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 FAS-14
September 2005

	TO:	Freestanding Ambulatory Surgery Centers Participating in MassHealth

	FROM:	Beth Waldman, Medicaid Director 

	RE:	Freestanding Ambulatory Surgery Center Manual (Revisions to Service Codes and Descriptions)

The Centers for Medicare and Medicaid Services (CMS) have revised the HealthCare Common Procedure Coding System (HCPCS) for 2005.  This letter transmits revisions to the Freestanding Ambulatory Surgery Center Manual service codes and descriptions section. The revised Subchapter 6 is effective for dates of service on or after May 15, 2005.

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 directly 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 regulation.  The Division of Health Care Finance and Policy also has the regulations available on disk.  The regulation title is 114.3 CMR 16.00: Surgery and Related Anesthesia.

	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

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.)
	
	Freestanding Ambulatory Surgery Center Manual

Pages xii and 6-1 through 6-22

OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)

	Freestanding Ambulatory Surgery Center Manual

Page xii – transmitted by Transmittal Letter FAS-6

Pages 6-1 through 6-22 – transmitted by Transmittal Letter FAS-13

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 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 freestanding ambulatory surgery centers, those matters are covered in 130 CMR Chapter 423.000, reproduced as Subchapter 4 in the Freestanding Ambulatory Surgery Center 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.

