Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter FPA-50 December 2013 TO: Family Planning Agencies Participating in MassHealth FROM: Kristin L. Thorn, Medicaid Director RE: Family Planning Agency Manual (RevisCare Act) ions to MassHealth Regulations-Affordable This letter transmits revised regulations and an updated Subchapter 6 of the Family Planning Manual. The revised regulations and Subchapter 6 implement a change in coverage for the diagnosis of infertility. This change was prompted by requirements of the Affordable Care Act regarding coverage of Essential Health Benefits. These regulations are effective January 1, 2014. The revised Subchapter 6 is effective for dates of service on or after January 1, 2014. 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 the information in 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 Family Planning Agency Manual Pages 4-7, 4-8, and 6-1 through 6-14 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Family Planning Agency Manual Pages 4-7 and 4-8 — transmitted by Transmittal Letter FPA-39 Pages 6-1 through 6-14 — transmitted by Transmittal Letter FPA-49 Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 421.000) Page 4-7 Family Planning Manual Transmittal Letter FPA-50 Date 01/01/14 421.417: Noncovered Services The MassHealth agency does not pay for the treatment of male or female infertility, including, but not limited to, laboratory tests, drugs, and procedures associated with such treatment; however, MassHealth does pay for the diagnosis of male or female infertility. (130 CMR 421.418 through 421.420 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 421.000) Page 4-8 Family Planning Manual Transmittal Letter FPA-50 Date 01/01/14 421.421: Coordination of Services When a family planning agency is located in a community health center, a hospital, or another primary-care setting, the agency must demonstrate that family planning services are coordinated with and integrated into other services delivered on site. Such coordination includes at a minimum: (A) either one central medical record for each member in which all medical and health-care services are recorded, or a mechanism for transferring relevant information to medical records to ensure continuity of care; (B) avoidance of duplication of medical examinations and laboratory tests; and (C) in-house referrals, as appropriate. 421.422: Emergency Backup A family planning agency must have provisions for 24-hour emergency backup. Each member must be given the emergency telephone number in writing at the time of initiation of services. The telephone number must also be displayed prominently in the family planning agency. 421.423: Recordkeeping Requirements (A) Payment for any service listed in 130 CMR 421.000 is conditioned upon its full and complete documentation in the member's medical record. A family planning agency must maintain a record of all medical and contraceptive services provided to a member for at least six years following the date of service. Every member visit or telephone call with the staff must be recorded. The documentation must include the reason for each visit or telephone call and any action taken. (B) The medical record must contain, but is not limited to, the following information: (1) the member's name, address, telephone number, date of birth, and MassHealth identification number; (2) the date of service; (3) the name, title, and signature of the person performing the service or making the contact; (4) the type of visit (for example, annual or routine); (5) medical history and history update; (6) pertinent findings on examination; (7) laboratory tests and results; (8) abnormal findings and follow-up treatment; (9) drugs administered or prescribed, including strength, dosage, route, regimen, and number of refills; (10) drugs dispensed, including strength, dosage, route, regimen, and number of units; (11) the contraceptive method used and any special instructions; (12) a summary of counseling; and (13) plans for follow-up. (C) Basic information collected during previous visits with the member (for example, identifying data or medical history) does not need to be repeated in the medical record for subsequent visits as long as the entire medical record reflects continuity of care. Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-1 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 601 Definitions and Early Periodic Screening, Diagnosis and Treatment (EPSDT) Services (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. (C) Early and Periodic Screening, Diagnosis and Treatment (EPSDT) 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 421.000 and 450.000. A family planning agency provider 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 Family Planning Agency Manual. 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 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: - an expanded problem-focused history; - an expanded problem-focused examination; and - straightforward medical decision making 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 99204 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 moderate 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 602 Service Codes and Descriptions: Visits (cont.) Service Code Service Description 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 or other qualified health-care professional. Usually the presenting problem(s) are minimal. Typically, five minutes are spent performing and supervising these services (minimal service) 99212 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 problem-focused history; - a problem-focused examination; - straightforward medical decision making 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) 99214 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 detailed history; - a detailed examination; - medical decision making of moderate complexity 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) Preventive Medicine, New Patient 99384 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) 99385 18-39 years 99386 40-64 years Preventive Medicine, Established Patient 99394 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 laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) 99395 18-39 years 99396 40-64 years Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-3 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 603 Service Codes and Descriptions: Contraceptive Supplies and Drugs Service Code Service Description 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) 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.) J7300 Intrauterine copper contraceptive (use for Paraguard) J7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg (use for Mirena) 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 11981 or 11983) 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 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) Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-4 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 604 Service Codes and Descriptions: Medical and Surgery Procedures (cont.) Service Code Service Description 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) of vagina/cervix 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 of cervex, 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) 58300 Insertion of intrauterine device (IUD) 58301 Removal of intrauterine device (IUD) 58340 Catherization and introduction of saline or contrast material for saline infusion sonohysterography (SIS) or hysterosalpingography 58565 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants 605 Service Codes and Descriptions: Laboratory Services Service Code Service Description 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-5 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 605 Service Codes and Descriptions: Laboratory Services (cont.) 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, nontreponemal antibody, qualitative (e.g., VDRL, RPR, ART) (86592), antibody screen, RBC, each serum technique (86850); blood typing, ABO (86900); and blood typing, Rh (D) (86901).) 