Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter COH-8 January 2014 TO: Chronic Disease and Rehabilitation Outpatient Hospitals Participating in MassHealth FROM: Kristin L. Thorn, Medicaid Director RE: Chronic Disease and Rehabilitation Outpatient Hospital Manual (New Subchapter 6) This letter transmits the addition of Subchapter 6 to the Chronic Disease and Rehabilitation Outpatient Hospital Manual. Subchapter 6 contains a list of service codes and allowable modifiers. MassHealth has also expanded the list of allowable modifiers for use with MassHealth-covered service codes, as described in All Provider Bulletin 227 (June 2012). These updates are effective for dates of service on or after July 1, 2012. Because MassHealth pays for most of the Healthcare Common Procedures Coding System (HCPCS) codes from the Centers for Medicare & Medicaid Services (CMS), Subchapter 6 of the Chronic Disease and Rehabilitation Outpatient Hospital Manual lists only those codes that • are not payable under MassHealth; or • are categorized as Level II HCPCS codes that are payable under the MassHealth chronic disease and rehabilitation (CDR) outpatient hospital program. For outpatient CDR hospital services that are not reimbursed according to the CDR outpatient methodology or the clinical laboratory fee schedule, CDR outpatient hospitals must refer to the applicable MassHealth provider manual to determine which services are payable and which are not payable (e.g., adult day health, adult foster care, ambulance services, dental, home health, physician services, psychiatric day treatment, vision care, etc.). MassHealth providers must refer to the official list of HCPCS codes and descriptions as posted on the CMS website at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. The services codes in this Subchapter 6 are effective for dates of service on or after July 1, 2013. This letter also transmits a list of allowable modifiers for use when billing with MassHealth-covered service codes. The list of modifiers is divided into the following service groups. • general outpatient use • therapy services • behavioral health screening • National Drug Code (NDC) • Provider Preventable Conditions (PPCs) MassHealth Transmittal Letter COH-8 January 2014 Page 2 MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions If you have any questions about 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.) Chronic Disease and Rehabilitation Outpatient Manual Pages 6-1 through 6-12 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-1Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/13 601 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 Codes 99217 99218 99219 99220 99221 99222 99223 99224 99225 99226 99231 99232 99233 99234 99235 99236 99238 99239 99251 99252 99253 99254 99255 99281 99282 99283 99284 99285 99288 99291 99292 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 99374 99375 99377 99378 99379 99380 99401 99402 99403 99404 99406 99408 99409 99411 99412 99420 99429 99441 99442 99443 99444 99450 99455 99456 99464 99465 99466 99467 99468 99469 99471 99472 99475 99476 99477 99478 99479 99480 99485 99486 99487 99488 99489 99495 99496 99499 10040 11004 11005 11006 11008 11920 11921 11922 11950 11951 11952 11954 11960 11970 11971 11976 11980 11981 11982 11983 13100 13101 13102 13120 13121 13122 13131 13132 13133 13150 13151 13152 13153 13160 14000 14001 14020 14021 14040 14041 14060 14061 14301 14302 14350 15040 15050 15100 15101 15110 15111 15115 15116 15120 15121 15130 15131 15135 15136 15150 15151 15152 15155 15156 15200 15201 15220 15221 15240 15241 15260 15261 15271 15272 15273 15274 15275 15276 15277 15278 15570 15572 15574 15576 15600 15610 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/13 603 Nonpayable Anesthesia Service Codes Codes 00100 through 01999 are not payable under the outpatient hospital program. These codes may be billed as medical claims in accordance with the physician regulations at 130 CMR 433.454. 604 Nonpayable Surgery Service Codes 10040 11004 11005 11006 11008 11920 11921 11922 11950 11951 11952 11954 11960 11970 11971 11976 11980 11981 11982 11983 13100 13101 13102 13120 13121 13122 13131 13132 13133 13150 13151 13152 13153 13160 14000 14001 14020 14021 14040 14041 14060 14061 14301 14302 14350 15040 15050 15100 15101 15110 15111 15115 15116 15120 15121 15130 15131 15135 15136 15150 15151 15152 15155 15156 15200 15201 15220 15221 15240 15241 15260 15261 15271 15272 15273 15274 15275 15276 15277 15278 15570 15572 15574 15576 15600 15610 15620 15630 15650 15731 15732 15734 15736 15738 15740-16036 17000-19499 20100 20101 20102 20103 20150 20200 20205 20206 20220 20225 20240 20245 20250 20251 20252 20552 20553 20660 20661 20662 20663 20664 20690 20692 20693 20694 20802-20838 20900-20999 21010 21045 21120-21299 21310-21499 21510 21555 21556 21557 21600 21610 21615 21616 21620 21627 21630 21632 21685-21936 22010-22328 22526 22527 22532-22905 23200 23210 23220 23332 23472 23900 23920 23921 24065-24155 24201 24900 24920 24930 24931 24940 25800 25805 25810 25820 25825 25830 25900 25905 25907 25909 25915 25920 25922 25924 25927 25929 25931 26415 26416 26432 26449-26596 26820-26863 26910 26951 26952 26992 27000-27036 27049 27054 27059 27066 27067 27070 27071 27075 27076 27077 27078 27080 27090 27091 27098 27100 27105 27110 27111 27120 27122 27125 27130-27187 27202 27215 27217 27218 27222 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-3 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/13 604 Nonpayable Surgery Service Codes (cont.) 27226 27227 27228 27232 27235 27236 27244 27245 27248 27253 27254 27258 27259 27269 27280 27282 27284 27286 27290 27295 27303 27305 27306 27307 27324 27325 27326 27330 27331 27332 27333 27334 27335 27350 27355 27356 27360 27329 27364 27365 27381 27386 27390 27391 27392 27393 27394 27395 27396 27397 27400-27495 27506 27507 27509 27511 27513 27514 27519 27524 27535 27536 27540 27556 27557 27558 27566 27580 27590 27591 27592 27594 27596 27598 27599 27600 27601 27602 27605 27606 27614 27625 27616 27620 27625 27626 27634 27635 27637 27638 27645 27646 27647 27650-27745 27756 27758 27759 27766 27769 27784 27792 27814 27822 27823 27826 27827 27828 27829 27832 27846 27848 27870 27871 27880 27881 27882 27884 27886 27888 27889 28010 28011 28022 28024 28035 28046 28047 28052 28054 28062 28070 28072 28080 28086 28088 28100-28175 28192 28193 28200-28280 28406 28200-28280 28406 28415 28420 28445 28446 28465 28485 28505 28525 28531 28555 28585 28615 28645 28675 28705-28825 31225 31230 31290 31291 31360 31365 31367 31368 31370 31375 31380 31382 31390 31395 31584 31587 31725 31760 31766 31770 31775 31780 31781 31785 31786 31800 31805 32035 32036 32095 32100 32110 32120 32124 32140 32141 32150 32151 32160 32200 32225 32310 32320 32440-32540 32650 32651 32652 32653 32654 32655 32656 32658 32659 32661 32662 32663 32664 32665 32800 32810 32815 32820 32850 32851 32852 32853 32854 32855 32856 32900 32905 32906 32940 32997 33015 33020 33025 33030 33031 33050 33120 33130 33140 33141 33202 33203 33206 33207 33208 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-4 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/13 604 Nonpayable Surgery Service Codes (cont.) 