The following service codes are payable by MassHealth, subject to all conditions and limitations in MassHealth 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 for 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 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 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
15260
15261
15350
15351
15400
15401
15570
15572
15574
15576
15600
15610
15620
15630
15650
15732
15734
15736
15738
15740
15750
15760
15770
15820 (PA)
15821 (PA) 
15822 (PA)
15823 (PA)
15831 (PA)
15832 (PA)
15833 (PA)
15834 (PA)
15835
15840
15841
15845
15920
15922
15931
15933
15934
15935
15936
15937
15940
15941
15944
15945
15946
15950
15951
15952
15953
15956
15958
16015
19020
19100
19101
19102
19103
19110
19112
19120
19125
19126
19140 (PA)
19160
19162
19180
19182
19290
19291
19318 (PA)
19328 (PA)
19330 (PA)
19340 (PA)
19342 (PA)
19350 (PA)
19357 (PA)
19366 (PA)
19380 (PA)
20005
20200
20205
20206
20220
20225
20240
20245
20250
20251
20525
20650
20670
20680
20690
20692
20693
20694
20900
20902
20910
20912
20920
20922
20924
20926
20975
21010
21015
21025
21026
21029
21031
21034
21040
21044
21046
21047
21050
21060
21070
21100
21181
21206 (PA)
21208 (PA)
21209 (PA)
21210 (PA)
21215 (PA)
21230 (PA)
21235 (PA)
21240 (PA)
21242 (PA)
21243 (PA)
21244 (PA)
21267 (PA)
21270 (PA)
21275 (PA)
21280 (PA)
21282 (PA)
21295 (PA)
21296 (PA)
21300
21310
21315
21320
21325
21330
21335
21336
21337
21338
21339
21340
21345
21355
21400
21401
21421
21440
21445
21450
21451
21452
21453
21454
21461
21462
21465
21480
21485
21490
21493
21494
21497
21501
21502
21555
21556
21600
21610
21700
21720
21725
21800
21805
21820
21925
21930
21935
22305
22310
22315
22505
22900
23000
23020
23030
23031
23035
23040
23044
23066
23075
23076
23077
23100
23101
23105
23106
23107
23120
23125
23130
23140
23145
23146
23150
23155
23156
23170
23172
23174
23180
23182
23184
23190
23195
23330
23331
23395
23397
23400
23405
23406
23410
23412
23415
23420
23430
23440
23450
23455
23460
23462
23465
23466
23480
23485
23490
23491
23500
23505
23515
23520
23525
23530
23532
23540
23545
23550
23552
23570
23575
23585
23600
23605
23615
23616
23620
23625
23630
23650
23655
23660
23665
23670
23675
23680
23700
23800
23802
23921
23930
23931
23935
24000
24006
24066
24075
24076
24077
24100
24101
24102
24105
24110
24115
24116
24120
24125
24126
24130
24134
24136
24138
24140
24145
24147
24155
24160
24164
24201
24301
24305
24310
24320
24330
24331
24340
24341
24342
24345
24350
24351
24352
24354
24356
24360
24361
24362
24363
24365
24366
24400
24410
24420
24430
24435
24470
24495
24498
24500
24505
24515
24516
24530
24535
24538
24545
24546
24560
24565
24566
24575
24576
24577
24579
24582
24586
24587
24600
24605
24615
24620
24635
24655
24665
24666
24670
24675
24685
24800
24802
24925
25000
25020
25023
25024
25025
25028
25031
25035
25040
25066
25075
25076
25077
25085
25100
25101
25105
25107
25110
25111
25112
25115
25116
25118
25119
25120
25125
25126
25130
25135
25136
25145
25150
25151
25210
25215
25230
25240
25248
25250
25251
25260
25263
25265
25270
25272
25274
25275
25280
25290
25295
25300
25301
25310
25312
25315
25316
25320
25332
25335
25337
25350
25355
25360
25365
25370
25375
25390
25391
25392
25393
25400
25405
25415
25420
25425
25426
25440
25441
25442
25443
25444
25445
25446
25447
25449
25450
25455
25490
25491
25492
25505
25515
25520
25525
25526
25535
25545
25565
25574
25575
25605
25611
25620
25624
25628
25635
25645
25660
25670
25671
25675
25676
25680
25685
25690
25695
25800
25805
25810
25820
25825
25830
25907
25922
25929
26011
26020
26025
26030
26034
26040
26045
26055
26060
26070
26075
26080
26100
26105
26110
26115
26116
26117
26121
26123
26125
26130
26135
26140
26145
26160
26170
26180
26185
26200
26205
26210
26215
26230
26235
26236
26250
26255
26260
26261
26262
26320
26350
26352
26356
26357
26358
26370
26372
26373
26390
26392
26410
26412
26415
26416
26418
26420
26426
26428
26432
26433
26434
26437
26440
26442
26445
26449
26450
26455
26460
26471
26474
26476
26477
26478
26479
26480
26483
26485
26489
26490
26492
26494
26496
26497
26498
26499
26500
26502
26504
26508
26510
26516
26517
26518
26520
26525
26530
26531
26535
26536
26540
26541
26542
26545
26546
26548
26550
26555
26560
26561
26562
26565
26567
26568
26580
26587
26590
26591
26593
26596
26605
26607
26608
26615
26645
26650
26665
26675
26676
26685
26686
26705
26706
26715
26727
26735
26742
26746
26756
26765
26776
26785
26820
26841
26842
26843
26844
26850
26852
26860
26861
26862
26863
26910
26951
26952
26990
26991
27000
27001
27003
27033
27035
27040
27041
27047
27048
27049
27050
27052
27060
27062
27065
27066
27067
27080
27086
27087
27097
27098
27100
27105
27110
27111
27193
27194
27202
27230
27238
27246
27250
27252
27257
27265
27266
27275
27301
27305
27306
27307
27310
27315
27320
27323
27324
27327
27328
27329
27330
27331
27332
27333
27334
27335
27340
27345
27347
27350
27355
27356
27357
27358
27360
27372
27380
27381
27385
27386
27390
27391
27392
27393
27394
27395
27396