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, plasma, or whole blood 82247 Bilirubin; total 82248 direct 82270 Blood, occult; by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection) 82310 Calcium; total 82465 Cholesterol, serum or whole blood, total Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-6 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 605 Service Codes and Descriptions: Laboratory Services (cont.) Service Code Service Description 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 glycosylated (A1C) 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 84132 Potassium; serum, plasma, or whole blood 84144 Progesterone 84146 Prolactin 84155 Protein, total, except by refractometry; serum, plasma, or whole blood 84156 urine 84157 other source (e.g., synovial fluid, cerebrospinal fluid) 84160 Protein, total, by refractometry, any source 84163 Pregnancy-associated plasma protein-A (PAPP-A) 84165 Protein; electrophoretic fractionation and quantitation, serum 84166 electrophoretic fractionation and quantitation, other fluids with concentration (e.g., urine, CSF) Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-7 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 605 Service Codes and Descriptions: Laboratory Services (cont.) Service Code Service Description 84295 Sodium; serum, plasma, or whole blood 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) 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-8 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 605 Service Codes and Descriptions: Laboratory Services (cont.) Service Code Service Description 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, nontreponemal antibody; 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. For example, a test for antibody to an enterovirus is coded as 86658. Coxsackieviruses are enteroviruses, but there are no codes for the individual species of enterovirus. If assays are performed for antibodies to coxsackie A and B species, each assay should be separately coded. Similarly, if multiple assays are performed for antibodies of different immunoglobulin classes, each assay should be coded separately. When a coding option exists for reporting IgM specific antibodies (e.g., 86632) the corresponding nonspecific code (e.g., 86631) may be reported for performance of either an antibody analysis not specific for a particular immunoglobulin class or an IgG analysis. 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, nonspecific type test 86695 herpes simplex, type 1 86696 herpes simplex, type 2 86701 HIV-1 86702 HIV-2 86703 HIV-1 and HIV-2, single result 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 rubella Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-9 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 605 Service Codes and Descriptions: Laboratory Services (cont.) Service Code Service Description 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, any other source except urine, blood, or stool, aerobic, with isolation and presumptive identification of isolates 87075 any source; except blood, 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 each isolate, urine 87101 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail 87102 other source (except blood) 87103 blood 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-10 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 605 Service Codes and Descriptions: Laboratory Services (cont.) Service Code Service Description 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 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 87389 HIV-1 antigen(s), with HIV-1 and HIV-2 antibodies, single result 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, reverse transcription and amplified probe technique 87522 hepatitis C, reverse transcription and 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, reverse transcription and amplified probe technique 87536 HIV-1, reverse transcription and quantification 87537 HIV-2, direct probe technique 87538 HIV-2, reverse transcription and amplified probe technique 87539 HIV-2, reverse transcription and 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-11 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 605 Service Codes and Descriptions: Laboratory Services (cont.) Service Code Service Description 87622 papillomavirus, human, quantification 87631 respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), multiplex reverse transcription and amplified probe technique, multiple types or subtypes, 3-5 targets 87632 respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), multiplex reverse transcription and amplified probe technique, multiple types or subtypes, 6-11 targets 87633 respiratory virus (e.g., adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), multiplex reverse transcription and amplified probe technique, multiple types or subtypes, 12-25 targets 87810 Infectious agent antigen detection by immunoassay with direct optical observation; Chlamydia trachomatis 87850 Neisseria gonorrhoeae 87910 Infectious agent genotype analysis by nucleic acid (DNA or RNA); cytomegalovirus 87912 Hepatitis B virus ANATOMIC PATHOLOGY CYTOPATHOLOGY 88104 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation 88106 simple filter method with interpretation 88108 Cytopathology, concentration technique, smears and interpretation (e.g., Saccomanno technique) 88112 Cytopathology, selective cellular enhancement technique with interpretation (e.g., liquid-based slide preparation method), except cervical or vaginal 88130 Sex chromatin identification; Barr bodies Codes 88141-88155, 88164-88167, and 88174-88175 are used to report cervical or vaginal screening by various methods and to report physician interpretation services. Use codes 8815088154 to report conventional Pap smears that are examined using non-Bethesda reporting. Use codes 88164-88167 to report conventional Pap smears that are examined using the Bethesda System of reporting. Use codes 88142-88143 to report liquid-based specimens processed as thin- layer preparations 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. Manual rescreening requires a complete visual assessment of the entire slide initially screened by either an automated or manual process. Manual review represents as assessment of selected cells or regions of a slide identified by initial automated review. 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-12 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 605 Service Codes and Descriptions: Laboratory Services (cont.) Service Code Service Description 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.) 88160 Cytopathology, smears, any other source; screening and interpretation 88161 preparation, screening, and interpretation 88162 extended study involving over five 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-13 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 605 Service Codes and Descriptions: Laboratory Services (cont.) Service Code Service Description OTHER PROCEDURES 89050 Cell count, miscellaneous body fluids (e.g., cerebrospinal fluid, joint fluid), except blood REPRODUCTIVE MEDICINE PROCEDURES 89300 Semen analysis; presence and/or motility of sperm including Huhner test (post coital) 89310 motility and count (not including Huhner test) 89320 volume, count, motility, and differential G0027 Semen analysis; presence and/or motility of sperm excluding Huhner 606 Modifiers The following service code modifiers are allowed for billing under MassHealth. 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period 59 Distinct procedural service LT Left side (used to identify procedures performed on the left side of the body) RT Right side (used to identify procedures performed on the right side of the body) The following modifiers are for Provider Preventable Conditions (PPCs) that are National Coverage Determinations. PA Surgical or other invasive procedure on wrong body part PB Surgical or other invasive procedure on wrong patient PC Wrong surgery or other invasive procedure on patient For more information on the use of these modifiers, see Appendix V of your provider manual. 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 Physician’s Current Procedural Terminology (CPT) code book. Commonwealth of Massachusetts MassHealth Provider Manual Series Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-14 Family Planning Agency Manual Transmittal Letter FPA-50 Date 01/01/14 This page is reserved.