33210 33211 33212 33213 33214 33215 33216 33217 33218 33220 33222 33225 33226 33233 33234 33235 33236 33237 33238 33240 33241 33243 33250 33251 33254 33255 33256 33257 33258 33259 33261 33265 33266 33300-33335 33400-33496 33500-33572 33600-33697 33702-33788 33800-33891 33910-33999 34001-34490 34501 34502 34510 34520 34530 34800-34834 34900 35001 35002 35005 35011 35013 35021 35022 35045 35081 35082 35091 35092 35102 35103 35111 35112 35121 35122 35131 35132 35141 35142 35151 35152 35182 35189 35211 35216 35221 35231 35241 35246 35251 35261 35271 35276 35281 35301 35302 35303 35304 35305 35306 35311 35321 35331 35341 35351 35355 35361 35363 35371 35372 35390 35400 35450 35452 35458 35460 35550-35587 35600-35697 35700 35701 35721 35741 35870 35875 35876 35879 35881 35883 35884 35901 35903 35905 35907 36415 36416 36468 36469 36591 36592 36598 36660 36822 36823 37140 37145 37160 37180 37181 37182 37183 37184 37185 37186 37187 37188 37195 37197 37200 37202 37204 37210 37211 37212 37213 37214 37215 37216 37616 37617 37618 37660 37765 37766 37788 38100 38101 38102 38115 38380 38381 38382 38562 38564 38700-38780 38900 39000-39599 41130 41135 41140 41145 41150 41153 41155 41870 41872 42426 42845 42892 42894 42953 42961 42971 43100-43135 43300-43425 43460 43496 43500 43501 43502 43520 43605-43641 43644 43645 43752 43770 43771 43772 43773 43774 43775 43800-43888 44005-44160 44187 44188 44202 44203 44204 44205 44210 44211 44212 44227 44300 44310 44314 44316 44320 44322 44345 44346 44602-44680 44700 44701 44705 44715 44720 44721 44800 44820 44850 44899 44900 44950 44955 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-5 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/13 604 Nonpayable Surgery Service Codes (cont.) 44960 45110 45111 45112 45113 45114 45116 45119 45120 45121 45123 45126 45130 45135 45136 45395 45397 45400 45402 45540 45550 45562 45563 45800 45805 45820 45825 46700-46947 47010 47015 47100-47147 47300 47350 47360 47361 47362 47380 47381 47400 47420 47425 47460 47480 47550 47570 47600-47900 48000 48001 48020 48100 48105 48120 48140 48145 48146 48148 48150 48152 48153 48154 48155 48160 48400 48500-48556 49000 49002 49010 49020 49021 49040 49041 49060 49061 49062 49203 49204 49205 49215 49220 49250 49255 49425 49428 49605 49606 49610 49611 49900 49904 49905 49906 50010 50040 50045 50065 50070 50075 50100 50120 50125 50130 50135 50205 50220 50225 50230 50234 50236 50240 50250 50280 50290 50300 50320 50323 50325 50327 50328 50329 50340 50360 50365 50370 50380 50400 50405 50500 50520 50526 50540 50545 50546 50547 50548 50600 50605 50610 50620 50630 50650 50660 50700-50940 51060 51525 51530 51550 51555 51565 51570 51575 51580 51585 51590 51595 51596 51597 51701 51702 51800-51980 53400-53520 54115 54120 54125 54130 54135 54300-54440 54535 54600-54680 54900 54901 55060 55175 55180 55250 55400 55450 55605 55650 55801-55866 55970 55980 56620 56625 56630 56631 56632 56633 56634 56637 56640 56700 56740 56800 56805 56810 57065 57105 57106 57107 57109 57110 57111 57112 57200-57335 57531 57540 57545 57700 57720 58140 58145 58146 58150 58152 58180 58200 58210 58240 58260 58262 58263 58267 58270 58275 58280 58285 58290 58291 58292 58293 58294 58400 58410 58520 58540 58541-58579 58600 58605 58611 58615 58660-58679 58700-52770 58822 58825 58925-58976 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-6 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/13 604 Nonpayable Surgery Service Codes (cont.) 59030 59070 59072 59076 59100-59160 59200 59300 59320 59325 59350 59400-59430 59510-59899 60200 60210 60212 60220 60225 60240 66252 60254 60260 60270 60271 