Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter PHY-129 February 2011 TO: Physicians Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Physician Manual (2011 HCPCS) This letter transmits revisions to the service codes in the Physician Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) for 2011. The revised Subchapter 6 is effective for dates of service on or after January 1, 2011. Providers should use the American Medical Association Current Procedural Terminology (CPT) 2011 code book to get service descriptions for the codes listed in Subchapter 6 of the Physician Manual. The codes in Subchapter 6 are arranged in the following way to describe what MassHealth covers. • Section 602 lists CPT codes that are not ordinarily payable under MassHealth. (All other numeric CPT codes in the CPT 2011 code book are payable, subject to all limitations and conditions of payment in MassHealth regulations at 130 CMR 433.000 and 450.000.) • Section 603 lists CPT codes that have special limitations or requirements, such as prior authorization (PA), individual consideration, or attachment requirements. • Section 604 lists Level II HCPCS codes that are payable under MassHealth and have special limitations or requirements, such as prior authorization (PA), individual consideration, or attachment requirements. A physician may request prior approval for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age even if it is not designated as covered or payable in the Physician Manual. If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The regulation titles are 114.3 CMR 16.00: Surgery and Related Anesthesia Care; 114.3 CMR 17.00: Medicine; 114.3 CMR 18.00: Radiology; and 114.3 CMR 20.00: Laboratory. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/sprDivision of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp Behavioral Health Screening Reminder All primary-care providers serving MassHealth-enrolled members under the age of 21 (except MassHealth Limited) are reminded they must offer to use a standardized behavioral health screening tool when performing the behavioral health screening component of an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) or Pediatric Preventive Health-care Screening and Diagnosis (PPHSD) visit, according to Appendix W of your MassHealth provider manual. Appendix W contains a menu of screening tools from which to choose. MassHealth will pay for the administration and scoring of the standardized behavioral health screening tool in addition to, and separately from, the office visit. MassHealth provided detailed information about the new requirements surrounding the standardized behavioral health screening tool in Transmittal Letter ALL-155, which communicated the initial updates to the EPSDT/PPHSD regulations (130 CMR 450.140 through 450.150), Appendix W, and Appendix Z. When billing the behavioral health screening, providers must bill Service Code 96110 with its appropriate modifier. These modifiers can be found in Section 605 of Subchapter 6 of the Physician Manual. For your convenience, the list of modifiers has been reproduced below. Behavioral Health Screening of Members < 21 Years Service Code 96110 and Modifier Servicing Provider When No Behavioral Health Need Identified* When Behavioral Health Need Identified* Physician, Independent Nurse Midwife, Independent Nurse Practitioner 96110 U1 96110 U2 Nurse Midwife employed by Physician 96110 U3 96110 U4 Nurse Practitioner employed by Physician 96110 U5 96110 U6 Physician Assistant employed by Physician 96110 U7 96110 U8 *“Behavioral health need identified” means the provider administering the screening tool, in her or his professional judgment, identifies a child with a potential behavioral health services need. See www.mass.gov/masshealth/childbehavioralhealth for more information and training. Consultation Codes Effective January 1, 2011, the consultation codes are no longer recognized by MassHealth for payment. Providers should bill patient evaluation and management (E/M) visits with E/M codes that represent where the visit occurs, and that identify the complexity of the visit performed. In the office or other outpatient setting where a consultation is performed, physicians and qualified nonphysician practitioners should use the appropriate service codes (99201–99205; 99211– 99215), depending on the complexity of the visit and whether the patient is a new or established patient to that physician. In an inpatient hospital or nursing facility setting, all physicians (and qualified nonphysician practitioners where permitted) who perform an initial consultation may bill the initial hospital care service codes (99221 – 99223) or nursing facility care service codes (99304–99306). Removal of Prior Authorization for Maxillofacial Prosthetics Effective January 1, 2010, MassHealth has removed the prior authorization requirement for maxillofacial prosthetics on cleft palate and cancer reconstruction cases. The following service codes no longer require prior authorization. 21076 21079 21081 21083 21086 21089 21077 21080 21082 21084 21088 21097 Fluoroscopy with Paravertebral Facet Joint Injections Providers are reminded that imaging guidance and localization are required for the performance of paravertebral facet joint injections described by Service Codes 64490-64495. Image guidance (fluoroscopy or CT) and any injection of contrast are inclusive components of Service Codes 64490-64495. Digital Mammography Effective January 1, 2011, digital mammography Service Codes G0202, G0204, and G0206 are payable under MassHealth. Providers are reminded to bill the professional and technical components individually on separate claim lines with the appropriate modifier 26 or TC. Any claims for such services that are not billed with modifier 26 or TC will be denied. Multiple Surgery Payment and Global Surgery Periods MassHealth is currently developing new regulations about multiple surgery payment and global surgery periods. These changes will be reflected in revised regulations to be issued within the coming months. Bilateral Procedures: Change to Modifier 50 Billing Payment for bilateral procedures performed at the same operative session must be identified by the appropriate service code and the modifier 50. Only one claim line should be billed for both procedures. The addition of the modifier 50 to the bilateral code will allow 150% of the allowable fee contained in 114.3 CMR 16.05(4) to be paid to the eligible provider for performance of both bilateral procedures. MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth. Questions If you have any questions about this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Physician Manual Pages vi, vii, and 6-1 through 6-20 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Physician Manual Pages vi and 6-1 through 6-20 — transmitted by Transmittal Letter PHY-128 Pages vii — transmitted by Transmittal Letter PHY-109 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Physician Manual Transmittal Letter PHY-129 Date 01/01/11 6. Service Codes Introduction ................................................................................................................................... 6-1 Nonpayable CPT Codes................................................................................................................. 6-1 Codes That Have Special Requirements or Limitations................................................................. 6-4 Payable HCPCS Level II Service Codes........................................................................................ 6-11 Modifiers....................................................................................................................................... 6-18 Appendix A. Directory .................................................................................................................. A-1 Appendix B. Enrollment Centers .................................................................................................. B-1 Appendix C. Third-Party-Liability Codes .................................................................................... C-1 Appendix D. (Reserved) Appendix E. Admission Guidelines.............................................................................................. E-1 Appendix F. (Reserved) Appendix G. (Reserved) Appendix H. (Reserved) Appendix I. Utilization Management Program............................................................................ I-1 Appendix J. (Reserved) Appendix K. Teaching Physicians ................................................................................................ K-1 Appendix W. EPSDT Services: Medical and Dental Protocol and Periodicity Schedules............. W-1 Appendix X. Family Assistance Copayments and Deductibles..................................................... X-1 Appendix Y. EVS Codes/Messages .............................................................................................. Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes.............................................................. Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Preface Page vii Physician Manual Transmittal Letter PHY-129 Date 01/01/11 The regulations and instructions governing provider participation in MassHealth are published in the Provider Manual Series. MassHealth publishes a separate manual for each provider type. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, administrative and billing instructions, and general information. MassHealth regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. MassHealth regulations are assigned Title 130 of the Code. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For physicians, those matters are covered in 130 CMR Chapter 433.000, reproduced as Subchapter 4 in the Physician Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead MassHealth’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with MassHealth and its members. 601 Introduction MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2011 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 MassHealth regulations at 130 CMR 433.000 and 450.000, except for those codes listed in Section 602 of this subchapter, Category II codes ending in F, and Category III codes ending in T. In addition, a physician may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age even if it is not designated as covered or payable in the Physician Manual. • 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 allowed under MassHealth. 602 Nonpayable CPT Codes Regardless of nonpayable status, a physician may request prior authorization for any medically necessary service for a MassHealth Standard or CommonHealth member younger than 21 years of age. MassHealth does not pay for services billed under the following codes. 10040 11922 11950 11951 11952 11954 15775 15776 15780 15781 15782 15783 15786 15787 15788 15789 15792 15793 15819 15824 15825 15826 15828 15829 15847 15876 15877 15878 15879 17340 17360 17380 19316 19324 19325 19355 19396 20930 20936 20985 21120 21121 21122 21123 21125 21127 21245 21246 21248 21249 22526 22527 22841 22856 22861 22864 32491 32850 32855 32856 33930 33933 33940 33944 36415 36416 36468 36469 36591 36592 36598 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 61630 61635 61640 61641 61642 62287 63043 63044 65760 65765 65767 65771 69090 71552 72159 72198 73225 74263 75571 76140 76390 76496 76497 76498 77336 77370 77371 77372 77373 77401 77402 77403 77404 77406 77407 77408 77409 77411 77412 77413 77414 77416 77417 77418 77421 77422 77423 77520 77522 77523 77525 77790 78267 78268 78351 80500 80502 82075 82962 83987 84061 84145 84431 84830 86079 86305 86890 86891 86910 86911 86927 86930 86931 86932 86945 86950 86960 86965 86985 87150 87153 87493 87900 87901 87903 87904 88000 88005 88007 88012 88014 88016 88020 88025 88027 88028 88029 88036 88037 88040 88045 88099 88125 88333 88334 88738 88749 89250 89251 89253 89254 89255 89257 89258 89259 89260 89261 89264 89268 89272 89280 89281 89290 89291 89300 89310 89320 89321 89322 89325 89329 89330 89331 89335 89342 89343 89344 89346 89352 89353 89354 89356 89398 90281 90283 90284 90287 90384 90386 90389 90396 90586 90633 90634 90644 90645 90646 90647 90648 90654 90665 90669 90670 90680 90698 90700 90701 90702 90708 90710 90712 90720 90721 90723 90743 90744 90748 90845 90865 90875 90876 90880 90885 90889 90901 90911 90940 90989 90993 90997 90999 91132 91133 92314 92315 92316 92317 92325 92352 92353 92354 92355 92358 92371 92531 92532 92533 92534 92548 92559 92560 92561 92562 92564 92597 92605 92606 92613 92615 92617 92630 92633 93660 93668 93770 93786 94005 94015 94644 94645 95012 95052 95120 95125 95130 95131 95132 95133 95134 95824 95965 95966 95967 95992 96000 96001 96002 96003 96004 96040 96101 96102 96103 96105 96111 96116 96118 96119 96120 96125 96150 96151 96152 96153 96154 96155 96376 96567 96902 96904 97005 97006 97014 97537 97545 97546 97597 97598 97602 97605 97606 97755 97810 97811 97813 97814 98940 98941 98942 98943 98960 98961 98962 98966 98967 98968 98969 99001 99002 99024 99026 99027 99053 99056 99058 99060 99071 99075 99078 99080 99082 99090 99091 99100 99116 99135 99140 99143 99144 99145 99148 99149 99150 99172 99190 99191 99192 