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-123 January 2009 TO: Physician Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Physician Manual (Application of Fluoride Varnish by Pediatricians and Other Qualified Health Care Professionals) This letter transmits revisions to the MassHealth physician regulations at 130 CMR 433.000 effective October 1, 2008. The revised regulations allow pediatricians and other qualified health care professionals to apply medically necessary fluoride varnish to eligible MassHealth members under age 21. Covered Service Effective October 1, 2008, physicians and other qualified health care professionals may apply fluoride varnish to eligible MassHealth members under age 21. In general, MassHealth expects that this will occur during a pediatric preventive care visit. The purpose of applying fluoride varnish during a well child visit is to increase access to preventive dental treatment in an effort to intercept and prevent early childhood caries in children at moderate to high risk for dental caries. Please note: This service does not require a referral for members of the PCC Plan. Eligible Members This service is primarily intended for children up to age 3; however, the service is allowed for children up to age 21 who are eligible for MassHealth. Qualified Providers Physicians, physician assistants, nurse practitioners, registered nurses, and licensed practical nurses who complete the required training as described below, are eligible to apply the fluoride varnish subject to the limitations of state law. Required Training Providers must complete a MassHealth-approved training program on how to apply fluoride varnish, maintain proof of completion of the training, and provide such documentation to MassHealth upon request. For a list of MassHealth-approved training programs and additional information and resources, please visit the MassHealth Web site page that will be available on Monday, February 2, 2009, www.mass.gov/masshealth/fluoridevarnish. Restrictions/Limitations Fluoride varnish application is not recommended to exceed one application every 180 days from first tooth eruption (usually at 6 months) to the third birthday. This service is recommended during a well child visit and will be delivered along with oral health anticipatory guidance that includes patient self-management goals as well as appropriate dental referral, if necessary. Communications Any member without a dental provider should be referred to an appropriate dental provider. MassHealth Dental Customer Service can assist members in locating a dental provider. MassHealth Dental Customer Service can be reached at 1-800-207-5019, or e-mail your inquiry to inquiries@masshealth-dental.net. Billing Requirements Providers must submit claims for fluoride varnish services in accordance with applicable program regulations. Providers should bill MassHealth with Service Code D1206 on the MassHealth Claim Form No. 5 or transmitted through the 837P format. Physicians should not use the mid-level modifiers (SA, SB, or HN) when submitting a claim for fluoride varnish services provided by a qualified staff member as listed in 130 CMR 433.448(C) under the supervision of a physician. For MassHealth managed care organization (MCO) members, providers must contact the appropriate MCO customer service center listed below. Boston Medical Center HealthNet Plan: 1-888-900-1451 Fallon Community Health Plan: 1-866-275-3247 Network Health: 1-888-257-1985 Neighborhood Health Plan: 1-800-462-5449 If you have any questions about the information in this bulletin, 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 iv-a, 4-39 through 4-44, 6-11, and 6-12 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Physician Manual Pages iv-a and 4-39 through 4-42 — transmitted by Transmittal Letter PHY-122 Pages 4-43 and 4-44 — transmitted by Transmittal Letter PHY-109 Pages 6-11 and 6-12 — transmitted by Transmittal Letter PHY-121 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv-a Physician Manual Transmittal Letter PHY-123 Date 10/01/08 4. Program Regulations (cont.) 433.441: Pharmacy Services: Prescription Requirements................................................... 4-35 433.442: Pharmacy Services: Covered Drugs and Medical Supplies.................................. 4-36 433.443: Pharmacy Services: Limitations on Coverage of Drugs....................................... 4-37 433.444: Pharmacy Services: Insurance Coverage.............................................................. 4-38 433.445: Pharmacy Services: Prior Authorization.............................................................. 4-39 433.446: Pharmacy Services: Member Copayments........................................................... 4-40 433.447: Pharmacy Services: Payment............................................................................... 4-40 433.448: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services........ 4-40 433.449: Fluoride Varnish Services .................................................................................... 4-41 (130 CMR 433.450 Reserved) Part 3. Surgery Services 433.451: Surgery Services: Introduction ............................................................................ 4-41 433.452: Surgery Services: Payment .................................................................................. 4-42 (130 CMR 433.453 Reserved) 433.454: Anesthesia Services .............................................................................................. 4-44 433.455: Abortion Services ................................................................................................. 