27397
27400
27403
27405
27407
27409
27418
27420
27422
27424
27425
27427
27428
27429
27430
27435
27437
27438
27441
27442
27443
27496
27497
27498
27499
27500
27501
27502
27503
27508
27509
27510
27516
27517
27520
27530
27532
27538
27550
27552
27560
27562
27566
27570
27594
27600
27601
27602
27603
27604
27605
27606
27607
27610
27612
27614
27615
27618
27619
27620
27625
27626
27630
27635
27637
27638
27640
27641
27647
27650
27652
27654
27656
27658
27659
27664
27665
27675
27676
27680
27681
27685
27686
27687
27690
27691
27692
27695
27696
27698
27700
27704
27705
27707
27709
27730
27732
27734
27740
27742
27745
27750
27752
27756
27758
27759
27760
27762
27766
27780
27781
27784
27786
27788
27792
27808
27810
27814
27816
27818
27822
27823
27824
27825
27826
27827
27828
27829
27830
27831
27832
27840
27842
27846
27848
27860
27870
27871
27884
27889
27892
27893
27894
28002
28003
28005
28008
28011
28020
28022
28024
28030
28035
28043
28045
28046
28050
28052
28054
28060
28062
28070
28072
28080
28086
28088
28090
28092
28100
28102
28103
28104
28106
28107
28110
28111
28112
28113
28114
28116
28118
28119
28120
28122
28126
28130
28140
28150
28153
28160
28171
28173
28175
28192
28193
28200
28202
28208
28210
28222
28225
28226
28234
28238
28240
28250
28260
28261
28262
28264
28270
28280
28285
28286
28288
28289
28290
28292
28293
28294
28296
28297
28298
28299
28300
28302
28304
28305
28306
28307
28308
28309
28310
28312
28313
28315
28320
28322
28340
28341
28344
28345
28400
28405
28406
28415
28420
28435
28436
28445
28456
28465
28476
28485
28496
28505
28525
28531
28545
28546
28555
28575
28576
28585
28605
28606
28615
28635
28636
28645
28665
28666
28675
28705
28715
28725
28730
28735
28737
28740
28750
28755
28760
28810
28820
28825
29800 (PA) 
29804 (PA) 
29805
29806
29807
29819
29820
29821
29822
29823
29824
29825
29826
29827
29830
29834
29835
29836
29837
29838
29840
29843
29844
29845
29846
29847
29848
29850
29851
29855
29856
29860
29861
29862
29863
29870
29871
29874
29875
29876
29877
29879
29880
29881
29882
29883
29884
29885
29886
29887
29888
29889
29891
29892
29893
29894
29895
29897
29898
29899
29900
29901
29902
30115
30117
30118
30120
30125
30130
30140
30150
30160
30310
30320
30400 (PA)
30410 (PA)
30420 (PA)
30430 (PA)
30435 (PA)
30450 (PA)
30460
30462
30465
30520
30540
30545
30560
30580
30600
30620
30630
30801
30802
30903
30905
30906
30915
30920
30930
31020
31030
31032
31050
31051
31070
31075
31080
31081
31084
31085
31086
31087
31090
31200
31201
31205
31233
31235
31237
31238
31239
31240
31254
31255
31256
31267
31276
31287
31288
31300
31320
31400
31420
31510
31511
31512
31513
31515
31525
31526
31527
31528
31529
31530
31531
31535
31536
31540
31541
31560
31561
31570
31571
31576
31577
31578
31580
31582
31585
31586
31588
31590
31595
31611
31612
31613
31614
31615
31622
31623
31624
31625
31628
31629
31630
31631
31635
31640
31641
31643
31645
31646
31656
31700
31717
31720
31730
31750
31755
31820
31825
31830
32000
32400
32405
32420
33010
33011
33222
33223
35188
35207
35875
35876
36260
36261
36262
36488
36489
36490
36491
36530
36531
36532
36533
36534
36535
36555
36556
36557
36558
36560
36561
36563
36565
36566
36568
36569
36570
36571
36575
36576
36578
36580
36581
36582
36583
36584
36585
36589
36590
36640
36800
36810
36815
36819
36820
36821
36825
36830
36831
36832
36833
36835
36860
36861
36870
37607
37609
37650
37700
37720
37730
37735
37760
37780
37785
37790
38300
38305
38308
38500
38505
38510
38520
38525
38530
38542
38550
38555
38570
38571
38572
38740
38745
38760
40500
40510
40520
40525
40527
40530
40650
40652
40654
40700
40701
40720
40761
40801
40806
40814
40816
40818
40819
40831
40840 (PA)
40842 (PA)
40843 (PA)
40844 (PA)
40845 (PA)
41005
41006
41007
41008
41009
41010
41015
41016
41017
41018
41112
41113
41114
41116
41120
41250
41251
41252
41500
41510
41520
41800
41827
42000
42107
42120
42140 (PA)
42145
42180
42182
42200
42205
42210
42215
42220
42226
42235
42260
42300
42305
42310
42320
42325
42340
42405
42408
42409
42410
42415
42420
42425
42440
42450
42500
42505
42507
42508
42509
42510
42600
42700
42720
42725
42800
42802
42804
42806
42808
42810
42815
42820
42821
42825
42826
42830
42831
42835
42836
42860
42870
42890
42892
42900
42950
42955
42960
42962
42972
43200
43201
43202
43204
43205
43215
43216
43217
43219
43220
43226
43227
43228
43231
43232
43234
43235
43236
43239
43240
43241
43242
43243
43244
43245
43246
43247
43248
43249
43250
43251
43255
43256
43258
43259
43260
43261
43262
43263
43264
43265
43267
43268
43269
43271
43272
43450
43453
43456
43458
43600
43653
43750
43760
43870
44100
44312
44340
44360
44361
44363
44364
44365
44366
44369
44370
44372
44373
44376
44377
44378
44379
44380
44382
44383
44385
44386
44388
44389
44390
44391
44392
44393
44394
45000
45005
45020
45100
45108
45150
45160
45170
45190
45305
45307
45308
45309
45315
45317
45320
45321
45331
45332
45333
45334
45335
45337
45338
45339
45340
45355
45378
45379
45380
45381
45382
45383
45384
45385
45386
45500
45505
45560
45900
45905
45910
45915