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99288 99315 99316 99339 99340 99354 99355 99356 99357 99358 99359 99360 99363 99364 99366 99367 99368 99374 99375 99377 99378 99379 99380 99401 99402 99403 99404 99406 99408 99409 99411 99412 99420 99429 99441 99442 99443 99444 99450 99455 99456 99500 99501 99502 99503 99504 99505 99506 99507 99509 99510 99511 99512 99601 99602 99605 99606 99607 The service codes in this section 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 codes. Legend Centrifuging required: Service Code 99000 may be used only to pay a physician who centri- fuges and mails a specimen to a laboratory for analysis. (See 130 CMR 433.439.) Covered for members =12: This code is payable only for members aged 12 years or older; available free of charge through the Massachusetts Immunization Program for children under 12 years of age. Covered for members 19 to 26: This code is payable only for members aged 19 to 26 years; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. Covered for members birth to 21: This code is payable only for members aged birth to 21 years; used to claim for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your provider manual, must be accompanied by modifiers found in Section 605 under Behavioral Health Screening Modifiers to indicate whether a behavioral health need was identified. Covered for members = 19: This code is payable only for members aged 19 or older; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 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 for Units > 8: Prior authorization is required for claims submitted with greater than 8 units on a given date of service. PA: Service requires prior authorization. See 130 CMR 433.408 for more information. Urgent Care Only: Service Codes 99050 and 99051 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 15431 IC 15820 PA 15821 PA 15822 PA 15823 PA 15830 PA 15832 PA 15833 PA 15834 PA 15835 PA 15836 PA 15837 PA 15838 PA 15839 PA 15999 IC 17999 IC 19300 PA 19318 PA 19328 PA 19350 PA 19499 IC 20999 IC 21085 PA 21088 IC 21089 IC 21137 PA 21138 PA 21139 PA 21146 PA 21147 PA 21150 PA 21151 PA 21155 PA 21159 PA 21160 PA 21172 PA 21175 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 21299 PA; IC 21499 IC 21742 IC 21743 IC 21899 IC 22857 PA 22862 PA 22865 PA 22899 IC 22999 IC 23929 IC 24940 IC 24999 IC 25999 IC 26989 IC 27299 IC 27599 IC 27899 IC 28890 PA 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 33981 IC 33982 IC 33983 IC 33999 IC 36299 IC 36470 PA 36471 PA 37501 IC 37799 IC 38129 IC 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 PA; IC 41821 IC 41850 IC 41899 IC 42280 PA 42281 PA 42299 IC 42699 IC 42999 IC 43289 IC 43499 IC 43644 PA 43645 PA 43647 PA; IC 43648 IC 43659 IC 43770 PA 43771 PA 43772 PA 43773 PA 43774 PA 43775 PA 43846 PA 43847 PA 43848 PA 43881 PA; IC 43882 IC 43886 PA 43887 PA 43888 PA 43999 IC 44133 IC 44135 PA; IC 44136 PA; IC 44238 IC 44799 IC 44899 IC 44979 IC 45499 IC 45999 IC 46999 IC 47135 PA 47136 PA 47379 IC 47399 IC 47579 IC 47999 IC 48554 PA 48999 IC 49329 IC 49659 IC 49906 IC 49999 IC 50549 IC 50949 IC 51925 HI-1 51999 IC 53899 IC 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 57335 IC 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 58541 HI-1 58542 HI-1 58543 HI-1 58544 HI-1 58548 HI-1 58550 HI-1 58552 HI-1 58553 HI-1 58554 HI-1 58565 CS-18 or CS-21 58570 HI-1 58571 HI-1 58572 HI-1 58573 HI-1 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 64650 PA 64653 PA 64999 IC 65757 IC 66999 IC 67299 IC 67399 IC 67599 IC 67900 PA 67901 PA 67902 PA 67903 PA 67904 PA 67906 PA 67908 PA 67999 IC 68399 IC 68899 IC 69300 PA 69399 IC 69710 IC 69799 IC 69930 PA 69949 IC 69979 IC 74261 PA 74262 PA 76499 IC 76999 IC 77058 PA 77059 PA 77299 IC 77399 IC 77499 IC 77799 IC 78099 IC 78199 IC 78299 IC 78399 IC 78499 IC 78599 IC 78699 IC 78799 IC 78999 IC 79999 IC 80100 PA for Units > 8 80101 PA for units > 8 81099 IC 84999 IC 85999 IC 86849 IC 86999 IC 87999 IC 88199 IC 88299 IC 88384 IC 88399 IC 89240 IC 90288 IC 90291 IC 90296 IC 90378 PA; IC 90393 PA; IC 90399 IC 90476 IC 90477 IC 90581 IC 90632 Covered for adults = 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90636 IC 90649 Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90650 Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90661 IC 90662 IC 90663 IC 90664 IC 90666 IC 90667 IC 90668 IC 90676 IC 90681 IC; Covered for members = 