Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER AOH-16 December 2007 TO: Acute Outpatient Hospitals and Hospital-Licensed Health Centers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Acute Outpatient Hospital Manual (Revised Service Codes and Appendix F— Behavioral-Health Screening Tool, Tobacco-Cessation Services, and HCPCS Changes) This letter transmits revisions to the service codes in Subchapter 6 of the Acute Outpatient Hospital Manual and updates billing information for acute outpatient hospitals (AOHs), including their hospital-licensed health centers and provider-based satellites. An updated Appendix F, which describes revenue codes and billing combinations, is also attached. Behavioral-Health Screening Tool Effective for dates of service on or after December 31, 2007, all primary-care providers serving MassHealth-enrolled members under the age of 21 (except MassHealth Limited) must offer to use a standardized behavioral-health screening tool when performing the behavioral-health screening component of an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) or Pediatric Preventive Health-Care Screening and Diagnosis (PPHSD) visit according to Appendix W of your provider manual. Appendix W contains a menu of screening tools from which to choose. MassHealth will pay for the administration and scoring of the standardized behavioral- health screening tool in addition to and separately from the office visit. MassHealth provided detailed information about the new requirements surrounding the standardized behavioral-health screening tool in Transmittal Letter All-155, which communicated updates to the EPSDT/PPHSD regulations (130 CMR 450.140 through 150, Appendix W, and Appendix Z). To implement this requirement, Subchapter 6 of the Acute Outpatient Hospital Manual has been revised to add a new Section 604 that describes CPT code 96110. Claims for behavioral-health screens conducted as the behavioral-health component of an of EPSDT or PPHSD visit for members under the age of 21 using the tools listed in Appendix W must be submitted using CPT code 96110. Code 96110 can be used only to bill for using one of the approved behavioral- health screening tools during an EPSDT/PPHSD visit. Distinct modifiers are required with the 96110 code. The modifiers are described in Section 604. Effective July 1, 2008, failure to include the modifier will result in denial of the claim. These modifiers indicate whether the screen identified a behavioral-health need or not. Identification of a behavioral-health need includes needs identified in the areas of social-emotional well-being and mental health. Behavioral Health Screening of Members < 21 Years CPT Code 96110 and Modifier Servicing Provider When No Behavioral-Health Need Identified When Behavioral-Health Need Identified Hospital Outpatient Department 96110 U1 96110 U2 If you wish to obtain a fee schedule for CPT Code 96110, you may download the Division of Health Care Finance and Policy (DHCFP) regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of DHCFP regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses and telephone numbers below). The regulation title is 114.1 CMR 36.00. 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 Revised Subchapter 6 (Service Codes) This transmittal letter updates the nonpayable CPT codes, payable CPT codes, and payable modifiers. Sections 602 and 603 update the CPT codes while section 604 lists the payable modifiers along with their appropriate CPT codes. The regulations are in effect for services provided on or after January 1, 2008. The revised Subchapter 6 applies only when billing for services that are reimbursed either according to the Payment Amount Per Episode (PAPE) methodology, or according to the Division of Health Care Finance and Policy (DHCFP) Clinical Laboratory Fee Schedule (114.3 CMR 20.00). MassHealth providers must refer to the official list of CPT and HCPCS codes with descriptions as posted on the CMS Web site at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. For outpatient hospital services that are not reimbursed according to the PAPE methodology or according to the DHCFP Clinical Laboratory Fee Schedule, AOHs must refer to the MassHealth provider manuals