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-17 December 2006 TO: Freestanding Ambulatory Surgery Centers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Freestanding Ambulatory Surgery Center Manual (Revisions to Service Codes) This letter transmits revisions to the service codes in the Freestanding Ambulatory Surgery Center Manual. The Centers for Medicare and Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2007. The revised Subchapter 6 is effective for dates of service on or after January 1, 2007. Twenty-two codes have been deleted and 22 codes have been added. Replacement codes and their deleted counterparts are indicated on the following chart. Deleted Codes New Replacement Codes Deleted Code (cont.) New Replacement Codes (cont.) 15000 15002, 15004 49085 49402 15831 15830 (PA) , 15847 54152 (replaced by existing code 54150) 19140 19300 (PA) 19160 19301 54820 54865 19162 19302 55859 55875 19180 19303 56720 56442 19182 19304 57820 57558 21300 No replacement 67350 67346 25611 25606 25620 25607, 25608, 25609 26504 (replaced by existing code 26390) 27315 27325 27320 27326 28030 28055 31700 No replacement If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of 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 paper copy of the publication. The regulation title for Surgery and Related Anesthesia is 114.3 CMR 16.00 . Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp MASSHEALTH TRANSMITTAL LETTER FAS-17 December 2006 Page 2 MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site 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.) 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 6-1, 6-2, 6-21, and 6-22 — transmitted by Transmittal Letter FAS-16 Pages vi and 6-3 through 6-20 — transmitted by Transmittal Letter FAS-15 Commonwealth of Massachusetts Subchapter Number and Title Page MassHealth Table of Contents vi Provider Manual Series Transmittal Letter Date Freestanding Ambulatory Surgery Center Manual FAS-17 01/01/07 6. Service Codes Payable Surgery Services. 6-1 Periodontic Service Codes and 6-21 Exodontic Service Codes and Descriptions 6-21 Dental Surgery Procedures 6-21 Prosthetic Service Codes and Descriptions 6-22 Modifiers 6-22 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix E Admission Guidelines E-1 Appendix W. EPSDT Services: Medical Protocol and Periodicity 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 MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Payable Services MassHealth pays for the following services in a freestanding ambulatory surgery center, subject to all conditions and limitations in MassHealth regulations at 130 CMR 423.000 and 450.000. Codes 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 and 450.271 for more information. PA: Service requires prior authorization. See 130 CMR 423.406, 450.303, 420.410, 433.408, and 424.421, in the Freestanding Ambulatory Surgery Center, Dental , Physician , Podiatrist, and All Provider Manuals respectively, for more information. Commonwealth of Massachusetts Subchapter Number and Title Page MassHealth 6. Service Codes 6-2 Provider Manual Series Transmittal Letter Date Freestanding Ambulatory Surgery Center Manual FAS-17 01/01/07 601 Payable Surgery Services (cont.) 