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90690 IC 90692 IC 90693 IC 90696 IC 90707 Covered for members = 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90713 Covered for members = 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90715 Covered for members = 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90716 Covered for members = 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90718 IC 90719 IC 90725 IC 90727 IC 90732 Covered for members = 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90734 IC; Covered for members = 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90736 IC; PA is required for members less than age 60 90738 IC 90749 IC 90867 IC 90868 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 90952 IC 90953 IC 91110 PA 91111 PA 91299 IC 92065 PA 92250 PA 92310 PA; includes supply of lenses 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 93229 IC 93299 IC 93745 IC 93799 IC 94772 IC 94774 IC 94775 IC 94776 IC 94777 IC 94799 IC 95199 IC 95803 IC 95999 IC 96110 Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report; Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; must be accompanied by modifiers found in Section 605 under Behavioral Health Screening Modifiers to indicate whether a behavioral health need was identified. 96379 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 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; IC 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; IC 97140 PA for PT >20 97150 PA for PT >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 97760 PA for OT >20 97761 PA for OT >20 97762 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 99051 Urgent care only 99070 IC; excluding family planning supplies, such as trays, used in the collection of specimens 99174 PA 99195 For hematologic disorders only 99199 IC 99499 IC 99600 IC 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 (IC) A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose (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 outpatient 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 G0202 Screening mammography, producing direct digital image, bilateral, all views G0204 Diagnostic mammography, producing direct digital image, bilateral, all views G0206 Diagnostic mammography, producing direct digital image, unilateral, all views 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 J0129 Injection, abatacept, 10 mg (PA) J0135 Injection, adalimumab, 20 mg (PA) J0171 Injection, Adrenalin, epinephrine, 0.1 mg (IC) 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 J0461 Injection, atropine sulfate, 0.01 mg J0475 Injection, baclofen, 10 mg 604 HCPCS Level II Service Codes (cont.) Service Code Service Description J0476 Injection, baclofen, 50 mcg for intrathecal trial J0558 Injection, penicillin G benzathine and penicillin G procaine, 100,000 units (IC) J0561 Injection, penicillin G benzathine, 100,000 units (IC) J0585 Injection onabotulinumtoxinA, 1 unit (PA) J0586 Injection, abobotulinumtoxinA, 5 units (PA) J0587 Injection rimabotulinumtoxinB, 100 units (PA) J0592 Injection, buprenorphine HCl, 0.1 mg J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units (IC) J0598 Injection, C1 esterase inhibitor (human), Cinryze,10 units (PA) J0638 Injection, canakinumab, 1 mg (PA) (IC) 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 3 mg and betamethasone sodium phosphate 3 mg J0718 Injection, certolizumab pegol, 1 mg (PA) J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg (PA) (IC) J0780 Injection, prochlorperazine, up to 10 mg J0833 Injection, cosyntropin, not otherwise specified, 0.25 mg J0834 Injection, cosyntropin (Cortrosyn), 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 604 HCPCS Level II Service Codes (cont.) Service Code Service Description J1200 Injection, diphenhydramine HCl, up to 50 mg J1260 Injection, dolasetron mesylate, 10 mg J1290 Injection, ecallantide, 1 mg (IC) J1300 Injection, eculizumab, 10 mg (IC) 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 J1559 Injection, immune globulin (Hizentra), 100 mg (PA) (IC) J1561 Injection, immune globulin, (Gamunex), intravenous, nonlyophilized (e.g., liquid), 500 mg J1562 Injection, immune globulin, (Vivaglobin), 100 mg (PA) J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg (PA) J1569 Injection, immune globulin (Gammagard liquid), intravenous, nonlyophilized (e.g., liquid), 500 mg J1571 Injection, hepatitis B immune globulin (Hepagam B), intramuscular, 0.5 ml J1580 Injection, garamycin, gentamicin, up to 80 mg J1599 Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified, 500 mg (PA) (IC) 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 (IC) J1720 Injection, hydrocortisone sodium succinate, up to 100 mg J1740 Injection, ibandronate sodium, 1 mg (PA) J1743 Injection, idursulfase, 1 mg (IC) J1745 Injection, infliximab, 10 mg (PA) J1750 Injection, iron dextran, 50 mg J1786 Injection, imiglucerase, 10 units (PA) (IC) J1790 Injection, droperidol, up to 5 mg J1800 Injection, propranolol HCl, up to 1 mg J1826 Injection, interferon beta-1a, 30 mcg (IC) J1885 Injection, ketorolac, tromethamine, per 15 mg J1890 Injection, cephalothin sodium, up to 1 g (IC) 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 604 HCPCS Level II Service Codes (cont.) Service Code Service Description J2248 Injection, micafungin sodium, 1 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 J2315 Injection, naltrexone, depot form, 1 mg (PA) J2323 Injection, natalizumab, 1 mg J2355 Injection, oprelvekin, 5 mg (PA) J2357 Injection, omalizumab, 5 mg (PA) J2358 Injection, olanzapine, long-acting, 1 mg (PA) (IC) J2405 Injection, ondansetron HCl, per 1 mg J2426 Injection, paliperidone palmitate extended release, 1 mg (PA) (IC) J2430 Injection, pamidronate disodium, per 30 mg J2440 Injection, papaverine HC1, up to 60 mg J2469 Injection, palonosetron HCl, 25 mcg J2503 Injection, pegaptanib sodium, 0.3 mg J2505 Injection, pegfilgrastim, 6 mg 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 J2562 Injection, plerixafor, 1 mg J2675 Injection, progesterone, per 50 mg J2680 Injection, fluphenazine decanoate, up to 25 mg J2760 Injection, phentolamine mesylate, up to 5 mg J2778 Injection, ranibizumab, 0.1 mg J2785 Injection, regadenoson, 0.1 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 J2793 Injection, rilonacept, 1 mg (PA) J2794 Injection, risperidone, long acting, 0.5 mg J2796 Injection, romiplostim, 10 mcg (PA) J2820 Injection, sargramostim (GM-CSF), 50 mcg J2910 Injection, aurothioglucose, up to 50 mg (IC) 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, IC) J2941 Injection, somatropin, 1 mg (PA) 604 HCPCS Level II Service Codes (cont.) Service Code Service Description J3010 Injection, fentanyl citrate, 0.1 mg J3030 Injection, sumatriptan succinate, 6 mg J3095 Injection, telavancin, 10 mg (PA) (IC) J3110 Injection, teriparatide, 10 mcg (PA, IC) J3120 Injection, testosterone enanthate, up to 100 mg J3130 Injection, testosterone enanthate, up to 200 mg J3230 Injection, chlorpromazine HCl, up to 50 mg J3240 Injection, thyrotropin alpha, 0.9 mg. provided in 1.1 mg vial J3243 Injection, tigecycline, 1 mg J3250 Injection, trimethobenzamide HCl, up to 200 mg J3262 Injection, tocilizumab, 1 mg (PA) (IC) J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg J3302 Injection, triamcinolone diacetate, per 5 mg J3303 Injection, triamcinolone hexacetonide, per 5 mg J3357 Injection, ustekinumab, 1 mg (PA) (IC) J3360 Injection, diazepam, up to 5 mg J3385 Injection, velaglucerase alfa, 100 units (PA) (IC) J3396 Injection, verteporfin, 0.1 mg J3410 Injection, hydroxyzine HCl, up to 25 mg J3411 Injection, thiamine HCI, 100 mg J3430 Injection, phytonadione (vitamin K), per 1 mg J3487 Injection, zoledronic acid (Zometa), 1 mg J3490 Unclassified drugs (IC) J3490-FP Unclassified drugs (service provided as part of Medicaid family planning program) (Use for medications and injectables 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 J7060 5% dextrose/water (500 ml = 1 unit) J7070 Infusion, D-5-W, 1,000 cc J7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg (IC) J7303 Contraceptive supply, hormone containing vaginal ring, each (IC) J7304 Contraceptive supply, hormone containing patch, each (IC) J7307 Etonogestrel (contraceptive) implant system, including implant and supplies (IC) J7309 Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 g (IC) J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg (IC) J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose (PA) J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose (PA) J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose (PA) J7325 Hyaluronan or derivative, Synvisc or Synvisc-One for intra-articular injection, 1 mg (PA) J7335 Capsaicin 8% patch, per 10 sq cm (PA) (IC) J7599 Immunosuppressive drug, not otherwise specidfied (IC) 604 HCPCS Level