46020
46030
46040
46045
46050
46060
46080
46200
46210
46211
46220
46250
46255
46257
46258
46260
46261
46262
46270
46275
46280
46285
46288
46608
46610
46611
46612
46615
46700
46750
46753
46754
46760
46761
46762
46917
46922
46924
46937
46938
47000
47510
47511
47525
47530
47552
47553
47554
47555
47556
47560
47561
47630
48102
49080
49081
49085
49180
49250
49320
49321
49322
49420
49421
49422
49426
49495
49496
49500
49501
49505
49507
49520
49521
49525
49540
49550
49553
49555
49557
49560
49561
49565
49566
49568
49570
49572
49580
49582
49585
49587
49590
49600
49650
49651
50200
50390
50392
50393
50395
50396
50398
50551
50553
50555
50557
50561
50590
50688
50947
50948
50951
50953
50955
50957
50961
50970
50972
50974
50976
50980
51010
51020
51030
51040
51045
51050
51065
51080
51500
51520
51710
51715 (PA)
51726
51772
51785
51880
52000
52001
52005
52007
52010
52204
52214
52224
52234
52235
52240
52250
52260
52270
52275
52276
52277
52281
52282
52283
52285
52290
52300
52305
52310
52315
52317
52318
52320
52325
52327 (PA)
52330
52332
52334
52341
52342
52343
52344
52345
52346
52351
52352
52353
52354
52355
52400
52450
52500
52510
52601
52606
52612
52614
52620
52630
52640
52647
52648
52700
53000
53010
53020
53040
53080
53200
53210
53215
53220
53230
53235
53240
53250
53260
53265
53270
53275
53400
53405
53410
53420
53425
53430
53431
53440
53442
53444
53445
53446
53447
53449
53450
53460
53502
53505
53510
53515
53520
53605
53665
53850 (PA)
54000
54001
54015
54057
54060
54065
54100
54105
54110
54111
54112
54115
54120
54150
54152
54160
54161
54162
54163
54164
54205
54220
54300
54304
54308
54312
54316
54318
54322
54324
54326
54328
54340
54344
54348
54352
54360
54380
54385 
54400 (PA)
54401 (PA)
54405 (PA)
54406
54408
54410
54415
54416
54420
54435
54440
54450
54500
54505
54512
54520
54522
54530
54550
54600
54620
54640
54660
54670
54680
54690
54700
54800
54820
54830
54840
54860
54861
55040
55041
55060
55100
55110
55120
55150
55175
55180
55250 (CS-18 or CS-21)
55500
55520
55530
55535
55540
55550
55680
55700
55705
55720
55725
55859
56440
56441
56515
56620
56625
56700
56720
56740
56800
56810
57000
57010
57020
57023
57065
57105
57130
57135
57180
57200
57210
57220
57230
57240
57250
57260
57265
57268
57289
57291
57300
57400
57410
57415
57513
57520
57522
57530
57550
57555
57556
57700
57720
57820
58120
58145
58350
58353
58545
58546
58550
58555
58558
58559
58560 (CS-18 or CS-21)
58561 (CS-18 or CS- 21)
58562
58563
58660
58661 (CS-18 or CS-21)
58662
58670 (CS-18 or CS-21)
58671 (CS-18 or CS-21)
58672
58673
58800
58820
58900
59160
59320
59812
59820
59821
59840 (CPA-2)
59841 (CPA-2) (first trimester)
59870
59871
60000
60200
60280
60281
61020
61026
61050
61055
61070
61215
61790
61791
61885
61886
61888
62194
62225
62230
62263
62268
62269
62270
62272
62273
62280
62281
62282
62287
62294
62310
62311
62318
62319
62350
62355
62360
62361
62362
62365
63600
63610
63650
63660
63685
63688
63744
63746
64410
64415
64417
64420
64421
64430
64470
64472
64475
64476
64479
64480
64483
64484
64510
64520
64530
64553
64573
64575
64577
64580
64585
64590
64595
64600
64605
64610
64620
64622
64623
64626
64627
64630
64680
64702
64704
64708
64712
64713
64714
64716
64718
64719
64721
64722
64726
64727
64732
64734
64736
64738
64740
64742
64744
64746
64771
64772
64774
64776
64778
64782
64783
64784
64786
64787
64788
64790
64792
64795
64802
64821
64831
64832
64834
64835
64836
64837
64840
64856
64857
64858
64859
64861
64862
64864
64865
64870
64872
64874
64876
64885
64886
64890
64891
64892
64893
64895
64896
64897
64898
64901
64902
64905
64907
65091
65093
65101
65103
65105
65110
65112
65114
65130
65135
65140
65150
65155
65175
65235
65260
65265
65270
65272
65275
65280
65285
65290
65400
65410
65420
65426
65710
65730
65750
65755
65770
65772
65775
65800
65805
65810
65815
65850
65865
65870
65875
65880
65900
65920
65930
66020
66030
66130
66150
66155
66160
66165
66170
66172
66180
66185
66220
66225
66250
66500
66505
66600
66605
66625
66630
66635
66680
66682
66700
66710
66720
66740
66821
66825
66830
66840
66850
66852
66920
66930
66940
66982
66983
66984
66985
66986
67005
67010
67015
67025
67027
67030
67031
67036
67038
67039
67040
67107
67108
67112
67115
67120
67121
67141
67218
67227
67250
67255
67311
67312
67314
67316
67318
67320
67331
67332
67334
67335
67340
67350
67400
67405
67412
67413
67415
67420
67430
67440
67450
67550
67560
67715
67808
67830
67835
67880
67882
67900 (PA)
67901 (PA)
67902 (PA)
67903 (PA)
67904 (PA)
67906 (PA)
67908 (PA)
67909 (PA)
67911 (PA)
67914
67916 (PA)
67917 (PA)
67921
67923 (PA)
67924 (PA)
67935
67950
67961 (PA)
67966 (PA)
67971 (PA)
67973 (PA)
67974 (PA)
67975 (PA)
68115
68130
68320
68325
68326
68328
68330
68335
68340
68360
68362
68500
68505
68510
68520
68525
68540
68550
68700
68720
68745
68750
68770
68810
68811
68815
69110
69120
69140
69145
69150
69205
69300 (PA)
69310
69320
69421
69436
69440
69450
69501
69502
69505
69511
69530
69550
69552
69601
69602
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 (PA)