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 15002 15004 15040 15050 15100 15101 15110 15111 15115 15116 15120 15121 15130 15131 15135 15136 15150 15151 Service Code 15152 15155 15156 15157 15200 15201 15220 15221 15240 15241 15260 15261 15300 15301 15320 15321 15330 15331 15335 15336 15400 15401 15420 15421 15430 15431 15570 15572 15574 15576 15600 15610 15620 15630 15650 15732 15734 15736 15738 15740 15750 15760 15770 15820 (PA) 15821 (PA) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-3 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Payable Surgery Services (cont.) Service Code Service Code Service Code 15822 (PA) 19301 21026 15823 (PA) 19302 21029 15830 (PA) 19303 21031 15832 (PA) 19304 21034 15833 (PA) 19318 (PA) 21040 15834 (PA) 19328 (PA) 21044 15835 19330 (PA) 21046 15840 19340 (PA) 21047 15841 19342 (PA) 21050 15845 19350 (PA) 21060 15847 19357 (PA) 21070 15920 19366 (PA) 21100 15922 19370 (PA) 21181 15931 19371 (PA) 21206 (PA) 15933 19380 (PA) 21208 (PA) 15934 20005 21209 (PA) 15935 20200 21210 (PA) 15936 20205 21215 (PA) 15937 20206 21230 (PA) 15940 20220 21235 (PA) 15941 20225 21240 (PA) 15944 20240 21242 (PA) 15945 20245 21243 (PA) 15946 20250 21244 (PA) 15950 20251 21267 (PA) 15951 20525 21270 (PA) 15952 20650 21275 (PA) 15953 20670 21280 (PA) 15956 20680 21282 (PA) 15958 20690 21295 (PA) 16025 20692 21296 (PA) 16030 20693 21310 19020 20694 21315 19100 20900 21320 19101 20902 21325 19102 20910 21330 19103 20912 21335 19110 20920 21336 19112 20922 21337 19120 20924 21338 19125 20926 21339 19126 20975 21340 19290 21010 21345 19291 21015 21355 19300 (PA) 21025 21400 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-4 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 21401 23077 23500 21421 23100 23505 21440 23101 23515 21445 23105 23520 21450 23106 23525 21451 23107 23530 21452 23120 23532 21453 23125 23540 21454 23130 23545 21461 23140 23550 21462 23145 23552 21465 23146 23570 21480 23150 23575 21485 23155 23585 21490 23156 23600 21497 23170 23605 21501 23172 23615 21502 23174 23616 21555 23180 23620 21556 23182 23625 21600 23184 23630 21610 23190 23650 21700 23195 23655 21720 23330 23660 21725 23331 23665 21800 23395 23670 21805 23397 23675 21820 23400 23680 21925 23405 23700 21930 23406 23800 21935 23410 23802 22305 23412 23921 22310 23415 23930 22315 23420 23931 22505 23430 23935 22900 23440 24000 23000 23450 24006 23020 23455 24066 23030 23460 24075 23031 23462 24076 23035 23465 24077 23040 23466 24100 23044 23480 24101 23066 23485 24102 23075 23490 24105 23076 23491 24110 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-5 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 24115 24505 25100 24116 24515 25101 24120 24516 25105 24125 24530 25107 24126 24535 25109 24130 24538 25110 24134 24545 25111 24136 24546 25112 24138 24560 25115 24140 24565 25116 24145 24566 25118 24147 24575 25119 24155 24576 25120 24160 24577 25125 24164 24579 25126 24201 24582 25130 24301 24586 25135 24305 24587 25136 24310 24600 25145 24320 24605 25150 24330 24615 25151 24331 24620 25210 24340 24635 25215 24341 24655 25230 24342 24665 25240 24345 24666 25248 24350 24670 25250 24351 24675 25251 24352 24685 25260 24354 24800 25263 24356 24802 25265 24360 24925 25270 24361 25000 25272 24362 25020 25274 24363 25023 25275 24365 25024 25280 24366 25025 25290 24400 25028 25295 24410 25031 25300 24420 25035 25301 24430 25040 25310 24435 25066 25312 24470 25075 25315 24495 25076 25316 24498 25077 25320 24500 25085 25332 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-6 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 25335 25609 26140 25337 25624 26145 25350 25628 26160 25355 25635 26170 25360 25645 26180 25365 25660 26185 25370 25670 26200 25375 25671 26205 25390 25675 26210 25391 25676 26215 25392 25680 26230 25393 25685 26235 25400 25690 26236 25405 25695 26250 25415 25800 26255 25420 25805 26260 25425 25810 26261 25426 25820 26262 25440 25825 26320 25441 25830 26350 25442 25907 26352 25443 25922 26356 25444 25929 26357 25445 26011 26358 25446 26020 26370 25447 26025 26372 25449 26030 26373 25450 26034 26390 25455 26040 26392 25490 26045 26410 25491 26055 26412 25492 26060 26415 25505 26070 26416 25515 26075 26418 25520 26080 26420 25525 26100 26426 25526 26105 26428 25535 26110 26432 25545 26115 26433 25565 26116 