listed below to determine which services are payable and which are not payable. These provider manuals are available on the MassHealth Web site at www.mass.gov/masshealth. Adult Day Health – AOHs billing for adult day health services must refer to Subchapter 6 of the Adult Day Health Manual. Adult Foster Care – AOHs billing for adult foster care services must refer to Subchapter 6 of the Adult Foster Care Manual. Ambulance Services – AOHs billing for ambulance services must refer to Subchapter 6 of the Transportation Manual. Dental Services – AOHs billing for dental services must refer to Subchapter 6 of the Dental Manual except when the conditions in 130 CMR 420.429(A) or (D) apply. In those instances, AOHs should refer to Subchapter 6 of the Acute Outpatient Hospital Manual. Early Intervention Program – AOHs billing for early intervention program services must refer to Subchapter 6 in the Early Intervention Program Manual. Hearing Aid Dispensing – AOHs billing for the dispensing of hearing aids must refer to Subchapter 6 of the Hearing Instrument Specialist Manual. Home Health Services – AOHs billing for home health services must refer to Subchapter 6 of the Home Health Agency Manual. Physician Services –- AOHs billing for hospital-based physician or entity services must refer to Subchapter 6 of the Physician Manual. Psychiatric Day Treatment Program – AOHs billing for psychiatric-day-treatment programs must refer to Subchapter 6 of the Psychiatric Day Treatment Program Manual. Vision Care Materials Dispensing – AOHs billing for the dispensing of ophthalmic materials must refer to Subchapter 6 of the Vision Care Manual. Prior-authorization requests may be submitted to MassHealth for any medically necessary service for a MassHealth Standard or CommonHealth member younger than 21 years of age. No changes have been made to the billable codes and nonpayable codes found in Subchapter 6 of the Acute Outpatient Hospital Manual. AOHs billing for hospital-based physician or entity services must refer to Subchapter 6 of the Physician Manual. The revised Subchapter 6 applies only when billing for services that are reimbursed either according to the Payment Amount Per Episode (PAPE) methodology, or according to the DHCFP Clinical Laboratory Fee Schedule (114.3 CMR 20.00). Tobacco-Cessation Counseling Services The MassHealth tobacco-cessation benefit covers both pharmacotherapy and counseling services. Effective January 1, 2008, the code for counseling used in combination with provider- specific modifiers is changing from Service Code G0376 to Service Code 99407. Please note that acute outpatient hospitals and hospital-licensed health centers will use only the 99407 code and the TF and HQ modifiers. To implement this requirement, Subchapter 6 has been revised to add a new Section 605 that describes the codes and modifiers to bill for tobacco-cessation services. Because Service Code 99407 represents tobacco-cessation services that are distinct from other evaluation and management services, it may be billed in addition to, and on the same date of service, as other evaluation and management service codes, with the exception of code 99420. Tobacco-Cessation Counseling Services Individual tobacco- cessation counseling visit, at least 30 minutes Individual tobacco- cessation intake/ assessment counseling visit, at least 45 minutes Group tobacco-cessation counseling visit, at least 60-90 minutes Servicing Provider Service Code + Modifier Service Code + Modifier Service Code + Modifier Physician, Independent Nurse Practitioner, Independent Nurse Midwife 99407 (no required modifier) 99407 TF 99407 HQ For more information on payment for acute-outpatient-hospital services, refer to the Hospital Rate Year (HRY) 2006 Acute Hospital Request for Application (RFA) for dates of service covering November 1, 2005, through September 30, 2008, and the HRY 2008 RFA for dates of service on or after October 1, 2006. Hospitals can locate the HRY 2006 and 2007 RFAs as well as regulatory and billing information on the MassHealth Web site at www.mass.gov/masshealth. If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Acute Outpatient Hospital Manual Pages vi, 6-1 through 6-6, and F-1 through F-8 