Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter LAB-39 February 2012 TO: Independent Clinical Laboratories Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Independent Clinical Laboratory Manual (2012 HCPCS) This letter transmits revisions to the service codes in the Independent Clinical Laboratory Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) codes for 2012. The revised Subchapter 6 is effective for dates of service on or after January 1, 2012. In addition, this revised Subchapter 6 has omitted service code descriptions. Providers should refer to the American Medical Association’s Current Procedural Terminology (CPT) code book or the Healthcare Procedure Coding System (HCPCS) Level II code book for the descriptions of the service codes listed in Subchapter 6 of the LAB manual. Division of Health Care Finance and Policy (DHCFP) regulations establish the fee schedule for covered services in the Independent Clinical Laboratory Manual. You may download the regulations at no cost at www.mass.gov/dhcfp, or purchase a paper copy from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The specific regulation titles for laboratory services are Surgery and Anesthesia Services: 114.3 CMR 16.00 and Clinical Laboratory Services: 114.3 CMR 20.00. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth. MassHealth Transmittal Letter LAB-39 February 2012 Page 2 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 Independent Clinical Laboratory Manual Pages vi and 6-1 through 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Independent Clinical Laboratory Manual Page vi — transmitted by Transmittal Letter LAB-35 Pages 6-1 through 6-34 — transmitted by Transmittal Letter LAB-37 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Independent Clinical Laboratory Manual Transmittal Letter LAB-39 Date 01/01/12 6. Service Codes Introduction ……………………………………………………………………………………... 6-1 Payable Laboratory Services........................................................................ ................................ 6-1 Appendix A. Directory....................................................................... ............................................ A-1 Appendix B. Enrollment Centers......................................................................... .......................... B-1 Appendix C. Third-Party-Liability Codes........................................................................... ............ C-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 6-1 Independent Clinical Laboratory Manual Transmittal Letter LAB-39 Date 01/01/12 601 Introduction MassHealth providers should refer to the American Medical Association’s Current Procedural Terminology (CPT) code book or the Healthcare Common Procedure Coding System (HCPCS) Level II code book for the service codes and service descriptions when billing for services provided to MassHealth members. 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 401.000 and 450.000. An independent clinical laboratory 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 Independent Clinical Laboratory Manual. Legend: IC: Claim requires individual consideration. See 130 CMR 401.419 and 450.271 for more information. PA: Service requires prior authorization. See 130 CMR 450.303 for more information. 602 Payable Laboratory Services This section lists CPT codes and HCPCS Level II codes that are payable under MassHealth. 