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-47 October 2012 TO: Family Planning Agency Providers Participating in MassHealth FROM: Julian J. Harris M.D., Medicaid Director RE: Family Planning Agency Manual (2012 HCPCS) This letter transmits revisions to the service codes in the Family Planning Agency Manual. The Centers for Medicare & Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2012. The revised Subchapter 6 is effective for dates of service on or after July 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 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 Website This transmittal letter and attached pages are available on the MassHealth website 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.) Family Planning Agency Manual Pages 6-3 and 6-4 OBSOLETE MATERIAL (The pages listed here are no longer in effect.)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-45 MassHealth Transmittal Letter FPA-47 October 2012 Page 3 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-3 Family Planning Agency Manual Transmittal Letter FPA-47 Date 07/01/12 603 Service Codes and Descriptions: Contraceptive Supplies and Drugs Service Code Service Description 99396 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; 40-64 years Preventive Medicine, Individual Counseling 99402 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes (HIV pre- and post-test counseling only; two visits per day; maximum eight visits per year) 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 MassHealth will pay the provider's cost.) (I.C.) J7303 Contraceptive supply, hormone-containing vaginal ring, each J7304 Contraceptive supply, hormone-containing patch, each J7307 Etonogestrel (contraceptive) implant system, including implants and supplies (must be billed with either 11975 or 11977) S4989 Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies (I.C.) S4993 Contraceptive pills for birth control 90649 Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), three-dose schedule, for intramuscular use (I.C.) 90650 Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, three-dose schedule, for intramuscular use Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-4 Family Planning Agency Manual Transmittal Letter FPA-47 Date 07/01/12 604 Service Codes and Descriptions: Medical and Surgery Procedures Service Code Service Description 11976 Removal, implantable contraceptive capsules (S.P.) 11981 Insertion, non-biodegradable drug delivery implant 11983 Removal with reinsertion, nonbiodegradable drug delivery implant 19100 Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) 49082 Adominal paracentesis (diagnostic or therapeutic); without imaging guidance 49083 with imaging guidance 49084 Peritoneal lavage, including imaging guidance, when performed 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 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) 58340 Catherization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography 58565 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants