Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/dma MASSHEALTH TRANSMITTAL LETTER AOH-5 April 2004 TO: Acute Outpatient Hospitals and Hospital Licensed Health Centers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Revised Service Codes and Billing Information This letter transmits revisions to the service codes, and updates billing information for acute outpatient hospitals (AOHs), including their hospital-licensed health centers and provider-based satellites. A new Appendix F, which describes the revenue codes and billing combinations, is also attached. Revised Subchapter 6 (Service Codes) Effective April 30, 2004, MassHealth has restructured Subchapter 6 of the Acute Outpatient Hospital Manual as follows: • The revised Subchapter 6 lists those HCPCS codes that are not payable under the MassHealth Acute Outpatient Hospital Program; and • The revised Subchapter 6 lists Level II HCPCS that are payable under the MassHealth Acute Outpatient Hospital Program. Please Note: Providers billing electronically using the 837 Institutional (837I) claim format must use HIPAA-compliant four-digit revenue codes. Providers billing on paper UB-92 claims or on the MassHealth-proprietary electronic media claim (EMC) format must continue to use three-digit revenue codes. 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). The revised Subchapter 6 is effective for all claims with dates of service on or after April 30, 2004. MassHealth providers must refer to the official list of HCPCS codes and descriptions as posted on the Centers for Medicare and Medicaid Services Web site at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. MASSHEALTH TRANSMITTAL LETTER AOH-5 April 2004 Page 2 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. Adult Day Health – AOHs billing for adult day health services must refer to the Subchapter 6 of the Adult Day Health Manual. Adult Foster Care – AOHs billing for adult foster care services must refer to the Subchapter 6 of the Adult Foster Care Manual. Ambulance Services – AOHs billing for ambulance services must refer to the 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, acute outpatient hospitalsAOHs should refer to the Subchapter 6 of the Acute Outpatient Hospital Manual. Early Intervention Program – AOHs billing for early intervention program services must refer to the Subchapter 6 in the Early Intervention Program Manual. Hearing Aid Dispensing – AOHs billing for the dispensing of hearing aids must refer to the Subchapter 6 of the Audiologist Manual. Home Health – AOHs billing for home health services must refer to the Subchapter 6 in 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 the Subchapter 6 of the Psychiatric Day Treatment Program Manual. The Norplant System – AOHs billing for the Norplant System must refer to Subchapter 6 of the Physician Manual. Vision Care Materials Dispensing – AOHs billing for the dispensing of ophthalmic materials must refer to the Subchapter 6 of the Vision Care Manual. MASSHEALTH TRANSMITTAL LETTER AOH-5 April 2004 Page 3 Prior-authorization requests may be submitted to MassHealth for any medically necessary service for a MassHealth Standard member less than 21 years of age. For more information on reimbursement for AOH services, providers should refer to the Hospital Rate Year (HRY) 2004 Acute Hospital Request for Application (RFA). Hospitals can locate the HRY 2004 RFA as well as regulatory and billing information on the MassHealth Web site at: mass.gov/masshealth. Billing for Emergency Department Screening Fee(s) Effective for claims with dates of service on or after October 1, 2003, AOHs may bill a facility screening fee when nonemergency services are provided in the emergency department. In addition to this facility screening fee, AOHs may bill for a professional screening fee when such nonemergency services are provided by a hospital-based physician. Emergency department screening fees may be billed on the paper claim form no. 05, MassHealth proprietary EMC, or 837 Professional (837P) claim formats. The service code for the professional services of the hospital-based physician is T1023. The service code and modifier for the facility fee is