80047 80174 80415 81050 82120 80048 80176 80416 81099 (IC) 82127 80050 80178 80417 82000 82128 80051 80182 80418 82003 82131 80053 80184 80420 82009 82135 80055 80185 80422 82010 82136 80061 80186 80424 82013 82139 80069 80188 80426 82016 82140 80074 80190 80428 82017 82143 80076 80192 80430 82024 82145 80102 80194 80432 82030 82150 80103 80195 80434 82040 82154 80150 80196 80435 82042 82157 80152 80197 80436 82043 82160 80154 80198 80438 82044 82163 80156 80200 80439 82045 82164 80157 80201 80440 82055 82172 80158 80202 81000 82085 82175 80160 80299 81001 82088 82180 80162 80400 81002 82101 82190 80164 80402 81003 82103 82205 80166 80406 81005 82104 82232 80168 80408 81007 82105 82239 80170 80410 81015 82106 82240 80172 80412 81020 82107 82247 80173 80414 81025 82108 82248 Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes Page 6-2 Transmittal Letter LAB-39 Date 01/01/12 602 Payable Laboratory Services (cont.) 82252 82507 82690 82980 83540 82261 82520 82693 82985 83550 82270 82523 82696 83001 83570 82271 82525 82705 83002 83582 82272 82528 82710 83003 83586 82274 82530 82715 83008 83593 82286 82533 82725 83009 83605 82300 82540 82726 83010 83615 82306 82541 82728 83012 83625 82308 82542 82731 83013 83630 82310 82543 82735 83014 83631 82330 82544 82742 83015 83632 82331 82550 82746 83018 83633 82340 82552 82747 83020 83634 82355 82553 82757 83021 83655 82360 82554 82759 83026 83661 82365 82565 82760 83030 83662 82370 82570 82775 83033 83663 82373 82575 82776 83036 83664 82374 82585 82784 83037 83670 82375 82595 82785 83045 83690 82376 82600 82787 83050 83695 82378 82607 82800 83051 83698 82379 82608 82803 83055 83700 82380 82610 82805 83060 83701 82382 82615 82810 83065 83704 82383 82626 82820 83068 83718 82384 82627 82930 83069 83719 82387 82633 82938 83070 83721 82390 82634 82941 83071 83727 82397 82638 82943 83080 83735 82415 82646 82945 83088 83775 82435 82649 82946 83090 83785 82436 82651 82947 83150 83788 82438 82652 82948 83491 83789 82441 82654 82950 83497 83805 82465 82656 82951 83498 83825 82480 82657 82952 83499 83835 82482 82658 82953 83500 83840 82485 82664 82955 83505 83857 82486 82666 82960 83516 83858 82487 82668 82963 83518 83861 82488 82670 82965 83519 83864 82489 82671 82975 83520 83866 82491 82672 82977 83525 83872 82492 82677 82978 83527 83873 82495 82679 82979 83528 83874 Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes Page 6-3 Transmittal Letter LAB-39 Date 01/01/12 602 Payable Laboratory Services (cont.) 83876 84075 84238 84512 85175 83880 84078 84244 84520 85210 83883 84080 84252 84525 85220 83885 84081 84255 84540 85230 83887 84085 84260 84545 85240 83890 84087 84270 84550 85244 83891 84100 84275 84560 85245 83892 84105 84285 84577 85246 83893 84106 84295 84578 85247 83894 84110 84300 84580 85250 83896 84112 84302 84583 85260 83897 84119 84305 84585 85270 83898 84120 84307 84586 85280 83900 84126 84311 84588 85290 83901 84127 84315 84590 85291 83902 84132 84375 84591 85292 83903 84133 84376 84597 85293 83904 84134 84377 84600 85300 83905 84135 84378 84620 85301 83906 84138 84379 84630 85302 83907 84140 84392 84681 85303 83908 84143 84402 84702 85305 83909 84144 84403 84703 85306 83912 84146 84425 84704 85307 83913 84150 84430 84999 (IC) 85335 83914 84152 84432 85002 85337 83915 84153 84436 85004 85345 83916 84154 84437 85007 85347 83918 84155 84439 85008 85348 83919 84156 84442 85009 85360 83921 84157 84443 85013 85362 83925 84160 84445 85014 85366 83930 84163 84446 85018 85370 83935 84165 84449 85025 85378 83937 84166 84450 85027 85379 83945 84181 84460 85032 85380 83950 84182 84466 85041 85384 83951 84202 84478 85044 85385 83970 84203 84479 85045 85390 83986 84206 84480 85046 85396 83992 84207 84481 85048 85397 83993 84210 84482 85049 85400 84022 84220 84484 85055 85410 84030 84228 84485 85060 85415 84035 84233 84488 85097 85420 84060 84234 84490 85130 85421 84066 84235 84510 85170 85441 Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes Page 6-4 Transmittal Letter LAB-39 Date 01/01/12 602 Payable Laboratory Services (cont.) 85445 86155 86359 86658 86765 85460 86156 86360 86663 86768 85461 86157 86361 86664 86771 85475 86160 86367 86665 86774 85520 86161 