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Page vi — transmitted by Transmittal Letter AOH-8 Pages 6-1 through 6-4 and F-1 through F-8 — transmitted by Transmittal Letter AOH-11 MASSHEALTH TRANSMITTAL LETTER AOH-16 December 2007 Page 4 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Acute Outpatient Hospital Transmittal Letter AOH-16 Date 01/01/08 6. Service Codes Introduction 6-1 Nonpayable Codes - Level I HCPCS 6-1 Payable Codes - Level II HCPCS 6-4 Payable Tobacco Cessation Services 6-5 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix D. Utilization Management Program D-1 Appendix E. Admission Guidelines E-1 Appendix F. Revenue Codes and HCPCS Combination Guide F-1 Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule W-1 Appendix X. Family Assistance Copayment and Deductibles X-1 Appendix Y. REVS/Codes Messages Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes Z-1 601 Introduction MassHealth providers must refer to the official list of HCPCS codes and descriptions as posted on the Centers for Medicare & Medicaid Services Web site at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. CPT Codes MassHealth pays for services billed using 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, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. Section 604 contains further information about billing for Service Code 96110. Section 605 contains further information about billing tobacco-cessation services. Level II HCPCS Codes MassHealth pays for services billed using only those Level II HCPCS codes listed in Section 603 of this subchapter that are in effect at the time of service, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. For a list of billable revenue codes and HCPCS billing combinations, please refer to Appendix F of the Acute Outpatient Hospital Manual. The list in Appendix F is to be used only as a guide. 602 Nonpayable Services - CPT MassHealth does not ordinarily pay for services billed under the following codes and code ranges. An acute outpatient hospital (AOH) provider may request prior authorization 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 Acute Outpatient Hospital Manual. 0001F 0005F 0012F 4002F 4006F 4009F 4011F 0016T 0017T 0019T 0024T 0026T 0027T 0028T 0029T 0030T 0031T 0032T 0041T 0042T 0043T 0046T 0047T 0048T 0049T 0050T 0051T 0052T 0053T 0054T 0055T 0056T 0058T 0059T 0060T 0061T 0062T 0063T 0065T 0066T 0067T 0068T 0069T 0070T 0071T 0072T 0073T 0074T 0075T 0076T 0077T 0078T 0079T 0080T 0081T 0084T 0085T 0086T 0087T 0088T 0089T 0090T 0092T 0093T 0095T 0096T 0098T 0099T 0100T 0101T 0102T 0103T 0104T 0105T 0106T 0107T 0108T 0109T 0110T 0111T 0115T 0116T 0117T 0123T 0124T 0126T 0130T 0133T 0135T 0137T 0140T 0141T 0142T 0143T 0144T 0145T 0146T 0147T 0148T 0148T 0149T 0150T 0151T 0152T 0153T 0154T 0155T 0156T 0157T 0158T 0159T 0160T 0161T 0162T 0163T 0164T 0165T 0166T 0167T 0168T 0169T 0170T 0171T 0172T 0173T 0174T 0175T 0176T 0177T 00100- 01999 10040 11922 11950 11951 11952 11954 15781 15782 15783 15786 15787 15788 15789 15792 15793 15819 15824 15825 15826 15828 15829 15847 15876 15877 15878 15879 17340 17360 17380 19316 19324 19325 19355 19396 20930 20936 21120 21121 21122 21123 21125 21127 21245 21246 21248 21249 22526 22527 22841 32491 32850 32851 32852 32853 32854 32855 32856 33930 33933 33935 33940 33944 33945 34803 36415 36416 36468 36469 36540 36598 37765 37766 41870 41872 43644 43645 43752 43842 43843 43845 44132 44133 44135 44136 44137 47133 47143 47144 47145 44720 44721 47135 47136 47140 47141 47142 47146 47147 48160 48551 48552 48554 48556 50320 50323 50325 50327 50328 50329 50340 50360 50365 50370 50380 51701 51702 58750 58752 58760 58956 58970 58974 58976 59070 59072 59412 59897 61630 61635 61640 61641 61642 62287 63043 63044 65760 65765 65767 65771 65780 65781 65782 69090 71552 72159 72198 73225 76140 76150 76350 76390 76496 76497 76498 77399 78267 78268 78351 80500 80502 82075 82962 84061 84830 86079 86890 86891 86910 86911 86927 86930 86931 86932 86960 86985 87900 87903 87904 88000 88005 88007 88012 88014 88016 88020 88025 88027 88028 88029 88036 88037 88040 88045 88099 88125 88325 88333 88334 89250 89251 89253 89254 89255 89257 89258 89259 89260 89261 89264 89268 89272 89280 89281 89290 89291 89300 89310 89320 