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

TO:
FROM:
RE:

MASSHEALTH
TRANSMITTAL LETTER FPA-35
October 2003
Family Planning Agencies Participating in MassHealth Beth Waldman, Acting Commissioner
Family Planning Agency Manual (Revisions to Service Codes and Descriptions)

This letter transmits revisions to the service codes and descriptions in the Family Planning Agency Manual. The revised Subchapter 6 is effective for dates of service on or after October 16, 2003.
The Centers for Medicare and Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) for 2003. All MassHealth local codes have been removed from the Family Planning Agency Manual in compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, as amended. Please note that you must use a modifier with some codes to accurately reflect the service provided. The attached Subchapter 6 contains codes with modifiers, where applicable.
I.	Billing Guidelines
Please find attached a crosswalk from the obsolete MassHealth local service codes and modifiers to the new national service codes and modifiers for the revised Subchapter 6.
Please note that you must use the FP modifier when billing for medications related to family planning services using the new standard code J3490. Failure to use this modifier will result in a denied claim. The use of this modifier is in addition to checking off the Family Planning indicator on the claim form, or making the appropriate entry on an electronic claim, for all family planning services.
Please also note that the billing units have changed for the new standard codes.
II.	How to Obtain a Family Planning Agency Fee Schedule with the New Service Codes
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 is 114.3 CMR 12.00: Family Planning Services.

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 FPA-35 October 2003 Page 2
III. Web Site Access and Questions
All of the information in this transmittal letter, as well as the revised regulations, is available on the Division’s Web site at www.mass.gov/dma.
If you have any questions, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Pages 6-1 through 6-12
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Pages 6-1 through 6-12—transmitted by Transmittal Letter FPA-34

Family Planning Agency Service Code Crosswalk
Effective for dates of service beginning October 16, 2003