60280 60281 60505 60520 60521 60522 60540 60545 60600 60605 60650 61105-61253 61304-61875 62005-62148 62161 62162 62163 62164 62165 62180 62190 62192 62200 62201 62220 62223 62256 62258 62287 63043 63044 63050 63051 63076 63077 63078 63081 63082 63085 63086 63087 63088 63090 63091 63101-63308 63700 63702 63704 63706 63707 63709 63710 63740 63741 64752 64755 64760 64809 64818 64866 64868 64885-64911 65091-65175 65273 65710-65782 66220 66225 66680 66682 66821 66825 66982 66983 66984 66985 66986 67101-67121 67250 67255 67311-67345 67875 67880 67882 67900-67924 67871 67973 67974 67975 68320 68325 68326 68328 68330 68335 68340 68360 68362 68371 68500 68505 68520 68540 68550 68700 68705 68720 68745 68750 68760 68761 68770 68815 68816 69090 69150 69155 69300 69310 69320 69501-69554 69601-69676 69950 69955 605 Nonpayable Radiology Service Codes 71552 72159 72198 73225 74263 75571 75900 75952 75953 75954 75956 75957 75958 75959 76140 76496 76497 76498 78267 78268 78351 606 Nonpayable Pathology and Laboratory Service Codes 80100 80101 80104 80502 81200-81393 81400-81400 81401 81402 81403 81404 81405 81406 81407 81408 81479 81500 81506 81508 81509 81510 81511 81512 81599 82075 82962 83987 84145 84431 86079 86305 86352 86780 86825 86826 86890 86891 86910 86911 86927 86930 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-7 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/13 606 Nonpayable Pathology and Laboratory Service Codes (cont.) 86931 86932 86960 86985 87150 87153 87493 87903 87904 88000 88005 88007 88012 88014 88016 88020 88025 88027 88028 88029 88036 88037 88040 88045 88099 88125 88333 88334 88738 88749 89250 89251 89253 89254 89255 89257 89258 89259 89260 89261 89264 89268 89272 89280 89281 89290 89291 89300 89310 89320 89321 89322 89325 89329 89330 89331 89335 89342 89343 89344 89346 89352 89353 89354 89356 89398 607 Nonpayable Medicine Services Codes 90281 90283 90284 90287 90384 90386 90389 90396 90634 90644 90645 90646 90647 90648 90654 90669 90670 90696 90698 90700 90702 90708 90710 90712 90720 90721 90723 90743 90744 90748 90791 90792 90832 90833 90834 90836 90837 90838 90839 90840 90845 90865 90875 90876 90880 90885 90889 90901 90911 90940 90989 90993 90997 90999 91132 91133 92265 92270 92275 92283 92284 92285 92286 92287 92314 92315 92316 92317 92325 92352 92353 92354 92358 92371 92531 92532 92533 92534 92540 92548 92550 92559 92560 92561 92562 92564 92570 92630 92633 92970 92971 92975 92992 92993 93660 93770 93786 94005 94011 94012 94013 94015 94774 94775 94776 94777 95052 95120 95125 95130 95131 95132 95134 95824 95965 95967 95992 96000 96001 96002 96003 96004 96150 96151 96152 96153 96154 96155 96376 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 98966 98967 98968 98969 99000 99001 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-8 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/13 607 Nonpayable Medicine Services Codes (cont.) 99002 99024 99026 99027 99050 99051 99053 99056 99058 99060 99071 99075 99078 99080 99082 99090 99091 99100 99116 99135 99140 99143 99144 99145 99148 99149 99150 99172 99190 99191 99192 99199 99500 99501 99502 99503 99504 99505 99506 99507 99509 99510 99511 99512 99600 99601 99602 99605 99606 99607 608 Nonpayable CPT Category I and III Codes 0001F 0005F 0012F 0014F 0015F 0500F 0501F 0502F 0503F 0505F 0507F 0509F 0513F 0514F 0516F 0517F 0518F 0519F 0520F 0521F 0001F 0005F 0012F 0014F 0015F 0500F 0501F 0502F 0503F 0505F 0507F 0509F 0513F 0514F 0516F 0517F 0518F 0519F 0520F 0521F 0525F 0526F 0528F 0529F 0535F 0540F 0550F 0551F 0556F 0557F 0575F 1000F 1002F 1003F 1004F 1005F 1006F 1007F 1008F 