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-23
March 2003
TO:      Independent Clinical Laboratories Participating in MassHealth FROM:      Douglas S. Brown, Acting Commissioner
RE:      Independent Clinical Laboratory Manual (2003 HCPCS)

The federal government has revised the HCFA Common Procedure Coding System (HCPCS) for MassHealth billing.
This letter transmits changes to your provider manual that contain the new and revised codes. The revised Subchapter 6 is effective for dates of service on or after April 1, 2003.
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 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 publication. The Division of Health Care Finance and Policy also has regulations available on disk. The regulation title is 114.3 CMR 20.00: Laboratory.

Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr
DMA Web Site

Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp

This transmittal letter and attached pages are available on the Division’s Web site at www.mass.gov/dma.
Questions
If you have any questions about this transmittal letter, please contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Independent Clinical Laboratory Manual
Pages vi and 6-13 through 6-34

MASSHEALTH
TRANSMITTAL LETTER LAB-23 March 2003 Page 2
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Independent Clinical Laboratory Manual
Pages vi and 6-13 through 6-36 — transmitted by Transmittal Letter LAB-22

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
INDEPENDENT CLINICAL LABORATORY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-13	

	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)

Service		
Code	Service Description	
83864	Mucopolysaccharides, acid; quantitative	
83866	screen	
83872	Mucin, synovial fluid (Ropes test)	
83873	Myelin basic protein, cerebrospinal fluid	
83874	Myoglobin	
83880	Natriuretic peptide	
83883	Nephelometry, each analyte not elsewhere specified	
83885	Nickel	
83887	Nicotine	
	Molecular Diagnostics	
The series of codes 83890-83912 is intended for use with molecular diagnostic techniques for analysis of nucleic acids. These services are coded by procedure rather than analyte. Code separately for each procedure used in an analysis. For example, a procedure requiring isolation of DNA, restriction endonuclease digestion, electrophoresis, and nucleic acid probe amplification would be coded 83890, 83892, 83894, and 83898.

83890 83891 83892 83893 83894 83896 83897 83898 83901 83902 83903
83904 83905 83906 83912 83915 83916 83918 83919 83921 83925

Molecular diagnostics; molecular isolation or extraction
isolation or extraction of highly purified nucleic acid
enzymatic digestion
dot/slot blot production
separation by gel electrophoresis (e.g., agarose, polyacrylamide)
nucleic acid probe, each
nucleic acid transfer (e.g., Southern, Northern)
amplification of patient nucleic acid (e.g., PCR, LCR), single primer pair, each primer pair
amplification of patient nucleic acid, multiplex, each multiplex reaction
reverse transcription
mutation scanning, by physical properties (e.g., single strand conformational polymorphisms
(SSCP), heteroduplex, denaturing gradient gel electrophoresis (DGGE), RNA’ase A), single
segment, each
mutation identification by sequencing, single segment, each segment
mutation identification by allele specific transcription, single segment, each segment
mutation identification by allele specific translation, single segment, each segment
interpretation and report Nucleotidase 5-Oligoclonal immune (oligoclonal bands) Organic acids; total, quantitative, each specimen
qualitative, each specimen Organic acid, single, quantitative Opiates (e.g., morphine, meperidine)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
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	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)
Service
Code	Service Description
83930	Osmolality; blood
83935	urine
83937	Osteocalcin (bone g1a protein) (I.C.)
83945	Oxalate
83950	Oncoprotein, HER-2/neu
83970	Parathormone (parathyroid hormone)
83986	pH, body fluid, except blood
83992	Phencyclidine (PCP)
84022	Phenothiazine
84030	Phenylalanine (PKU), blood
84035	Phenylketones, qualitative
84060	Phosphatase, acid; total
84066	prostatic
84075	Phosphatase, alkaline
84078	heat stable (total not included)
84080	isoenzymes
84081	Phosphatidylglycerol
84085	Phosphogluconate, 6-, dehydrogenase, RBC
84087	Phosphohexose isomerase
84100	Phosphorus inorganic (phosphate);
84105	urine
84106	Porphobilinogen, urine; qualitative
84110	quantitative
84119	Porphyrins, urine; qualitative
84120	quantitation and fractionation
84126	Porphyrins, feces; quantitative
84127	qualitative
84132	Potassium; serum
84133	urine
84134	Prealbumin
84135	Pregnanediol
84138	Pregnanetriol
84140	Pregnenolone (I.C.)
84143	17-hydroxypregnenolone (I.C.)
84144	Progesterone
84146	Prolactin
84150	Prostaglandin, each
84152	Prostate specific antigen (PSA); complexed (direct measurement)
0	total
1	free
84155	Protein; total, except refractometry
84160	refractometric
84165	electrophoretic fractionation and quantitation
84181	Western Blot, with interpretation and report, blood or other body fluid

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
INDEPENDENT CLINICAL LABORATORY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-13	