Transmittal Letter FPA-35 October 2003 Attachment 1

Obsolete Code	Obsolete Code Description	New Code Modifier	New Code Description	Comments	
X1051	Diaphragm (including applicator and cream or jelly)	A4266	Diaphragm for contraceptive use	Includes applicator and cream or jelly.	
X1052	Condoms (three)	A4267	Contraceptive supply, condom, male, each	Bill per condom, not per package.	
X1054	Contraceptive jelly	A4269	Contraceptive supply, spermicide (e.g., foam, gel), each	Bill per package/tube.	
X1056	Contraceptive cream	A4269	Contraceptive supply, spermicide (e.g., foam, gel), each	Bill per package/tube.	
X1057	Contraceptive film (three)	A4269	Contraceptive supply, spermicide (e.g., foam, gel), each	Bill per package of film.	
X1058	Contraceptive foam	A4269	Contraceptive supply, spermicide (e.g., foam, gel), each	Bill per package/tube.	
X1059	Female condoms with lubricant (six)	A4268	Contraceptive supply, condom, female, each	Bill per condom, not per package.	
X1060	Female condoms with lubricant six	A4268	Contraceptive supply, condom, female, each	Bill per condom, not per package.	
X1061	Contraceptive suppositories (package of 12)	A4269	Contraceptive supply, spermicide (e.g., foam, gel), each	Bill per package, not per suppository.	
X1063	Cervical sponges (three)	A4269	Contraceptive supply, spermicide (e.g., foam, gel), each	Bill per package, not per sponge.	
X1069	Medications and injectables related to family planning services with the exception of Rho (D) human immune globulin and contraceptive injectables, such as Depo-Provera (the Division will pay for these items at the provider’s cost) (I.C.)	J3490FP	Unclassified drugs (service provided as part of Medicaid family planning program) (use for medications and injectibles related to family planning services, with the exception of Rho(D) human immune globulin, and contraceptive injectables such as Depo-Provera, items for which the Division pays the provider's cost) (I.C.)	Providers must use both the FP modifier and the Family Planning Indicator on the claim form. Failure to use the FP modifier will result in a denied claim.	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-1	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
601   Definitions
 (A)	New Patient — a patient who has not received any professional services from the provider within the past three years.
 (B)	Established Patient — a patient who has received professional services from the provider within the past three years.
602   Service Codes and Descriptions: Visits
Service
Code       Service Description
New Patient
99201      Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components:
 -	a problem-focused history;
 -	a problem-focused examination; and
 -	straightforward medical decision making (brief service) 99203      Office or other outpatient visit for the evaluation and management of a new patient, which requires
these three key components:
 -	a detailed history;
 -	a detailed examination; and
 -	medical decision making of low complexity 99205      Office or other outpatient visit for the evaluation and management of a new patient, which requires
these three key components:
 -	a comprehensive history;
 -	a comprehensive examination; and
 -	medical decision making of high complexity (comprehensive service)
Established Patient
99211      Office or other outpatient visit for the evaluation and management of an established patient, that
may not require the presence of a physician. (minimal service) 99213      Office or other outpatient visit for the evaluation and management of an established patient, which
requires at least two of these three key components:
 -	an expanded problem-focused history;
 -	an expanded problem-focused examination;
 -	medical decision making of low complexity (limited service) 99215      Office or other outpatient visit for the evaluation and management of an established patient, which
requires at least two of these three key components:
 -	a comprehensive history;
 -	a comprehensive examination;
 -	medical decision making of high complexity (comprehensive service)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-2	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
603   Service Codes and Descriptions: Contraceptive Supplies and Drugs
Service
Code       Service Description
A4261     Cervical cap for contraceptive use (I.C.)
A4266     Diaphragm for contraceptive use (includes applicator and cream or jelly)
A4267     Contraceptive supply, condom, male, each
A4268     Contraceptive supply, condom, female, each
A4269     Contraceptive supply, spermicide (e.g., foam, gel), each (per package/tube)
J1055      Injection, medroxyprogesterone acetate for contraceptive use, 150 mg (Use for Depo-Provera.)
(I.C.) J1056      Injection, medroxyprogesterone acetate/estradiol cypionate, 5 mg/25 mg (Use for Lunelle monthly
contraceptive.) (I.C.) J3490-FP Unclassified drugs (Use for medications and injectibles related to family planning services, with
the exception of (a) Rho(D) human immune globulin; and (b) contraceptive injectables such as
Depo-Provera, items for which the Division will pay the provider's cost) (I.C.) S4989     Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies (I.C.) S4993     Contraceptive pills for birth control
604   Service Codes and Descriptions: Medical and Surgery Procedures
Service
Code       Service Description
11975	Insertion, implantable contraceptive capsules (global rate for Norplant System of Contraception,
includes counseling prior to insertion, the price of the Norplant device, the insertion procedure, and one follow-up visit)
 11976	Removal, implantable contraceptive capsules (S.P.)
 11977	Removal with reinsertion, implantable contraceptive capsules (global rate for Norplant System of
Contraception, includes the price of the Norplant device, removal of an old device, insertion
of a new device, and one follow-up visit) 19100     Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) 49080     Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); initial 55250     Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen
examination(s) (Consent for Sterilization form CS-18 or CS-21 required) 55450     Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) (Consent for
Sterilization form CS-18 or CS-21 required) 56420     Incision and drainage of Bartholin’s gland abscess 56501     Destruction of lesion(s), vulva; simple (e.g., laser surgery, electrosurgery, cryosurgery,
chemosurgery)
 56605	Biopsy of vulva or perineum (separate procedure); one lesion
 56606	each separate additional lesion (List separately in addition to code for primary procedure.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-3	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
604	Service Codes and Descriptions: Medical and Surgery Procedures (cont.)
Service
Code       Service Description
57061      Destruction of vaginal lesion(s); simple (e.g., laser surgery, electrosurgery, cryosurgery,
chemosurgery) 57100      Biopsy of vaginal mucosa; simple (separate procedure)
57420	Colposcopy of the entire vagina, with cervix if present
57421	with biopsy(ies)
57452      Colposcopy of the cervix including upper/adjacent vagina
 57454	with biopsy(ies) of the cervix and endocervical curettage
 57455	with biopsy(ies) of the cervix
 57456	with endocervical curettage

