Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street Boston, MA 02111 www.mass.gov/masshealth

MassHealth

MASSHEALTH
TRANSMITTAL LETTER PHY-102
November 2004
TO:      Physicians Participating in MassHealth, FROM:      Beth Waldman, Medicaid Director

RE:

Physician Manual (2004 HCPCS Codes)

This letter transmits a revised Subchapter 6 of the Physician Manual. Providers should use this revised Subchapter 6 along with the American Medical Association Current Procedural Terminology (CPT) 2004 code book. Subchapter 6 of the Physician Manual contains the following information:
•	CPT codes that are not payable under MassHealth (all other CPT codes in the CPT 2004 code book are payable, subject to all limitations and conditions of payment in MassHealth’s regulations at 130 CMR 433.000 and 450.000);
•	CPT codes that have special limitations or requirements, such as prior authorization, individual consideration, or attachment requirements; and
•	Level II HCPCS codes that are payable under MassHealth and have special limitations or requirements, such as prior authorization, individual consideration, or attachment requirements.
In addition, pursuant to 130 CMR 450.144(A), a physician may request prior authorization for any medically necessary service for a member under 21 years of age, even if it is listed as not payable in Subchapter 6 of the Physician Manual.
How to Obtain a Physician Fee Schedule
Providers who want to obtain a fee schedule 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). Providers must contact them first to find out the price of the publication. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for medicine is 114.3 CMR 17.00: Medicine. The regulation title for surgery and anesthesia is 114.3 CMR 16.00: Surgery and Related Anesthesia Care. The regulation title for radiology is 114.3 CMR 18.00: Radiology. The regulation title for laboratory 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

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

MASSHEALTH
TRANSMITTAL LETTER PHY-102 November 2004 Page 2
Effective Date
The changes to codes listed in Subchapter 6 are effective for dates of service on or after October 1, 2004.
Mid-Level Practitioner/EPSDT Modifiers
A.	Mid-Level Practitioner Modifiers
As conveyed in Transmittal Letter PHY-97 (November 2003), modifiers R3, R4, R5, S1, S2, S3, W5, W6, and W7 are obsolete. Providers billing for services performed by a non-independent mid-level practitioner under the employing physician’s MassHealth servicing provider number should apply modifier SA (nurse practitioner), HN (physician assistant), and SB (nurse midwife) to the service code. Independent nurse practitioners and nurse midwives who are currently enrolled with MassHealth under their own provider number should not use modifier SA or SB.
B.	EPSDT Billing Instructions
The modifiers used to indicate services provided under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program (EP, Y3, R4, R5, S2, S3, W6, and W7) were made obsolete effective November 1, 2003 (see Transmittal Letter PHY-97). Providers billing for EPSDT services should bill using Service Code S0302 (completed early and periodic screening, diagnosis, and treatment (EPSDT) service) in addition to the appropriate preventive medicine service code (99381-99385 and 99391-99395). Providers billing for EPSDT services performed by a non-independent mid-level practitioner under the employing physician’s MassHealth servicing provider number should apply the appropriate mid-level modifier to the preventive medicine code. No modifier should be applied to Service Code S0302.
Drugs Supplied in a Physician’s Office
Just as when you prescribe drugs to MassHealth member, before dispensing drugs in a physician’s office, please check the MassHealth Drug List at www.mass.gov/druglist to see if the drug is covered and if it requires a prior authorization.
A. Billing for Drugs with Specific HCPCS Codes
When billing for drugs supplied in a physician’s office, list the HCPCS code once for the drug administered on the claim form. List each drug separately for each date of service. MassHealth denies a claim as a duplicate where a drug is listed more than once for the same date of service.
Units are entered in multiples of the units shown in the HCPCS narrative description. For example, if the description for the code is 50 mg and 200 mg are provided, four units are billed. If the dosage given to the member is not a multiple of the dosage in the HCPCS description, round to the next highest unit. If the full dosage given to the member is less than the minimum dosage specified in the code description, report one unit.

