Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER FAS-13 September 2003
TO:      Freestanding Ambulatory Surgery Centers Participating in MassHealth
FROM:      Douglas S. Brown, Acting Commissioner
RE:      Freestanding Ambulatory Surgery Center Manual (Restructured Subchapter 6 and Service Code Update)
The federal government has revised the Healthcare Common Procedure Coding System (HCPCS) for MassHealth billing.
This letter transmits a revised Subchapter 6 of the Freestanding Ambulatory Surgery Center Manual. Providers should use this revised Subchapter 6 in conjunction with the American Medical Association Current Procedural Terminology (CPT) 2003 code book to obtain service code descriptions. Subchapter 6 lists CPT and Level II codes that
•	are payable under MassHealth; and
•	have special limitations or requirements, such as prior authorization, individual consideration, or attachment requirements.
We have restructured Subchapter 6 because we recognize that most providers use their CPT codebooks for service codes and descriptions, and refer to the Division’s Subchapter 6 only to determine what limitations or restrictions might apply to a specific code for MassHealth. We hope that this restructured Subchapter 6 will be easier to use, and will make your provider manual more manageable.
Terminated Procedures
Procedure code X1835 has been deleted from the list of payable procedure codes. Providers who are submitting a claim for a terminated procedure should use the most appropriate procedure code along with modifier 73 or modifier 74.
Effective Date
The revised Subchapter 6 is effective for dates of service on or after August 15, 2003. The new codes introduced under the CPT 2003 code book and the HCPCS Level II code book are effective for dates of service on or after August 15, 2003. We will accept either the new or the old codes for dates of service through September 30, 2003. For dates of service on or after October 1, 2003, providers must use the new codes to receive payment.

MASSHEALTH
TRANSMITTAL LETTER FAS-13 September 2003 Page 2
How to Obtain an FAS Fee Schedule
If you wish to obtain a fee schedule, you may purchase Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the publication. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for freestanding ambulatory surgery centers is 114.3 CMR 47.

Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.state.ma.us/sec/spr/spridx.htm

Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp

Appendix D
The Division has deleted Appendix D of the Freestanding Ambulatory Surgery Center Manual because it is out of date and no longer used.
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.)
Freestanding Ambulatory Surgery Center Manual
Pages vi and 6-1 through 6-22
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Freestanding Ambulatory Surgery Center Manual
Pages vi, vi-a, vi-b, 6-1 through 6-8, 6-11 through 6-42, 6-45 through 6-48, 6-53 through 6-84, and 6-87 through 6-100—transmitted by Transmittal Letter FAS-11
Page vii—transmitted by Transmittal Letter FAS-10
Pages 6-9, 6-10, 6-43, 6-44, 6-49 through 6-52, 6-85, and 6-86—transmitted by Transmittal Letter FAS-12
Pages D-1 through D-18—transmitted by Transmittal Letter FAS-8

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FREESTANDING AMBULATORY SURGERY CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
vi	

	TRANSMITTAL LETTER
FAS-13	DATE
10/01/03	
6.	SERVICE CODES
601	Surgery Service Codes and Descriptions 		6-1
602	Periodontic Service Codes and Descriptions 		6-20
603	Exodontic Service Codes and Descriptions 		6-20
604	Dental Surgery Procedures 		6-20
605	Prosthetic Service Codes and Descriptions 		6-21
606	Modifiers 		6-21
601	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FREESTANDING AMBULATORY SURGERY CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-1	

	TRANSMITTAL LETTER
FAS-13	DATE
10/01/03	
601   Surgery Service Codes
The following service codes are payable by MassHealth, subject to all conditions and limitations in the Division’s regulations at 423.000 and 450.000. Codes in Subchapter 6 with additional text as shown in the legend below require specific attachments, or prior authorization, or have specific instructions or limitations.
Legend:
CPA-2: A completed Certification of Payable Abortion Form is required. See 130 CMR 423.419 for
additional information. CS-18: A completed Sterilization Consent Form (for members aged 18 through 20) is required. See 130
CMR 423.417 and 130 CMR 423.418 for additional information. CS-21: A completed Sterilization Consent Form (for members aged 21 and older) is required. See 130 CMR
423.417 and 130 CMR 423.418 for additional information. IC: Claim requires individual consideration. See 130 CMR 423.402 for more information. PA: Service requires prior authorization. See 130 CMR 423.406 for more information. Under 21 and S.C. only: Payable service for members who are under age 21 and adults who meet the
special circumstances criteria as stated in the Dental Manual. See 130 CMR 420.432 in the Dental
Manual for more information.