4-45 433.456: Sterilization Services: Introduction ..................................................................... 4-46 433.457: Sterilization Services: Informed Consent ........................................................... 4-47 433.458: Sterilization Services: Consent Form Requirements............................................ 4-48 433.459: Hysterectomy Services ......................................................................................... 4-49 (130 CMR 433.460 through 433.465 Reserved) Part 4. Other Services 433.466: Durable Medical Equipment and Medical/Surgical Supplies: Introduction ....................................................................................................... 4-51 433.467: Durable Medical Equipment and Medical/Surgical Supplies: Prescription Requirements .................................................................................................... 4-51 433.468: Durable Medical Equipment and Medical/Surgical Supplies: Prior- Authorization Requirements ............................................................................. 4-52 433.469: Oxygen and Respiratory Therapy Equipment ...................................................... 4-52 433.470: Transportation Services ........................................................................................ 4-53 433.471: Therapy, Speech and Hearing Clinic, and Amputee Clinic Services ................... 4-54 433.472: Mental Health Services ......................................................................................... 4-55 (130 CMR 433.473 through 433.475 Reserved) 433.476: Alternatives to Institutional Care: Introduction ................................................... 4-58 433.477: Alternatives to Institutional Care: Adult Foster Care .......................................... 4-58 433.478: Alternatives to Institutional Care: Home Health Services ................................... 4-58 433.479: Alternatives to Institutional Care: Private Duty Nursing Services ...................... 4-59 433.480: Alternatives to Institutional Care: Adult Day Health Services ............................ 4-59 433.481: Alternatives to Institutional Care: Independent Living Programs ....................... 4-60 433.482: Alternatives to Institutional Care: Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) .......................................................................... 4-60 433.483: Alternatives to Institutional Care: Day Habilitation Centers ............................... 4-61 433.484: The Massachusetts Special Education Law (Chapter 766) ................................... 4-61 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 433.000) Page 4-39 Physician Manual Transmittal Letter PHY-123 Date 10/01/08 MassHealth-covered medications. (2) Medicare Part D One-Time Supplies. The MassHealth agency pays for one-time supplies of prescribed medications, as described in 130 CMR 406.414(C)(2)(a) and (b), if the medication is a MassHealth-covered medication and the MassHealth member would otherwise be entitled to MassHealth pharmacy benefits but for being eligible for Medicare prescription drug coverage. MassHealth prior authorization does not apply to such one-time supplies. The MassHealth agency pays for the one-time supplies in all instances in which the pharmacist cannot bill a Medicare Part D prescription drug plan at the time the prescription is presented. The MassHealth agency pays for a one-time 72-hour supply of prescribed medications. (3) Cost-Sharing Assistance for MassHealth Members Enrolled in a Medicare Part D Prescription Drug Plan. For the purpose of 130 CMR 433.444(C)(3)(a) and (b), the “applicable MassHealth copayment” is the copayment the MassHealth member would pay for prescription drugs if the drugs were covered by MassHealth and not covered by Medicare Part D. MassHealth members who are enrolled in a Medicare Part D prescription drug plan and are charged a copayment or deductible in excess of the member’s applicable MassHealth copayment for a drug that MassHealth would otherwise cover, must pay the applicable MassHealth copayment and the MassHealth agency pays the difference between the applicable MassHealth copayment and the amount charged by the Medicare Part D prescription drug plan. 433.445: Pharmacy Services: Prior Authorization (A) Prescribers must obtain prior authorization from the MassHealth agency for drugs identified by the MassHealth agency in accordance with 130 CMR 450.303. If the limitations on covered drugs specified in 130 CMR 433.442(A) and 433.443(A) and (C) would result in inadequate treatment for a diagnosed medical condition, the prescriber may submit a written request, including written documentation of medical necessity, to the MassHealth agency for prior authorization for an otherwise noncovered drug. (B) All prior-authorization requests must be submitted in accordance with the instructions for requesting prior authorization in Subchapter 5 of the Physician Manual. If the MassHealth agency approves the request, it will notify the pharmacy and the member. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 433.000) Page 4-40 Physician Manual Transmittal Letter PHY-123 Date 10/01/08 (C) The MassHealth agency will authorize at least a 72-hour emergency supply of a prescription drug to the extent required by federal law. (See 42 U.S.C. 1396r-8(d)(5).) The MassHealth agency acts on requests for prior authorization for a drug within a time period consistent with federal regulations. (D) Prior authorization does not waive any other prerequisites to payment such as, but not limited to, member eligibility or requirements of other health insurers. (E) The MassHealth Drug List specifies the drugs that are payable under MassHealth. Any drug that does not appear on the MassHealth Drug List requires prior authorization, as set forth in 130 CMR 406.000. MassHealth evaluates the prior-authorization status of drugs on an ongoing basis, and updates the MassHealth Drug List accordingly. 