MASSHEALTH
TRANSMITTAL LETTER PHY-102 November 2004 Page 3
B. Billing for Drugs Using Unlisted HCPCS Codes or Drugs Requiring Individual Consideration
Claims for drugs not listed in Subchapter 6 of the Physician Manual should be billed using an unlisted code. For drugs billed with an unlisted code and for drugs requiring individual consideration (IC), providers must include an invoice from a wholesale drug distributor, drug manufacturer, or pharmacy that indicates the actual acquisition cost of the drug. MassHealth reimburses a physician for unlisted drugs and drugs requiring IC at the physician’s acquisition cost. Additionally, indicate the name, strength, dose, units administered, and National Drug Code (NDC) number for every drug. When more than one drug is listed on an invoice, providers must indicate which drug is being billed. This information must be submitted as a separate attachment to the claim. For electronic submissions, this information must be submitted with the claims attachment form (CAF), in addition to the invoice.
Dosimetry Services
Effective for dates of service beginning October 1, 2004, dosimetry services (Service Codes 77330-77334 and 77399) are payable to physicians under MassHealth. The physician’s professional component is covered when the billed service represents the physician’s (e.g. radiologist, radiation oncologist) involvement in the care. Radiation dosimetry calculations are payable only when the physician personally performs the service described in the code or when the physician has participated in the provision of the service (e.g. reviewed or validated the physicist’s calculation). Services provided by a radiation physicist are included in the facility payment and are not billable as a professional component. This is true whether the physicist is employed by the radiologist or is employed by, or is under contract with, the hospital.
Global Payment
MassHealth eliminated global billing for services with a professional and technical component as stated in Transmittal Letters PHY-98 and PHY-100 (January 2004 and May 2004). Effective for dates of service beginning February 1, 2004, physicians, nurse practitioners, and nurse midwives furnishing both the professional and technical components of a service must bill for these components separately to receive the equivalent of the global payment. To bill the professional component, providers must append modifier 26 to the appropriate service code. To bill the technical component, the provider must report the same service code on a second claim line and append modifier TC.
For dates of service on or after February 1, 2004, services that have professional and technical components must be billed with a modifier, using two claim lines if both modifiers are billed. Claims for such services that are not billed with modifier 26 or TC will be denied with error code 135 (modifier required). This denial will be reflected with an adjustment reason code 04 and remark code M78 on the HIPAA-compliant 835 Health Care Claim Payment/Advice transaction. Claims billed with a modifier 99 will be denied with error code 063 (modifier inappropriate/incorrect for service billed). This denial will be reflected with an adjustment reason code B18 and remark code M78 on the HIPAA-compliant 835 Health Care Claim Payment/Advice transaction.

MASSHEALTH
TRANSMITTAL LETTER PHY-102 November 2004 Page 4
Questions
Providers with questions about the information in this transmittal letter may contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Physician Manual
Pages 6-1 through 6-16
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Physician Manual
Pages 6-1 through 6-16 — transmitted by Transmittal Letter PHY-100

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-1	

	TRANSMITTAL LETTER
PHY-102	DATE
10/01/04	
601 Introduction
MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2004 code book for the service codes and service descriptions when billing for services provided to MassHealth members. MassHealth pays for all medicine, radiology, surgery, and anesthesia CPT codes in effect at the time of service, subject to all conditions and limitations described in the MassHealth regulations at 130 CMR 433.000 and 450.000, except for those codes listed in Section 602 of this subchapter. In addition, a physician may request prior authorization for any medically necessary service for a member under 21 years of age.
•	Section 602 lists CPT service codes that are not payable under MassHealth.
•	Section 603 lists service codes that have special requirements or limitations. Beside each service code in Section 603 is an explanation of the requirement or limitation.
•	Section 604 lists Level II HCPCS codes that are payable under MassHealth.
•	Section 605 lists service code modifiers payable under MassHealth.
602 Nonpayable CPT Codes
MassHealth does not pay for services billed under the following codes.

0001T	0032T	15782	19325	36469	
0003T	0033T	15783	19355	36540	
0005T	0034T	15786	19370	37765	
0006T	0035T	15787	19371	37766	
0007T	0036T	15788	19396	38204	
0008T	0037T	15789	20930	38207	
0009T	0038T	15792	20936	38208	
0010T	0039T	15793	21120	38209	
0012T	0040T	15810	21121	38210	
0013T	0041T	15811	21122	38211	
0014T	0042T	15819	21123	38212	
0016T	0043T	15824	21125	38213	
0017T	0044T	15825	21127	38214	
0018T	10040	15826	21245	38215	
0019T	11920	15828	21246	41870	
0020T	11921	15829	21248	41872	
0021T	11922	15876	21249	43752	
0023T	11950	15877	22841	43842	
0024T	11951	15878	32491	43843	
0026T	11952	15879	32850	44132	
0027T	11954	17340	33930	47133	
0028T	15775	17360	33940	48160	
0029T	15776	17380	36415	48550	
0030T	15780	19316	36416	50300	
0031T	15781	19324	36468	51701	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-2	

	TRANSMITTAL LETTER
PHY-102	DATE
10/01/04	
602 Nonpayable CPT Codes (cont.)

