Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
www.mass.gov/masshealth
MassHealth
Transmittal Letter PHY-138
May 2013
TO:     Physicians Participating in MassHealth
FROM:     Julian J. Harris, M.D., Medicaid Director
RE:     Physician Manual (New Modifiers for National Correct Coding Initiatives)
This letter transmits updates to the modifier section of Subchapter 6 of the Physician Manual. Subchapter 6 now includes the new modifiers that were listed in All Provider Bulletin 227 (June 2012), which introduced the modifiers allowed under the NCCI.
Please Note: The 2013 updates to the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes are not reflected in this revised Subchapter 6. MassHealth will issue a revised Subchapter 6 containing the 2013 service codes in a separate transmittal letter shortly.
The revised Subchapter 6 is effective for dates of service on or after July 1, 2012.
MassHealth Website
This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth.
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 6-24
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Physician Manual
Pages 6-1 through 6-20 — transmitted by Transmittal Letter PHY-134
Pages 6-21 and 6-22 — transmitted by Transmittal Letter PHY-136

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-1	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	
601	Introduction
MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2012 code book for the descriptions for the service codes 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, CPT Category II codes ending in F, and CPT Category III codes ending in T.
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 codes that are not payable under MassHealth.
•	Section 603 lists CPT 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	15825	21120	33940	41872
11922	15826	21121	33944	43752
11950	15828	21122	36415	43842
11951	15829	21123	36416	43843
11952	15847	21245	36468	43845
11954	15876	21246	36469	44132
15775	15877	21248	36591	44715
15776	15878	21249	36592	47133
15780	15879	22526	36598	47143
15781	17340	22527	38204	47144
15782	17360	22841	38207	47145
15783	17380	22856	38208	48160
15786	19316	22861	38209	48550
15787	19324	22864	38210	48551
15788	19325	32491	38211	50300
15789	19355	32850	38212	50323
15792	19396	32855	38213	50325
15793	20930	32856	38214	51701
15819	20936	33930	38215	51702
15824	20985	33933	41870	54900

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-2	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	
602 Nonpayable CPT Codes (cont.)

54901	77336	81213	81297	82962
55200	77370	81214	81298	83987
55300	77371	81215	81299	84061
55400	77372	81216	81300	84145
55870	77373	81217	81301	84431
55970	77401	81220	81302	84830
55980	77402	81221	81303	86079
58321	77403	81222	81304	86305
58322	77404	81223	81310	86890
58323	77406	81224	81315	86891
58345	77407	81225	81316	86910
58350	77408	81226	81317	86911
58750	77409	81227	81318	86927
58752	77411	81228	81319	86930
58760	77412	81229	81330	86931
58970	77413	81240	81331	86932
58974	77414	81241	81332	86945
58976	77416	81242	81340	86950
59070	77417	81243	81341	86960
59072	77418	81244	81342	86965
59412	77422	81245	81350	86985
59897	77423	81250	81355	87150
61630	77424	81251	81370	87153
61635	77425	81255	81371	87493
61640	77520	81256	81372	87900
61641	77522	81257	81373	87901
61642	77523	81260	81374	87903
62287	77525	81261	81375	87904
63043	77790	81262	81376	88000
63044	78267	81263	81377	88005
65760	78268	81264	81378	88007
65765	78351	81265	81379	88012
65767	80100	81266	81380	88014
65771	80101	81267	81381	88016
69090	80104	81270	81382	88020
71552	80500	81275	81383	88025
72159	80502	81280	81400	88027
72198	81200	81281	81401	88028
73225	81205	81282	81402	88029
74263	81206	81290	81403	88036
75571	81207	81291	81404	88037
76140	81808	81292	81405	88040
76390	81209	81293	81406	88045
76496	81210	81294	81407	88099
76497	81211	81295	81408	88125
76498	81212	81296	82075	88333

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-3	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	
602 Nonpayable CPT Codes (cont.)