II Service Codes (cont.) Service Code Service Description J7608 Acetylcysteine, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit-dose form, per g J7614 Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 0.5 mg (PA) J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, noncompounded, administered through DME J7626 Budesonide, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, up to 0.5 mg J7633 Budesonide, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 0.25 mg (IC) J7639 Dornase alpha, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per mg J7644 Ipratropium bromide, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per mg J7669 Metaproterenol sulfate, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per 10 mg J7676 Pentamidine isethionate, inhalation solution, compounded product, administered through DME, unit dose form, per 300 mg (IC) J7682 Tobramycin, inhalation solution, FDA-approved final product, noncompounded, unit dose form, administered through DME, per 300 mg J7686 Treprostinil, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, 1.74 mg (PA) (IC) J7699 NOC drugs, inhalation solution administered through DME (IC) J7799 NOC drugs, other than inhalation drugs, administered through DME (IC) J8562 Fludarabine phosphate, oral, 10 mg (IC) J9000 Injection, doxorubicin HCl, 10 mg J9001 Injection, doxorubicin HCl, all lipid formulations, 10 mg J9025 Injection, azacitidine, 1 mg J9031 BCG (intravesical), per instillation J9035 Injection, bevacizumab, 10 mg J9040 Injection bleomycin sulfate, 15 units J9041 Injection, bortezomib, 0.1 mg J9045 Injection, carboplatin, 50 mg J9055 Injection, cetuximab, 10 mg J9060 Injection, cisplatin, powder or solution, 10 mg J9070 Injection, cyclophosphamide, 100 mg J9130 Dacarbazine, 100 mg J9155 Injection, degarelix, 1 mg (PA) J9171 Injection, docetaxel, 1 mg J9178 Injection, epirubicin HCl, 2 mg J9181 Injection, etoposide, 10 mg J9190 Injection, fluorouracil, 500 mg J9201 Injection, gemcitabine HC1, 200 mg 604 HCPCS Level II Service Codes (cont.) Service Code Service Description J9202 Goserelin acetate implant, per 3.6 mg (PA) J9206 Injection, irinotecan, 20 mg J9212 Injection, interferon alfacon-1, recombinant, 1 mcg J9213 Injection, interferon, alfa-2a, recombinant, 3 million units J9214 Injection, interferon, alfa-2b, recombinant, 1 million units J9215 Injection, interferon alfa-N3 (human leukocyte derived), 250,000 IU (IC) J9216 Injection, interferon gamma-1-b, 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 J9261 Injection, nelarabine, 50 mg (PA) J9263 Injection, oxaliplatin, 0.5 mg J9264 Injection, paclitaxel protein-bound particles, 1 mg J9265 Injection, paclitaxel, 30 mg J9293 Injection, mitoxantrone HCl, per 5 mg J9300 Injection, gemtuzumab ozogamicin, 5 mg J9302 Injection, ofatumumab, 10 mg (PA) (IC) J9305 Injection, pemetrexed, 10 mg J9307 Injection, pralatrexate, 1 mg (IC) J9310 Injection, rituximab, 100 mg (PA) J9315 Injection, romidepsin, 1 mg (PA) (IC) J9340 Injection, thiotepa, 15 mg J9351 Injection, topotecan, 0.1 mg (IC) J9355 Trastuzumab, 10 mg J9360 Injection, vinblastine sulfate, 1 mg J9370 Vincristine sulfate, 1 mg J9390 Injection vinorelbine tartrate, 10 mg J9395 Injection, fulvestrant, 25 mg (PA) J9999 Not otherwise classified, antineoplastic drugs (IC) Q4101 Apligraf, per sq cm Q4102 Oasis wound matrix, per sq cm Q4103 Oasis burn matrix, per sq cm Q4104 Integra bilayer matrix wound dressing (BMWD), per sq cm Q4106 Dermagraft, per sq cm Q4107 GRAFTJACKET, per sq cm Q4108 Integra matrix, per sq cm Q4110 PriMatrix, per sq cm S0020 Injection, bupivicaine HCl, 30 ml S0021 Injection, cefoperazone sodium, 1 g (IC) S0023 Injection, cimetidine HCl, 300 mg 604 HCPCS Level II Service Codes (cont.) Service Code Service Description S0077 Injection, clindamycin phosphate, 300 mg S0302 Completed early periodic screening diagnosis and treatment (EPSDT) service (or preventative pediatric healthcare screening and diagnosis (PPHSD) service) (List in addition to code for appropriate evaluation and management service.) S2260 Induced abortion, 17 to 24 weeks, (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 V2600 Hand held low vision aids and other nonspectacle-mounted aids (PA) (IC) V2610 Single lens, spectacle mounted low vision aids (PA) (IC) V2615 Telescopic and other compound lens system, including distance-vision telescopic, near-vision telescopes, and compound microscopic