51702	76497	86950	89330	90880	
54900	76498	86965	89335	90885	
54901	77336	86985	89342	90889	
55200	77370	87901	89343	90901	
55300	77401	87903	89344	90911	
55400	77402	87904	89346	90939	
55870	77403	88000	89352	90940	
55970	77404	88005	89353	90989	
55980	77406	88007	89354	90993	
58321	77407	88012	89356	90997	
58322	77408	88014	90281	90999	
58323	77409	88016	90283	91132	
58345	77411	88020	90287	91133	
58350	77412	88025	90379	92314	
58750	77413	88027	90384	92315	
58752	77414	88028	90386	92316	
58760	77416	88029	90389	92317	
58970	77417	88036	90396	92325	
58974	77418	88037	90586	92330	
58976	77520	88040	90633	92335	
59070	77522	88045	90634	92352	
59072	77523	88099	90636	92353	
59412	77525	88125	90645	92354	
59897	77790	89250	90646	92355	
62287	78267	89251	90647	92358	
63043	78268	89253	90648	92371	
63044	78351	89254	90669	92390	
65760	78890	89255	90680	92391	
65765	78891	89257	90698	92392	
65767	80500	89258	90700	92393	
65771	80502	89259	90701	92395	
69090	82075	89260	90702	92396	
71552	82962	89261	90708	92510	
72159	84061	89264	90710	92532	
72198	84830	89268	90712	92533	
73225	86079	89272	90715	92534	
76082	86585	89280	90718	92548	
76083	86890	89281	90720	92559	
76093	86891	89290	90721	92560	
76094	86910	89291	90723	92561	
76140	86911	89300	90744	92562	
76150	86927	89310	90748	92564	
76350	86930	89320	90845	92597	
76390	86931	89321	90865	92605	
76400	86932	89325	90875	92606	
76496	86945	89329	90876	92613	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-3	

	TRANSMITTAL LETTER
PHY-102	DATE
10/01/04	
602 Nonpayable CPT Codes (cont.)

92615	97545	99354	
92617	97546	99355	
93660	96567	99356	
93668	97601	99357	
93760	97602	99358	
93762	97755	99359	
93770	97780	99360	
93784	97781	99361	
93786	97802	99362	
93788	97803	99371	
93790	97804	99372	
94015	98940	99373	
95052	98941	99374	
95120	98942	99375	
95125	98943	99377	
95130	99001	99378	
95131	99002	99379	
95132	99024	99380	
95133	99026	99401	
95134	99027	99402	
95824	99056	99403	
95965	99058	99404	
95966	99071	99411	
95967	99075	99412	
96000	99078	99420	
96001	99080	99429	
96002	99090	99450	
96003	99091	99455	
96004	99100	99456	
96100	99116	99500	
96105	99135	99501	
96110	99140	99502	
96111	99141	99503	
96115	99142	99504	
96117	99172	99505	
96150	99190	99506	
96151	99191	99507	
96152	99192	99509	
96153	99271	99510	
96154	99272	99511	
96155	99273	99512	
96902	99274	99601	
97005	99275	99602	
97006	99288		
97014	99315		
97537	99316		

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-4	

	TRANSMITTAL LETTER
PHY-102	DATE
10/01/04	
603 Codes That Have Special Requirements or Limitations
The following service codes are payable by MassHealth, subject to all conditions and limitations in MassHealth regulations at 130 CMR 433.000 and 450.000, but require specific attachments or prior authorization, or have other specific instructions or limitations. Refer to Section 604 for specific requirements or limitations for HCPCS Level II.
Legend:
*: Available free of charge through the Massachusetts Immunization Program for children under 19
years of age. Centrifuging required: Service Code 99000 may be used only to pay a physician who centrifuges
and mails a specimen to a laboratory for analysis. (See 130 CMR 433.439.) Covered for adults ≥ 19: This code is payable only for adults aged 19 or older. CPA-2: A completed Certification of Payable Abortion Form must be completed. See 130 CMR
450.234 through 450.260 and 130 CMR 433.455 for more information. CS-18: A completed Sterilization Consent Form (for members aged 18 through 20) must be
completed. See 130 CMR 450.234 through 450.260 and 130 CMR 433.456 through 433.458 for
more information. CS-21: A completed Sterilization Consent Form (for members aged 21 and older) must be
completed. See 130 CMR 450.234 through 450.260 and 130 CMR 433.456 through 433.458 for
more information. HI-1: A completed Hysterectomy Information Form must be completed. See 130 CMR 450.234
through 450.260 and 130 CMR 433.459 for more information. IC: Claim requires individual consideration. See 130 CMR 433.406 for more information. PA for OMT >8: Prior authorization is required for more than eight osteopathic manipulative
therapy visits in a 12-month period. PA for OT >8: Prior authorization is required for more than eight occupational therapy visits in a
12-month period. PA for PT >8: Prior authorization is required for more than eight physical therapy visits, regardless
of modality, in a 12-month period. PA for ST >15: Prior authorization is required for more than 15 speech/language therapy visits in a
12-month period. PA: Service requires prior authorization. See 130 CMR 433.408 for more information. Urgent Care Only: Service Codes 99050, 99052, and 99054 may be used only for urgent care
provided in the office after hours, in addition to the basic service.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-5	

	TRANSMITTAL LETTER
PHY-102	DATE
10/01/04	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

