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

MASSHEALTH
TRANSMITTAL LETTER PHY-105
June 2005

	TO:	Physicians Participating in MassHealth

	FROM:	Beth Waldman, Medicaid Director

	RE:	Physician Manual (2005 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) 2005 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  2005 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

Effective Date

The changes to codes listed in Subchapter 6 are effective for dates of service on or after May 15, 2005. Code changes previously identified in Physician Bulletin 82 and effective on or after 1/1/05, have been incorporated within Subchapter 6.

Questions

If you have any questions about the information in 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.)

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-102

601  Introduction

MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2005 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. 

0003T
0008T
0010T
0016T
0017T
0018T
0019T
0020T
0021T
0023T
0024T
0026T
0027T
0028T
0029T
0030T
0031T
0032T
0033T
0034T
0035T
0036T
0037T
0038T
0039T
0040T
0041T
0042T
0043T
0044T
0045T
0046T
0047T
0048T
0049T
0050T
0051T
0052T
0053T
0054T
0055T
0056T
0058T
0059T
0060T
0061T
0062T
0063T
0064T
0065T
0066T
0067T
0068T
0069T
0070T
0071T
0072T
0073T
0074T
0075T
0076T
0077T
0078T
0079T
0080T
0081T
0082T
0083T
0084T
0085T
0086T
0087T
0088T
10040
11922
11950
11951
11952
11954
15775
15776
15780
15781
15782
15783
15786
15787
15788
15789
15792
15793
15810
15811
15819
15824
15825
15826
15828
15829
15876
15877
15878
15879
17340
17360
17380
19316
19324
19325
19355
19370
19371
19396
20930
20936
21120
21121
21122
21123
21125
21127
21245
21246
21248
21249
22841
32491
32850
32855
32856
33930
33933
33944
33940
36415
36416
36468
36469
36540
37765
37766
38204
38207
38208
38209
38210
38211
38212
38213
38214
38215
41870
41872
43752
43842
43843
43845
44132
44715
47133
47143
47144
47145
48160
48550
48551
50300
50323
50325
51701
51702
54900
54901
55200
55300
55400
55870
55970
55980
58321
58322
58323
58345
58350
58750
58752
58760
58970
58974
58976
59070
59072
59412
59897
62287
63043
63044
65760
65765
65767
65771
69090
71552
72159
72198
73225
76082
76083
76093
76094
76140
76150
76350
76390
76400
76496
76497
76498
77336
77370
77401
77402
77403
77404
77406
77407
77408
77409
77411
77412
77413
77414
77416
77417
77418
77520
77522
77523
77525
77790
78267
78268
78351
78890
78891
80500
80502
82075
82962
84061
84830
86079
86585
86890
86891
86910
86911
86927
86930
86931
86932
86945
86950
86965
86985
87901
87903
87904
88000
88005
88007
88012
88014
88016
88020
88025
88027
88028
88029
88036
88037
88040
88045
88099
88125
89250
89251
89253
89254
89255
89257
89258
89259
89260
89261
89264
89268
89272
89280
89281
89290
89291
89300
89310
89320
89321
89325
89329
89330
89335
89342
89343
89344
89346
89352
89353
89354
89356
90281
90283
90287
90379
90384
90386
90389
90396
90586
90633
90634
90636
90645
90646
90647
90648
90669
90680
90698
90700
90701
90702
90708
90710
90712
90715
90718
90720
90721
90723
90744
90748
90845
90865
90875
90876
90880
90885
90889
90901
90911
90939
90940
90989
90993
90997
90999
91132
91133
92314
92315
92316
92317
92325
92330
92335
92352
92353
92354
92355
92358
92371
92390
92391
92392
92393
92395
92396
92510
92531
92532
92533
92534
92548
92559
92560
92561
92562
92564
92597
92605
92606
92613
92615
92617
93660
93668
93760
93762
93770
93784
93786
93788
93790
94015
95052
95120
95125
95130
95131
95132
95133
95134
95824
95965
95966
95967
96000
96001
96002
96003
96004
96100
96105
96110
96111
96115
96117
96150
96151
96152
96153
96154
96155
96567
96902
97005
97006
97014
97537
97545
97546
97597
97598
97602
97605
97606
97755
97802
97803
97804
97810
97811
97813
97814
98940
98941
98942
98943
99001
99002
99024
99026
99027
99056
99058
99071
99075
99078
99080
99082
99090
99091
99100
99116
99135
99140
99141
99142
99172
99190
99191
99192
99271
99272
99273
99274
99275
99288
99315
99316
99354
99355
99356
99357
99358
99359
99360
99361
99362
99371
99372
99373
99374
99375
99377
99378
99379
99380
99401
99402
99403
99404
99411
99412
99420
99429
99450
99455
99456
99500
99501
99502
99503
99504
99505
99506
99507
99509
99510
99511
99512
99601
99602