26434 25574 26117 26437 25575 26121 26440 25605 26123 26442 25606 26125 26445 25607 26130 26449 25608 26135 26450 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-7 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 26455 26580 27003 26460 26587 27033 26471 26590 27035 26474 26591 27040 26476 26593 27041 26477 26596 27047 26478 26605 27048 26479 26607 27049 26480 26608 27050 26483 26615 27052 26485 26645 27060 26489 26650 27062 26490 26665 27065 26492 26675 27066 26494 26676 27067 26496 26685 27080 26497 26686 27086 26498 26705 27087 26499 26706 27097 26500 26715 27098 26502 26727 27100 26508 26735 27105 26510 26742 27110 26516 26746 27111 26517 26756 27193 26518 26765 27194 26520 26776 27202 26525 26785 27230 26530 26820 27238 26531 26841 27246 26535 26842 27250 26536 26843 27252 26540 26844 27257 26541 26850 27265 26542 26852 27266 26545 26860 27275 26546 26861 27301 26548 26862 27305 26550 26863 27306 26555 26910 27307 26560 26951 27310 26561 26952 27323 26562 26990 27324 26565 26991 27325 26567 27000 27326 26568 27001 27327 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-8 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 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 27391 27560 27692 27392 27562 27695 27393 27566 27696 27394 27570 27698 27395 27594 27700 27396 27600 27704 27397 27601 27705 27400 27602 27707 27403 27603 27709 27405 27604 27730 27407 27605 27732 27409 27606 27734 27418 27607 27740 27420 27610 27742 27422 27612 27745 27424 27614 27750 27425 27615 27752 27427 27618 27756 27428 27619 27758 27429 27620 27759 27430 27625 27760 27435 27626 27762 27437 27630 27766 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-9 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 27780 28050 28226 27781 28052 28234 27784 28054 28238 27786 28055 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 27842 28114 28300 27846 28116 28302 27848 28118 28304 27860 28119 28305 27870 28120 28306 27871 28122 28307 27884 28126 28308 27889 28130 28309 27892 28140 28310 27893 28150 28312 27894 28153 28313 28002 28160 28315 28003 28171 28320 28005 28173 28322 28008 28175 28340 28011 28192 28341 28020 28193 28344 28022 28200 28345 28024 28202 28400 28035 28208 28405 28043 28210 28406 28045 28222 28415 28046 28225 28420 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-10 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 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 (PA) 28645 29855 30410 (PA) 28665 29856 30420 (PA) 28666 29860 30430 (PA) 28675 29861 30435 (PA) 28705 29862 30450 (PA) 28715 29863 30460 28725 29870 30462 28730 29871 30465 28735 29874 30520 28737 29875 30540 28740 29876 30545 28750 29877 30560 28755 29879 30580 28760 29880 30600 28810 29881 30620 28820 29882 30630 28825 29883 30801 29800 (PA) 29884 30802 29804 (PA) 29885 30903 29805 29886 30905 29806 29887 30906 29807 29888 30915 29819 29889 30920 29820 29891 30930 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-11 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 31020 31535 32405 31030 31536 32420 31032 31540 33010 31050 31541 33011 31051 31560 33222 31070 31561 33223 31075 31570 35188 31080 31571 35207 31081 31576 35875 31084 31577 35876 31085 31578 36260 31086 31580 36261 31087 31582 36262 31090 31588 36488 31200 31590 36489 31201 31595 36490 31205 31611 36491 31233 31612 36530 31235 31613 36531 31237 31614 36532 31238 31615 36533 31239 31622 36534 31240 31623 36535 31254 31624 36555 31255 31625 36556 31256 31628 36557 31267 31629 36558 31276 31630 36560 31287 31631 36561 31288 31635 36563 31300 31640 36565 31320 31641 36566 31400 31643 36568 31420 31645 36569 31510 31646 36570 31511 31656 36571 31512 31717 36575 31513 31720 36576 31515 31730 36578 31525 31750 36580 31526 31755 36581 31527 31820 36582 