 57460	with loop electrode biopsy(ies) of the cervix
 57461	with loop electrode conization of the cervix 57500      Biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate
procedure) 57505      Endocervical curettage (not done as part of a dilation and curettage)
57510	Cautery of cervix; electro or thermal
57511	cryocautery, initial or repeat
57513	laser ablation
57520     Conization of cervix, with or without fulguration, with or without dilation and curettage, with or
without repair; cold knife or laser
57522	loop electrode excision
58100     Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical
dilation, any method (separate procedure)
605	Service Codes and Descriptions: Laboratory Services
ORGAN OR DISEASE-ORIENTED PANELS
These panels were developed for coding purposes only and should not be interpreted as clinical parameters. The tests listed with each panel identify the defined components of that panel. These panel components are not intended to limit the performance of other tests. If one performs tests in addition to those specifically indicated for a particular panel, those tests should be reported separately in addition to the panel code.
Service
Code       Service Description
80055      Obstetric panel (This panel must include the following: hemogram, automated, and manual differential WBC count (CBC) (85022) or hemogram and platelet count, automated, and automated complete differential WBC count (CBC) (85025); hepatitis B surface antigen (HBsAg) (87340); antibody, rubella (86762); syphilis test, qualitative (e.g., VDRL, RPR, ART) (86592), antibody screen, RBC, each serum technique (86850); blood typing, ABO (86900), and blood typing, Rh (D) (86901).)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-4	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
605   Service Codes and Descriptions: Laboratory Services (cont.)

Service Code
80061
80074
80076
81000
81001 81002 81003 81005 81007 81025 81099
82040 82247 82248 82270
82273 82310

Service Description
Lipid panel (This panel must include the following: cholesterol, serum, total (82465); lipoprotein,
direct measurement, high density cholesterol (HDL cholesterol) (83718); and triglycerides
(84478).) Acute hepatitis panel (This panel must include the following: hepatitis A antibody (HAAb); IgM
antibody (86709); hepatitis B core antibody (HbcAb), IgM antibody (86705); hepatitis B
surface antigen (HbsAg) (87340); and hepatitis C antibody (86803).) Hepatic function panel (This panel must include the following: albumin (82040); bilirubin, total
(82247); bilirubin, direct (82248); phosphatase, alkaline (84075); protein, total (84155);
transferase, alanine amino (ALT) (SGPT) (84460); and transferase, aspartate amino (AST)
(SGOT) (84450).)
URINALYSIS
Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes,
nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents;
nonautomated, with microscopy
automated, with microscopy
nonautomated, without microscopy
automated, without microscopy Urinalysis; qualitative or semiquantitative, except immunoassays
bacteriuria screen, except by culture or dipstick Urine pregnancy test, by visual color comparison methods Unlisted urinalysis procedure
CHEMISTRY
The material for examination may be from any source. The examination is quantitative unless specified. Clinical information derived from the results of laboratory data that is mathematically calculated (e.g., free thyroxine index (T7)) is considered part of the test procedure and therefore is not a separately reportable service.
Albumin; serum Bilirubin; total
direct Blood, occult; by peroxidase activity (e.g., guaiac), qualitative; feces, 1-3 simultaneous
determinations
other sources Calcium; total

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-5	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
605   Service Codes and Descriptions: Laboratory Services (cont.)
Service
Code	Service Description
82465	Cholesterol, serum or whole blood, total
82540	Creatine
82550	Creatine kinase (CK), (CPK); total
82565	Creatinine; blood
82570	other source
82607	Cyanocobalamin (vitamin B-12)
82627	Dehydroepiandrosterone-sulfate (DHEA-S)
 82670	Estradiol
 82671	Estrogens; fractionated
82672	total
82677	Estriol
82679	Estrone
82746	Folic acid; serum
82947	Glucose; quantitative, blood (except reagent strip)
82950	post-glucose dose (includes glucose)
82951	tolerance test (GTT), three specimens (includes glucose)
82955	Glucose-6-phosphate dehydrogenase (G6PD); quantitative
82960	screen
83001	Gonadotropin; follicle-stimulating hormone (FSH)
83002	luteinizing hormone (LH)
83003	Growth hormone, human (HGH) (somatotropin)
83036	Hemoglobin; glycated
83491	Hydroxycorticosteroids, 17- (17-OHCS)
83540	Iron
83550	Iron-binding capacity
83586	Ketosteroids, 17- (17-KS); total
83593	fractionation
83615	Lactate dehydrogenase (LD), (LDH)
83625	isoenzymes, separation and quantitation
83718	Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
84060	Phosphatase, acid; total
84066	prostatic
84075	Phosphatase, alkaline
84078	heat stable (total not included)
84080	isoenzymes

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-6	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
605   Service Codes and Descriptions: Laboratory Services (cont.)
Service
Code	Service Description
84132	Potassium; serum
84144	Progesterone
84146	Prolactin
84155	Protein; total, except refractometry
84160	refractometric
84165	electrophoretic fractionation and quantitation
84295	Sodium; serum
84300	urine
84402	Testosterone; free
84403	total
84436	Thyroxine; total
84437	requiring elution (e.g., neonatal)
84439	free
84443	Thyroid-stimulating hormone (TSH)
84450	Transferase; aspartate amino (AST) (SGOT)
84460	alanine amino (ALT) (SGPT)
 84478	Triglycerides
 84479	Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)
84480	Triiodothyronine T3; total (TT-3)
84520	Urea nitrogen; quantitative
84550	Uric acid; blood
84590	Vitamin A
84702	Gonadotropin, chorionic (hCG); quantitative
84703	qualitative
HEMATOLOGY AND COAGULATION
85007	Blood count; blood smear, microscopic examination with manual differential WBC count
 85008	blood smear, microscopic examination without manual differential WBC count
 85009	manual differential WBC count, buffy coat

 85013	spun microhematocrit
 85014	hematocrit (Hct) 85018	hemoglobin (Hgb)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-7	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
605   Service Codes and Descriptions: Laboratory Services (cont.)
Service
Code       Service Description
85025	complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated
differential WBC count
85027	complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count)
85041	red blood cell (RBC), automated
85610      Prothrombin time
85651	Sedimentation rate, erythrocyte; nonautomated
85652	automated
85660      Sickling of RBC, reduction
IMMUNOLOGY
86038      Antinuclear antibodies (ANA)
86171      Complement fixation tests, each antigen
86235      Extractable nuclear antigen, antibody to, any method (e.g., nRNP, SS-A, SS-B, Sm, RNP,
Sc170, J01), each antibody 86280      Hemagglutination inhibition test (HAI)
86308	Heterophile antibodies; screening
 86309	titer
 86310	titers after absorption with beef cells and guinea pig kidney

 86317	Immunoassay for infectious agent antibody, quantitative, not otherwise specified
 86318	Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (e.g., reagent strip)
86592	Syphilis test; qualitative (e.g., VDRL, RPR, ART)
86593	quantitative
The following codes (86628-86804) are qualitative or semiquantitative immunoassays performed by multiple step methods for the detection of antibodies to infectious agents. For immunoassays by single step method (e.g., reagent strips), use code 86318. Procedures for the identification of antibodies should be coded as precisely as possible. For example, an antibody to a virus could be coded with increasing specificity for virus, family, genus, species, or type. In some cases, further precision may be added to codes by specifying the class of immunoglobulin being detected. When multiple tests are done to detect antibodies to organisms classified more precisely than the specificity allowed by available codes, it is appropriate to code each as a separate service.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-8	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
605   Service Codes and Descriptions: Laboratory Services (cont.)
Service
Code	Service Description
86628	Antibody; candida
 86631	chlamydia
 86632	chlamydia, IgM

 86687	HTLV-I
 86688	HTLV-II
 86689	HTLV or HIV antibody, confirmatory test (e.g., Western Blot) 86692	hepatitis, delta agent