86376 86666 86777 85525 86162 86378 86668 86778 85530 86171 86382 86671 86780 85536 86185 86384 86674 86784 85540 86200 86386 86677 86787 85547 86215 86403 86682 86788 85549 86225 86406 86684 86789 85555 86226 86430 86687 86790 85557 86235 86431 86688 86793 85576 86243 86480 86689 86800 85597 86255 86481 86692 86803 85598 86256 86485 86694 86804 85610 86277 86486 86695 86805 85611 86280 86490 86696 86806 85612 86294 86510 86698 86807 85613 86300 86590 86701 86808 85635 86301 86592 86702 86812 85651 86304 86593 86703 86813 85652 86308 86602 86704 86816 85660 86309 86603 86705 86817 85670 86310 86606 86706 86821 85675 86316 86609 86707 86822 85705 86317 86611 86708 86825 85730 86318 86612 86709 86826 85732 86320 86615 86710 86849 (IC) 85810 86325 86617 86713 86850 85999 (IC) 86327 86618 86717 86860 86000 86329 86619 86720 86870 86001 86331 86622 86723 86880 86003 86332 86625 86727 86885 86005 86334 86628 86729 86886 86021 86335 86631 86732 86900 86022 86336 86632 86735 86901 86023 86337 86635 86738 86902 86038 86340 86638 86741 86904 86039 86341 86641 86744 86905 86060 86343 86644 86747 86906 86063 86344 86645 86750 86920 86140 86352 86648 86753 86921 86141 86353 86651 86756 86922 86146 86355 86652 86757 86923 86147 86356 86653 86759 86940 86148 86357 86654 86762 86941 Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes Page 6-5 Transmittal Letter LAB-39 Date 01/01/12 602 Payable Laboratory Services (cont.) 86970 87184 87332 87512 87652 86971 87185 87335 87515 87653 86972 87186 87336 87516 87660 86975 87187 87337 87517 87797 86976 87188 87338 87520 87798 86977 87190 87339 87521 87799 86978 87197 87340 87522 87800 86999 (IC) 87205 87341 87525 87801 87001 87206 87350 87526 87802 87003 87207 87380 87527 87803 87015 87209 87385 87528 87804 87040 87210 87389 87529 87807 87045 87220 87390 87530 87808 87046 87230 87391 87531 87809 87070 87250 87400 87532 87810 87071 87252 87420 87533 87850 87073 87253 87425 87534 87880 87075 87254 87427 87535 87899 87076 87255 87430 87536 87900 87077 87260 87449 87537 87901 87081 87265 87450 87538 87902 87084 87267 87451 87539 87903 87086 87269 87470 87540 87904 87088 87270 87471 87541 87905 87101 87271 87472 87542 87906 87102 87272 87475 87550 87999 (PA)(IC) 87103 87273 87476 87551 88104 87106 87274 87477 87552 88106 87107 87275 87480 87555 88108 87109 87276 87481 87556 88112 87110 87277 87482 87557 88120 87116 87278 87485 87560 88121 87118 87279 87486 87561 88130 87140 87280 87487 87562 88140 87143 87281 87490 87580 88141 87147 87283 87491 87581 88142 87149 87285 87492 87582 88143 87152 87290 87495 87590 88147 87158 87299 87496 87591 88148 87164 87300 87497 87592 88150 87166 87301 87498 87620 88152 87168 87305 87500 87621 88153 87169 87320 87501 87622 88154 87172 87324 87502 87640 88155 87176 87327 87503 87641 88160 87177 87328 87510 87650 88161 87181 87329 87511 87651 88162 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-6 Independent Clinical Laboratory Manual Transmittal Letter LAB-39 Date 01/01/12 602 Payable Laboratory Services (cont.) 88164 88249 88312 88386 93024 88165 88261 88313 88387 93040 88166 88262 88314 88388 93041 88167 88263 88319 88399 (IC) 93042 88172 88264 88342 88720 93224 88173 88267 88346 88740 93225 88174 88269 88347 88741 93226 88175 88271 88348 89049 93227 88177 88272 88349 89050 93228 88182 88273 88355 89051 93229 (IC) 88184 88274 88356 89055 93268 88185 88275 88358 89060 93278 88187 88280 88360 89125 93724 88188 88283 88361 89160 93799 (IC) 88189 88285 88362 89190 G0431 88199 (IC) 88289 88363 89220 (IC) G0434 88230 88291 88365 89230 (IC) P9604 88233 88299 (IC) 88367 89240 (IC) S3820 88235 88300 88368 93000 S3820 (QP) 88237 88302 88371 93005 S3822 88239 88304 88372 93010 S3823 88240 88305 88380 (IC) 93015 88241 88307 88381 93016 88245 88309 88384 93017 88248 88311 88385 93018