	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)
Service
Code	Service Description
84182	Western Blot, with interpretation and report, blood or other body fluid, immunological probe
for band identification, each
84202	Protoporphyrin, RBC; quantitative
84203	screen
84206	Proinsulin
84207	Pyridoxal phosphate (vitamin B-6)
84210	Pyruvate
84220	Pyruvate kinase
84228	Quinine
84233	Receptor assay; estrogen
84234	progesterone
84235	endocrine, other than estrogen or progesterone (specify hormone)
84238	non-endocrine (e.g., acetylcholine) (specify receptor)
84244	Renin
84252	Riboflavin (vitamin B-2)
84255	Selenium
84260	Serotonin
84270	Sex hormone binding globulin (SHBG)
84275	Sialic acid
84285	Silica
84295	Sodium; serum
84300	urine
84302	other source
84305	Somatomedin
84307	Somatostatin
84311	Spectrophotometry, analyte not elsewhere specified
84315	Specific gravity (except urine)
0	Sugars, chromatographic, TLC or paper chromatography
1	Sugars (mon-, di, and oligosaccharides); single qualitative, each specimen

0	multiple qualitative, each specimen
1	single quantitative, each specimen
84379	multiple quantitative, each specimen
84392	Sulfate, urine
84402	Testosterone; free
84403	total
84425	Thiamine (vitamin B-1)
84430	Thiocyanate
84432	Thyroglobulin
84436	Thyroxine; total
84437	requiring elution (e.g., neonatal)
84439	free
0	Thyroxine binding globulin (TBG)
1	Thyroid-stimulating hormone (TSH)

0	Thyroid-stimulating immune globulins (TSI)
1	Tocopherol alpha (vitamin E)
0	
Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
INDEPENDENT CLINICAL LABORATORY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-13	

	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)
Service
Code	Service Description
84449	Transcortin (cortisol binding globulin) (I.C.)
84450	Transferase; aspartate amino (AST) (SGOT)
84460	alanine amino (ALT) (SGPT)
84466	Transferrin (I.C.)
0	Triglycerides
1	Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)
2	Triiodothyronine T3; total (TT-3)

0	free
1	reverse
84484	Troponin, quantitative
84485	Trypsin; duodenal fluid
84488	feces, qualitative
84490	feces, quantitative, 24-hour collection
84510	Tyrosine
84512	Troponin, qualitative
84520	Urea nitrogen; quantitative
84525	semiquantitative (e.g., reagent strip test)
84540	Urea nitrogen, urine
84545	Urea nitrogen, clearance
84550	Uric acid; blood
84560	other source
0	Urobilinogen, feces, quantitative
1	Urobilinogen, urine; qualitative 84580	quantitative, timed specimen 84583	semiquantitative
84585	Vanillylmandelic acid (VMA), urine
84586	Vasoactive intestinal peptide (VIP) (I.C.)
84588	Vasopressin (antidiuretic hormone, ADH)
84590	Vitamin A
84591	Vitamin, not otherwise specified
84597	Vitamin K
84600	Volatiles (e.g., acetic anhydride, carbon tetrachloride, dichloroethane, dichloromethane,
diethylether, isopropyl alcohol, methanol)
84620	Xylose absorption test, blood and/or urine
84630	Zinc
84681	C-peptide
84702	Gonadotropin, chorionic (hCG); quantitative
84703	qualitative
84999	Unlisted chemistry procedure (I.C.)
HEMATOLOGY AND COAGULATION
85002      Bleeding time
85004      Blood count; automated differential WBC count
85007	blood smear, microscopic examination with manual differential WBC count

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
INDEPENDENT CLINICAL LABORATORY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-13	

	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)
Service
Code	Service Description
0	blood smear, microscopic examination without manual differential WBC count
1	manual differential WBC count, buffy coat

0	spun microhematocrit
1	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)
85032	manual cell count (erythrocyte, leukocyte, or platelet) each
85041	red blood cell (RBC), automated
0	reticulocyte, manual
1	reticulocyte, automated
2	reticulocytes, hemoglobin concentration

0	leukocyte (WBC), automated
1	platelet, automated
85060	Blood smear, peripheral, interpretation by physician with written report
85097	Bone marrow, smear interpretation
85130	Chromogenic substrate assay
85170	Clot retraction
85175	Clot lysis time, whole blood dilution
85210	Clotting; factor II, prothrombin, specific
85220	factor V (AcG or proaccelerin), labile factor
85230	factor VII (proconvertin, stable factor)
85240	factor VIII (AHG), one stage
0	factor VIII related antigen
1	factor VIII, VW factor, ristocetin cofactor
2	factor VIII, VW factor antigen
3	factor VIII, von Willebrand factor, multimetric analysis 85250	factor IX (PTC or Christmas) 85260	factor X (Stuart-Prower) 85270	factor XI (PTA) 85280	factor XII (Hageman)