01999	IC	21088	IC; PA	
15820	PA	21089	IC; PA	
15821	PA	21137	PA	
15822	PA	21138	PA	
15823	PA	21139	PA	
15831	PA	21141	PA	
15832	PA	21142	PA	
15833	PA	21143	PA	
15834	PA	21145	PA	
15835	PA	21146	PA	
15836	PA	21147	PA	
15837	PA	21150	PA	
15838	PA	21151	PA	
15839	PA	21154	PA	
15999	IC	21155	PA	
17999	IC	21159	PA	
19140	PA	21160	PA	
19318	PA	21172	PA	
19328	PA	21175	PA	
19330	PA	21179	PA	
19340	PA	21180	PA	
19342	PA	21181	PA	
19350	PA	21182	PA	
19357	PA	21183	PA	
19361	PA	21184	PA	
19364	PA	21188	PA	
19366	PA	21193	PA	
19367	PA	21194	PA	
19368	PA	21195	PA	
19369	PA	21196	PA	
19380	PA	21198	PA	
19499	IC	21206	PA	
20999	IC	21208	PA	
21076	PA	21209	PA	
21077	PA	21210	PA	
21079	PA	21215	PA	
21080	PA	21230	PA	
21081	PA	21235	PA	
21082	PA	21240	PA	
21083	PA	21242	PA	
21084	PA	21243	PA	
21085	PA	21244	PA	
21086	PA	21247	PA	
21087	PA	21255	PA	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-6	

	TRANSMITTAL LETTER
PHY-102	DATE
10/01/04	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

21256	PA	32853	PA	
21260	PA	32854	PA	
21261	PA	32999	IC	
21263	PA	33935	PA	
21267	PA	33945	PA	
21268	PA	33999	IC	
21270	PA	36299	IC	
21275	PA	36470	PA	
21280	PA	36471	PA	
21282	PA	37501	IC	
21295	PA	37799	IC	
21296	PA	38129	IC	
21299	IC; PA	38204	IC	
21499	IC	38205	PA	
21742	IC	38230	PA	
21743	IC	38240	PA	
21899	IC	38241	PA	
22899	IC	38242	PA	
22999	IC	38589	IC	
23929	IC	38999	IC	
24940	IC	39499	IC	
24999	IC	39599	IC	
25999	IC	40799	IC	
26989	IC	40840	PA	
27299	IC	40842	PA	
27599	IC	40843	PA	
27899	IC	40844	PA	
28899	IC	40845	PA	
29799	IC	40899	IC	
29800	PA	41599	IC	
29804	PA	41820	IC; PA	
29999	IC	41821	IC	
30400	PA	41850	IC	
30410	PA	41899	IC	
30420	PA	42140	PA	
30430	PA	42280	PA	
30435	PA	42281	PA	
30450	PA	42299	IC	
30999	IC	42699	IC	
31299	IC	42999	IC	
31599	IC	43289	IC	
31899	IC	43499	IC	
32851	PA	43659	IC	
32852	PA	43846	PA	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-7	

	TRANSMITTAL LETTER
PHY-102	DATE
10/01/04	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

43847	PA	55250	CS-18 or CS-21	
43848	PA	55450	CS-18 or CS-21	
43999	IC	55559	IC	
44133	IC; PA	55899	IC	
44135	IC; PA	56800	PA	
44136	IC; PA	56805	IC; PA	
44238	IC	57335	IC; PA	
44239	IC	58150	HI-1	
44799	IC	58152	HI-1	
44899	IC	58180	HI-1	
44979	IC	58200	HI-1	
45999	IC	58210	HI-1	
46999	IC	58240	HI-1	
47135	PA	58260	HI-1	
47136	PA	58262	HI-1	
47140	PA	58263	HI-1	
47141	PA	58267	HI-1	
47142	PA	58270	HI-1	
47379	IC	58275	HI-1	
47399	IC	58280	HI-1	
47579	IC	58285	HI-1	
47999	IC	58290	HI-1	
48554	PA	58291	HI-1	
48556	PA	58292	HI-1	
48999	IC	58293	HI-1	
49329	IC	58294	HI-1	
49659	IC	58550	HI-1	
49906	IC	58552	HI-1	
49999	IC	58553	HI-1	
50549	IC	58554	HI-1	
50949	IC	58578	IC	
51597	HI-1	58579	IC	
51715	PA	58600	CS-18 or CS-21	
51925	HI-1	58605	CS-18 or CS-21	
53850	PA	58611	CS-18 or CS-21	
53852	PA	58615	CS-18 or CS-21	
53899	IC	58661	CS-18 or CS-21	
54240	PA	58670	CS-18 or CS-21	
54250	PA	58671	CS-18 or CS-21	
54400	PA	58679	IC	
54401	PA	58951	HI-1	
54405	PA	58999	IC	
54440	IC	59135	HI-1	
54699	IC	59525	HI-1	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-8	

	TRANSMITTAL LETTER
PHY-102	DATE
10/01/04	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