89321 89325 89329 89330 89335 89342 89343 89344 89346 89352 89353 89354 89356 90281 90283 90287 90379 90384 90386 90389 90396 90586 90633 90634 90636 90645 90646 90647 90648 90669 90680 90698 90700 90701 90702 90708 90710 90712 90715 90718 90720 90721 90723 90744 90748 90816 90817 90818 90819 90821 90822 90823 90824 90826 90827 90828 90829 90845 90865 90875 90876 90880 90885 90889 90901 90911 90940 90989 90993 90997 90999 91111 91132 91133 92025 92314 92315 92316 92317 92325 92352 92353 92354 92355 92358 92371 92531 92532 92533 92534 92548 92559 92560 92561 92562 92564 92630 92633 92640 93660 93760 93762 93770 93786 94005 94015 94774 94775 94776 94777 95052 95120 95125 95130 95131 95132 95133 95134 95824 95965 95966 95967 96000 96001 96002 96003 96004 96150 96151 96152 96153 96154 96155 96523 96567 96902 96904 97005 97006 97537 97545 97546 97597 97598 97602 97605 97606 97755 97810 97811 97813 97814 98940 98941 98942 98943 98960 98961 98962 99000 99001 99002 99024 99026 99027 99050 99051 99053 99056 99058 99060 99071 99075 99078 99080 99082 99090 99091 99100 99116 99135 99140 99143 99144 99148 99149 99150 99172 99190 99191 99192 99199 99251 99252 99253 99254 99255 99288 99289 99290 99293 99294 99295 99296 99298 99299 99300 99304 99305 99306 99307 99308 99309 99310 99315 99316 99318 99324 99325 99326 99327 99328 99334 99335 99336 99337 99339 99340 99341 99342 99343 99344 99345 99347 99348 99349 99350 99354 99355 99356 99357 99358 99359 99360 99361 99362 99371 99372 99373 99374 99375 99377 99378 99379 99380 99401 99402 99403 99404 99411 99412 99420 99429 99450 99455 99456 99500 99501 99502 99503 99504 99505 99506 99507 99509 99510 99511 99512 99600 99601 99602 603 Payable Services - Level II HCPCS The following Level II HCPCS describe services that are covered by MassHealth for AOHs and hospital-licensed health centers (HLHCs). A4641 A9500 A9502 A9503 A9505 A9512 A9537 G0105 G0108 G0109 G0121 G0270 G0271 J0128 J0129 J0135 J0207 J0348 J0475 J0640 J0740 J1094 J1325 J1327 J1562 J1620 J1626 J1740 J1742 J1745 J1825 J1830 J1950 J2175 J2260 J2270 J2357 J2430 J2469 J2550 J2770 J3110 J3243 J3396 J3490 J7319 J7340 J7341 J7342 J7343 J7344 J7345 J7346 J7501 J7504 J7505 J7525 J8510 J8520 J8521 J8530 J8560 J8600 J8610 J8700 J9000 J9001 J9015 J9020 J9031 J9035 J9040 J9041 J9045 J9050 J9055 J9060 J9062 J9065 J9070 J9080 J9090 J9091 J9092 J9093 J9094 J9095 J9096 J9097 J9100 J9110 J9120 J9130 J9140 J9150 J9151 J9160 J9165 J9170 J9181 J9182 J9185 J9190 J9200 J9202 J9206 J9208 J9209 J9211 J9213 J9214 J9215 J9216 J9217 J9218 J9219 J9230 J9245 J9250 J9261 J9265 J9266 J9268 J9270 J9280 J9290 J9291 J9293 J9305 J9320 J9340 J9350 J9355 J9357 J9360 J9370 J9375 J9380 J9390 J9600 J9999 L8614 L8615 L8616 L8617 L8618 L8619 L8690 L8691 Q4079 Q4083 Q4084 Q4085 Q4086 S0023 S0028 S0077 S0162 S2083 604 Modifiers Modifiers for Behavioral-Health Screening The 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 includes needs in the area of behavioral health, social-emotional wellbeing, or mental health. Modifier Modifier Description U1 Completed 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. U2 Completed 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 behavioral-health need identified. Modifiers for Tobacco-Cessation Services The 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. Modifier Modifier Description HQ Group counseling, at least 60-90 minutes TF Intermediate level of care, at least 45 minutes This page is reserved. Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-3 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-6 DATE DRAFT Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Acute Outpatient Hospital Manual Transmittal Letter AOH-16 Date 01/01/08 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-4 Acute Outpatient Hospital Manual Transmittal Letter AOH- 16 Date 01/01/08 602 Nonpayable Codes - CPT (cont.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-2 Acute Outpatient Hospital Manual Transmittal Letter AOH-9 Date 07/06/06 602 Nonpayable Services - CPT (cont.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-5 Acute Outpatient Hospital Manual Transmittal Letter AOH-16 Date 01/01/08 603 Payable Services – Level II HCPCS (cont.