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 >20:  Prior authorization is required for more than 20 osteopathic manipulative therapy visits in a 12-month period.
PA for OT >20:  Prior authorization is required for more than 20 occupational therapy visits in a 12-month period.
PA for PT >20:  Prior authorization is required for more than 20 physical therapy visits, regardless of modality, in a 12-month period.
PA for ST >35:  Prior authorization is required for more than 35 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.

01999	IC
11920	PA
11921	PA
15820	PA
15821	PA
15822	PA
15823	PA
15831	PA
15832	PA
15833	PA
15834	PA
15835	PA
15836	PA
15837	PA
15838	PA
15839	PA
15999	IC
17999	IC
19140	PA
19318	PA
19328	PA
19330	PA
19340	PA
19342	PA
19350	PA
19357	PA
19361	PA
19364	PA
19366	PA
19367	PA
19368	PA
19369	PA
19380	PA
19499	IC
20999	IC
21076	PA
21077	PA
21079	PA
21080	PA
21081	PA
21082	PA
21083	PA
21084	PA
21085	PA
21086	PA
21087	PA
21088	IC; PA
21089	IC; PA
21137	PA
21138	PA
21139	PA
21141	PA
21142	PA
21143	PA
        21145	PA
        21146	PA
        21147	PA
        21150	PA
        21151	PA
        21154	PA
        21155	PA
21159	PA
        21160	PA
        21172	PA
21175	PA
21179	PA
        21180	PA
        21181	PA
        21182	PA
        21183	PA
        21184	PA
        21188	PA
        21193	PA
        21194	PA
        21195	PA
        21196	PA
21198	PA
        21206	PA
        21208	PA
        21209	PA
        21210	PA
        21215	PA
        21230	PA
        21235	PA
        21240	PA
21242	PA
21243	PA
        21244	PA
21247	PA
21255	PA
21256	PA
21260	PA
21261	PA
21263	PA
21267	PA
21268	PA
21270	PA
21275	PA
21280	PA
21282	PA
21295	PA
21296	PA
21299	IC; PA
21499	IC
21742	IC
21743	IC
21899	IC
22899	IC
22999	IC
23929	IC
24940	IC
24999	IC
25999	IC
26989	IC
27299	IC
27599	IC
27899	IC
28899	IC
29799	IC
29800	PA
29804	PA
29999	IC
30400	PA
30410	PA
30420	PA
30430	PA
30435	PA
30450	PA
30999	IC
31299	IC
31599	IC
31899	IC
32851	PA
32852	PA
32853	PA
        32854	PA
        32999	IC
        33935	PA
        33945	PA
33999	IC
        36299	IC
        36470	PA
        36471	PA
        37501	IC
        37799	IC
        38129	IC
        38205	PA
        38230	PA
        38240	PA
        38241	PA
        38242	PA
        38589	IC
        38999	IC
        39499	IC
        39599	IC
        40799	IC
        40840	PA
        40842	PA
        40843	PA
        40844	PA
        40845	PA
        40899	IC
        41599	IC
        41820	IC; PA
        41821	IC
        41850	IC
        41899	IC
42140	PA
42280	PA
42281	PA
42299	IC
42699	IC
42999	IC
43289	IC
43499	IC
43644	PA
43645	PA
43659	IC
43846	PA
