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 FPA-38
March 2005

	TO:	Family Planning Agencies Participating in MassHealth

	FROM:	Beth Waldman, Medicaid Director 

	RE:	Family Planning Agency Manual (Revision to Service Code and Description)

This letter transmits a revision to Service Code 58565 in Subchapter 6 of the Family Planning Agency Manual.  This change is effective for dates of service on or after January 1, 2005.

If you wish to obtain a fee schedule, you may purchase Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or directly from the Division of Health Care Finance and Policy (see addresses and telephone numbers below).  You must contact them first to find out the price of the regulation.  The Division of Health Care Finance and Policy also has the regulations available on disk and on their Web site.  The regulation title is 114.3 CMR 16.00: Surgery and Related Anesthesia Care and 114.3 CMR 20.00: Laboratory.

	Massachusetts State Bookstore		Division of Health Care Finance and Policy
	State House, Room 116		Two Boylston Street
	Boston, MA  02133		Boston, MA  02116
	Telephone:  617-727-2834		Telephone:  617-988-3100
	www.mass.gov/sec/spr		www.mass.gov/dhcfp

Providers with questions about the information in this transmittal letter may contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.

NEW MATERIAL
(The pages listed here contain new or revised language.)
	
	Family Planning Agency Manual

Pages 6-3 and 6-4

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(The pages listed here are no longer in effect.)

	Family Planning Agency Manual

	Pages 6-3 and 6-4 – transmitted by Transmittal Letter FPA-37

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series	
SUBCHAPTER NUMBER AND TITLE

6 SERVICE CODES AND DESCRIPTIONS	
PAGE

6-3	

FAMILY PLANNING AGENCY
MANUAL	
TRANSMITTAL LETTER

FPA-38	
DATE

01/01/05	

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)
57425	Laparoscopy, surgical, colpopexy (suspension of vaginal apex)
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)
58565  		Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants 

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:  blood count, complete (CBC), automated, and automated differential WBC count (85025 or 85027 and 85004) or blood count, complete (CBC), automated (85027), and appropriate manual differential WBC count (85007 or 85009); 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	
SUBCHAPTER NUMBER AND TITLE

6 SERVICE CODES AND DESCRIPTIONS	
PAGE

6-4	

FAMILY PLANNING AGENCY
MANUAL	
TRANSMITTAL LETTER

FPA-38	
DATE

01/01/05	

605	Service Codes and Descriptions:  Laboratory Services (cont.)

Service
Code		Service Description

80061	Lipid panel (This panel must include the following:  cholesterol, serum, total (82465); lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718); and triglycerides  (84478).)
80074	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).)
80076	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

81000	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
81001		automated, with microscopy
81002		nonautomated, without microscopy
81003		automated, without microscopy
81005	Urinalysis; qualitative or semiquantitative, except immunoassays
81007		bacteriuria screen, except by culture or dipstick
81025	Urine pregnancy test, by visual color comparison methods
81099	Unlisted urinalysis procedure 

CHEMISTRY

The material for examination may be from any source unless otherwise specified in the code description.  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.

82040	Albumin; serum
82247	Bilirubin; total
82248		direct
82270	Blood, occult; by peroxidase activity (e.g., guaiac), qualitative; feces, 1-3 simultaneous determinations
82273		other sources
82310	Calcium; total