T1023-U1. The modifier U1 must be used when billing for the facility fee. Failure to use the modifier U1 will result in a denied claim. Surgical Pathology HCPCS and Rates For HRY 2004, AOHs must refer to DHCFP’s Surgical and Related Anesthesia Fee Schedule (114.3 CMR 16.00) for cytopathology service rates. These rates apply to HCPCS codes in the 88104-88199 range. Changes to Revenue Code and HCPCS Billing for Laboratory and Radiology Services In an effort to simplify billing for laboratory and radiology services provided by AOHs, the following revenue code and HCPCS billing combinations have been changed for claims with dates of service on or after April 30, 2004. 1. All payable laboratory services within the range of 80048 to 89399 may be billed with any of the following revenue codes: 0300, 0301, 0302, 0304, 0305, 0306, 0307, 0309, 0310, 0311, 0312, 0314, and 0319. 2. All payable radiology services within the range of 70010 to 79999 may be billed with any of the following revenue codes: 0320, 0321, 0322, 0323, 0324, 0329, 0330, 0333, 0340, 0341, 0342, 0349, 0350, 0351, 0352, 0359, 0400, 0401, 0402, 0403, 0404, 0610, 0611, and 0612. For a more detailed guide to revenue codes and HCPCS billing combinations, please refer to the attached Appendix F of the Acute Outpatient Hospital Manual. Providers are reminded that when billing using the 837 Institutional (837I) claim format, they must use HIPAA-compliant four-digit revenue codes. Providers billing on the paper UB-92 claims or on the MassHealth-proprietary EMC format must continue to use three-digit revenue codes. MASSHEALTH TRANSMITTAL LETTER AOH-5 April 2004 Page 4 Questions Providers with questions about the information in this transmittal letter may contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231. NEW MATERIAL (The pages listed here contain new or revised language.) Acute Outpatient Hospital Manual Pages vi, vii, 6-1 through 6-4, and F-1 through F-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Pages vi, vi-a through vi-d, 6.1-1 through 6.1-32, 6.2-1 through 6.2-134, 6.3-1 through 6.3-24, 6.4-1 through 6.4-36, and 6.5-1 through 6.5-4 — transmitted by Transmittal Letter AOH-4 Page vii — transmitted by Transmittal Letter AOH-1 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series ACUTE OUTPATIENT HOSPITAL MANUAL SUBCHAPTER NUMBER AND TITLE TABLE OF CONTENTS PAGE vi TRANSMITTAL LETTER AOH-5 DATE 04/30/04 6. SERVICE CODES 601 Introduction .................................................................................................................... 6-1 602 Nonpayable Codes - Level I HCPCS.............................................................................. 6-1 603 Payable Codes - Level II HCPCS .................................................................................. 6-4 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 PERIODICY SCHEDULE............................................................................... W-1 Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES ................ X-1 Appendix Y. REVS/CODES MESSAGES ............................................................................ Y-1 Appendix Z. EPSDT SERVICES LABORATORY CODES................................................. Z-1 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE PREFACE PAGE vii ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-5 DATE 04/30/04 The regulations and instructions governing provider participation in MassHealth are published in the Provider Manual Series. MassHealth publishes a separate manual for each provider type. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, billing instructions, and general information. MassHealth’s regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. MassHealth regulations are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For acute outpatient hospitals, those matters are covered in 130 CMR Chapter 410.000, reproduced as Subchapter 4 in the Outpatient Hospital Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("pen-and-ink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead MassHealth’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with MassHealth and its members. • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-1 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-5 DATE 04/30/04 601 Introduction MassHealth providers must refer to the official list of HCPCS codes and descriptions as posted on the Centers for Medicare and Medicaid Services Web site at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. Level I HCPCS Codes MassHealth pays for all medicine, radiology, laboratory, surgery, and anesthesia Level I HCPCS 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’s regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. Level II HCPCS Codes MassHealth pays for all Level II HCPCS codes in effect at the time of service listed in Section 603 of this subchapter, subject to all conditions and limitations described in MassHealth’s 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 Codes - Level I HCPCS MassHealth does not pay for services billed under the following codes. For members under age 21, MassHealth regulations at 130 CMR 450.144(A) allow providers to seek coverage when medically necessary, by requesting prior authorization. 0001F 0016T 0044T 11922 15825 21121 0002F 0017T 0045T 11950 15826 21122 0003F 0018T 0046T 11951 15828 21123 0004F 0019T 0047T 11952 15829 21125 0005F 0020T 0048T 11954 15876 21127 0006F 0021T 0049T 15775 15877 21245 0007F 0023T 0050T 15776 15878 21246 0008F 0030T 0051T 15780 15879 21248 0009F 0031T 0052T 15781 17340 21249 0010F 0032T 0053T 15782 17360 22841 0011F 0033T 0054T 15783 17380 32491 0001T 0034T 0055T 15786 19316 32850 0005T 0035T 0056T 15787 19324 33930 0006T 0036T 0057T 15788 19325 33940 0007T 0037T 0058T 15789 19355 36415 0008T 0038T 0059T 15792 19370 36416 0009T 0039T 0060T 15793 19371 36468 0010T 0040T 0061T 15810 19396 36469 0012T 0041T 10040 15811 20930 36540 0013T 0042T 11920 15819 20936 37765 0014T 0043T 11921 15824 21120 37766 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series ACUTE OUTPATIENT HOSPITAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-2 TRANSMITTAL LETTER AOH-5 DATE 04/30/04 602 Nonpayable Code – Level I HCPCS (cont.) 41870 76497 89251 90646 91132 95134 41872 76498 89252 90647 91133 95824 43752 77399 89253 90648 92314 95965 43842 78267 89254 90665 92315 95966 43843 78268 89255 90669 92316 95967 44132 78351 89256 90680 92317 96000 44133 80500 89257 90698 92325 96001 44135 80502 89258 90700 92330 96002 44136 82075 89259 90701 92335 96003 47133 82962 89260 90702 92352 96004 48160 84061 89261 90708 92353 96150 58750 84830 89264 90710 92354 96151 58752 86079 89268 90712 92355 96152 58760 86585 89272 90715 92358 96153 58970 86890 89280 90718 92371 96154 58974 86891 89281 90720 92390 96155 58976 86910 89290 90721 92391 96567 59070 86911 89291 90723 92392 96902 59072 86927 89300 90744 92393 97005 59412 86930 89310 90748 92395 97006 59897 86931 89320 90816 92396 97139 62287 86932 89321 90817 92531 97530 63043 86945 89325 90818 92532 97537 63044 86950 89329 90819 92533 97545 65760 86965 89330 90821 92534 97546 65765 86985 89335 90822 92548 97601 65767 87901 89342 90823 92559 97602 65771 87903 89343 90824 92560 97755 65780 87904 89344 90826 92561 97780 65781 88000 89346 90827 92562 97781 65782 88005 89352 90828 92564 97802 69090 88007 89353 90829 93660 97803 71552 88012 89354 90845 93760 97804 72159 88014 89356 90865 93762 98940 72198 88016 90281 90875 93770 98941 73225 88020 90283 90876 93784 98942 76082 88025 90287 90880 93786 98943 76083 88027 90379 90885 93788 99000 76085 88028 90384 90889 93790 99001 76093 88029 90386 90901 94015 99002 76094 88036 90389 90911 95052 99024 76140 88037 90396 90939 95120 99026 76150 88040 90586 90940 95125 99027 76350 88045 90633 90989 95130 99050 76390 88099 90634 90993 95131 99056 76400 88125 90636 90997 95132 99058 76496 89250 90645 90999 95133 99071 602 Nonpayable Code – Level I HCPCS (cont.) • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series ACUTE OUTPATIENT HOSPITAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-3 TRANSMITTAL LETTER AOH-5 DATE 04/30/04 99075 99234 99289 99331 99361 99450 99078 99235 99290 99332 99362 99455 99080 99236 99293 99333 99371 99456 99082 99238 99294 99341 99372 99500 99090 99239 99295 99342 99373 99501 99091 99251 99296 99343 99374 99502 