43847	PA
43848	PA
43999	IC
44133	IC; PA
44135	IC; PA
44136	IC; PA
44137	IC
44238	IC
44239	IC
44799	IC
44899	IC
44979	IC
45999	IC
46999	IC
47135	PA
47136	PA
47140	PA
47141	PA
47142	PA
47379	IC
47399	IC
47579	IC
47999	IC
48554	PA
48556	PA
48999	IC
49329	IC
49659	IC
49906	IC
49999	IC
50549	IC
50949	IC
51597	HI-1
51715	PA
51925	HI-1
53850	PA
53852	PA
53899	IC
54240	PA
54250	PA
54400	PA
54401	PA
54405	PA
54440	IC
54699	IC
55250	CS-18 or CS-21
55450	CS-18 or CS-21
55559	IC
55899	IC
56800	PA
56805	IC; PA
57335	IC; PA
58150	HI-1
58152	HI-1
58180	HI-1
58200	HI-1
58210	HI-1
58240	HI-1
58260	HI-1
58262	HI-1
58263	HI-1
58267	HI-1
58270	HI-1
58275	HI-1
58280	HI-1
58285	HI-1
58290	HI-1
58291	HI-1
58292	HI-1
58293	HI-1
58294	HI-1
58550	HI-1
58552	HI-1
58553	HI-1
58554	HI-1
58565	CS-18 or CS-21
58578	IC
58579	IC
58600	CS-18 or CS-21
58605	CS-18 or CS-21
58611	CS-18 or CS-21
58615	CS-18 or CS-21
58661	CS-18 or CS-21
58670	CS-18 or CS-21
58671	CS-18 or CS-21
58679	IC
58951	HI-1
58956	HI-1
58999	IC
59135	HI-1
59525	HI-1
59840	CPA-2 (first trimester)
59841	CPA-2 (first trimester)
59850	CPA-2 (second trimester, third trimester in hospital only)
59851	CPA-2 (second trimester, third trimester in hospital only) 
59852	CPA-2 (second trimester, third trimester in hospital only) 
59855	CPA-2
59856	CPA-2
59857	CPA-2
59898	IC
59899	IC
60659	IC
60699	IC
64999	IC
66999	IC
67299	IC
67399	IC
67599	IC
67900	PA
67901	PA
67902	PA
67903	PA
67904	PA
67906	PA
67908	PA
67909	PA
67911	PA
67916	PA
67917	PA
67923	PA
67924	PA
67961	PA
67966	PA
67971	PA
67973	PA
67974	PA
67975	PA
67999	IC
68399	IC
68899	IC
69300	PA
69399	IC
69710	IC
69799	IC
69930	PA
69949	IC
69979	IC
70336	PA
75556	IC
76499	IC
76999	IC
77299	IC
77399	IC
77499	IC
77799	IC
78099	IC
78199	IC
78299	IC
78399	IC
78499	IC
78599	IC
78608	IC
78609	IC
78699	IC
78799	IC
78999	IC
79999	IC
81099	IC
82045	IC
82656	IC
83009	IC
83630	IC
84163	IC
84999	IC
85999	IC
86064	IC
86379	IC
86587	IC
86849	IC
86999	IC
87807	IC
87999	IC; PA
88199	IC
88299	IC
88380	IC
88399	IC
89230	IC
89240	IC
90288	IC
90291	IC
90296	IC
90371	Covered for adults >17
90378	IC; PA
90393	IC, PA
90399	IC
90467	IC
90468	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 >35
92507	PA for ST >35
92508	PA for ST >35
92526	PA for ST >35
92610	PA for ST >35
92700	IC
92992	IC
92993	IC
93745	IC
93799	IC
94642	IC
94772	IC
94799	IC
95199	IC
95999	IC
96545	IC
96549	IC
96999	IC
97001	PA for PT >20
97002	PA for PT >20
97003	PA for OT >20
97004	PA for OT >20
97010	PA for PT >20
97012	PA for PT >20
97016	PA for PT >20
97018	PA for PT >20
97020	PA for PT >20
97022	PA for PT >20
97024	PA for PT >20                                          

