Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
Independent Diagnostic Testing 
Facility Manual 
Subchapter Number and Title 
Table of Contents 
Page 
vi 
Transmittal Letter 
IDTF-12 
Date 
01/01/13 

6. Service Codes and Descriptions 

 Introduction ................................................................................................................................. 6-1 
Portable X Ray: Radiology Service Codes ................................................................................. 6-1 
Freestanding Magnetic Resonance Imaging (FMRI): Radiology Service Codes ......................... 6-2 
Diagnostic Imaging Centers: Radiology Service Codes …………………………………………. 6-2 
Mobile Mammography Van: Radiology Service Codes ............................................................. 6-5 
Sleep Centers: Radiology Service Codes .................................................................................... 6-5 
Modifiers ................................................................................................................................. 6-5 


Appendix A. Directory ..................................................................................................................... A-1 
Appendix B. Enrollment Centers ...................................................................................................... B-1 
Appendix C. Third-Party-Liability Codes ........................................................................................ C-1 
Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider 
Preventable Conditions ............................................................................................... U-1 
Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions ....................... V-1 
Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity Schedules............... W-1 
Appendix X. Family Assistance Copayments and Deductibles ........................................................ X-1 
Appendix Y. EVS Codes/Messages ................................................................................................. Y-1 
Appendix Z. EPSDT/PPHSD Screening Services Codes.................................................................. Z-1