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-19 December 2007 TO: Freestanding Ambulatory Surgery Centers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Freestanding Ambulatory Surgery Center Manual (2008 HCPCS) This letter transmits revisions to the service codes in the Freestanding Ambulatory Surgery Center Manual. The Centers for Medicare & Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2008. The revised Subchapter 6 is effective for dates of service on or after January 1, 2008. Previously used codes and their replacements are indicated on the chart below. Codes Used for Dates of Service through 12/31/07 Replacement Codes for Dates of Service on/after 1/1/08 32000 32421 43750 Replaced by existing code 43246 51010 51102 52510 No replacement 67038 67041, 67042, 67043 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 freestanding ambulatory surgical facility services is 114.3 CMR 47.00: Freestanding Ambulatory Surgical Facilities. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/sprDivision of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp 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Ambulatory Surgery Center Manual Pages vi and 6-11 through 6-22 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Freestanding Ambulatory Surgery Center Manual Pages vi and 6-11 through 6-22 — transmitted by Transmittal Letter FAS-17 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Freestanding Ambulatory Surgery Center Manual Transmittal Letter FAS-19 Date 01/01/08 6. Service Codes Payable Surgery Services............................................................................................................. 6-1 Periodontic Service Codes and Descriptions .............................................................................. 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/PPHSD Screening Services Codes ............................................................. Z-1 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 31588 31590 31595 31611 31612 31613 31614 31615 31622 31623 31624 31625 31628 31629 31630 31631 31635 31640 31641 31643 31645 31646 31656 31717 31720 31730 31750 31755 31820 31825 31830 32400 32405 32420 32421 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 37718 37722 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 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 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 49180 49250 49320 49321 49322 49402 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 51020 51030 51040 51045 51050 51065 51080 51102 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 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 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 54830 54840 54860 54861 54865 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 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 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) 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 67039 67040 67041 67042 67043 67107 67108 67112 67115 67120 67121 67141 67218 67227 67250 67255 67311 67312 67314 67316 67318 67320 67331 67332 67334 67335 67340 67346 67400 68328 69605 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 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 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) (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) 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 This page is reserved.