0	factor XIII (fibrin stabilizing)
1	factor XIII (fibrin stabilizing), screen solubility
2	prekallikrein assay (Fletcher factor assay)
3	high molecular weight kininogen assay (Fitzgerald factor assay)
85300	Clotting inhibitors or anticoagulants; antithrombin III, activity
0	antithrombin III, antigen assay
1	protein C, antigen
2	protein C, activity

0	protein S, total
1	protein S, free
85307	Activated Protein C (APC) resistance assay
85335	Factor inhibitor test
85337	Thrombomodulin

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
INDEPENDENT CLINICAL LABORATORY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-13	

	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)
Service
Code	Service Description
85345	Coagulation time; Lee and White
85347	activated
85348	other methods
85360	Euglobulin lysis
85362	Fibrin(ogen) degradation (split) products (FDP)(FSP); agglutination slide; semiquantitative
85366	paracoagulation
85370	quantitative
85378	Fibrin degradation products, D-dimer; qualitative or semiquantitative
0	quantitative
1	ultrasensitive (e.g., for evaluation for venous thromboembolism), qualitative or semiquantitative
85384	Fibrinogen; activity
85385	antigen
85390	Fibrinolysins or coagulopathy screen, interpretation and report
85400	Fibrinolytic factors and inhibitors; plasmin
85410	alpha-2 antiplasmin
85415	plasminogen activator
85420	plasminogen, except antigenic assay
85421	plasminogen, antigenic assay
85441	Heinz bodies; direct
85445	induced, acetyl phenylhydrazine
85460	Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; differential lysis (Kleihauer-Betke)
85461	rosette
85475	Hemolysin, acid
85520	Heparin assay
85525	Heparin neutralization
85530	Heparin-protamine tolerance test
85536	Iron stain, peripheral blood
85540	Leukocyte alkaline phosphatase with count
85547	Mechanical fragility, RBC
85549	Muramidase
85555	Osmotic fragility, RBC; unincubated
85557	incubated
85576	Platelet; aggregation (in vitro), each agent
85597	Platelet neutralization
85610	Prothrombin time
85611	substitution, plasma fractions, each
85612	Russell viper venom time (includes venom); undiluted
85613	diluted
85635	Reptilase test
85651	Sedimentation rate, erythrocyte; non-automated
85652	automated
85660	Sickling of RBC, reduction
85670	Thrombin time; plasma
85675	titer

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
INDEPENDENT CLINICAL LABORATORY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-13	

	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)
Service
Code	Service Description
85705	Thromboplastin inhibition; tissue
85730	Thromboplastin time, partial (PTT); plasma or whole blood
85732	substitution, plasma fractions, each
85810	Viscosity
85999	Unlisted hematology and coagulation procedure (I.C.)
IMMUNOLOGY
86000	Agglutinins, febrile (e.g., Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain
spotted fever, scrub typhus), each antigen
86001	Allergen specific IgG; quantitative or semiquantitative, each allergen
86003	Allergen specific IgE; quantitative or semiquantitative, each allergen
86005	qualitative, multiallergen screen (dipstick, paddle, or disk)
86021	Antibody identification; leukocyte antibodies
0	platelet antibodies
1	platelet-associated immunoglobulin assay
86038	Antinuclear antibodies (ANA)
86039	titer
86060	Antistreptolysin 0; titer
86063	screen
86140	C-reactive protein
86141	high sensitivity (hsCRP)
0	Beta 2 Glycoprotein I antibody, each
1	Cardiolipin (phospholipid) antibody, each Ig class
2	Anti-phosphatidylserine (phospholipid) antibody

0	Chemotaxis assay, specify method
1	Cold agglutinin; screen
86157	titer
86160	Complement; antigen, each component
86161	functional activity, each component
86162	total hemolytic (CH50)
86171	Complement fixation tests, each antigen
86185	Counterimmunoelectrophoresis, each antigen
86215	Deoxyribonuclease, antibody
86225	Deoxyribonucleic acid (DNA), antibody; native or double stranded
86226	single stranded
86235	Extractable nuclear antigen, antibody to, any method (e.g., nRNP, SS-A, SS-B, Sm, RNP,
Sc170, J01), each antibody
86243	Fc receptor
86255	Fluorescent noninfectious agent antibody; screen, each antibody
86256	titer, each antibody
86277	Growth hormone, human (HGH), antibody
86280	Hemagglutination inhibition test (HAI)
86294	Immunoassay for tumor antigen, qualitative or semiquantitative (e.g., bladder tumor antigen)
86300	Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
INDEPENDENT CLINICAL LABORATORY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-13	

	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)

Service Code

Service Description

86301	CA 19-9
86304	CA 125
86308	Heterophile antibodies; screening
0	titer
1	titers after absorption with beef cells and guinea pig kidney

