J2440J2469J2503J2505J2507J2510J2515J2550J2560J2562J2675J2680J2760J2778J2785J2788J2790J2792J2793J2794J2796J2820J2910J2916J2920J2930J2940J2941J3010J3030J3095J3110J3120J3130J3230J3240J3243J3250J3262J3301J3302J3303J3357J3360J3385J3396J3410J3411J3430J3487J3490J3590J7030J7060J7070J7302J7303J7304J7307J7309J7312J7321J7323J7324J7325J7326J7335J7599J7608J7614J7620J7626J7633J7639J7644J7665J7669J7676J7682J7686J7699J7799J8561J8562J9000J9001J9025J9031J9035J9040J9041J9043J9045J9055J9060J9070J9130J9155J9171J9178J9179J9181J9190J9201J9202Commonwealth of MassachusettsMassHealthProvider Manual SeriesSubchapter Number and Title6. Service Codes and DescriptionsPage6-11Chronic Disease and Rehabilitation Outpatient Hospital ManualTransmittal LetterCOH-8Date07/01/13609 Payable HCPCS Level II Codes (cont.)J9206J9212J9213J9214J9215J9216J9217J9218J9219J9228J9250J9260J9261J9263J9264J9265J9293J9300J9302J9305J9307J9310J9315J9340J9351J9355J9360J9370J9390J9395J9999L8614L8615L8616L8617L8618L8619L8690L8691Q0081Q0083Q0084Q4100Q4101Q4102Q4103Q4104Q4105Q4106Q4107Q4108Q4110Q4111Q4112Q4113Q4114Q4115S0023S0028S0077S0302S2083Commonwealth of MassachusettsMassHealthProvider Manual SeriesSubchapter Number and Title6. Service Codes and DescriptionsPage6-12Chronic Disease and Rehabilitation Outpatient Hospital ManualTransmittal LetterCOH-8Date07/01/12610 ModifiersThe following service code modifiers are allowed for billing under MassHealth. See Subchapter 5 of the Chronic Disease and Rehabilitation Outpatient Hospital Manual for billing instructions related to the use of modifiers. Modifiers are required to be used with procedure codes in some circumstances and should be used only as applicable and when appropriate. The patient’s records must support the use of a modifier. Modifiers for General Outpatient Use24 Unrelated evaluation and management service by the same physician during a postoperative period25 Significant, 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 service27 Multiple outpatient hospital evaluation and management encounters on the same date 50Bilateral procedure57Decision for surgery58 Staged or related procedure or service by the same physician or other qualified health care professional during postoperative period59 Distinct procedural service78 Unplanned 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 period79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period91 Repeat clinical diagnostic laboratory testE1 Upper left, eyelidE2 Lower left, eyelidE3 Upper right, eyelidE4 Lower right, eyelidF1 Left hand, second digitF2 Left hand, third digitF3 Left hand, fourth digitF4 Left hand, fifth digitF5 Right hand, thumbF6 Right hand, second digitF7 Right hand, third digitF8 Right hand, fourth digitF9 Right hand, fifth digitFA Left hand, thumbLC Left circumflex coronary arteryLD Left anterior descending coronary arteryLT Left side (used to identify procedures performed on the left side of the body)RC Right coronary arteryRT Right side (used to identify procedures performed on the right side of the body)T1 Left foot, second digitT2 Left foot, third digitT3 Left foot, fourth digitT4 Left foot, fifth digitCommonwealth of MassachusettsMassHealthProvider Manual SeriesSubchapter Number and Title6. Service Codes and DescriptionsPage6-13Chronic Disease and Rehabilitation Outpatient Hospital ManualTransmittal LetterCOH-8Date07/01/12610 Modifiers (cont.)T5 Right foot, great toe T6 Right foot, second digitT7 Right foot, third digitT8 Right foot, fourth digitT9 Right foot, fifth digitTA Left foot, great toeModifiers for Therapy ServicesHCPCS codes for therapy services are required to be differentiated according to the type of therapist providing the service (occupational, physical, or speech/language therapy). The following modifiers should be used to differentiate between the therapy services. GN Speech/language therapyGO Occupational therapyGP Physical therapyModifiers 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 MassHealth provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. Service Code 96110 must be accompanied by one of the modifiers listed below to indicate whether a behavioral health need was identified. “Behavioral health need identified” means the provider administering the screening tool, in her or his professional judgment, identified a child with a potential behavioral health services need.U1Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your MassHealth provider manual with no behavioral health need identified.U2Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your MassHealth provider Modifiers for Provider Preventable Conditions that Are National Coverage DeterminationsPASurgical 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 monwealth of MassachusettsMassHealthProvider Manual SeriesSubchapter Number and Title6. Service Codes and DescriptionsPage6-14Chronic Disease and Rehabilitation Outpatient Hospital ManualTransmittal LetterCOH-8Date07/01/12This page is reserved. ................
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