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-6 Acute Outpatient Hospital Manual Transmittal Letter AOH-11 Date 01/01/07 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-6 Acute Outpatient Hospital Manual Transmittal Letter AOH-11 Date 01/01/07 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-6 Acute Outpatient Hospital Manual Transmittal Letter AOH- 16 Date 01/01/08 MassHealth Revenue Codes and HCPCS Combination Guide The following crosswalk should be used as a guide for acute outpatient hospitals (AOHs), hospital-licensed health centers, and provider-based satellites, when billing for MassHealth-covered services. For most revenue codes, ranges of HCPCS are listed.Hospitals should reference Subchapter 6 of the Acute Outpatient Hospital Manual to determine if a specific code within a range is covered by MassHealth, since not all codes in the ranges are payable by MassHealth. Revenue Code Description HCPCS Required? Allowable HCPCS 025X Pharmacy 0250 General no N/A 0251 Generic drugs no N/A 0252 Non-generic drugs no N/A 0253 Take-home drugs no N/A 0254 Drugs incident to other diagnostic services no N/A 0255 Drugs incident to radiology no N/A 0257 Nonprescription drugs no N/A 0258 IV solutions no N/A 026X IV Therapy 0260 General yes within 90760 – 90768 range and 96420 027X Medical/Surgical Supplies and Devices – General 0270 General no N/A 0271 Non-sterile supply no N/A 0272 Sterile supply no N/A 0273 Take-home supplies no N/A 0274 Prosthetic/orthotic devices no N/A 0275 Pacemaker no N/A 0276 Intraocular lens no N/A 0278 Other implants no N/A 028X Oncology 0280 General yes within 99201 – 99290 range 029X DME 0290 General no N/A 0291 Rental no N/A 0292 Purchase of new DME no N/A 0293 Purchase of used DME no N/A 030X Laboratory 0300 General yes within 80048 – 89356 range 0301 Chemistry yes within 80048 – 89356 range 0302 Immunology yes within 80048 – 89356 range 0304 Nonroutine dialysis yes within 80048 – 89356 range 0305 Hematology yes within 80048 – 89356 range 0306 Bacteriology and microbiology yes within 80048 – 89356 range 0307 Urology yes within 80048 – 89356 range 0309 Other yes within 80048 – 89356 range 031X Laboratory Pathological – General 0310 Laboratory pathological – general yes within 80048 – 89356 range 0311 Cytology yes within 80048 – 89356 range 0312 Histology yes within 80048 – 89356 range 0314 Biopsy yes within 80048 – 89356 range 0319 Other yes within 80048 – 89356 range 032X Radiology – Diagnostic 0320 General yes within 70010 – 79999 range 0321 Angiocardiography yes within 70010 – 79999 range 0322 Arthrography yes within 70010 – 79999 range 0323 Arteriography yes within 70010 – 79999 range 0324 Chest X ray yes within 70010 – 79999 range 0329 Other yes within 70010 – 79999 range 033X Radiology–Therapeutic and/or Chemotherapy Administration 0330 General yes within 70010 – 79999 range 0331 Chemotherapy administration – injected yes within 96400 – 96549 range 0332 Chemotherapy – oral yes within 96400 – 96549 range 0333 Radiation therapy yes within 70010 – 79999 range 0335 Chemotherapy administration – IV yes within 96400 – 96549 range 034X Nuclear Medicine 0340 General yes within 70010 – 79999 range 0341 Diagnostic yes within 70010 – 79999 range 0342 Therapeutic yes within 70010 – 79999 range 0343 Diagnostic radiopharmaceuticals yes within A4641 – A9566 range 0349 Other yes within 70010 – 79999 range 035X Computerized Tomographic (CT) Scans 0350 General yes within 70010 – 79999 range 0351 Head scan yes within 70010 – 79999 range 0352 Body scan yes within 70010 – 79999 range 0359 Other yes within 70010 – 79999 range 036X Operating Room Services 0360 General yes within 10021 – 69990, 90772, 90773, 90779, 92018, 92019, 92502 – 92596, 92599, 92620, 92621, 92950 – 92961, 96567, 96570, 96571, 99170, 99185, 99186, 99291, 99292, and 99440, ranges 0361 Minor surgery yes within 10021 – 69990, 90772, 90773, 90779, 92018, 92019, 92502 – 92596, 92599, 92620, 92621, 92950 – 92961, 96567, 96570, 96571, 99170, 99185, 99186, 99291, 99292, and 99440, ranges 037X Anesthesia 0370 General no N/A 0371 Anesthesia incident to radiology no N/A 0372 Anesthesia incident to other diagnostic services no N/A 038X Blood 0381 Packed red blood cells no N/A 0383 Plasma no N/A 0384 Platelets no N/A 0385 Leukocytes no N/A 