0	Immunoassay for tumor antigen; other antigen, quantitative (e.g., CA 50, 72-4, 549), each
1	Immunoassay for infectious agent antibody, quantitative, not otherwise specified
2	Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method
(e.g., reagent strip)
86320	Immunoelectrophoresis; serum
86325	other fluids (e.g., urine, cerobrospinal fluid) with concentration
86327	crossed (two-dimensional assay)
86329	Immunodiffusion; not elsewhere specified
86331	gel diffusion, qualitative (Ouchterlony), each antigen or antibody
86332	Immune complex assay
86334	Immunofixation electrophoresis
0	Inhibin A
1	Insulin antibodies

0	Intrinsic factor antibodies
1	Islet cell antibody (I.C.)
86343	Leukocyte histamine release test (LHR)
86344	Leukocyte phagocytosis
86353	Lymphocyte transformation, mitogen (phytomitogen) or antigen-induced blastogenesis
86359	T cells; total count (I.C.)
0	absolute CD4 and CD8 count, including ratio
1	absolute CD4 count
86376	Microsomal antibodies (e.g., thyroid or liver-kidney), each
86378	Migration inhibitory factor test (MIF)
86382	Neutralization test, viral
86384	Nitroblue tetrazolium dye test (NTD)
86403	Particle agglutination; screen, each antibody
86406	titer, each antibody
86430	Rheumatoid factor; qualitative
86431	quantitative
86485	Skin test; candida
86490	coccidioidomycosis (I.C.)
86510	histoplasmosis (I.C.)
86586	unlisted antigen, each
86590	Streptokinase, antibody
86592	Syphilis test; qualitative (e.g., VDRL, RPR, ART)
86593	quantitative

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
INDEPENDENT CLINICAL LABORATORY MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-13	

	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)
Service
Code       Service Description
The following codes (86602-86804) 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.

86602	Antibody; actinomyces	
86603	adenovirus	
86606	Aspergillus	
86609	bacterium, not elsewhere specified	
86611	Bartonella	
86612	Blastomyces	
86615	Bordetella	
86617	Borrelia burgdorferi (Lyme disease) confirmatory test (e.g., Western blot or immunoblot)	
86618	Borrelia burgdorferi (Lyme disease)	
86619	Borrelia (relapsing fever)	
86622	Brucella	
86625	Campylobacter	
86628	Candida	
86631	Chlamydia	
86632	Chlamydia, IgM	
86635	Coccidioides	
86638	Coxiella Brunetii (Q fever)	
86641	Cryptococcus	
86644	cytomegalovirus (CMV)	
86645	cytomegalovirus (CMV), IgM	
86648	Diphtheria	
86651	encephalitis, California (La Crosse)	
86652	encephalitis, Eastern equine	
86653	encephalitis, St. Louis	
86654	encephalitis, Western equine	
86658	enterovirus (e.g., coxsackie, echo, polio)	
86663	Epstein-Barr (EB) virus, early antigen (EA)	
86664	Epstein-Barr (EB) virus, nuclear antigen (EBNA)	
86665	Epstein-Barr (EB) virus, viral capsid (VCA)	
86666	Ehrlichia	
86668	Francisella Tularensis	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
INDEPENDENT CLINICAL LABORATORY MANUAL	SUBCHAPTER NUMBER AND TITLE
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6-13	

	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)
Service
Code       Service Description
86671	fungus, not elsewhere specified
86674	Giardia Lamblia
86677	Helicobacter pylori
86682	helminth, not elsewhere specified
86684	Hemophilus influenza
0	HTLV-I
1	HTLV-II
86689	HTLV or HIV antibody, confirmatory test (e.g., Western blot)
86692	hepatitis, delta agent
0	herpes simplex, non-specific type test
1	herpes simplex, type 1
86696	herpes simplex, type 2
86698	histoplasma
0	HIV-1
1	HIV-2
2	HIV-1 and HIV-2, single assay
86704	Hepatitis B core antibody (HBcAb); total
86705	IgM antibody
0	Hepatitis B surface antibody (HBsAb)
1	Hepatitis Be antibody (HBeAb)
2	Hepatitis A antibody (HAAb); total
86709	IgM antibody
86710	Antibody; influenza virus
86713	Legionella
86717	Leishmania
86720	Leptospira
86723	Listeria monocytogenes
86727	lymphocytic choriomeningitis
86729	Lymphogranuloma Venereum
86732	mucormycosis
86735	mumps
86738	Mycoplasma
86741	Neisseria meningitidis
86744	Nocardia
86747	parvovirus
86750	Plasmodium (malaria)
86753	protozoa, not elsewhere specified
86756	respiratory syncytial virus
86757	Rickettsia
86759	rotavirus
86762	rubella
86765	rubeola
86768	Salmonella
86771	Shigella
86774	tetanus