 86694	herpes simplex, non-specific type test
 86695	herpes simplex, type 1
 86696	herpes simplex, type 2
86704	Hepatitis B core antibody (HBcAb); total
86705	IgM antibody
 86706	Hepatitis B surface antibody (HBsAb)
 86707	Hepatitis Be antibody (HBeAb)
 86708	Hepatitis A antibody (HAAb); total
86709	IgM antibody
86762	Antibody; rubella
86781	Treponema Pallidum, confirmatory test (e.g., FTA-abs)
86803	Hepatitis C antibody
86804	confirmatory test (e.g., immunoblot)
TRANSFUSION MEDICINE
86850	Antibody screen, RBC, each serum technique
86900	Blood typing; ABO
86901	Rh (D) (I.C.)
86906	Rh phenotyping, complete
MICROBIOLOGY
87070	Culture, bacterial; any other source except urine, blood or stool, with isolation and presumptive
identification of isolates
87075	any source; anaerobic with isolation and presumptive identification of isolates
87081	Culture, presumptive, pathogenic organisms, screening only
87086	Culture, bacterial; quantitative colony count, urine
87088	with isolation and presumptive identification of isolates, urine
87101	Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or
nail
 87102	other source (except blood)
 87103	blood

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-9	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
605   Service Codes and Descriptions: Laboratory Services (cont.)

Service Code

Service Description

87110      Culture, chlamydia, any source
87140      Culture, typing; immunofluorescent method, each antiserum
87164      Dark field examination, any source (e.g., penile, vaginal, oral, skin); includes specimen collection
87177      Ova and parasites, direct smears, concentration and identification
87181      Susceptibility studies, antimicrobial agent; agar dilution method, per agent (e.g., antibiotic
gradient strip)
87184	disk method, per plate (12 or fewer agents)
87186	microdilution or agar dilution (minimum inhibitory concentration (MIC) or breakpoint), each
multiantimicrobial, per plate
87188	macrobroth dilution method, each agent
87205	Smear, primary source, with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types
 87206	fluorescent and/or acid-fast stain for bacteria, fungi, parasites, viruses, or cell types
 87207	special stain for inclusion bodies or parasites (e.g., malaria, coccidia, microsporidia, trypanosomes, herpes viruses)
87210	wet mount for infectious agents (e.g., saline, India ink, KOH preps)
87220      Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (e.g., scabies)
87252	Virus isolation; tissue culture inoculation, observation, and presumptive identification by
cytopathic effect
87253	tissue culture, additional studies or definitive identification (e.g., hemabsorption,
neutralization, immunofluoresence stain), each isolate
Infectious agents by antigen detection, immunofluorescence microscopy, or nucleic acid probe techniques should be reported as precisely as possible. The most specific code possible should be reported. For identification of antibodies to many of the listed infectious agents, see 86602-86804.
87270	Infectious agent antigen detection by immunofluorescent technique; chlamydia trachomatis
87273	Herpes simplex virus type 2
87274	Herpes simplex virus type 1
87285	Treponema pallidum

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-10	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
605   Service Codes and Descriptions: Laboratory Services (cont.)
Service
Code       Service Description
87320      Infectious agent antigen detection by enzyme immunoassay technique, qualitative or
semiquantitative, multiple step method; chlamydia trachomatis
87340	hepatitis B surface antigen (HBsAg)
87350	hepatitis Be antigen (HBeAg)
87380	hepatitis, delta agent
 87390	HIV-1
 87391	HIV-2
87480	Infectious agent detection by nucleic acid (DNA or RNA); candida species, direct probe technique
 87481	Candida species, amplified probe technique
 87482	Candida species, quantification

 87490	Chlamydia trachomatis, direct probe technique
 87491	Chlamydia trachomatis, amplified probe technique
 87492	Chlamydia trachomatis, quantification

 87510	Gardnerella vaginalis, direct probe technique
 87511	Gardnerella vaginalis, amplified probe technique
 87512	Gardnerella vaginalis, quantification

 87515	hepatitis B virus, direct probe technique
 87516	hepatitis B virus, amplified probe technique
 87517	hepatitis B virus, quantification

 87520	hepatitis C, direct probe technique
 87521	hepatitis C, amplified probe technique
 87522	hepatitis C, quantification

 87528	Herpes simplex virus, direct probe technique
 87529	Herpes simplex virus, amplified probe technique
 87530	Herpes simplex virus, quantification