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) (PA)
D4341    	Periodontal scaling and root planing—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)

D7111	Coronal remnants – deciduous tooth
D7140	Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
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 (PA)
D7230	Removal of impacted tooth—partially bony (PA)
D7240	Removal of impacted tooth—completely bony (PA)
D7283	Placement of device to facilitate eruption of impacted tooth (under 21 only) (PA)

604	Dental Surgery Procedures

Service
Code    	Description

D7310	Alveoloplasty in conjunction with extactions—per quadrant 
D7311	Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces,  per quadrant
D7320	Alveoloplasty not in conjunction with extractions—per quadrant 
D7321	Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant
D7340	Vestibuloplasty—ridge extension (second epithelialization) (PA)
D7960	Frenulectomy (frenectomy or frenotomy)—separate procedure
D7963	Frenuloplasty
D7970	Excision of hyperplastic tissue—per arch (PA)
D7999	Unspecified oral surgery procedure, by report (P.A) (IC)
D9930	Treatment of complications (postsurgical) – unusual circumstances, by report (IC)

605	Prosthetic Service Codes and Descriptions

Service		
Code	Description
Integumentary System

L8500	Artificial larynx, any type (IC)
L8501	Tracheostomy speaking valve (IC)
L8510	Voice amplifier (IC)
L8600	Implantable breast prosthesis, silicone or equal (IC)
L8603	Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and 
necessary supplies (IC)
L8606	Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies (IC)

Head:  Skull, Facial Bones, and Temporomandibular Joint

L8610	Ocular implant (IC)
L8612	Aqueous shunt (IC)
L8613	Ossicular implant (IC)
L8614	Cochlear device/system (IC)
L8619	Cochlear implant external speech processor, replacement (IC)

Upper Extremity

L8630	Metacarpophalangeal joint implant (IC)

Lower Extremity — Joint:  Knee, Ankle, Toe

L8641	Metatarsal joint implant (IC)
L8642	Hallux implant (IC)
L8658	Interphalangeal joint spacer, silicone or equal, each (IC)

Cardiovascular System

L8670	Vascular graft material, synthetic, implant (IC) 

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

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