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
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	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)
Service
Code	Service Description
0	Toxoplasma
1	Toxoplasma, IgM
86781	Treponema Pallidum, confirmatory test (e.g., FTA-abs)
86784	trichinella
86787	varicella-zoster
86790	virus, not elsewhere specified
86793	Yersinia
86800	Thyroglobulin antibody
86803	Hepatitis C antibody;
86804	confirmatory test (e.g., immunoblot)
Tissue Typing
86805	Lymphocytotoxicity assay, visual crossmatch; with titration
86806	without titration
86807	Serum screening for cytotoxic percent reactive antibody (PRA); standard method
86808	quick method
86812	HLA typing; A, B, or C (e.g., A10, B7, B27), single antigen
86813	A, B, or C, multiple antigens
0	DR/DQ, single antigen
1	DR/DQ, multiple antigens

0	lymphocyte culture, mixed (MLC)
1	lymphocyte culture, primed (PLC)
86849	Unlisted immunology procedure (I.C.)
TRANSFUSION MEDICINE
86850	Antibody screen, RBC, each serum technique (I.C.)
86860	Antibody elution (RBC), each elution (I.C.)
86870	Antibody identification, RBC antibodies, each panel for each serum technique (I.C.)
86880	Antihuman globulin test (Coombs test); direct, each antiserum
0	indirect, qualitative, each antiserum
1	indirect, titer, each antiserum
86900	Blood typing; ABO
86901	Rh (D) (I.C.)
0	antigen screening for compatible blood unit using reagent serum, per unit screened
1	antigen screening for compatible unit using patient serum, per unit screened
2	RBC antigens, other than ABO or Rh (D), each
3	Rh phenotyping, complete
86920	Compatibility test each unit; immediate spin technique (I.C.)
0	incubation technique (I.C.)
1	antiglobulin technique (I.C.)
86940	Hemolysins and agglutinins; auto, screen, each
86941	incubated

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
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	TRANSMITTAL LETTER
LAB-23	DATE
04/01/03	
601   Laboratory Service Codes and Descriptions (cont.)
Service
Code       Service Description
86970	Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility
testing; incubation with chemical agents or drugs, each
0	incubation with enzymes, each
1	by density gradient separation
86975	Pretreatment of serum for use in RBC antibody identification; incubation with drugs, each
0	by dilution
1	incubation with inhibitors, each
2	by differential red-cell absorption using patient RBCs or RBCs of known phenotype, each absorption
86999      Unlisted transfusion medicine procedure (I.C.)
MICROBIOLOGY
87001      Animal inoculation, small animal; with observation
87003	with observation and dissection
87015      Concentration (any type), for infectious agents
87040      Culture, bacterial; blood, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate)
0	feces, with isolation and preliminary examination (e.g., KIA, LIA), Salmonella and Shigella species
1	stool, additional pathogens, isolation and preliminary examination (e.g., Campylobacter, Yersinia, Vibrio, E. coli 0157), each plate