59840	CPA-2 (first trimester)	69399	IC	
59841	CPA-2 (first trimester)	69710	IC	
59850	CPA-2 (second trimester, third	69799	IC	
	trimester in hospital only)	69930	PA	
59851	CPA-2 (second trimester, third	69949	IC	
	trimester in hospital only)	69979	IC	
59852	CPA-2 (second trimester, third	70336	PA	
	trimester in hospital only)	75556	IC	
59855	CPA-2	76499	IC	
59856	CPA-2	76999	IC	
59857	CPA-2	77299	IC	
59898	IC	77499	IC	
59899	IC	77799	IC	
60659	IC	78099	IC	
60699	IC	78199	IC	
64681	IC	78299	IC	
64999	IC	78399	IC	
66999	IC	78499	IC	
67299	IC	78599	IC	
67399	IC	78608	IC	
67599	IC	78609	IC	
67900	PA	78699	IC	
67901	PA	78799	IC	
67902	PA	78990	IC	
67903	PA	78999	IC	
67904	PA	79900	IC	
67906	PA	79999	IC	
67908	PA	81099	IC	
67909	PA	84999	IC	
67911	PA	85999	IC	
67916	PA	86849	IC	
67917	PA	86999	IC	
67923	PA	87999	IC; PA	
67924	PA	88199	IC	
67961	PA	88299	IC	
67966	PA	88380	IC	
67971	PA	88399	IC	
67973	PA	89230	IC	
67974	PA	89240	IC	
67975	PA	90288	IC	
67999	IC	90291	IC	
68399	IC	90296	IC	
68899	IC	90371	Covered for adults >17	
69300	PA	90378	IC; PA	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-9	

	TRANSMITTAL LETTER
PHY-102	DATE
10/01/04	
603 Codes That Have Special Requirements or Limitations (cont.)

Service Code and Req. or Limit
90393	IC	
90399	IC	
90473	IC	
90474	IC	
90476	IC	
90477	IC	
90581	IC	
90632	Covered for adults >17	
90660	IC; PA	
90665	IC	
90690	IC	
90692	IC	
90693	IC	
90707	Covered for adults >17	
90713	Covered for adults >17	
90716	Covered for adults >17	
90719	IC	
90725	IC	
90727	IC	
90734	IC	
90749	IC	
90799	IC	
90899	IC	
90935	For hospitalized member only; not for	
	chronic maintenance	
90937	For hospitalized member only; not for	
	chronic maintenance	
90945	For hospitalized member only; not for	
	chronic maintenance	
90947	For hospitalized member only; not for	
	chronic maintenance	
91110	PA	
91123	IC	
91299	IC	
92065	PA	
92250	PA	
92310	PA	
92311	PA; includes supply of lenses	
92312	PA; includes supply of lenses	
92313	PA; includes supply of lenses	
92326	PA	
92499	IC	
92506	PA for ST >15	
92507	PA for ST >15	

Service Code and Req. or Limit
92508	PA for ST >15	
92526	PA for ST >15	
92610	PA for ST >15	
92700	IC	
93799	IC	
94642	IC	
94772	IC	
94799	IC	
95071	IC	
95199	IC	
95999	IC	
96545	IC	
96549	IC	
96999	IC	
97001	PA for PT >8	
97002	PA for PT >8	
97003	PA for OT >8	
97004	PA for OT >8	
97010	PA for PT >8	
97012	PA for PT >8	
97016	PA for PT >8	
97018	PA for PT >8	
97020	PA for PT >8	
97022	PA for PT >8	
97024	PA for PT >8	
97026	PA for PT >8	
97028	PA for PT >8	
97032	PA for PT >8	
97033	PA for PT >8	
97034	PA for PT >8	
97035	PA for PT >8	
97036	PA for PT >8	
97039	IC; PA for PT >8	
97110	PA for PT >8	
97112	PA for PT >8	
97113	IC; PA for PT >8	
97116	PA for PT >8	
97124	PA for PT >8	
97139	PA for PT >8	
97140	PA for PT >8	
97150	PA for PT >8	
97504	PA for OT >8	
97520	PA for OT >8	
97530	PA for OT >8	

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603 Codes That Have Special Requirements or Limitations (cont.) Service Code and Req. or Limit
97532	PA for OT >8	
97533	PA for OT >8	
97535	PA for OT >8	
97542	PA for OT >8	
97799	IC	
98925	PA for OMT >8	
98926	PA for OMT >8	
98927	PA for OMT >8	
98928	PA for OMT >8; IC	
98929	PA for OMT >8; IC	
99000	Centrifuging required	
99050	Urgent care only	
99052	Urgent care only	
99054	Urgent care only	
99070	IC; excluding family planning	
	supplies, such as trays, used in the	
	collection of specimens	
99185	IC	
99186	IC	
99195	For hematologic disorders only	
99199	IC	
99289	IC	
99290	IC	
99296	IC	
99344	IC	
99345	IC	
99350	IC	
99499	IC	
99600	IC	