31528 31825 36583 31529 31830 36584 31530 32000 36585 31531 32400 36589 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-12 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 36590 40500 41800 36640 40510 41827 36800 40520 42000 36810 40525 42107 36815 40527 42120 36819 40530 42140 (PA) 36820 40650 42145 36821 40652 42180 36825 40654 42182 36830 40700 42200 36831 40701 42205 36832 40720 42210 36833 40761 42215 36835 40801 42220 36860 40806 42226 36861 40814 42235 36870 40816 42260 37607 40818 42300 37609 40819 42305 37650 40831 42310 37700 40840 (PA) 42320 37718 40842 (PA) 42340 37722 40843 (PA) 42405 37735 40844 (PA) 42408 37760 40845 (PA) 42409 37780 41005 42410 37785 41006 42415 37790 41007 42420 38300 41008 42425 38305 41009 42440 38308 41010 42450 38500 41015 42500 38505 41016 42505 38510 41017 42507 38520 41018 42508 38525 41112 42509 38530 41113 42510 38542 41114 42600 38550 41116 42700 38555 41120 42720 38570 41250 42725 38571 41251 42800 38572 41252 42802 38740 41500 42804 38745 41510 42806 38760 41520 42808 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-13 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 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 42955 43268 45108 42960 43269 45150 42962 43271 45160 42972 43272 45170 43200 43450 45190 43201 43453 45305 43202 43456 45307 43204 43458 45308 43205 43600 45309 43215 43653 45315 43216 43750 45317 43217 43760 45320 43219 43870 45321 43220 44100 45331 43226 44312 45332 43227 44340 45333 43228 44360 45334 43231 44361 45335 43232 44363 45337 43234 44364 45338 43235 44365 45339 43236 44366 45340 43239 44369 45355 43240 44370 45378 43241 44372 45379 43242 44373 45380 43243 44376 45381 43244 44377 45382 43245 44378 45383 43246 44379 45384 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-14 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 45385 46924 49566 45386 46937 49568 45500 46938 49570 45505 47000 49572 45560 47510 49580 45900 47511 49582 45905 47525 49585 45910 47530 49587 45915 47552 49590 46020 47553 49600 46030 47554 49650 46040 47555 49651 46045 47556 50200 46050 47560 50390 46060 47561 50392 46080 47630 50393 46200 48102 50395 46210 49080 50396 46211 49081 50398 46220 49180 50551 46250 49250 50553 46255 49320 50555 46257 49321 50557 46258 49322 50561 46260 49402 50590 46261 49420 50688 46262 49421 50947 46270 49422 50948 46275 49426 50951 46280 49495 50953 46285 49496 50955 46288 49500 50957 46608 49501 50961 46610 49505 50970 46611 49507 50972 46612 49520 50974 46615 49521 50976 46700 49525 50980 46750 49540 51010 46753 49550 51020 46754 49553 51030 46760 49555 51040 46761 49557 51045 46762 49560 51050 46917 49561 51065 46922 49565 51080 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-15 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 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 52005 52510 53510 52007 52601 53515 52010 52606 53520 52204 52612 53605 52214 52614 53665 52224 52620 53850 (PA) 52234 52630 54000 52235 52640 54001 52240 52647 54015 52250 52648 54057 52260 52700 54060 52270 53000 54065 52275 53010 54100 52276 53020 54105 52277 53040 54110 52281 53080 54111 52282 53200 54112 52283 53210 54115 52285 53215 54120 52290 53220 54150 52300 53230 54160 52305 53235 54161 52310 53240 54162 52315 53250 54163 52317 53260 54164 52318 53265 54205 52320 53270 54220 52325 53275 54300 52327 (PA) 53400 54304 52330 53405 54308 52332 53410 54312 52334 53420 54316 52341 53425 54318 52342 53430 54322 52343 53431 54324 52344 53440 54326 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-16 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code 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 54830 54840 54860 54861 54865 55040 55041 55060 55100 55110 Service Code 55120 55150 55175 55180 55250 (CS-18 