Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter IDTF-11 June 2012 TO: Independent Diagnostic Testing Facilities Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: IDTF Manual (New Modifiers for Provider Preventable Conditions That Are National Coverage Determinations) This letter transmits updates to Subchapter 6 of the IDTF Manual to add modifiers for Provider Preventable Conditions (PPCs) that are National Coverage Determinations. For more information about PPCs and related billing instructions, see Transmittal Letter ALL-195. These updates are effective for dates of service on or after July 1, 2012. Please Note: Two modifiers that are currently allowed by MassHealth, technical component (TC) and professional component (26), have also been added to Subchapter 6. 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.) Independent Diagnostic Testing Facility Manual Pages vi, 6-5, and 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Independent Diagnostic Testing Facility Manual Pages vi, 6-5, and 6-6 — transmitted by Transmittal Letter IDTF-10 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-11 * Date 07/01/12 6. Service Codes and Descriptions Introduction 6-1 Portable X Ray: Radiology Service Codes 6-1 Freestanding Magnetic Resonance Imaging (FMRI): Radiology Service Codes 6-2 Diagnostic Imaging Centers: Radiology Service Codes …………………………………………. 6-2 Diagnostic Imaging Centers: Radiology Service Codes 6-5 Sleep Centers: Radiology Service Codes 6-5 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider Preventable Conditions U-1 Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions V-1 Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity Schedules W-1 Appendix X. Family Assistance Copayments and Deductibles X-1 Appendix Y. EVS Codes/Messages Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-5 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-11 Date 07/01/12 604 Diagnostic Imaging Centers: Radiology Service Codes (cont.) Service Code Service Code Service Code Service Code Service Code 93880 93882 93886 93888 93890 93893 93922 93923 93924 93925 93926 93930 93931 93965 93970 93971 93975 93976 93978 93979 93980 93981 93990 93998 (IC) 95950 95951 95953 95956 A4641 IC) A9500 (IC) A9502 (IC) A9503 (IC) A9505 (IC) A9512 (IC) A9537 (IC) G0202 G0204 G0206 605 Diagnostic Imaging Centers: Radiology Service Codes Service Code Service Code Service Code Service Code Service Code 76645 77051 77052 77053 77054 77055 77056 77057 G0202 G0204 G0206 606 Sleep Centers: Radiology Service Codes Service Code Service Code Service Code Service Code 95800 95805 95807 95810 95801 95806 95808 95811 607 Modifiers The following service code modifiers are allowed for billing under MassHealth. Modifier Modifier Description 26 Professional Component TC Technical Component The following modifiers are for Provider Preventable Conditions (PPCs) that are National Coverage Determinations. Modifier Modifier Description 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-6 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-11 Date 07/01/12 This page is reserved.