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604 HCPCS Level II Service Codes
This section lists Level II HCPCS codes that are payable under MassHealth. Refer to the Centers for Medicare and Medicaid Web site at www.cms.gov/medicare/hcpcs for more detailed descriptions when billing for Level II HCPCS codes provided to MassHealth members.
Service
Code	Service Description
A4261	Cervical cap for contraceptive use (IC)
A4266	Diaphragm for contraceptive use
A4267	Contraceptive supply, condom, male, each
A4268	Contraceptive supply, condom, female, each
A4269	Contraceptive supply, spermicide (e.g., foam, gel), each
H2011	Crisis intervention service, per 15 minutes
J0170	Injection, adrenalin, epinephrine, up to 1 ml ampule
J0215	Injection, alefacept, 0.5 mg (PA)
J0256	Injection, alpha 1-proteinase inhibitor–human, 10 mg
J0290	Injection, ampicillin sodium 500 mg
J0295	Injection, ampicillin sodium / sulbactam sodium, per 1.5 g
J0456	Injection, azithromycin, 500 mg
J0475	Injection, baclofen, 10 mg (PA)
J0476	Injection, baclofen, 50 mcg for intrathecal trial (PA)
J0530	Injection, penicillin G benzathine and penicillin G procaine, up to 600,000 units
J0540	Injection, penicillin G benzathine and penicillin G procaine, up to 1,200,000 units
J0550	Injection, penicillin G benzathine and penicillin G procaine, up to 2,400,000 units
J0560	Injection, penicillin G benzathine, up to 600,000 units
J0570	Injection, penicillin G benzathine, up to 1,200,000 units
J0580	Injection, penicillin G benzathine, up to 2,400,000 units
J0585	Botulinum toxin type A, per unit (PA)
J0587	Botulinum toxin type B, per 100 units (PA)
J0640	Injection, leucovorin calcium, per 50 mg
J0690	Injection, cefazolin sodium, 500 mg
J0694	Injection, cefoxitin sodium, 1 g
J0696	Injection, ceftriaxone sodium, per 250 mg
J0697	Injection, sterile cefuroxime sodium, per 750 mg
J0702	Injection, betamethasone acetate and betamethasone sodium phosphate, per 3 mg
J0704	Injection, betamethasone sodium phosphate, per 4 mg
J0780	Injection, prochlorperazine, up to 10 mg
J0880	Injection, darbepoetin alfa, 5 mcg (PA)
J0900	Injection, testosterone enanthate and estradiol valerate, up to 1 cc
J1020	Injection, methylprednisolone acetate, 20 mg
J1030	Injection, methylprednisolone acetate, 40 mg
J1040	Injection, methylprednisolone acetate, 80 mg
J1055	Injection, medroxyprogesterone acetate for contraceptive use, 150 mg (150 mg Depo-Provera) (IC)
J1056	Injection, medroxyprogesterone acetate/estradiol cypionate, 5 mg/25 mg (5 mg/25 mg Lunelle)
(IC)
J1060	Injection, testerone cypionate and estradiol cypionate, up to 1 ml
J1070	Injection, testosterone cypionate, up to 100 mg

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PHY-102	DATE
10/01/04	
604 HCPCS Level II Service Codes (cont.)
Service
Code	Service Description
J1080	Injection, testosterone cypionate, 1 cc, 200 mg
J1100	Injection, dexamethosone sodium phosphate, 1 mg
J1160	Injection, digoxin, up to 0.5 mg
J1170	Injection, hydromorphone, up to 4 mg
J1200	Injection, diphendydramine HCl, up to 50 mg
J1260	Injection, dolasetron mesylate, 10 mg
J1320	Injection, amitriptyline HCl, up to 20 mg
J1438	Injection, etanercept, 25 mg (PA)
J1440	Injection, filgrastim (G-CSF), 300 mcg (PA)
J1441	Injection, filgrastim (G-CSF), 480 mcg (PA)
J1460	Injection, gamma globulin, intramuscular, 1 cc
J1470	Injection, gamma globulin, intramuscular, 2 cc
J1480	Injection, gamma globulin, intramuscular, 3 cc
J1490	Injection, gamma globulin, intramuscular, 4 cc
J1500	Injection, gamma globulin, intramuscular, 5 cc
J1510	Injection, gamma globulin, intramuscular, 6 cc
J1520	Injection, gamma globulin, intramuscular, 7 cc
J1530	Injection, gamma globulin, intramuscular, 8 cc
J1540	Injection, gamma globulin, intramuscular, 9 cc
J1550	Injection, gamma globulin, intramuscular, 10 cc
J1563	Injection, immune globulin, intravenous, 1 g (PA)
J1564	Injection, immune globulin, 10 mg (PA)
J1626	Injection, granisetron HCl, 100 mcg
J1630	Injection, haloperidol, up to 5 mg
J1650	Injection, enoxaparin sodium, 10 mg
J1655	Injection, tinzaparin sodium, 1000 IU
J1670	Injection, tetanus immune globulin, human, up to 250 units
J1710	Injection, hydrocortisone sodium phosphate, up to 50 mg
J1720	Injection, hydrocortisone sodium succinate, up to 100 mg
J1745	Injection, infliximab, 10 mg (PA)
J1750	Injection, iron dextran, 50 mg
J1790	Injection, droperidol, up to 5 mg
J1800	Injection, propranolol HCl, up to 1 mg
J1885	Injection, ketorolac, tromethamine, per 15 mg
J1890	Injection, cephalothin sodium, up to 1 g
J1950	Injection, leuprolide acetate (for depot suspension), per 3.75 mg (PA)
J1956	Injection, levofloxacin, 250 mg
J1990	Injection, chlordiazepoxide HCl, up to 100 mg
J2060	Injection, lorazepam, 2 mg
J2150	Injection, mannitol, 25% in 50 ml
J2250	Injection, midazolam HCl, per 1 mg
J2271	Injection, morphine sulfate, 100 mg
J2275	Injection, morphine sulfate (preservative-free sterile solution), per 10 mg