Service Code

Service Code

Service Code

10121 10180 11010 11011 11012 11042 11043 11044 11404 11406 11424 11426 11444 11446 11450 11451 11462 11463 11470 11471 11604 11606 11624 11626 11644 11646 11770 11771

11772 11960 11970 11971 12005 12006 12007 12016 12017 12018 12020 12021 12034 12035 12036 12037 12044 12045 12046 12047 12054 12055 12056 12057 13100 13101 13120 13121

13131 13132 13150 13151 13152 13160 14000 14001 14020 14021 14040 14041 14060 14061 14300 14350 15000 15050 15100 15101 15120 15121 15200 15201 15220 15221 15240 15241

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY		6 SERVICE CODES	6-2	

		TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL		FAS-13		10/01/03	
601   Surgery Service Codes (cont.)					
Service Code	Service Code		Service Code	
15260		15945			20650	
15261		15946			20670	
15350		15950			20680	
15351		15951			20690	
15400		15952			20692	
15401		15953			20693	
15570		15956			20694	
15572		15958			20900	
15574		16015			20902	
15576		19020			20910	
15600		19100			20912	
15610		19101			20920	
15620		19102			20922	
15630		19103			20924	
15650		19110			20926	
15732		19112			20975	
15734		19120			21010	
15736		19125			21015	
15738		19126			21025	
15740		19140	(PA.)		21026	
15750		19160			21029	
15760		19162			21030	
15770		19180			21031	
15820	(PA.)	19182			21032	
15821	(PA.)	19290			21034	
15822	(PA.)	19291			21040	
15823	(PA.)	19318	(PA.)		21044	
15831	(PA.)	19328	(PA.)		21046	
15832	(PA.)	19330	(PA.)		21047	
15833	(PA.)	19340	(PA.)		21050	
15834	(PA.)	19342	(PA.)		21060	
15835		19350	(PA.)		21070	
15840		19357	(PA.)		21100	
15841		19366	(PA.)		21110	
15845		19380	(PA.)		21127	
15920		20005			21181	
15922		20200			21206 (P.A.)	
15931		20205			21208 (P.A.)	
15933		20206			21209 (P.A.)	
15934		20220			21210 (P.A.)	
15935		20225			21215 (P.A.)	
15936		20240			21230 (P.A.)	
15937		20245			21235 (P.A.)	
15940		20250			21240 (P.A.)	
15941		20251			21242 (P.A.)	
15944		20525			21243 (P.A.)		

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY	6 SERVICE CODES	6-3	

	TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL	FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code	Service Code	
21244	(PA.)	21610		23190	
21267	(PA.)	21700		23195	
21270	(PA.)	21720		23330	
21275	(PA.)	21725		23331	
21280	(PA.)	21800		23395	
21282	(PA.)	21805		23397	
21295	(PA.)	21820		23400	
21296	(PA.)	21925		23405	
21300		21930		23406	
21310		21935		23410	
21315		22305		23412	
21320		22310		23415	
21325		22315		23420	
21330		22505		23430	
21335		22900		23440	
21336		23000		23450	
21337		23020		23455	
21338		23030		23460	
21339		23031		23462	
21340		23035		23465	
21345		23040		23466	
21355		23044		23480	
21400		23066		23485	
21401		23075		23490	
21421		23076		23491	
21440		23077		23500	
21445		23100		23505	
21450		23101		23515	
21451		23105		23520	
21452		23106		23525	
21453		23107		23530	
21454		23120		23532	
21461		23125		23540	
21462		23130		23545	
21465		23140		23550	
21480		23145		23552	
21485		23146		23570	
21490		23150		23575	
21493		23155		23585	
21494		23156		23600	
21497		23170		23605	
21501		23172		23615	
21502		23174		23616	
21555		23180		23620	
21556		23182		23625	
21600		23184		23630			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY	6 SERVICE CODES	6-4	

	TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL	FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code	Service Code	
23650		24331		24620	
23655		24340		24635	
23660		24341		24655	
23665		24342		24665	
23670		24345		24666	
23675		24350		24670	
23680		24351		24675	
23700		24352		24685	
23800		24354		24800	
23802		24356		24802	
23921		24360		24925	
23930		24361		25000	
23931		24362		25020	
23935		24363		25023	
24000		24365		25024	
24006		24366		25025	
24066		24400		25028	
24075		24410		25031	
24076		24420		25035	
24077		24430		25040	
24100		24435		25066	
24101		24470		25075	
24102		24495		25076	
24105		24498		25077	
24110		24500		25085	
24115		24505		25100	
24116		24515		25101	
24120		24516		25105	
24125		24530		25107	
24126		24535		25110	
24130		24538		25111	
24134		24545		25112	
24136		24546		25115	
24138		24560		25116	
24140		24565		25118	
24145		24566		25119	
24147		24575		25120	
24155		24576		25125	
24160		24577		25126	
24164		24579		25130	
24201		24582		25135	
24301		24586		25136	
24305		24587		25145	
24310		24600		25150	
24320		24605		25151	
24330		24615		25210			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY	6 SERVICE CODES	6-5	

	TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL	FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code	Service Code	
25215		25444		26020	
25230		25445		26025	
25240		25446		26030	
25248		25447		26034	
25250		25449		26040	
25251		25450		26045	
25260		25455		26055	
25263		25490		26060	
25265		25491		26070	
25270		25492		26075	
25272		25505		26080	
25274		25515		26100	
25275		25520		26105	
25280		25525		26110	
25290		25526		26115	
25295		25535		26116	
25300		25545		26117	
25301		25565		26121	
25310		25574		26123	
25312		25575		26125	
25315		25605		26130	
25316		25611		26135	
25320		25620		26140	
25332		25624		26145	
25335		25628		26160	
25337		25635		26170	
25350		25645		26180	
25355		25660		26185	
25360		25670		26200	
25365		25671		26205	
25370		25675		26210	
25375		25676		26215	
25390		25680		26230	
25391		25685		26235	
25392		25690		26236	
25393		25695		26250	
25400		25800		26255	
25405		25805		26260	
25415		25810		26261	
25420		25820		26262	
25425		25825		26320	
25426		25830		26350	
25440		25907		26352	
25441		25922		26356	
25442		25929		26357	
25443		26011		26358			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY	6 SERVICE CODES	6-6	

	TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL	FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code	Service Code	
26370		26516		26746	
26372		26517		26756	
26373		26518		26765	
26390		26520		26776	
26392		26525		26785	
26410		26530		26820	
26412		26531		26841	
26415		26535		26842	
26416		26536		26843	
26418		26540		26844	
26420		26541		26850	
26426		26542		26852	
26428		26545		26860	
26432		26546		26861	
26433		26548		26862	
26434		26550		26863	
26437		26555		26910	
26440		26560		26951	
26442		26561		26952	
26445		26562		26990	
26449		26565		26991	
26450		26567		27000	
26455		26568		27001	
26460		26580		27003	
26471		26587		27033	
26474		26590		27035	
26476		26591		27040	
26477		26593		27041	
26478		26596		27047	
26479		26605		27048	
26480		26607		27049	
26483		26608		27050	
26485		26615		27052	
26489		26645		27060	
26490		26650		27062	
26492		26665		27065	
26494		26675		27066	
26496		26676		27067	
26497		26685		27080	
26498		26686		27086	
26499		26705		27087	
26500		26706		27097	
26502		26715		27098	
26504		26727		27100	
26508		26735		27105	
26510		26742		27110			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY	6 SERVICE CODES	6-7	

	TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL	FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code	Service Code	
27111		27391		27560	
27193		27392		27562	
27194		27393		27566	
27202		27394		27570	
27230		27395		27594	
27238		27396		27600	
27246		27397		27601	
27250		27400		27602	
27252		27403		27603	
27257		27405		27604	
27265		27407		27605	
27266		27409		27606	
27275		27418		27607	
27301		27420		27610	
27305		27422		27612	
27306		27424		27614	
27307		27425		27615	
27310		27427		27618	
27315		27428		27619	
27320		27429		27620	
27323		27430		27625	
27324		27435		27626	
27327		27437		27630	
27328		27438		27635	
27329		27441		27637	
27330		27442		27638	
27331		27443		27640	
27332		27496		27641	
27333		27497		27647	
27334		27498		27650	
27335		27499		27652	
27340		27500		27654	
27345		27501		27656	
27347		27502		27658	
27350		27503		27659	
27355		27508		27664	
27356		27509		27665	
27357		27510		27675	
27358		27516		27676	
27360		27517		27680	
27372		27520		27681	
27380		27530		27685	
27381		27532		27686	
27385		27538		27687	
27386		27550		27690	
27390		27552		27691			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY	6 SERVICE CODES	6-8	

	TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL	FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code	Service Code	
27692		27842		28114	
27695		27846		28116	
27696		27848		28118	
27698		27860		28119	
27700		27870		28120	
27704		27871		28122	
27705		27884		28126	
27707		27889		28130	
27709		27892		28140	
27730		27893		28150	
27732		27894		28153	
27734		28002		28160	
27740		28003		28171	
27742		28005		28173	
27745		28008		28175	
27750		28011		28192	
27752		28020		28193	
27756		28022		28200	
27758		28024		28202	
27759		28030		28208	
27760		28035		28210	
27762		28043		28222	
27766		28045		28225	
27780		28046		28226	
27781		28050		28234	
27784		28052		28238	
27786		28054		28240	
27788		28060		28250	
27792		28062		28260	
27808		28070		28261	
27810		28072		28262	
27814		28080		28264	
27816		28086		28270	
27818		28088		28280	
27822		28090		28285	
27823		28092		28286	
27824		28100		28288	
27825		28102		28289	
27826		28103		28290	
27827		28104		28292	
27828		28106		28293	
27829		28107		28294	
27830		28110		28296	
27831		28111		28297	
27832		28112		28298	
27840		28113		28299			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY		6 SERVICE CODES	6-9	

		TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL		FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code		Service Code	
28300		28665		29856	
28302		28666		29860	
28304		28675		29861	
28305		28705		29862	
28306		28715		29863	
28307		28725		29870	
28308		28730		29871	
28309		28735		29874	
28310		28737		29875	
28312		28740		29876	
28313		28750		29877	
28315		28755		29879	
28320		28760		29880	
28322		28810		29881	
28340		28820		29882	
28341		28825		29883	
28344		29800 (P.A.)		29884	
28345		29804 (P.A.)		29885	
28400		29805		29886	
28405		29806		29887	
28406		29807		29888	
28415		29819		29889	
28420		29820		29891	
28435		29821		29892	
28436		29822		29893	
28445		29823		29894	
28456		29824		29895	
28465		29825		29897	
28476		29826		29898	
28485		29827		29899	
28496		29830		29900	
28505		29834		29901	
28525		29835		29902	
28531		29836		30115	
28545		29837		30117	
28546		29838		30118	
28555		29840		30120	
28575		29843		30125	
28576		29844		30130	
28585		29845		30140	
28605		29846		30150	
28606		29847		30160	
28615		29848		30310	
28635		29850		30320	
28636		29851		30400 (P.A.)	
28645		29855			30410 (P.A.)		

