Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter FAS-24 April 2012 TO: Freestanding Ambulatory Surgery Centers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Freestanding Ambulatory Surgery Center Manual (2012 HCPCS) This letter transmits revisions to the service codes in the Freestanding Ambulatory Surgery Center (FASC) Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) codes for 2012. The revised Subchapter 6 is effective for dates of service on or after January 1, 2012. 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 specific regulation title for FASC services is114.3 CMR 47.00: Freestanding Ambulatory Surgical Facility Services. 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. MassHealth Transmittal Letter FAS-24 April 2012 Page 2 NEW MATERIAL (The pages listed here contain new or revised language.) Freestanding Ambulatory Surgery Center Manual Pages 6-1 through 6-12 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Freestanding Ambulatory Surgery Center Manual Pages 6-1 through 6-12 — transmitted by Transmittal Letter FAS-23 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6. Service Codes Transmittal Letter FAS-24 Page 6-1 Date 01/01/12 601 Payable Surgery Services MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 423.000 and 450.000. A freestanding ambulatory surgery center may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Freestanding Ambulatory Surgery Center Manual. 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 420.410, 423.406, 424.421, 433.408, and 450.303 in the Dental Manual, Freestanding Ambulatory Surgery Center Manual, Podiatrist Manual, Physician Manual, respectively, for more information. 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 14301 14302 14350 15002 15004 15040 15050 15100 15101 15110 15111 15115 15116 15120 15121 15130 15131 15135 15136 15150 15151 15152 15155 15156 15157 15200 15201 15220 15221 15240 15241 15260 15261 15271 15272 15273 15274 15275 15276 15277 15278 15570 15572 15574 15576 15600 15610 15620 15630 15650 15732 15734 15736 15650 15732 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6. Service Codes Transmittal Letter FAS-24 Page 6-2 Date 01/01/12 601 Payable Surgery Services (cont.) Service Code 15734 15736 15738 15740 15750 15760 15770 15820 (PA) 15821 (PA) 15822 (PA) 15823 (PA) 15830 (PA) 15832 (PA) 15833 (PA) 15834 (PA) 15835 15840 15841 15845 15847 15920 15922 15931 15933 15934 15935 15936 15937 15940 15941 15944 15945 15946 15950 15951 15952 15953 15956 15958 16025 16030 19020 19100 19101 19102 19103 19110 19112 19120 19125 19126 19290 19291 19300 (PA) 19301 19302 19303 19304 19318 (PA) 19328 (PA) 19330 (PA) 19340 (PA) 19342 (PA) 19350 (PA) 19357 (PA) 19366 (PA) 19370 (PA) 19371 (PA) 19380 (PA) 20005 20200 20205 20206 20220 20225 20240 20245 20250 20251 20525 20650 20670 20680 20690 20692 20693 20694 20900 20902 20924 20926 20975 21010 21011 21012 21013 21014 21015 21016 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) 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 21497 21501 21502 21552 21554 21555 21556 21600 21610 21700 21720 21725 21800 21805 21820 21925 21930 21931 21932 21933 21935 21936 22305 22310 22315 22505 22900 22901 22902 22903 22904 22905 23000 23020 23030 23031 23035 23040 23044 23066 23071 23073 23075 23076 23077 23078 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6. Service Codes Transmittal Letter FAS-24 Page 6-3 Date 01/01/12 601 Payable Surgery Services (cont.) Service Code 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 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 25071 25073 25075 25076 25077 25078 25085 25100 25101 25105 25107 25109 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6. Service Codes Transmittal Letter FAS-24 Page 6-4 Date 01/01/12 601 Payable Surgery Services (cont.) Service Code 25535 25545 25565 25574 25575 25605 25606 25607 25608 25609 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 26111 26113 26115 26116 26117 26118 26121 26123 26125 26130 26135 26140 26145 26160 26170 26180 26185 26200 26205 26210 26215 26230 26235 26236 26250 26260 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 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 27043 27045 27047 27048 27049 27050 27052 27059 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 27323 27324 27325 27326 27327 27328 27329 27330 27331 27332 27333 27334 27335 27337 27339 27340 27345 27347 27350 27355 27356 27357 27358 27360 27364 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 27616 27618 27619 27620 27625 27626 27630 27632 27634 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 28035 28039 28041 28043 28045 28046 28047 28050 28052 28054 28055 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6. Service Codes Transmittal Letter FAS-24 Page 6-6 Date 01/01/12 601 Payable Surgery Services (cont.) Service Code 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6. Service Codes Transmittal Letter FAS-24 Page 6-7 Date 01/01/12 601 Payable Surgery Services (cont.) Service Code 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 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 41115 41116 41120 41250 41251 41252 41500 41510 41520 41800 41805 41820 41827 41828 41872 41874 41899 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6. Service Codes Transmittal Letter FAS-24 Page 6-8 Date 01/01/12 601 Payable Surgery Services (cont.) Service Code 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 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 45171 45172 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 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 47000 47510 47511 47525 47530 47552 47553 47554 47555 47556 47560 47561 47630 48102 49082 49083 49084 49180 49250 49320 49321 49322 49402 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6. Service Codes Transmittal Letter FAS-24 Page 6-9 Date 01/01/12 601 Payable Surgery Services (cont.) Service Code 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 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 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6. Service Codes Transmittal Letter FAS-24 Page 6-10 Date 01/01/12 601 Payable Surgery Services (cont.) Service Code 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 63661 63662 63663 63664 63685 63688 63744 63746 64410 64415 64417 64420 64421 64430 64479 64480 64483 64484 64490 64491 64492 64493 64494 64495 64510 64520 64530 64553 64575 64580 64585 64590 64595 64600 64605 64610 64620 64630 64633 64634 64635 64636 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6. Service Codes Transmittal Letter FAS-24 Page 6-11 Date 01/01/12 601 Payable Surgery Services (cont.) Service Code 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 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 68330 68505 68325 68326 68328 68335 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 69670 69676 69700 Commonwealth of Massachusetts MassHealth Provider Manual Series Freestanding Ambulatory Surgery Center Manual Subchapter Number and Title 6. Service Codes Transmittal Letter FAS-24 Page 6-12 Date 01/01/12 601 Payable Surgery Services (cont.) Service Code 69711 69714 69715 69717 69718 69720 69725 68340 68360 68362 68500 69740 69745 69801 69805 69806 69820 69840 69905 69910 69915 69930 602 Modifiers 50 Bilateral procedure 51 Multiple procedures 73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure before the administration of anesthesia 74 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia G Ambulatory surgical center (ASC) facility service