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PHY-102	DATE
10/01/04	
604 HCPCS Level II Service Codes (cont.)
Service
Code	Service Description
J2300	Injection, nalbuphine HCl, per 10 mg
J2310	Injection, naloxone HCl, per 1 mg
J2405	Injection, ondansetron HCl, per 1 mg
J2430	Injection, pamidronate disodium, per 30 mg
J2440	Injection, papaverine HC1, up to 60 mg
J2505	Injection, prefilgrastim, 6 mg (PA)
J2510	Injection, penicillin G procaine, aqueous, up to 600,000 units
J2515	Injection, pentobarbital sodium, per 50 mg
J2560	Injection, phenobarbital sodium, up to 120 mg
J2675	Injection, progesterone, per 50 mg
J2760	Injection, phentolamine mesylate, up to 5 mg
J2765	Injection, metoclopramide HCl, up to 10 mg
J2780	Injection, ranitidine HCl, 25 mg
J2788	Injection, Rho d immune globulin, human, minidose, 50 mcg
J2790	Injection, Rho d immune globulin, human, full dose, 300 mcg
J2792	Injection, Rho d immune globulin, intravenous, human, solvent detergent, 100 IU
J2820	Injection, sargramostim (GM-CSF), 50 mcg (PA)
J2910	Injection, aurothioglucose, up to 50 mg
J2916	Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg
J2920	Injection, methylprednisolone sodium succinate, up to 40 mg
J2930	Injection, methylprednisolone sodium succinate, up to 125 mg
J2940	Injection, somatrem, 1 mg (PA)
J2941	Injection, somatropin, 1 mg (PA)
J3030	Injection, sumatriptan succinate, 6 mg
J3120	Injection, testosterone enanthate, up to 100 mg
J3130	Injection, testosterone enanthate, up to 200 mg
J3230	Injection, chlorpromazine HCl, up to 50 mg
J3250	Injection, trimethobenzamide HCl, up to 200 mg
J3301	Injection, triamcinolone acetonide, per 10 mg
J3302	Injection, triamcinolone diacetate, per 5 mg
J3303	Injection, triamcinolone hexacetonide, per 5 mg
J3395	Injection, verteporfin, 15 mg
J3410	Injection, hydroxyzine HCl, up to 25 mg
J3430	Injection, phytonadione (vitamin K), per 1 mg
J3487	Injection, zoledronic acid, 1 mg
J3490	Unclassified drugs (IC)
J3490-FP   Unclassified drugs (service provided as part of Medicaid family planning program) (Use for
medications and injectibles related to family planning services, with the exception of Rho(D) human immune globulin, and contraceptive injectables such as Depo-Provera, items for which MassHealth will pay the provider's costs.) (IC)
J3590	Unclassified biologics (IC)
J7030	Infusion, normal saline solution, 1,000 cc
J7040	Infusion, normal saline solution, sterile (500 ml = 1 unit)