1010F 1011F 1012F 1015F 1018F 1019F 1022F 1026F 1030F 1034F 1035F 1036F 1050F 1052F 1060F 1061F 1065F 1066F 1070F 1071F 1110F 1111F 1116F 1118F 1119F 1121F 1125F 1126F 1127F 1128F 1150F 1151F 1153F 1157F 1159F 1160F 2019F 2020F 2021F 2022F 2024F 2026F 3014F 3015F 3016F 3017F 3018F 3019F 3020F 3021F 3022F 3023F 3025F 3027F 3073F 3100F 3110F 3111F 3112F 3125F 3150F 3155F 3160F 3250F 3260F 3265F 3266F 3267F 3268F 3269F 3270F 3271F 3272F 3273F 3274F 3278F 3279F 3280F 3281F 3284F 3285F 3292F 3294F 3315F 3316F 3317F 3318F 3321F 3322F 3323F 3325F 3328F 3340F 3341F 3343F 3344F 3345F 3350F 3370F 3372F 3374F 3376F 3378F 3380F 3382F 3384F 3386F 3388F 3390F 3450F 3451F 3452F 3455F 3490F 3491F 3492F 3493F 3494F 3496F 3497F 3498F Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-9 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/13 608 Nonpayable Category II and III Codes (cont.) 3500F 3502F 3503F 3511F 3512F 3513F 3514F 3515F 3550F 3551F 3552F 3555F 4000F 4001F 4003F 4004F 4005F 4006F 4009F 4011F 4012F 4014F 4017F 4041F 4042F 4043F 4044F 4046F 4047F 4048F 4049F 4051F 4052F 4053F 4054F 4055F 4056F 4066F 4070F 4073F 4075F 4077F 4084F 4090F 4095F 4100F 4115F 4120F 4124F 4131F 4132F 4148F 4149F 4150F 4151F 4153F 4155F 4157F 4159F 4163F 4164F 4165F 4167F 4168F 4169F 4171F 4172F 4175F 4178F 4179F 4181F 4182F 4191F 4192F 4193F 4194F 4200F 4201F 4250F 4255F 4256F 4260F 4261F 4275F 4276F 4279F 4280F 4290F 4293F 4300F 4301F 4306F 4320F 4325F 5005F 5010F 5060F 6040F 6045F 7020F 7025F 0019T 0030T 0042T 0048T 0050T 0051T 0052T 0053T 0071T 0072T 0073T 0075T 0076T 0078T 0079T 0080T 0081T 0085T 0092T 0095T 0098T 0099T 0100T 0101T 0102T 0103T 0104T 0105T 0106T 0107T 0108T 0109T 0110T 0111T 0123T 0124T 0126T 0141T 0142T 0143T 0155T 0156T 0157T 0158T 0159T 0163T 0164T 0165T 0166T 0167T 0168T 0169T 0171T 0172T 0173T 0174T 0175T 0178T 0179T 0180T 0181T 0182T 0183T 0184T 0185T 0186T 0188T 0189T 0190T 0191T 0192T 0195T 0196T 0197T 0198T 0199T 0200T 0201T 0202T 0205T 0206T 0207T 0208T 0209T 0210T 0211T 0212T 0213T 0214T 0215T 0216T 0217T 0218T 0219T 0220T 0221T 0222T 0223T 0224T 0225T 0226T 0227T 0228T 0229T 0230T 0231T 0232T 0233T 0234T 0235T 0236T 0237T 0238T 0239T 0240T 0241T 0242T 0243T 0244T 0245T 0246T 0247T 0248T 0249T 0250T 0251T 0252T 0253T 0254T 0255T 0256T 0257T 0258T 0259T Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-10 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/13 609 Payable HCPCS Level II Codes This section lists Level II HCPCS codes that are payable under MassHealth when provided by CDR outpatient hospitals. A4641 A9500 A9502 A9503 A9505 A9512 A9537 G0105 G0108 G0109 G0121 G0202 G0206 G0270 G0271 J0129 J0135 J0171 J0207 J0215 J0256 J0290 J0295 J0348 J0456 J0461 J0475 J0476 J0558 J0561 J0585 J0586 J0587 J0592 J0597 J0598 J0638 J0640 J0690 J0694 J0696 J0697 J0702 J0715 J0718 J0775 J0780 J0833 J0834 J0840 J0881 J0882 J0885 J0886 J0897 J0900 J1020 J1030 J1040 J1055 J1056 J1060 J1070 J1080 J1094 J1100 J1160 J1170 J1200 J1260 J1290 J1300 J1320 J1438 J1440 J1441 J1460 J1557 J1559 J1561 J1562 J1566 J1569 J1571 J1580 J1599 J1626 J1630 J1650 J1655 J1670 J1710 J1720 J1725 J1740 J1743 J1745 J1750 J1786 J1790 J1800 J1826 J1885 J1890 J1950 J1956 J1990 J2060 J2150 J2175 J2248 J2250 J2270 J2271 J2275 J2300 J2310 J2315 J2323 J2355 J2357 J2358 J2405 J2426 J2430 J2440 J2469 J2503 J2505 J2507 J2510 J2515 J2550 J2560 J2562 J2675 J2680 J2760 J2778 J2785 J2788 J2790 J2792 J2793 J2794 J2796 J2820 J2910 J2916 J2920 J2930 J2940 J2941 J3010 J3030 J3095 J3110 J3120 J3130 J3230 J3240 J3243 J3250 J3262 J3301 J3302 J3303 J3357 J3360 J3385 J3396 J3410 J3411 J3430 J3487 J3490 