0	any other source except urine, blood, or stool, with isolation and presumptive identification of isolates
1	quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood, or stool
87073	quantitative, anaerobic with isolation and presumptive identification of isolates, any source
except urine, blood, or stool
0	any source, anaerobic with isolation and presumptive identification of isolates
1	anaerobic isolate, additional methods required for definitive identification, each isolate
87077	aerobic isolate, additional methods required for definitive identification, each isolate
87081	Culture, presumptive, pathogenic organisms, screening only
87084	with colony estimation from density chart
87086	Culture, bacterial; quantitative colony count, urine
87088	with isolation and presumptive identification of isolates, urine
87101	Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or
nail
0	other source (except blood)
1	blood
87106	Culture, fungi, definitive identification, each organism; yeast (Use in addition to codes 87101,
87102, or 87103 when appropriate.)
87107	mold
0	Culture, mycoplasma, any source
1	Culture, chlamydia, any source
0	
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601   Laboratory Service Codes and Descriptions (cont.)
Service
Code       Service Description
87116      Culture, tubercle or other acid-fast bacilli (e.g., TB, AFB, mycobacteria) any source, with isolation
and presumptive identification of isolates 87118      Culture, mycobacteria, definitive identification, each isolate 87140      Culture, typing; immunofluorescent method, each antiserum
87143	gas-liquid chromatography (GLC) or high pressure liquid chromatography (HPLC) method
87147	immunologic method, other than immunofluorescence (e.g., agglutination grouping), per
antiserum
87149	identification by nucleic acid probe
87152	identification by pulse field gel typing
87158	other methods
87164      Dark field examination, any source (e.g., penile, vaginal, oral, skin); includes specimen
collection
87166	without collection
87168	Macroscopic examination; arthropod
87169	parasite
87172      Pinworm exam (e.g., cellophane tape prep)
0	Homogenization, tissue, for culture
1	Ova and parasites, direct smears, concentration and identification 87181      Susceptibility studies, antimicrobial agent; agar dilution method, per agent (e.g., antibiotic
gradient strip)
0	disk method, per plate (12 or fewer agents)
1	enzyme detection (e.g., beta lactamase), per enzyme
2	microdilution or agar dilution (minimum inhibitory concentration (MIC) or breakpoint), each multiantimicrobial, per plate
3	microdilution or agar dilution, minimum lethal concentration (MLC), each plate (List separately in addition to code for primary procedure.)
87188	macrobroth dilution method, each agent
87190	mycobacteria, proportion method, each agent
87197      Serum bactericidal titer (Schlicter test)
87205	Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types
0	fluorescent and/or acid-fast stain for bacteria, fungi, parasites, viruses, or cell types
1	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) 87230      Toxin or antitoxin assay, tissue culture (e.g., Clostridium difficile toxin) 87250      Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and
dissection
0	tissue culture inoculation, observation, and presumptive identification by cytopathic effect
1	tissue culture, additional studies or definitive identification (e.g., hemabsorption, neutralization, immunofluorescence stain), each isolate
2	centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus
0	
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601   Laboratory Service Codes and Descriptions (cont.)
Service
Code       Service Description
87255	including identification by non-immunologic method, other than by cytopathic effect (eg,
virus specific enzymatic activity)
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. If there is no specific agent code, the general methodology code (e.g., 87299, 87449, 87450, 87797, 87798, 87799, 87899) should be used. For identification of antibodies to many of the listed infectious agents, see 86602-86804.
87260      Infectious agent antigen detection by immunofluorescent technique; adenovirus
87265	Bordetella pertussis/parapertussis
87267	Enterovirus, direct fluorescent antibody (DFA)
0	Chlamydia trachomatis
1	Cytomegalovirus, direct fluorescent antibody (DFA)
2	cryptosporidium/giardia
3	Herpes simplex virus type 2
4	Herpes simplex virus type 1
5	influenza B virus
6	influenza A virus
7	Legionella micdadei
8	Legionella pneumophila
9	Parainfluenza virus, each type
10	respiratory syncytial virus
87281	Pneumocystis carinii
87283	Rubeola
87285	Treponema pallidum
87290	Varicella zoster virus
87299	not otherwise specified, each organism
0	Infectious agent antigen detection by immunofluorescent technique, polyvalent for multiple organisms, each polyvalent antiserum
1	Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; adenovirus enteric types 40/41
87320	Chlamydia trachomatis
87324	Clostridium difficile toxin(s)
87327	Cryptococcus neoformans
87328	cryptosporidium/giardia
87332	cytomegalovirus
0	Escherichia coli 0157
1	Entamoeba histolytica dispar group
2	Entamoeba histolytica group
3	Helicobacter pylori, stool
4	Helicobacter pylori
5	hepatitis B surface antigen (HBsAg)
87341	hepatitis B surface antigen (HBsAg) neutralization
87350	hepatitis Be antigen (HBeAg)

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601   Laboratory Service Codes and Descriptions (cont.)
Service
Code       Service Description
87380	hepatitis, delta agent
87385	Histoplasma capsulatum
87390	HIV-1
87391	HIV-2
87400	influenza, A or B, each
87420	respiratory syncytial virus
87425	rotavirus
87427	Shiga-like toxin
87430	Streptococcus, group A
87449	Infectious agent antigen detection by enzyme immunoassay technique, qualitative or
semiquantitative; multiple step method, not otherwise specified, each organism
0	single step method, not otherwise specified, each organism
1	multiple step method, polyvalent for multiple organisms, each polyvalent antiserum
87470	Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella
quintana, direct probe technique
0	Bartonella henselae and Bartonella quintana, amplified probe technique
1	Bartonella henselae and Bartonella quintana, quantification

0	Borrelia burgdorferi, direct probe technique
1	Borrelia burgdorferi, amplified probe technique
2	Borrelia burgdorferi, quantification

0	Candida species, direct probe technique
1	Candida species, amplified probe technique
2	Candida species, quantification

0	Chlamydia pneumoniae, direct probe technique
1	Chlamydia pneumoniae, amplified probe technique
2	Chlamydia pneumoniae, quantification

0	Chlamydia trachomatis, direct probe technique
1	Chlamydia trachomatis, amplified probe technique
2	Chlamydia trachomatis, quantification

0	cytomegalovirus, direct probe technique
1	cytomegalovirus, amplified probe technique
2	cytomegalovirus, quantification

0	Gardnerella vaginalis, direct probe technique
1	Gardnerella vaginalis, amplified probe technique
2	Gardnerella vaginalis, quantification

0	hepatitis B virus, direct probe technique
1	hepatitis B virus, amplified probe technique
2	hepatitis B virus, quantification

0	hepatitis C, direct probe technique
1	hepatitis C, amplified probe technique
2	hepatitis C, quantification