lens system (PA) (IC) V2799 Vision service, miscellaneous (PA) (IC) 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. Modifier Modifer Description 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 Service provided as part of family planning program HN Bachelor’s degree level (Use to indicate physician assistant.) (This modifier is to be applied to codes for services billed by a physician that were performed by a physician assistant employed by the physician or group practice.) RB Replacement of a DME, orthotic or prosthetic item furnished as part of a repair (This modifier should only be used with 92340, 92341, and 92342 to bill for the dispensing of replacement lenses.) 605 Modifiers (cont.) Modifier Modifier Description SB Nurse midwife (This modifier is to be applied to codes for services billed by a physician that 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 codes 90460, 90461, 90471, and 90473 to identify administration of vaccines provided at no cost by the Massachusetts Department of Public Health for individuals aged 18 years and under, including those administered under the Vaccine for Children Program (VFC).) 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.) Modifiers for Tobacco-Cessation Services The following modifiers are used in combination with Service Code 99407 to report tobacco-cessation counseling. Service Code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) may also be billed without a modifier to report an individual smoking and tobacco-use cessation counseling visit of at least 30 minutes. Modifier Modifer Description HQ Group counseling, at least 60-90 minutes in duration, provided by a physician TD Individual counseling provided by a registered nurse (RN) TF Individual counseling, intermediate level of care (intake/assessment counseling, at least 45 minutes in duration) provided by a physician U1 Individual counseling services provided by a tobacco-cessation counselor U2 Individual intake/assessment counseling, at least 45 minutes in duration, provided by a nurse practitioner, nurse midwife, physician assistant, registered nurse, or a tobacco-cessation counselor, under the supervision of a physician U3 Group counseling, at least 60-90 minutes in duration, provided by a nurse practitioner, nurse midwife, physician assistant, registered nurse, or a tobacco-cessation counselor, under the supervision of a physician Modifiers for Behavioral-Health Screening The administration and scoring of standardized behavioral-health screening tools selected from the approved menu of tools found in Appendix W of your provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. Service Code 96110 must be accompanied by one of the modifiers listed below to indicate whether a behavioral-health need was identified. “Behavioral- health need identified” means the provider administering the screening tool, in his or her professional judgment, identified a child with a potential behavioral health services need. 605 Modifiers (cont.) Modifier Modifer Description U1 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified when administered by a physician, independent nurse midwife or independent nurse practitioner. U2 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified when administered by a physician, independent nurse midwife or independent nurse practitioner. U3 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified when administered by a nurse midwife employed by a physician. U4 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified when administered by a nurse midwife employed by a physician. U5 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified when administered by a nurse practitioner employed by a physician. U6 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified when administered by a nurse practitioner employed by a physician. U7 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified when administered by a physician assistant employed by a physician. U8 Completed a behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified when administered by a physician assistant employed by a physician. Modifier for Child and Adolescent Needs and Strengths (CANS) HA Service Code 90801 must be accompanied by this modifier to indicate that the Child and Adolescent Needs and Strengths (CANS) is included in the psychiatric diagnostic interview examination. This modifier may be billed only by psychiatrists.