433.446: Pharmacy Services: Member Copayments Under certain conditions, the MassHealth agency requires that members make a copayment to the dispensing pharmacy for each original prescription and for each refill for all drugs (whether prescription or over-the-counter) covered by MassHealth. The copayment requirements are detailed in 130 CMR 450.130. 433.447: Pharmacy Services: Payment Drugs and biologicals dispensed in the office are payable, subject to the service limitations at 130 CMR 433.404, 433.406, and 433.443. The MassHealth agency does not pay a physician separately for drugs that are considered routine and integral to the delivery of a physician’s professional services in the course of diagnosis or treatment. Such drugs are commonly provided without charge or are included in the physician’s fee for the service. The MassHealth agency does not pay separately for any oral drugs dispensed in the office for which the physician has not requested and received prior authorization from the MassHealth agency, with the exception of oral vaccines and oral radiopharmaceuticals, which do not require prior authorization. Claims for drugs and biologicals that are listed in Subchapter 6 of the Physician Manual must include the name of the drug or biological, strength, dosage, and number of units dispensed. A copy of the invoice showing the actual acquisition cost must be attached to the claim form for drugs and/or biologicals that are listed as requiring individual consideration in Subchapter 6 of the Physician Manual, and must include the National Drug Code (NDC). Claims without this information are denied. The MassHealth agency does not pay for a biological if the Massachusetts Department of Public Health distributes the biological free of charge. Payment for drugs may be claimed in addition to an office visit. 433.448: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services The MassHealth agency pays for all medically necessary physician services for EPSDT-eligible members in accordance with 130 CMR 450.140 et seq., without regard to service limitations described in 130 CMR 433.000, and with prior authorization. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 433.000) Page 4-41 Physician Manual Transmittal Letter PHY-123 Date 10/01/08 433.449: Fluoride Varnish Services (A) Eligible Members. Members must be under the age of 21 to be eligible for the application of fluoride varnish. (B) Qualified Providers. Physicians, nurse practitioners, registered nurses, licensed practical nurses, and physician assistants may apply fluoride varnish subject to the limitations of state law. Providers must complete a MassHealth-approved training on the application of fluoride varnish, maintain proof of completion of the training, and provide such proof to the MassHealth agency upon request. (C) Billing for an Office Visit and Fluoride Varnish Treatment/Procedure. A physician may bill for fluoride varnish services provided by the physician or a qualified staff member as listed in 130 CMR 433.449(B) under the supervision of a physician. The physician may bill for an office visit, in addition to the fluoride varnish application, only if fluoride varnish was not the sole service, treatment, or procedure provided during the visit. (D) Claims Submission. Physicians and independent nurse practitioners may submit claims for fluoride varnish services when they provide those services directly to MassHealth members. These are the only MassHealth provider types who may bill for this service independently under these regulations. A physician may also submit claims for fluoride varnish services that are provided by nurse practitioners, registered nurses, licensed practical nurses, and physician assistants according to 130 CMR 433.449(C). See Subchapter 6 of the Physician Manual for service codes and descriptions. (130 CMR 433.450 Reserved) Part 3. Surgery Services 433.451: Surgery Services: Introduction (A) Provider Eligibility. The MassHealth agency will pay a physician for surgery only if the physician is scrubbed and present in the operating room during the major portion of the operation. (See 130 CMR 433.421(D)(1) for the single exception to this requirement.) (B) Nonpayable Services. The MassHealth agency does not pay for (1) any experimental, unproven, cosmetic, or otherwise medically unnecessary procedure or treatment. This specifically includes, but is not limited to, sex-reassignment surgery, thyroid cartilage reduction surgery, and any other related surgeries; (2) the treatment of male or female infertility (including, but not limited to, laboratory tests, drugs, and procedures associated with such treatment); (3) reconstructive surgery, unless the MassHealth agency determines, pursuant to a request for prior authorization, the service is medically necessary to correct, repair, or ameliorate the Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 433.000) Page 4-42 Physician Manual Transmittal Letter PHY-123 Date 10/01/08 physical effects of physical disease or defect, or traumatic injury; (4) services billed under codes listed in Subchapter 6 of the Physician Manual as not payable; (5) services otherwise identified in MassHealth regulations at 130 CMR 433.000 or 450.000 as not payable; and (6) services billed with otherwise-covered service codes when such codes are used to bill for nonpayable circumstances as described in 130 CMR 433.404. 