99100 99252 99298 99344 99375 99503 99116 99253 99299 99345 99377 99504 99135 99254 99301 99347 99378 99505 99140 99255 99302 99348 99379 99506 99141 99261 99303 99349 99380 99507 99142 99262 99311 99350 99401 99509 99172 99263 99312 99354 99402 99510 99190 99271 99313 99355 99403 99511 99191 99272 99315 99356 99404 99512 99192 99273 99316 99357 99411 99600 99221 99274 99321 99358 99412 99601 99222 99275 99322 99359 99420 99602 99223 99288 99323 99360 99429 603 Payable Codes - Level II HCPCS The following lists Level II HCPCS that are covered by MassHealth for AOHs and hospital-licensed health centers (HLHCs). Effective for claims with dates of service on or after October 1, 2003, AOHs may bill a facility screening fee when nonemergency services are provided in the emergency department. In addition to this facility screening fee, AOHs may bill for a professional screening fee when such nonemergency services are provided by a hospital-based physician. Emergency department screening fees may be billed on the paper claim form no. 05, MassHealthproprietary EMC, or 837 Professional (837P) formats. The service code for the professional services of the hospital-based physician is T1023. The service code and modifier for the facility fee is T1023-U1. The modifier U1 must be used when billing for the facility fee. Failure to use the modifier U1 will result in a denied claim. J0207 J1745 J7504 J8600 J9040 J9090 J0640 J1825 J7505 J8610 J9045 J9091 J0740 J1830 J7525 J8700 J9050 J9092 J1325 J1950 J8510 J9000 J9060 J9093 J1327 J2260 J8520 J9001 J9062 J9094 J1620 J2430 J8521 J9015 J9065 J9095 J1626 J2770 J8530 J9020 J9070 J9096 J1742 J7501 J8560 J9031 J9080 J9097 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-4 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-5 DATE 04/30/04 602 Payable Codes -Level II HCPCS (cont.) J9100 J9170 J9208 J9219 J9280 J9360 J9110 J9180 J9209 J9230 J9290 J9370 J9120 J9181 J9211 J9245 J9291 J9375 J9130 J9182 J9213 J9250 J9293 J9380 J9140 J9185 J9214 J9260 J9320 J9390 J9150 J9190 J9215 J9265 J9340 J9600 J9151 J9200 J9216 J9266 J9350 J9999 J9160 J9202 J9217 J9268 J9355 Q0081 J9165 J9206 J9218 J9270 J9357 • Commonwealth of Massachusetts Division of Medical Assistance 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-5 DATE 04/30/04 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 MassHealth-covered services. For most revenue codes, ranges of HCPCS are listed. Hospitals should check Subchapter 6 in 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 no Q0081 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 Non-routine 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 – 89365 range • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX F: REVENUE CODES AND HCPCS COMBINATION GUIDE PAGE F-2 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-5 DATE 04/30/04 Revenue Code Description HCPCS Required? Allowable HCPCS 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 Xray 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 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 range, 92018, 92019, and 92502 0361 Minor surgery yes within 10021 – 69990 range, 92018, 92019, and 92502 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 no N/A 0391 Administration yes within 36430 – 36460 range 040X Other Imaging Services 0400 General yes within 70010 – 79999 range 0401 Diagnostic mammography yes within 70010 – 79999 range 0402 Ultrasound yes within 70010 – 79999 range 0403 Screening mammography yes within 70010 – 79999 range 0404 Positron emission tomography (PET) yes within 70010 – 79999 range 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 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX F: REVENUE CODES AND HCPCS COMBINATION GUIDE PAGE F-3 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-5 DATE 04/30/04 Revenue Code Description HCPCS Required? Allowable HCPCS 042X Physical Therapy 0420 General yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0421 Visit charge yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0423 Group charge yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0424 Evaluation or reevaluation yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 