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY	6 SERVICE CODES	6-10	

	TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL	FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code	Service Code	
30420	(PA.)	31254		31614	
30430	(PA.)	31255		31615	
30435	(PA.)	31256		31622	
30450	(PA.)	31267		31623	
30460		31276		31624	
30462		31287		31625	
30465		31288		31628	
30520		31300		31629	
30540		31320		31630	
30545		31400		31631	
30560		31420		31635	
30580		31510		31640	
30600		31511		31641	
30620		31512		31643	
30630		31513		31645	
30801		31515		31646	
30802		31525		31656	
30903		31526		31700	
30905		31527		31717	
30906		31528		31720	
30915		31529		31730	
30920		31530		31750	
30930		31531		31755	
31020		31535		31820	
31030		31536		31825	
31032		31540		31830	
31050		31541		32000	
31051		31560		32400	
31070		31561		32405	
31075		31570		32420	
31080		31571		33010	
31081		31576		33011	
31084		31577		33222	
31085		31578		33223	
31086		31580		35188	
31087		31582		35207	
31090		31585		35875	
31200		31586		35876	
31201		31588		36260	
31205		31590		36261	
31233		31595		36262	
31235		31600		36488	
31237		31601		36489	
31238		31611		36490	
31239		31612		36491	
31240		31613		36530			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY		6 SERVICE CODES	6-11	

		TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL		FAS-13		10/01/03	
601   Surgery Service Codes (cont.)					
Service Code	Service Code		Service Code	
36531		38572			41112	
36532		38740			41113	
36533		38745			41114	
36534		38760			41115	
36535		40500			41116	
36640		40510			41120	
36800		40520			41250	
36810		40525			41251	
36815		40527			41252	
36819		40530			41500	
36820		40650			41510	
36821		40652			41520	
36825		40654			41800	
36830		40700			41805	
36831		40701			41806	
36832		40702			41820 (P.A.)	
36833		40720			41825	
36835		40761			41826	
36860		40801			41827	
36861		40805			41830 (P.A.)	
36870		40806			41850	
37607		40814			42000	
37609		40816			42100	
37650		40818			42104	
37700		40819			42106	
37720		40830			42107	
37730		40831			42120	
37735		40840	(PA.)		42140 (P.A.)	
37760		40842	(PA.)		42145	
37780		40843	(PA.)		42160	
37785		40844	(PA.)		42180	
37790		40845	(PA.)		42182	
38300		41000			42200	
38305		41005			42205	
38308		41006			42210	
38500		41007			42215	
38505		41008			42220	
38510		41009			42225	
38520		41010			42226	
38525		41015			42227	
38530		41016			42235	
38542		41017			42260	
38550		41018			42281 (P.A.)	
38555		41105			42300	
38570		41108			42305	
38571		41110			42310			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY	6 SERVICE CODES	6-12	

	TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL	FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code	Service Code	
42320		42955		43268	
42325		42960		43269	
42326		42962		43271	
42330		42972		43272	
42340		43200		43450	
42400		43201		43453	
42405		43202		43456	
42408		43204		43458	
42409		43205		43600	
42410		43215		43653	
42415		43216		43750	
42420		43217		43760	
42425		43219		43870	
42440		43220		44100	
42450		43226		44312	
42500		43227		44340	
42505		43228		44360	
42507		43231		44361	
42508		43232		44363	
42509		43234		44364	
42510		43235		44365	
42600		43236		44366	
42700		43239		44369	
42720		43240		44370	
42725		43241		44372	
42800		43242		44373	
42802		43243		44376	
42804		43244		44377	
42806		43245		44378	
42808		43246		44379	
42810		43247		44380	
42815		43248		44382	
42820		43249		44383	
42821		43250		44385	
42825		43251		44386	
42826		43255		44388	
42830		43256		44389	
42831		43258		44390	
42835		43259		44391	
42836		43260		44392	
42860		43261		44393	
42870		43262		44394	
42890		43263		45000	
42892		43264		45005	
42900		43265		45020	
42950		43267		45100			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY	6 SERVICE CODES	6-13	

	TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL	FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code	Service Code	
45108		46080		47560	
45150		46200		47561	
45160		46210		47630	
45170		46211		48102	
45190		46220		49080	
45305		46250		49081	
45307		46255		49085	
45308		46257		49180	
45309		46258		49250	
45315		46260		49320	
45317		46261		49321	
45320		46262		49322	
45321		46270		49420	
45331		46275		49421	
45332		46280		49422	
45333		46285		49426	
45334		46288		49495	
45335		46608		49496	
45337		46610		49500	
45338		46611		49501	
45339		46612		49505	
45340		46615		49507	
45355		46700		49520	
45378		46705		49521	
45379		46750		49525	
45380		46751		49540	
45381		46753		49550	
45382		46754		49553	
45383		46760		49555	
45384		46761		49557	
45385		46762		49560	
45386		46917		49561	
45500		46922		49565	
45505		46924		49566	
45560		46937		49568	
45900		46938		49570	
45905		47000		49572	
45910		47510		49580	
45915		47511		49582	
46020		47525		49585	
46030		47530		49587	
46040		47552		49590	
46045		47553		49600	
46050		47554		49650	
46060		47555		49651	
46070		47556		50200			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY		6 SERVICE CODES	6-14	

		TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL		FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code		Service Code	
50390		52005		52510	
50392		52007		52601	
50393		52010		52606	
50395		52204		52612	
50396		52214		52614	
50398		52224		52620	
50551		52234		52630	
50553		52235		52640	
50555		52240		52647	
50557		52250		52648	
50559		52260		52700	
50561		52270		53000	
50590		52275		53010	
50688		52276		53020	
50947		52277		53040	
50948		52281		53080	
50951		52282		53200	
50953		52283		53210	
50955		52285		53215	
50957		52290		53220	
50959		52300		53230	
50961		52305		53235	
50970		52310		53240	
50972		52315		53250	
50974		52317		53260	
50976		52318		53265	
50978		52320		53270	
50980		52325		53275	
51010		52327 (P.A.)		53400	
51020		52330		53405	
51030		52332		53410	
51040		52334		53420	
51045		52341		53425	
51050		52342		53430	
51065		52343		53431	
51080		52344		53440	
51500		52345		53442	
51520		52346		53444	
51710		52351		53445	
51715 (	PA.)	52352		53446	
51726		52353		53447	
51772		52354		53449	
51785		52355		53450	
51880		52400		53460	
52000		52450		53502	
52001		52500			53505			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY		6 SERVICE CODES	6-15	

		TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL		FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code		Service Code	
53510		54401 (P.A.)		55540	
53515		54405 (P.A.)		55550	
53520		54406		55680	
53605		54408		55700	
53665		54410		55705	
53850 (	p.a.)	54415		55720	
54000		54416		55725	
54001		54420		55859	
54015		54435		56405	
54057		54440		56440	
54060		54450		56441	
54065		54500		56501	
54100		54505		56515	
54105		54512		56605	
54110		54520		56620	
54111		54522		56625	
54112		54530		56700	
54115		54550		56720	
54120		54600		56740	
54150		54620		56800	
54152		54640		56810	
54160		54660		57000	
54161		54670		57010	
54162		54680		57020	
54163		54690		57023	
54164		54700		57065	
54205		54800		57105	
54220		54820		57130	
54300		54830		57135	
54304		54840		57180	
54308		54860		57200	
54312		54861		57210	
54316		55040		57220	
54318		55041		57230	
54322		55060		57240	
54324		55100		57250	
54326		55110		57260	
54328		55120		57265	
54340		55150		57268	
54344		55175		57284	
54348		55180		57288	
54352		55250 (CS-18	or CS-21)	57289	
54360		55500		57291	
54380		55520		57300	
54385		55530		57400	
54400 (	p.a.)	55535			57410			

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FREESTANDING AMBULATORY SURGERY CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-16	