0	hepatitis G, direct probe technique
1	hepatitis G, amplified probe technique
2	hepatitis G, quantification
3	herpes simplex virus, direct probe technique
0	
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601   Laboratory Service Codes and Descriptions (cont.)
Service
Code	Service Description
0	herpes simplex virus, amplified probe technique
1	herpes simplex virus, quantification
2	herpes virus-6, direct probe technique
3	herpes virus-6, amplified probe technique
4	herpes virus-6, quantification
5	HIV-1, direct probe technique
6	HIV-1, amplified probe technique
7	HIV-1, quantification
8	HIV-2, direct probe technique
9	HIV-2, amplified probe technique
10	HIV-2, quantification
11	Legionella pneumophila, direct probe technique
12	Legionella pneumophila, amplified probe technique
13	Legionella pneumophila, quantification

0	Mycobacteria species, direct probe technique
1	Mycobacteria species, amplified probe technique
2	Mycobacteria species, quantification

0	Mycobacteria tuberculosis, direct probe technique
1	Mycobacteria tuberculosis, amplified probe technique
2	Mycobacteria tuberculosis, quantification

0	Mycobacteria avium-intracellulare, direct probe technique
1	Mycobacteria avium-intracellulare, amplified probe technique
2	Mycobacteria avium-intracellulare, quantification

0	Mycoplasma pneumoniae, direct probe technique
1	Mycoplasma pneumoniae, amplified probe technique
2	Mycoplasma pneumoniae, quantification

0	Neisseria gonorrhoeae, direct probe technique
1	Neisseria gonorrhoeae, amplified probe technique
2	Neisseria gonorrhoeae, quantification

0	papillomavirus, human, direct probe technique
1	papillomavirus, human, amplified probe technique
2	papillomavirus, human, quantification

0	Streptococcus, group A, direct probe technique
1	Streptococcus, group A, amplified probe technique
2	Streptococcus, group A, quantification
87797	Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe
technique, each organism
0	amplified probe technique, each organism
1	quantification, each organism
87800	Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s)
technique
87801	amplified probe(s) technique
87802	Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus,
group B
87803	Clostridium difficile toxin A

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601   Laboratory Service Codes and Descriptions (cont.)
Service
Code       Service Description
87804	influenza
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)
87902	Hepatitis C virus
87903	Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue
culture analysis, HIV 1; first through 10 drugs tested (P.A.)
87904	each additional one through five drugs tested (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
0	filter method only with interpretation
1	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
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

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601   Laboratory Service Codes and Descriptions (cont.)
Service
Code       Service Description
0	with manual screening and computer-assisted rescreening under physician supervision
1	with manual screening and rescreening under physician supervision
2	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
0	preparation, screening, and interpretation
1	extended study involving over 5 slides and/or multiple stains (I.C.)
88164	Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under
physician supervision
0	with manual screening and rescreening under physician supervision
1	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
88172	Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine
adequacy of specimen(s) (I.C.)
88173	interpretation and report
88174	Cytopathology, cervical or vaginal (any reported system), collected in preservative fluid,
automated thin layer preparation, screening by automated system, under physician
supervision
88175	with screening by automated system and manual rescreening, under physician supervision
88180	Flow cytometry; each cell surface, cytoplasmic or nuclear marker (I.C.)
88182	cell cycle or DNA analysis (I.C.)
88199	Unlisted cytopathology procedure (I.C.)
Cytogenetic Studies
88230	Tissue culture for non-neoplastic disorders; lymphocyte
88233	skin or other solid tissue biopsy
88235	amniotic fluid or chorionic villus cells
88237	Tissue culture for neoplastic disorders; bone marrow, blood cells
88239	solid tumor
0	Cryopreservation, freezing and storage of cells, each cell line
1	Thawing and expansion of frozen cells, each aliquot 88245      Chromosome analysis for breakage syndromes; baseline Sister Chromatid Exchange (SCE),
20-25 cells
0	baseline breakage, score 50-100 cells, count 20 cells, 2 karyotypes, (e.g., for ataxia telangiectasia, Fanconi anemia, fragile X)
1	score 100 cells, clastogen stress (e.g., diepoxybutane, mitomycin C, ionizing radiation, UV radiation)
88261	Chromosome analysis; count 5 cells, 1 karyotype, with banding
0	count 15-20 cells, 2 karyotypes, with banding
1	count 45 cells for mosaicism, 2 karyotypes, with banding
2	analyze 20-25 cells
0	
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601   Laboratory Service Codes and Descriptions (cont.)
Service
Code       Service Description
88267      Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with
banding 88269      Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, 1
karyotype, with banding
88271	Molecular cytogenetics; DNA probe, each (e.g., FISH)
0	chromosomal in situ hybridization, analyze 3-5 cells (e.g., for derivatives and markers)
1	chromosomal in situ hybridization, analyze 10-30 cells (e.g., for microdeletions)
2	interphase in situ hybridization, analyze 25-99 cells
88275	interphase in situ hybridization, analyze 100-300 cells
88280	Chromosome analysis; additional karyotypes, each study
88283	additional specialized banding technique (e.g., NOR, C-banding)
88285	additional cells counted, each study
88289	additional high resolution study
88291	Cytogenetics and molecular cytogenetics, interpretation and report
88299	Unlisted cytogenetic study (I.C.)
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
88311	Decalcification procedure (List separately in addition to code for surgical pathology
examination.)
88312	Special stains (List separately in addition to code for surgical pathology examination.); Group I
for microorganisms (e.g., Gridley, acid fast, methenamine silver), each
0	Group II, all other (e.g., iron, trichrome), except immunocytochemistry and immunoperoxidase stains, each
1	histochemical staining with frozen section(s)