433.452: Surgery Services: Payment The maximum allowable fees for the surgery services apply to surgery procedures performed in any setting. The MassHealth agency pays a physician for either a visit or a treatment/procedure, whichever commands a higher fee. The MassHealth agency does not pay for both a visit and a treatment/procedure provided to a member on the same day when they are performed in the same location. All maximum allowable fees for surgery procedures include payment for the initial application of casts, traction devices, or similar appliances. (A) Obstetrics. Obstetric fees include payment for procedures performed and care given to a member in a hospital or at home. However, the MassHealth agency will give individual consideration to a claim for extended obstetric preoperative or postoperative care due to unusual circumstances, if the physician requests it and attaches adequate medical documentation to the claim form. (B) Inpatient Services. (1) For surgery procedures performed on an inpatient in a licensed hospital, the fees include payment for preoperative diagnosis and postoperative care during the period of hospitalization. (2) The MassHealth agency will give individual consideration to a claim for extended preoperative or postoperative care due to unusual circumstances if the physician requests it and attaches adequate medical documentation to the claim form. (3) A physician who performs an inpatient surgery procedure but does not provide the postoperative care will be paid 85 percent of the maximum allowable fee. The physician providing the postoperative care will be paid according to the applicable office, hospital, or home visit fee. (C) Surgical Assistants. The MassHealth agency pays a surgical assistant at 15 percent of the allowable fee for the surgical procedure. The MassHealth agency will not pay for a surgical assistant if a surgical assistant is used in less than five percent of the cases for that procedure nationally. In addition, the MassHealth agency will not pay for a surgical assistant if (1) any component of the surgery is billed using a team surgery modifier pursuant to 130 CMR 433.452(D) or a two-surgeon modifier pursuant to 130 CMR 433.452(E); or (2) the surgery services were provided in a teaching hospital that has an approved training program related to the medical specialty required for the surgical procedure and a qualified resident available to perform the services. If no qualified resident is available to perform the services, the MassHealth agency will pay for a surgical assistant if the member’s medical record documents that a qualified resident was unavailable at the time of the surgery. (D) Team Surgery. Under some circumstances, the MassHealth agency pays for highly complex surgical procedures requiring the concomitant services of more than two surgeons as “team surgery.” The MassHealth agency pays a single consolidated payment for team surgery to the director of the surgical team. To receive payment, the director of the team must use the team surgery modifier. Payment includes all surgical assistant fees. The director of the surgical team is Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 433.000) Page 4-43 Physician Manual Transmittal Letter PHY-123 Date 10/01/08 expected to distribute the MassHealth payment to the other physician members of the surgical team. (E) Two Surgeons (Co-Surgery). The MassHealth agency pays for co-surgery when two surgeons work together as primary surgeons performing distinct parts of a reportable procedure. To receive payment, each surgeon must use the two surgeons modifier. The MassHealth agency pays 57.5 percent of the allowable fee to each of the two surgeons. Payment includes all surgical assistant fees. (F) Multiple Procedures. In most circumstances, the MassHealth agency pays for only one operative procedure in a single operative session. For example, it is inappropriate to request payment for both an exploratory laparotomy and an appendectomy, or for both an arthrotomy and a meniscectomy. When two definitive procedures are performed during the same operative session, and neither procedure is designated "I.P." (for independent procedure - see 130 CMR 433.452(G), the full maximum allowable fee will be paid for one procedure, and 50 percent of the maximum allowable fee will be paid for each additional procedure. (G) Independent Procedures. A number of surgery procedures are designated "I.P." in Subchapter 6 of the Physician Manual. I.P. is an abbreviation for independent procedure. An independent procedure is reimbursable only when no other procedure is performed during the same operative session, unless one of the exceptions in 130 CMR 433.452(G)(1) through (3) applies. (1) When during the same operative session an additional surgery procedure performed by the same physician is designated "I.P." and requires an unrelated operative incision, the full maximum allowable fee will be paid for the procedure with the largest fee, and 50 percent of the maximum allowable fee will be paid for each additional procedure, unless otherwise provided herein. In the event that two or more procedures are scheduled at the largest amount, the full maximum allowable fee will be paid for only one of the procedures, and 50 percent of the maximum allowable fee will be paid for each additional procedure, unless otherwise provided herein. (2) When during the same operative session one or more of the surgery procedures performed by the same physician is designated "I.P." and does not require an unrelated operative incision, the maximum allowable fee