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604 HCPCS Level II Service Codes (cont.)
Service
Code	Service Description
J7042	5% dextrose/normal saline (500 ml = 1 unit)
J7050	Infusion, normal saline solution, 250 cc
J7060	5% dextrose/water (500 ml = 1 unit)
J7070	Infusion, D-5-W, 1,000 cc
J7317	Sodium hyaluronate, per 20 to 25 mg dose for intra-articular injection (PA)
J7320	Hylan G-F 20, 16 mg, for intra-articular injection (PA)
J7599	Immunosuppressive drug, NOC (IC)
J9000	Doxorubicin HCl, 10 mg
J9001	Doxorubicin HCl, all lipid formulations, 10 mg
J9031	BCG live (intravesical), per instillation
J9040	Bleomycin sulfate, 15 units
J9045	Carboplatin, 50 mg
J9060	Cisplatin, powder or solution, per 10 mg
J9062	Cisplatin, 50 mg
J9070	Cyclophosphamide, 100 mg
J9080	Cyclophosphamide, 200 mg
J9090	Cyclophosphamide, 500 mg
J9091	Cyclophosphamide, 1 g
J9092	Cyclophosphamide, 2 g
J9093	Cyclophosphamide, lyophilized, 100 mg
J9094	Cyclophosphamide, lyophilized, 200 mg
J9095	Cyclophosphamide, lyophilized, 500 mg
J9096	Cyclophosphamide, lyophilized, 1 g
J9097	Cyclophosphamide, lyophilized, 2 g
J9130	Dacarbazine, 100 mg
J9140	Dacarbazine, 200 mg
J9170	Docetaxel, 20 mg
J9181	Etoposide, 10 mg
J9182	Etoposide, 100 mg
J9190	Fluorouracil, 500 mg
J9201	Gemcitabine HC1, 200 mg
J9202	Goserelin acetate implant, per 3.6 mg (PA)
J9206	Irinotecan, 20 mg
J9212	Injection, interferon Alfacon-1, recombinant, 1 mcg
J9213	Interferon alfa-2A, recombinant, 3 million units
J9214	Interferon alfa-2B, recombinant, 1 million units
J9215	Interferon alfa-N3 (human leukocyte derived), 250,000 IU
J9216	Interferon gamma-1B, 3 million units
J9217	Leuprolide acetate (for depot suspension), 7.5 mg (PA)
J9218	Leuprolide acetate, per 1 mg (PA)
J9219	Leuprolide acetate implant, 65 mg (PA)
J9250	Methotrexate sodium, 5 mg
J9260	Methotrexate sodium, 50 mg

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PHY-102	DATE
10/01/04	
604	HCPCS Level II Service Codes (cont.)
Service
Code        Service Description
J9263	Injection, oxaliplatin, 0.5 mg
J9265	Paclitaxel, 30 mg
J9300	Gemtuzumab ozogamicin, 5 mg
J9310	Rituximab, 100 mg
J9355	Trastuzumab, 10 mg
J9360	Vinblastine sulfate, 1 mg
J9370	Vincristine sulfate, 1 mg
J9375	Vincristine sulfate, 2 mg
J9380	Vincristine sulfate, 5 mg
J9390	Vinorelbine tartrate, per 10 mg
J9395	Injection, fulvestrant, 25 mg (PA)
J9999	NOC, antineoplastic drug (IC)
Q0136	Injection, epoetin alpha (for non ESRD use), per 1,000 units (PA)
R0070	Transportation of portable X-ray equipment and personnel to home or nursing home, per trip to
facility or location, one patient seen
50020	Injection, bupivicaine HCl, 30 ml
50021	Injection, ceftoperazone sodium, 1 gram (IC)
S0023	Injection, cimetidine HCl, 300 mg
S0028	Injection, famotidine, 20 mg
S0077	Injection, clindamycin phosphate, 300 mg
S0107	Injection, omalizumab, 25 mg (PA)
S0302	Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to
code for appropriate evaluation and management services.) S2260       Induced abortion, 17 to 24 weeks, any surgical method (CPA-2) (second trimester, third trimester
in hospital only) S4989       Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies (IC) S4993       Contraceptive pills for birth control T1023       Screening to determine the appropriateness of consideration of an individual for participation in a
specified program, project or treatment protocol, per encounter
605	Modifiers
The following service code modifiers are allowed for billing under MassHealth. See Subchapter 5 of
the Physician Manual for billing instructions related to the use of modi	
26	Professional component		
50	Bilateral procedure		
51	Multiple procedures		
54	Surgical care only		
62	Two surgeons		
66	Surgical team		
80	Assistant surgeon		
82	Assistant surgeon (when qualified resident surgeon not	available)	

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605 Modifiers (cont.)
99   Multiple modifiers
FP   Services provided as part of Medicaid Family Planning Program
HN Bachelor’s degree level (Use to indicate physician assistant.) (This modifier is to be applied to
service codes billed by a physician that were performed by a physician assistant employed by the physician or group practice.)
RP   Replacement and repair (This modifier should only be used with 92340, 92341, and 92342 to bill for the displacement of replacement lenses.)
SA  Nurse practitioner rendering service in collaboration with a physician (This modifier is to be applied to service codes billed by a physician which were performed by a non-independent nurse practitioner employed by the physician or group practice.) (An independent nurse practitioner billing under his/her own individual provider number should not use this modifier.)
SB  Nurse midwife (This modifier is to be applied to service codes billed by a physician which were
performed by a non-independent nurse midwife employed by the physician or group practice.) (An independent nurse midwife billing under his/her own individual provider number should not use this modifier.)
SL State supplied vaccine (This modifier should only be applied to Service codes 90471 and 90473 to identify vaccines administered under the Vaccine for Children Program (VFC) for individuals age 18 and under.)
TC  Technical component (The component of a service or procedure representing the cost of rent, equipment, utilities, supplies, administrative and technical salaries and benefits, and other overhead expenses of the service or procedures, excluding the physician’s professional component. When the technical component is reported separately the addition of modifier ‘-TC’ to the service code will let the technical component allowable fee contained in 114.3 CMR 17.04 be paid.)