97026	PA for PT >20
97028	PA for PT >20
97032	PA for PT >20
97033	PA for PT >20
97034	PA for PT >20
97035	PA for PT >20
97036	PA for PT >20
97039	PA for PT >20
97110	PA for PT >20
97112	PA for PT >20
97113	PA for PT >20
97116	PA for PT >20
97124	PA for PT >20
97139	PA for PT >20
97140	PA for PT >20
97150	PA for PT >20
97504	PA for OT >20
97520	PA for OT >20
97530	PA for OT >20
97532	PA for OT >20
97533	PA for OT >20
97535	PA for OT >20
97542	PA for OT >20
97799	IC
98925	PA for OMT >20
98926	PA for OMT >20
98927	PA for OMT >20
98928	PA for OMT >20; 
98929	PA for OMT >20; 
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
99195	For hematologic disorders only
99199	IC
99296	IC
99344	IC
99345	IC
99350	IC
99499	IC
99600	IC

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
A4641	Supply of radiopharmaceutical diagnostic imaging agent, not otherwise classified (IC) 
A9500	Supply of radiopharmaceutical diagnostic imaging agent, technetiumTc 99m sestamibi, per dose (IC) 
A9502	Supply of radiopharmaceutical diagnostic imaging agent technetiumTc 99m tetrofosmin, per unit dose (IC) 
A9503	Supply of radiopharmaceutical diagnostic imaging agent technetiumTc 99m medronate, up to 30 millicurie (IC) 
A9505	Supply of radiopharmaceutical diagnostic imaging agent thallous chloride T1-201, per millicurie (IC) 
H2011	Crisis intervention service, per 15 minutes
J0128	Injection, abarelix, 10 mg (PA) 
J0135	Injection, adalimumab, 20 mg (PA) 
J0215	Injection, alefacept, 0.5 mg (PA) 
J0256  	Injection, alpha 1-proteinase inhibitor–human, 10 mg 
J0295	Injection, ampicillin sodium / sulbactam sodium, per 1.5 g 
J0456	Injection, azithromycin, 500 mg 
J0475	Injection, baclofen, 10 mg 
J0476	Injection, baclofen, 50 mcg for intrathecal trial 
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 
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 
J1080	Injection, testosterone cypionate, 1 cc, 200 mg 
J1094	Injection, dexamethasone, acetate, 1 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
J2175	Injection, meperidine HCL, per 100 mg
J2250	Injection, midazolam HCl, per 1 mg
J2270	Injection, morphine sulfate, up to 10 mg
J2271	Injection, morphine sulfate, 100 mg 
J2275	Injection, morphine sulfate (preservative-free sterile solution), per 10 mg 
J2300	Injection, nalbuphine HCl, per 10 mg 
J2310	Injection, naloxone HCl, per 1 mg 
J2357	Injection, omalizumab, 5 mg (PA) 
J2405	Injection, ondansetron HCl, per 1 mg 
J2430	Injection, pamidronate disodium, per 30 mg 
J2440	Injection, papaverine HC1, up to 60 mg 
J2469	Injection, palonosetron, HCL, 25 mcg
J2505	Injection, prefilgrastim, 6 mg (PA) 
J2510	Injection, penicillin G procaine, aqueous, up to 600,000 units 
J2515	Injection, pentobarbital sodium, per 50 mg 
J2550	Injection, promethazine HCL, up to 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 
J3110	Injection, teriparatide, 10 mcg (PA) 
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 
J3396	Injection, verteporfin, 0.1 mg
J3410	Injection, hydroxyzine HCl, up to 25 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 
J7070	Infusion, D-5-W, 1,000 cc 
J7304	Contraceptive supply, hormone containing patch, each (IC) 
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
J9035	Injection, bevacizumab, 10 mg
J9040	Bleomycin sulfate, 15 units
J9041	Injection, bortezomib, 0.1 mg
J9045	Carboplatin, 50 mg 
J9055	Injection, cetuximab, 10 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 
J9263	Injection, oxaliplatin, 0.5 mg
J9265	Paclitaxel, 30 mg 
J9293	Injection, mitoxantrone HCL, per 5mg
J9300	Gemtuzumab ozogamicin, 5 mg 
J9305	Injection, pemetrexed, 10 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
S0020	Injection, bupivicaine HCl, 30 ml 
S0021	Injection, ceftoperazone sodium, 1 gram (IC)
S0023	Injection, cimetidine HCl, 300 mg (IC)
S0028	Injection, famotidine, 20 mg (IC)
S0077	Injection, clindamycin phosphate, 300 mg (IC)
S0162	Injection, efalizumab, 125 mg (IC), (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 modifiers. 

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)
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 90465, 90467, 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.)