will be paid for the procedure commanding the largest fee, and no payment will be made for any other procedure. (3) When during the same operative session all of the surgery procedures performed by the same physician are designated "I.P." and one or more requires an unrelated operative incision, payment is determined on the basis of individual consideration. (130 CMR 433.453 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 433.000) Page 4-44 Physician Manual Transmittal Letter PHY-123 Date 10/01/08 433.454: Anesthesia Services (A) Payment. (1) Payment Determination. Payment for anesthesia services is determined using base anesthesia units and time units. To determine payment, the MassHealth agency multiplies the anesthesia unit fee established by DHCFP by the time units reported on the claim pursuant to 130 CMR 433.454(A)(2)(c), plus the number of base units, if any have been set by DHCFP. The number of base units is the same for a surgical procedure, regardless of the type of anesthesia administered, including acupuncture (see 130 CMR 433.454(C)). (2) Calculation. (a) Anesthesia Units. The MassHealth agency pays for anesthesia services by multiplying the time units plus any base anesthesia units by the unit fee established by DHCFP. If DHCFP has not established base anesthesia units for a service, the MassHealth agency pays using time units only. (b) Determining Payable Anesthesia Time. Payable anesthesia time starts when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating room or equivalent area. Payable anesthesia time ends when the patient may be safely placed under postoperative supervision. (c) Reporting Time Units. A provider’s claim must report only payable time units. It must not include base anesthesia units or units that exceed the criteria described in 130 CMR 433.454(A)(1)(b) in the number of units field on the claim. To calculate the correct number of time units, the provider must determine the number of 15-minute intervals of payable anesthesia time plus any remaining fraction, provided such fraction equals or exceeds five minutes. (3) Multiple Surgery Procedures. When anesthesia is administered for multiple surgery procedures, the MassHealth agency applies only the base anesthesia units for the procedure with the largest number of units to determine the maximum allowable fee. (B) Services Provided by a Nurse-Anesthetist. (1) Anesthesia services provided by a nurse-anesthetist are payable only if the nurse-anesthetist (a) is authorized by law to perform the services; (b) is a full-time employee of the physician and is not a salaried employee of the hospital; and (c) performs the services under the direct and continuous supervision of the physician. (2) The supervising physician must be in the operating suite and responsible for no more than four operating rooms. Availability of the physician by telephone does not constitute direct and continuous supervision. (C) Acupuncture as an Anesthetic. The MassHealth agency pays for acupuncture only as a substitute for conventional surgical anesthesia. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-11 Physician Manual Transmittal Letter PHY-123 Date 10/01/08 604 HCPCS Level II Service Codes This section lists Level II HCPCS codes that are payable under MassHealth. Refer to the Centers for Medicare & Medicaid Services 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 Radiopharmaceutical, diagnostic, not otherwise classified (IC) A9500 Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries (IC) A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose, up to 40 millicuries (IC) A9503 Technetium Tc-99m medronate, diagnostic, per study, up to 30 millicuries (IC) A9505 Thallium T1-201 thallous chloride, diagnostic, per millicurie (IC) A9512 Technetium Tc-99m pertechnetate, diagnostic, per millicurie (IC) A9537 Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries (IC) D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients G0105 Colorectal cancer screening; colonoscopy on individual at high risk G0108 Diabetes outpatient self-management training services, individual, per 30 minutes G0109 Diabetes self-management training services, group session (two or more), per 30 minutes G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes G0271 Medical nutrition therapy, reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (two or more individuals), each 30 minutes H2011 Crisis intervention service, per 15 minutes J0129 Injection, abatacept, 10 mg (PA) J0135 Injection, adalimumab, 20 mg (PA) 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 J0348 Injection, anidulafungin, 1 mg J0456 Injection, azithromycin, 500 mg J0460 Injection, atropine sulfate, up to 0.3 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-12 Physician Manual Transmittal Letter PHY-123 Date 10/01/08 604 HCPCS Level II Service Codes (cont.) Service Code Service Description 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) J0592 Injection, buprenorphine HCL, 0.1 mg 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 J0835 Injection, cosyntropin, per 0.25 mg J0881 Injection, darbepoetin alfa, 1 mcg (non-ESRD use) (PA) J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis) (PA) J0885 Injection, epoetin alfa, (for non-ESRD use), 1000 units (PA) J0886 Injection, epoetin alfa, 1000 units (for ESRD on dialysis) (PA) J0900 Injection, testosterone enanthate and estradiol valerate, up to 1 cc (IC) 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 (IC) J1438 Injection, etanercept, 25 mg (PA) J1440 Injection, filgrastim (G-CSF), 300 mcg J1441 Injection, filgrastim (G-CSF), 480 mcg 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