043X Occupational Therapy 0430 General yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0431 Visit charge yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0433 Group rate yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0434 Evaluation or reevaluation yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 044X Speech-Language Pathology 0440 General yes within 92504 – 92526, 92601 – 92700, 97001 – 97542, and 97703 – 97799 ranges 0441 Visit charge yes within 92504 – 92526, 92601 – 92700, 97001 – 97542, and 97709 – 97799 ranges 0443 Group rate yes within 92504 – 92526, 92601 – 92700, 97001 – 97542, and 97709 – 97799 ranges 0444 Evaluation or reevaluation yes within 92504 – 92526, 92605 – 92700, 97001 – 97542, and 97703 – 97799 ranges 045X Emergency Room 0450 General yes within 10021 – 69990, 92202 – 92287, and 99281 – 99499 ranges 0456 Urgent care yes within 10021 – 69990, 92202 – 92287, and 99281 – 99499 ranges 0459 Other ER yes within 10021 – 69990, 92202 – 92287, and 99281 – 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 – 92604 ranges 0471 Diagnostic yes within 92504 – 92597 and 92601 – 92604 ranges 0472 Treatment yes within 92504 – 92597 and 92601 – 92604 ranges 0479 Other yes within 92504 – 92597 and 92601 – 92604 ranges 048X Cardiology 0480 General yes within 92950 – 92998 and 93270 – 93668 ranges • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX F: REVENUE CODES AND HCPCS COMBINATION GUIDE PAGE F-4 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-5 DATE 04/30/04 Revenue Code Description HCPCS Required? Allowable HCPCS 0481 Cardiac catheterization lab yes within 92950 – 92998 and 93270 – 93668 ranges 0482 Stress test yes within 92950 – 92998 and 93270 – 93668 ranges 0483 Echocardiology yes within 92950 – 92998 and 93270 – 93668 ranges 0489 Other yes within 92950 – 92998 and 93270 – 93668 ranges 049X Ambulatory Surgical Care 0490 General yes within 10021 – 69990 range and 92018, 92019 and 92502 0499 Other yes within 10021 – 69990 range and 92018, 92019, and 92502 051X Clinic 0510 General yes within 10021 – 69990, 92002– 92499, 95115 – 95250, 99201 – 99215, and 99381 – 99499 ranges 0515 Pediatric clinic yes within 10021 – 69990, 90202– 92499, 95115 – 95250, 99201 – 99215, and 99381 – 92499 ranges 0519 Other yes within 10021 – 69990, 90202 92499, 95115 – 95250, 99201 – 99215 and 99381 – 92499 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, 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 – 93278 range 0731 Holter monitor yes within 93000 – 93278 range 0732 Telemetry yes within 93000 – 93278 range 074X EEG 0740 General yes within 93000 – 96004 range 075X Gastroenterology 0750 General yes within 91000 – 91299 range • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX F: REVENUE CODES AND HCPCS COMBINATION GUIDE PAGE F-5 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-5 DATE 04/30/04 Revenue Code Description HCPCS Required? Allowable HCPCS 760X Treatment/Observation Room 0761 Treatment room yes within 10021 – 69990, 90202 – 92287, 99201 – 99215, and 99381 – 99499 ranges 0762 Observation room yes 99217 – 99220 range 077X Preventive Services 0771 Vaccine administration yes within 90471 – 90474 range 082X Hemodialysis 0820 General yes within 90918 – 90999 range 0821 Hemodialysis composite/other rate yes within 90918 – 90999 range 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 Behavoral Health Treatments/Service 0914 Individual therapy yes within 96150 – 96155 range 0918 Testing yes within 96100 – 96117 range 092X Other Diagnostic Services 0920 General yes within 92002 – 96004 range and 99170 0921 Peripheral vascular lab yes within 93668 – 93990 range 0922 Electromyelogram yes within 95860 – 96004 range 0924 Allergy testing yes within 95004 – 95078 range 094X Other Therapeutic Services 0940 General yes within 90780 – 90799, 95990 – 95999, 96567 – 96999, and 99173 – 99199 ranges 0943 Cardiac rehabilitation yes 93797, 93798 0944 Drug rehabilitation yes within 90801 – 90862 range • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX F: REVENUE CODES AND HCPCS COMBINATION GUIDE PAGE F-6 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-5 DATE 04/30/04 This page is reserved.