 87534	HIV-1, direct probe technique
 87535	HIV-1, amplified probe technique
 87536	HIV-1, quantification
 87537	HIV-2, direct probe technique
 87538	HIV-2, amplified probe technique
 87539	HIV-2, quantification

 87590	Neisseria gonorrhoeae, direct probe technique
 87591	Neisseria gonorrhoeae, amplified probe technique
 87592	Neisseria gonorrhoeae, quantification

 87620	papillomavirus, human, direct probe technique
 87621	papillomavirus, human, amplified probe technique
 87622	papillomavirus, human, quantification

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-11	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
605   Service Codes and Descriptions: Laboratory Services (cont.)
Service
Code       Service Description
87810      Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis
87850	Neisseria gonorrhoeae
ANATOMIC PATHOLOGY
Cytopathology
88104      Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation
 88106	filter method only with interpretation
 88107	smears and filter preparation with interpretation
88108	Cytopathology, concentration technique, smears and interpretation (e.g., Saccomanno technique)
88130      Sex chromatin identification; Barr bodies
Codes 88141-88155, 88164-88167 are used to report cervical or vaginal screening by various methods and to report physician interpretation services. Use codes 88150-88154 to report Pap smears that are examined using non-Bethesda reporting. Use codes 88164-88167 to report Pap smears that are examined using the Bethesda System of reporting. Use codes 88142-88143 to report specimens collected in fluid medium with automated thin layer preparation that are examined using any system of reporting (Bethesda or non-Bethesda). Within each of these three code families choose the one code that describes the screening method(s) used. Codes 88141 and 88155 should be reported in addition to the screening code chosen when the additional services are provided.
88141	Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician
(List separately in addition to code for technical service.)
88142	Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid,
automated thin layer preparation; manual screening under physician supervision
88143	with manual screening and rescreening under physician supervision
88147	Cytopathology smears, cervical or vaginal; screening by automated system under physician
supervision
88148	screening by automated system with manual rescreening under physician supervision
88150      Cytopathology, slides, cervical or vaginal; manual screening under physician supervision
 88152	with manual screening and computer-assisted rescreening under physician supervision
 88153	with manual screening and rescreening under physician supervision
 88154	with manual screening and computer-assisted rescreening using cell selection and review under physician supervision
88155	Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (e.g., maturation index,
karyopyknotic index, estrogenic index) (List separately in addition to code(s) for other technical and interpretation services.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
FAMILY PLANNING AGENCY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-12	

	TRANSMITTAL LETTER
FPA-35	DATE
10/16/03	
605   Service Codes and Descriptions: Laboratory Services (cont.)
Service
Code       Service Description
88160	Cytopathology, smears, any other source; screening and interpretation
 88161	preparation, screening, and interpretation
 88162	extended study involving over 5 slides and/or multiple stains (I.C.)
88164	Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under
physician supervision
 88165	with manual screening and rescreening under physician supervision
 88166	with manual screening and computer-assisted rescreening under physician supervision 86167            with manual screening and computer-assisted rescreening using cell selection and review
under physician supervision 88199      Unlisted cytopathology procedure (I.C.)
Cytogenetic Studies
88261	Chromosome analysis; count five cells, one karyotype, with banding
88262	count 15 to 20 cells, two karyotypes, with banding
88267      Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, one karyotype, with
banding
88280      Chromosome analysis; additional karyotypes, each study
88285	additional cells counted, each study
SURGICAL PATHOLOGY
Codes 88300 through 88309 are further clarified in the Current Procedural Terminology (CPT) code book.
88300	Level I - surgical pathology, gross examination only
88302	Level II - surgical pathology, gross and microscopic examination
88304	Level III - surgical pathology, gross and microscopic examination
88305	Level IV - surgical pathology, gross and microscopic examination
88307	Level V - surgical pathology, gross and microscopic examination
88309	Level VI - surgical pathology, gross and microscopic examination
MISCELLANEOUS
89050      Cell count, miscellaneous body fluids (e.g., cerebrospinal fluid, joint fluid), except blood
This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS codes are defined in the Current Procedural Terminology (CPT) code book.