Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma
MASSHEALTH
TRANSMITTAL LETTER LAB-21 January 2002
TO:      Independent Clinical Laboratories Participating in MassHealth
FROM:      Wendy E. Warring, Commissioner
RE:      Independent Clinical Laboratory Manual (New Service Codes)
Effective January 1, 2002, the Division is providing coverage for HIV genotype and phenotype resistance tests. These services are payable with prior authorization (PA) from the Division and only when provided by independent clinical laboratories with appropriate certifications from the Centers for Medicare and Medicaid Services under the Clinical Laboratory Improvement Act (CLIA). The new service codes are listed below.
87901    Infectious agent genotype analysis by nucleic acid (DNA or RNA), HIV 1,
reverse transcriptase and protease (P.A. required for third and subsequent tests performed within a calendar year)
87903	Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug
resistance tissue culture analysis, HIV 1; up to 10 drugs (P.A.)
87904	each additional drug, up to 5 drugs (List separately in addition to code for
primary procedure.) (P.A.)
Physicians who want to order these specialized tests to help them manage their HIV patients’ treatment must request PA from the Division. The Division will notify the physician of its decision by mail.
In order for the independent clinical laboratory to submit a bill for the above tests, the laboratory must obtain from the physician the PA number that appears on the approval letter from the Division. Independent laboratories must enter the six-character PA number in Item 4 on the claim form no. 9, or in its equivalent data field if the claim is submitted electronically.
This letter transmits updates to Subchapter 6 of the Independent Clinical Laboratory Manual. Independent clinical laboratories with appropriate CLIA certifications may begin using these three new codes effective January 1, 2002.
Please note that the Division has prioritized the addition of these codes, which were added to the HCPCS series in 2001, due to a perceived medical need in the patient population. The remaining 2001 updates will be issued at a later date.

MASSHEALTH
TRANSMITTAL LETTER LAB-21 January 2002 Page 2
NEW MATERIAL
(The pages listed here contain new or revised language.)
Independent Clinical Laboratory Manual
Pages 6-29 and 6-30
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Independent Clinical Laboratory Manual
Pages 6-29 and 6-30 — transmitted by Transmittal Letter LAB-20

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
INDEPENDENT CLINICAL LABORATORY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-29	

	TRANSMITTAL LETTER
LAB-21	DATE
01/01/02	
601   LABORATORY SERVICE CODES AND DESCRIPTIONS (cont.)
Service
Code	Service Description
87522	hepatitis C, quantification
 87525	hepatitis G, direct probe technique
 87526	hepatitis G, amplified probe technique
 87527	hepatitis G, quantification
 87528	herpes simplex virus, direct probe technique
 87529	herpes simplex virus, amplified probe technique
 87530	herpes simplex virus, quantification
 87531	herpes virus-6, direct probe technique
 87532	herpes virus-6, amplified probe technique
 87533	herpes virus-6, 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
 87540	Legionella pneumophila, direct probe technique
 87541	Legionella pneumophila, amplified probe technique
 87542	Legionella pneumophila, quantification

 87550	Mycobacteria species, direct probe technique
 87551	Mycobacteria species, amplified probe technique
 87552	Mycobacteria species, quantification

 87555	Mycobacteria tuberculosis, direct probe technique
 87556	Mycobacteria tuberculosis, amplified probe technique
 87557	Mycobacteria tuberculosis, quantification

 87560	Mycobacteria avium-intracellulare, direct probe technique
 87561	Mycobacteria avium-intracellulare, amplified probe technique
 87562	Mycobacteria avium-intracellulare, quantification

 87580	Mycoplasma pneumoniae, direct probe technique
 87581	Mycoplasma pneumoniae, amplified probe technique
 87582	Mycoplasma pneumoniae, 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

 87650	Streptococcus, group A, direct probe technique
 87651	Streptococcus, group A, amplified probe technique
 87652	Streptococcus, group A, quantification
87797	Infectious agent detection by nucleic acid (DNA or RNA); not otherwise specified, direct probe
technique, each organism
 87798	amplified probe technique, each organism
 87799	quantification, each organism

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
INDEPENDENT CLINICAL LABORATORY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-30	

	TRANSMITTAL LETTER
LAB-21	DATE
01/01/02	
601   LABORATORY SERVICE CODES AND DESCRIPTIONS (cont.)
Service
Code       Service Description
87810	Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis
87850	Neisseria gonorrhoeae
87880	Streptococcus, group A
87899	not otherwise specified
87901	Infectious agent genotype analysis by nucleic acid (DNA or RNA), HIV 1, reverse transcriptase
and protease (P.A. required for third and subsequent tests performed within a calendar year)
87903	Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue
culture analysis, HIV 1; up to 10 drugs (P.A.)
87904	each additional drug, up to 5 drugs (List separately in addition to code for primary procedure.)
(Use 87904 in conjunction with 87903.) (P.A.)
87999      Unlisted microbiology procedure (I.C.) (P.A.)
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
88140	peripheral blood smear, polymorphonuclear drumsticks
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 88142-88145 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
 88144	with manual screening and computer-assisted rescreening under physician supervision
 88145	with manual screening and computer-assisted rescreening using cell selection and review under physician supervision