	TRANSMITTAL LETTER
FAS-13	DATE
10/01/03	
601   Surgery Service Codes (cont.)
Service Code			Service Code	Service Code	
57415			59840 (CPA-2)	63610	
57460			59841 (CPA-2) (first	63650	
57513			trimester)	63660	
57520			59866	63685	
57522			59870	63688	
57530			59871	63744	
57550			60000	63746	
57555			60200	64410	
57556			60280	64415	
57700			60281	64417	
Service			61020	64420	
57720			61026	64421	
57800			61050	64430	
57820			61055	64470	
58120			61070	64472	
58145			61215	64475	
58353			61790	64476	
58545			61791	64479	
58546			61885	64480	
58555			61886	64483	
58558			61888	64484	
58559			62194	64510	
58560 (CS-18	or	CS-21)	62225	64520	
58561 (CS-18	or	CS- 21)	62230	64530	
58562			62263	64553	
58563			62268	64573	
58600 (CS-18	or	CS-21)	62269	64575	
58615 (CS-18	or	CS-21)	62270	64577	
58660			62272	64580	
58661 (CS-18	or	CS-21)	62273	64585	
58662			62280	64590	
58670 (CS-18	or	CS-21)	62281	64595	
58671 (CS-18	or	CS-21)	62282	64600	
58672			62287	64605	
58673			62294	64610	
58770			62310	64620	
58800			62311	64622	
58820			62318	64623	
58900			62319	64626	
59160			62350	64627	
59300			62355	64630	
59320			62360	64680	
59812			62361	64702	
59820			62362	64704	
59821			62365	64708	
59830			63600	64712	

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY	6 SERVICE CODES	6-17	

	TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL	FAS-13		10/01/03	
601   Surgery Service Codes (cont.)				
Service Code	Service Code	Service Code	
64713		64864		65426	
64714		64865		65710	
64716		64870		65730	
64718		64872		65750	
64719		64874		65755	
64721		64876		65770	
64722		64885		65772	
64726		64886		65775	
64727		64890		65800	
64732		64891		65805	
64734		64892		65810	
64736		64893		65815	
64738		64895		65850	
64740		64896		65865	
64742		64897		65870	
64744		64898		65875	
64746		64901		65880	
64771		64902		65900	
64772		64905		65920	
64774		64907		65930	
64776		65091		66020	
64778		65093		66030	
64782		65101		66130	
64783		65103		66150	
64784		65105		66155	
64786		65110		66160	
64787		65112		66165	
64788		65114		66170	
64790		65130		66172	
64792		65135		66180	
64795		65140		66185	
64802		65150		66220	
64821		65155		66225	
64831		65175		66250	
64832		65235		66500	
64834		65260		66505	
64835		65265		66600	
64836		65270		66605	
64837		65272		66625	
64840		65275		66630	
64856		65280		66635	
64857		65285		66680	
64858		65290		66682	
64859		65400		66700	
64861		65410		66710	
64862		65420		66720			

Commonwealth of Massachusetts	SUBCHAPTER NUMBER AND TITLE	PAGE	
Division of Medical Assistance Provider Manual Series
FREESTANDING AMBULATORY		6 SERVICE CODES	6-18	

		TRANSMITTAL LETTER	DATE	
	SURGERY CENTER MANUAL		FAS-13		10/01/03	
601   Surgery Service Codes (cont.)					
Service Code	Service Code		Service Code	
66740		67335			68325	
66821		67340			68326	
66825		67350			68328	
66830		67400			68330	
66840		67405			68335	
66850		67412			68340	
66852		67413			68360	
66920		67415			68362	
66930		67420			68500	
66940		67430			68505	
66982		67440			68510	
66983		67450			68520	
66984		67550			68525	
66985		67560			68540	
66986		67715			68550	
67005		67808			68700	
67010		67830			68720	
67015		67835			68745	
67025		67880			68750	
67027		67882			68770	
67030		67900	(PA.)		68810	
67031		67901	(PA.)		68811	
67036		67902	(PA.)		68815	
67038		67903	(PA.)		69110	
67039		67904	(PA.)		69120	
67040		67906	(PA.)		69140	
67107		67908	(PA.)		69145	
67108		67909	(PA.)		69150	
67112		67911	(PA.)		69205	
67115		67914			69300 (P.A.)	
67120		67916	(PA.)		69310	
67121		67917	(PA.)		69320	
67141		67921			69421	
67218		67923	(PA.)		69424	
67227		67924	(PA.)		69436	
67250		67935			69440	
67255		67950			69450	
67311		67961	(PA.)		69501	
67312		67966	(PA.)		69502	
67314		67971	(PA.)		69505	
67316		67973	(PA.)		69511	
67318		67974	(PA.)		69530	
67320		67975	(PA.)		69550	
67331		68115			69552	
67332		68130			69601	
67334		68320			69602			