or CS-21) 55500 55520 55530 55535 55540 55550 55680 55700 55705 55720 55725 55875 56440 56441 56442 56515 56620 56625 56700 56740 56800 56810 57000 57010 57020 57023 57065 57105 57130 57135 57180 57200 57210 57220 57230 57240 57250 57260 57265 57268 57289 Service Code 57291 57300 57400 57410 57415 57513 57520 57522 57530 57550 57555 57556 57558 57700 57720 58120 58145 58350 58353 58545 58546 58550 58555 58558 58559 58560 (CS-18 or CS-21) 58561 (CS-18 or CS- 21) 58562 58563 58565 (CS-18 or CS- 21) 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) 601 Surgery Service Codes (cont.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-17 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 Service Code 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 Service Code Service Code 63685 64718 63688 64719 63744 64721 63746 64722 64410 64726 64415 64727 64417 64732 64420 64734 64421 64736 64430 64738 64470 64740 64472 64742 64475 64744 64476 64746 64479 64771 64480 64772 64483 64774 64484 64776 64510 64778 64520 64782 64530 64783 64553 64784 64573 64786 64575 64787 64577 64788 64580 64790 64585 64792 64590 64795 64595 64802 64600 64821 64605 64831 64610 64832 64620 64834 64622 64835 64623 64836 64626 64837 64627 64840 64630 64856 64680 64857 64702 64858 64704 64859 64708 64861 64712 64862 64713 64864 64714 64865 64716 64870 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-18 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code Service Code 64872 65750 66830 64874 65755 66840 64876 65770 66850 64885 65772 66852 64886 65775 66920 64890 65800 66930 64891 65805 66940 64892 65810 66982 64893 65815 66983 64895 65850 66984 64896 65865 66985 64897 65870 66986 64898 65875 67005 64901 65880 67010 64902 65900 67015 64905 65920 67025 64907 65930 67027 65091 66020 67030 65093 66030 67031 65101 66130 67036 65103 66150 67038 65105 66155 67039 65110 66160 67040 65112 66165 67107 65114 66170 67108 65130 66172 67112 65135 66180 67115 65140 66185 67120 65150 66220 67121 65155 66225 67141 65175 66250 67218 65235 66500 67227 65260 66505 67250 65265 66600 67255 65270 66605 67311 65272 66625 67312 65275 66630 67314 65280 66635 67316 65285 66680 67318 65290 66682 67320 65400 66700 67331 65410 66710 67332 65420 66720 67334 65426 66740 67335 65710 66821 67340 65730 66825 67346 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-19 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 601 Surgery Service Codes (cont.) Service Code Service Code 67400 68330 67405 68335 67412 68340 67413 68360 67415 68362 67420 68500 67430 68505 67440 68510 67450 68520 67550 68525 67560 68540 67715 68550 67808 68700 67830 68720 67835 68745 67880 68750 67882 68770 67900 (PA) 68810 67901 (PA) 68811 67902 (PA) 68815 67903 (PA) 69110 67904 (PA) 69120 67906 (PA) 69140 67908 (PA) 69145 67909 (PA) 69150 67911 (PA) 69205 67914 69300 (PA) 67916 (PA) 69310 67917 (PA) 69320 67921 69421 67923 (PA) 69436 67924 (PA) 69440 67935 69450 67950 69501 67961 (PA) 69502 67966 (PA) 69505 67971 (PA) 69511 67973 (PA) 69530 67974 (PA) 69550 67975 (PA) 69552 68115 69601 68130 69602 68320 69603 68325 69604 68326 69605 68328 69620 Service Code 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-20 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 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) (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) (PA) 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 (PA) (IC) D9930 Treatment of complications (postsurgical) – unusual circumstances, by report (IC) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-21 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 605 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-22 Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-17 Date 01/01/07 This page is reserved.