0386 Other components no N/A 0387 Other derivatives no N/A 039X Blood Storage and Processing 0390 General yes within 82103 – 88347 range 0391 Administration yes within 36430 – 36460 range 040X Other Imaging Services 0400 General yes within 70010 – 79999 range 0401 Diagnostic mammography yes within 76082 – 76092 range 0402 Ultrasound yes within 70010 – 79999 range 0403 Screening mammography yes 77052 and 77057 0404 Positron emission tomography (PET) yes 78459, 78491, 78492, 78608, 78609, and within 78811 – 78816 ranges 041X Respiratory Services 0410 General yes within 94640 – 94668 range 0412 Inhalation services yes within 94640 – 94668 range 0413 Hyperbaric oxygen therapy yes 99183 0419 Other yes within 94640 – 94668 range 042X Physical Therapy 0420 General yes within 64550, 90901, 92506 – 92526, 92597, 92605 – 92616, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95903, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 0421 Visit charge yes within 64550, 90901, 92506 – 92526, 92597, 92605 – 92616, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95903, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 0423 Group charge yes within 64550, 90901, 90903, 92506 – 92526, 92597, 92605 – 92616, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 0424 Evaluation or reevaluation yes within 64550, 90901, 92506 – 92526, 92597, 92605 – 92616, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95903, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 043X Occupational Therapy 0430 General yes within 64550, 90901, 92506 – 92526, 92597, 92605 – 92616, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95903, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 0431 Visit charge yes within 64550, 90901, 92506 – 92526, 92597, 92605 – 92616, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95903, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 0433 Group rate yes within 64550, 90901, 92506 – 92526, 92597, 92605 – 92616, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95903, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 0434 Evaluation or reevaluation yes within 64550, 90901, 92506 – 92526, 92597, 92605 – 92616, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95903, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 044X Speech-Language Pathology 0440 General yes within 64550, 90901, 92506 – 92526, 92597, 92605 – 92616, 92640, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95903, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 0441 Visit charge yes within 64550, 90901, 92506 – 92526, 92597, 92605 – 92616, 92640, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95903, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 0443 Group rate yes within 64550, 90901, 92506 – 92526, 92597, 92605 – 92616, 92640, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95903, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 0444 Evaluation or reevaluation yes within 64550, 90901, 92506 – 92526, 92597, 92605 – 92616, 92640, 95831 – 95834, 95851, 95852, 95860 – 95870, 95900, 95903, 95904, 95934, 96105 – 96115, 97001 – 97542, 97597 – 97605, and 97703 – 97799 ranges 045X Emergency Room 0450 General yes within 10021 – 69990, 90772, 90773, 90779, 92202 – 92287, 92502 – 92596, 92599, 92620, 92621, 92950 – 92961, 96567, 96570, 96571, 99170, 99173, 99185, 99186, and 99241 – 99499 ranges 0456 Urgent care yes within 10021 – 69990, 90772, 90773, 90779, 92202 – 92287, 92502 – 92596, 92599, 92620, 92621, 92950 – 92961, 96567, 96570, 96571, 99170, 99185, 99186, and 99241 – 99499 ranges 0459 Other ER yes within 10021 – 69990, 90772, 90773, 90779, 92202 – 92287, 92502 – 92596, 92599, 92620, 92621, 92950 – 92961, 96567, 96570, 96571, 99170, 99173, 99185, 99186, and 99241 – 99499 ranges 046X Pulmonary Function 0460 General yes within 94010 – 94621 and 94680 – 94799 ranges 0469 Other yes within 94010 – 94621 and 94680 – 94799 ranges 047X Audiology 0470 General yes within 92504 – 92597 and 92601 – 92625 ranges 0471 Diagnostic yes within 92504 – 92597, 92601 – 92625 ranges and 92640 0472 Treatment yes within 92504 – 92597 and 92601 – 92625 ranges 0479 Other yes within 92504 – 92597, 92601 – 92625 ranges and 92640 048X Cardiology 0480 General yes within 92950 – 92998 and 93268 – 93668 ranges 0481 Cardiac catheterization lab yes within 92950 – 92998 and 93268 – 93668 ranges 0482 Stress test yes within 92950 – 92998, 93015 – 93024 and 93270 – 93668 ranges 0483 Echocardiology yes within 92950 – 92998 and 93268 – 93668 ranges 0489 Other yes within 92950 – 92998 and 93268 – 93668 ranges 049X Ambulatory Surgical Care 0490 General yes within 10021 – 69990 range 0499 Other yes within 10021 – 69990 range 051X Clinic 0510 General yes within 10021 – 69990, 90772, 90773, 90779, 92002 – 92499, 92502 – 92596, 92599, 92620, 92621, 92950 – 92961, 95115 – 95250, 96567, 96570, 96571, 99170, 99173, 99185, 99186, 99201 – 99215, 99241 – 99499 ranges, G0375, and G0376 0515 Pediatric clinic yes within 10021 – 69990, 92002 – 92499, 95115 – 95250, 99201 – 99215, and 99381 – 99499 ranges 0519 Other yes within 10021 – 69990, 92002 – 92499, 95115 – 95250, 99173, 99201 – 99215 and 99381 – 99499 ranges 053X Osteopathic Services 0530 General yes within 98925 – 98929 range 061X Magnetic Resonance Technology 0610 General yes within 70010 – 79999 range 0611 MRI – brain yes within 70010 – 79999 range 0612 MRI – spinal cord yes within 70010 – 79999 range 062X Medical/Surgical Supplies 0621 Supplies incident to radiology no N/A 0622 Supplies incident to other diagnostic services no N/A 063X Pharmacy 0634 EPO, less than 10,000 units no N/A 0635 EPO, 10,000 or more units no N/A 0636 Drugs requiring detail coding yes within J0120 – J9999, Q4079, Q4083 – Q4086, 90281 – 90399, and 90476 – 90749 ranges 070X Cast Room 0700 General yes within 10021 – 69999 range 071X Recovery Room 0710 General no N/A 072X Labor Room/Delivery 0720 General yes within 10021 – 69999 range 0721 Labor yes within 10021 – 69999 range 0722 Delivery yes within 10021 – 69999 range 073X EKG/ECG 0730 General yes within 93000 – 93014 and 93024 – 93278 ranges 0731 Holter monitor yes within 93000 – 93014 and 93024 – 93278 ranges 0732 Telemetry yes within 93000 – 93014 and 93024 – 93278 ranges 074X EEG 0740 General yes within 93000 – 96004 range 075X Gastroenterology 0750 General yes within 43200 – 43272, 44360 – 44397, 45300 – 45387, 49320 – 49329 and 91000 – 91299 ranges 760X Treatment/Observation Room 0761 Treatment room yes within 10021 – 69990, 90202 – 92287, 99201 – 99215, and 99381 – 99499 ranges 0762 Observation room yes within 99217 – 99220 and 99234 – 99236 ranges 077X Preventive Services 0771 Vaccine administration yes within 90471 – 90474 range 082X Hemodialysis 0820 General yes within 90918 – 90999 range and 93990 0821 Hemodialysis composite/other rate yes within 90918 – 90999 range and 93990 083X Peritoneal Dialysis 0830 General yes within 90918 – 90999 range 0831 Peritoneal composite/other rate yes within 90918 – 90999 range 084X CAPD 0840 General yes within 90918 – 90999 range 0841 CAPD composite/other rate yes within 90918 – 90999 range 085X CCPD 0850 General yes within 90918 – 90999 range 0851 CCPD composite/other rate yes within 90918 – 90999 range 090X Behavioral Health Treatments/Services 0900 General yes within 90801 – 90911 range 0901 Electroshock therapy yes within 90801 – 90911 range 091X Behavioral Health Treatments/Service 0914 Individual therapy yes within 90801 – 90899, 92220,and 96150 – 96155 ranges 0918 Testing yes 96020 and within 96100 – 96120 range 092X Other Diagnostic Services 0920 General yes within 51736 – 59025, 91110 – 91122, 92002 – 96004 ranges, 99170, and 99173 0921 Peripheral vascular lab yes within 54240 and 93668 – 93990 range 0922 Electromyelogram yes within 95860 – 96004 range 0924 Allergy testing yes within 95004 – 96004 range 0929 Other diagnostic service Yes within 91010 – 95999 range 094X Other Therapeutic Services 0940 General yes within 36516, 90760 – 90799, 95990 – 95991, 96567 – 96999, 99175, and 99185-99195 ranges 0942 Education/training yes within 97802 – 97804 range, 99407 G0108, G0109, G0270, and G0271 0943 Cardiac rehabilitation yes 93797 and 93798 0944 Drug rehabilitation yes within 90801 – 90899 range 0945 Alcohol rehabilitation yes within 90801 – 90899 range This page is reserved. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Appendix F. Revenue Codes and HCPCS Combination Guide Page F-1 Acute Outpatient Hospital Manual Transmittal Letter AOH-16 Date 01/01/08