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FREESTANDING AMBULATORY SURGERY CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-19	

	TRANSMITTAL LETTER
FAS-13	DATE
10/01/03	
601   Surgery Service Codes (cont.)
Service Code	Service Code	Service Code
69603 69604 69605 69620 69631 69632 69633 69635 69636 69637 69641 69642 69643 69644 69645 69646 69650 69660 69661 69662 69666 69667 69670 69676 69700 69711 69714 69715 69717 69718 69720 69725 69740 69745 69801 69802 69805 69806 69820 69840 69905 69910 69915 69930 (P.A.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FREESTANDING AMBULATORY SURGERY CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-20	

	TRANSMITTAL LETTER
FAS-13	DATE
10/01/03	
602	Periodontic Service Codes and Descriptions
Service
Code       Description
Surgical Services (includes usual postoperative services)
D4210     Gingivectomy or gingivoplasty—four or more contiguous teeth or bounded teeth, spaces per quadrant (once per quadrant per three-year period) (under 21 and S.C. only) (P.A.)
D4341     Periodontal scaling and root planning—four or more contiguous teeth or bounded teeth spaces, per quadrant (includes curettage) (once per quadrant per three-year period) (under 21 and S.C. only (P.A)
603	Exodontic Service Codes and Descriptions
Service
Code       Description
Extractions (Includes Local Anesthesia and Routine Postoperative Care)
D7110     Extraction--single tooth
D7120     Extraction--each additional tooth
D7210     Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone
and/or section of tooth D7220     Removal of impacted tooth—soft tissue (P.A.) D7230     Removal of impacted tooth—partially bony (P.A.) D7240     Removal of impacted tooth—completely bony (P.A.) D7281     Surgical exposure of impacted or unerupted tooth to aid eruption (for orthodontic purposes)
(under 21 only) (P.A.)
604	Dental Surgery Procedures
Service
Code       Description
D7310	Alveoloplasty in conjunction with extactions—per quadrant (seven or more extractions per arch)
D7320	Alveoloplasty not in conjunction with extractions—per quadrant
D7340	Vestibuloplasty—ridge extension (second epithelialization) (P.A.)
D7960	Frenulectomy (frenectomy or frenotomy)—separate procedure
D7970	Excision of hyperplastic tissue—per arch (P.A.)
D7999	Unspecified oral surgery procedure, by report (P.A) (I.C.)
D9930	Treatment of complications (post surgical) – unusual circumstances, by report (I.C.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FREESTANDING AMBULATORY SURGERY CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-21	

	TRANSMITTAL LETTER
FAS-13	DATE
10/01/03	
605	Prosthetic Service Codes and Descriptions
Service
Code       Description
Integumentary System
L8500      Artificial Larynx, any type (I.C.)
L8501      Tracheostomy speaking valve (I.C.)
L8510      Voice amplifier (I.C.)
L8600      Implantable breast prosthesis, silicone or equal (I.C.)
L8603      Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and
necessary supplies (I.C.) L8606      Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and
necessary supplies (I.C.)
Head: Skull, Facial Bones, and Temporomandibular Joint
L8610	Ocular implant (I.C.)
L8612	Aqueous shunt (I.C.)
L8613	Ossicular implant (I.C.)
L8614	Cochlear device/system (I.C.)
L8619	Cochlear implant external speech processor, replacement (I.C.)
Upper Extremity
L8630      Metacarpophalangeal joint implant (I.C.)
Lower Extremity — Joint: Knee, Ankle, Toe
L8641      Metatarsal joint implant (I.C.)
L8642      Hallux implant (I.C.)
L8658      Interphalangeal joint implant (I.C.)
Cardiovascular System
L8670      Vascular graft material, synthetic, implant (I.C.)
606	Modifiers
50	Bilateral procedure
51	Multiple procedures

73	Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia
74	Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia
73	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FREESTANDING AMBULATORY SURGERY CENTER MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-22	

	TRANSMITTAL LETTER
FAS-13	DATE
10/01/03	
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