J3590 J7030 J7060 J7070 J7302 J7303 J7304 J7307 J7309 J7312 J7321 J7323 J7324 J7325 J7326 J7335 J7599 J7608 J7614 J7620 J7626 J7633 J7639 J7644 J7665 J7669 J7676 J7682 J7686 J7699 J7799 J8561 J8562 J9000 J9001 J9025 J9031 J9035 J9040 J9041 J9043 J9045 J9055 J9060 J9070 J9130 J9155 J9171 J9178 J9179 J9181 J9190 J9201 J9202 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-11 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/13 609 Payable HCPCS Level II Codes (cont.) J9206 J9212 J9213 J9214 J9215 J9216 J9217 J9218 J9219 J9228 J9250 J9260 J9261 J9263 J9264 J9265 J9293 J9300 J9302 J9305 J9307 J9310 J9315 J9340 J9351 J9355 J9360 J9370 J9390 J9395 J9999 L8614 L8615 L8616 L8617 L8618 L8619 L8690 L8691 Q0081 Q0083 Q0084 Q4100 Q4101 Q4102 Q4103 Q4104 Q4105 Q4106 Q4107 Q4108 Q4110 Q4111 Q4112 Q4113 Q4114 Q4115 S0023 S0028 S0077 S0302 S2083 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-12 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/12 610 Modifiers The 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 Use 24 Unrelated evaluation and management service by the same physician during a postoperative period 25 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 service 27 Multiple outpatient hospital evaluation and management encounters on the same date 50 Bilateral procedure 57 Decision for surgery 58 Staged or related procedure or service by the same physician or other qualified health care professional during postoperative period 59 Distinct procedural service 78 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 period 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period 91 Repeat clinical diagnostic laboratory test E1 Upper left, eyelid E2 Lower left, eyelid E3 Upper right, eyelid E4 Lower right, eyelid F1 Left hand, second digit F2 Left hand, third digit F3 Left hand, fourth digit F4 Left hand, fifth digit F5 Right hand, thumb F6 Right hand, second digit F7 Right hand, third digit F8 Right hand, fourth digitF9 Right hand, fifth digit FA Left hand, thumb LC Left circumflex coronary artery LD Left anterior descending coronary artery LT Left side (used to identify procedures performed on the left side of the body) RC Right coronary artery RT Right side (used to identify procedures performed on the right side of the body) T1 Left foot, second digit T2 Left foot, third digit T3 Left foot, fourth digit T4 Left foot, fifth digit Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-13 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/12 610 Modifiers (cont.) T5 Right foot, great toe T6 Right foot, second digit T7 Right foot, third digit T8 Right foot, fourth digit T9 Right foot, fifth digit TA Left foot, great toe Modifiers for Therapy Services HCPCS 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 therapy GO Occupational therapy GP Physical therapy 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 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. 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 MassHealth 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 MassHealth provider Modifiers for Provider Preventable Conditions that Are National Coverage Determinations PA Surgical or other invasive procedure on wrong body part PB Surgical or other invasive procedure on wrong patient PC Wrong surgery or other invasive procedure on patient For more information on the use of these modifiers, see Appendix V of your provider manual. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-14 Chronic Disease and Rehabilitation Outpatient Hospital Manual Transmittal Letter COH-8 Date 07/01/12 This page is reserved.