0	Determinative histochemistry to identify chemical components (e.g., copper, zinc)
1	Determinative histochemistry or cytochemistry to identify enzyme constituents, each 88342      Immunocytochemistry (including tissue immunoperoxidase), each antibody
88346	Immunofluorescent study, each antibody; direct method
88347	indirect method
88348	Electron microscopy; diagnostic
88349	scanning
88355	Morphometric analysis; skeletal muscle
88356	nerve
88358	tumor
88362      Nerve-teasing preparations

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601   Laboratory Service Codes and Descriptions (cont.)

Service Code
88365 88371 88372 88380 88399
89050 89051 89055 89060
89100
89105
89125 89130
89132 89135 89136 89140 89141 89160 89190 89350 89355 89360 89365 89399

Service Description
Tissue in situ hybridization, interpretation and report
Protein analysis of tissue by Western Blot, with interpretation and report
immunological probe for band identification, each Microdissection (e.g., mechanical, laser capture) Unlisted surgical pathology procedure (I.C.)
OTHER PROCEDURES
Cell count, miscellaneous body fluids (e.g., cerebrospinal fluid, joint fluid), except blood
with differential count Leukocyte count, fecal Crystal identification by light microscopy with or without polarizing lens analysis, any body
fluid (except urine) Duodenal intubation and aspiration; single specimen (e.g., simple bile study or afferent loop
culture) plus appropriate test procedure (I.C.)
collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single
or double lumen tube Fat stain, feces, urine, or respiratory secretions Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or
cytopathology
after stimulation Gastric intubation, aspiration, and fractional collections (e.g., gastric secretory study); one hour
two hours
two hours including gastric stimulation (e.g., histalog, pentagastrin)
three hours, including gastric stimulation Meat fibers, feces Nasal smear for eosinophils
Sputum, obtaining specimen, aerosol induced technique (separate procedure) Starch granules, feces Sweat collection by iontophoresis Water load test Unlisted miscellaneous pathology test (I.C.)
MEDICINE
CARDIOVASCULAR

Cardiography
93000      Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
93005	tracing only, without interpretation and report
93010	interpretation and report only
93012      Telephonic transmission of post-symptom electrocardiogram rhythm strip(s), 24-hour attended
monitoring, per 30-day period
of time; tracing only (I.C.)

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601   Laboratory Service Codes and Descriptions (cont.)
Service
Code       Service Description
93014	physician review with interpretation and report only (I.C.)
93015	Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise,
continuous electrocardiographic monitoring, and/or pharmacological stress; with physician
supervision, with interpretation and report
93018	interpretation and report only
93024      Ergonovine provocation test (I.C.)
93040	Rhythm ECG, one to three leads; with interpretation and report
0	tracing only without interpretation and report
1	interpretation and report only
93224	Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording
and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation (I.C.)
0	recording (includes hook-up, recording, and disconnection) (I.C.)
1	scanning analysis with report (I.C.)
2	physician review and interpretation (I.C.)
93230	Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording
and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; includes recording, microprocessor-based analysis with report, physician review and interpretation (I.C.)
0	recording (includes hook-up, recording, and disconnection) (I.C.)
1	microprocessor-based analysis with report (I.C.)
2	physician review and interpretation (I.C.)
93235	Electrocardiographic monitoring for 24 hours by continuous computerized monitoring and
non-continuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient activated; includes monitoring and real-time data analysis with report, physician review and interpretation (I.C.)
0	monitoring and real-time data analysis with report (I.C.)
1	physician review and interpretation (I.C.) 93268      Patient demand single or multiple event recording with presymptom memory loop, 24-hour
attended monitoring, per 30-day period of time; includes transmission, physician review and interpretation (I.C.) 93278      Signal-averaged electrocardiography (SAECG), with or without ECG (I.C.)
Other Vascular Studies
93724      Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic
recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings)
93731	Electronic analysis of dual-chamber pacemaker system (includes evaluation of programmable
parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); without reprogramming
93732	with reprogramming

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93734	Electronic analysis of single-chamber pacemaker system (includes evaluation of programmable
parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); without reprogramming
93735	with reprogramming
Other Procedures
93799      Unlisted cardiovascular service or procedure (I.C.)
SUPPLEMENTARY
G0001     Routine venipuncture for collection of specimen(s) (single home-bound, nursing-facility patient)
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 Current Procedural Terminology (CPT) code book.