88334	90396	92325	95992	98967
88738	90586	92352	96000	98968
88749	90633	92353	96001	98969
89250	90634	92354	96002	99001
89251	90644	92355	96003	99002
89253	90645	92358	96004	99024
89254	90646	92371	96040	99026
89255	90647	92531	96101	99027
89257	90648	92532	96102	99053
89258	90665	92533	96103	99056
89259	90669	92534	96105	99058
89260	90670	92548	96111	99060
89261	90680	92559	96116	99071
89264	90698	92560	96118	99075
89268	90700	92561	96119	99078
89272	90701	92562	96120	99080
89280	90702	92564	96125	99082
89281	90708	92597	96150	99090
89290	90710	92605	96151	99091
89291	90712	92606	96152	99100
89300	90720	92613	96153	99116
89310	90721	92615	96154	99135
89320	90723	92617	96155	99140
89321	90743	92630	96376	99143
89322	90744	92633	96567	99144
89325	90748	93660	96902	99145
89329	90845	93668	96904	99148
89330	90865	93770	97005	99149
89331	90875	93786	97006	99150
89335	90876	94005	97014	99172
89342	90880	94015	97537	99190
89343	90885	94644	97545	99191
89344	90889	94645	97546	99192
89346	90901	95012	97755	99241
89352	90911	95052	97810	99242
89353	90940	95120	97811	99243
89354	90989	95125	97813	99244
89356	90993	95130	97814	99245
89398	90997	95131	98940	99251
90281	90999	95132	98941	99252
90283	91132	95133	98942	99253
90284	91133	95134	98943	99254
90287	92314	95824	98960	99255
90384	92315	95965	98961	99288
90386	92316	95966	98962	99315
90389	92317	95967	98966	99316

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-4	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	
602 Nonpayable CPT Codes (cont.)

99339	99366	99403	99444	99506
99340	99367	99404	99450	99507
99354	99368	99406	99442	99509
99355	99374	99408	99455	99510
99356	99375	99409	99456	99511
99357	99377	99411	99500	99512
99358	99378	99412	99501	99601
99359	99379	99420	99502	99602
99360	99380	99429	99503	99605
99363	99401	99441	99504	99606
99364	99402	99443	99505	99607
603 Codes That Have Special Requirements or Limitations
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 centrifuges 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 for all induced abortions, except medically induced abortions. 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.

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-5	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	
603 Codes That Have Special Requirements or Limitations (cont.)

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.
Service Code and Req. or Limit
01999	IC
11920	PA
11921	PA
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

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.
Service Code and Req. or Limit
20999	IC
21085	PA
21088	IC
21089	IC
21137	PA
21138	PA
21139	PA
21146	PA
21147	PA
21150	PA
21151	PA
21154	PA
21155	PA
21159	PA
21160	PA
21172	PA
21175	PA
21188	PA
21193	PA
21194	PA
21195	PA
21196	PA

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-6	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

21198	PA		30435	PA
21206	PA		30450	PA
21208	PA		30999	IC
21209	PA		31299	IC
21210	PA		31599	IC
21215	PA		31899	IC
21230	PA		32851	PA
21235	PA		32852	PA
21240	PA		32853	PA
21242	PA		32854	PA
21243	PA		32999	IC
21244	PA		33935	PA
21247	PA		33945	PA
21255	PA		33981	IC
21256	PA		33982	IC
21260	PA		33983	IC
21299	PA; IC		33999	IC
21499	IC		36299	IC
21742	IC		36470	PA
21743	IC		36471	PA
21899	IC		37501	IC
22857	PA		37799	IC
22862	PA		38129	IC
22865	PA		38230	PA
22899	IC		38240	PA
22999	IC		38241	PA
23929	IC		38242	PA
24940	IC		38589	IC
24999	IC		38999	IC
25999	IC		39499	IC
26989	IC		39599	IC
27299	IC		40799	IC
27599	IC		40840	PA
27899	IC		40842	PA
28890	PA		40843	PA
28899	IC		40844	PA
29799	IC		40845	PA
29800	PA		40899	IC
29804	PA		41599	IC
29999	IC		41820	PA; IC
30400	PA		41821	IC
30410	PA		41850	IC
30420	PA		41899	IC
30430	PA		42280	PA

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-7	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

42281	PA		49329	IC
42299	IC		49659	IC
42699	IC		49906	IC
42999	IC		49999	IC
43289	IC		50549	IC
43499	IC		50949	IC
43644	PA		51925	HI-1
43645	PA		51999	IC
43647	PA; IC		53899	IC
43648	IC		54400	PA
43659	IC		54401	PA
43770	PA		54405	PA
43771	PA		54440	IC
43772	PA		54699	IC
43773	PA		55250	CS-18 or CS-21
43774	PA		55450	CS-18 or CS-21
43775	PA		55559	IC
43846	PA		55899	IC
43847	PA		56800	PA
43848	PA		56805	IC
43881	PA; IC		57335	IC
43882	IC		58150	HI-1
43886	PA		58152	HI-1
43887	PA		58180	HI-1
43888	PA		58200	HI-1
43999	IC		58210	HI-1
44133	IC		58240	HI-1
44135	PA; IC		58260	HI-1
44136	PA; IC		58262	HI-1
44238	IC		58263	HI-1
44799	IC		58267	HI-1
44899	IC		58270	HI-1
44979	IC		58275	HI-1
45499	IC		58280	HI-1
45999	IC		58285	HI-1
46999	IC		58290	HI-1
47135	PA		58291	HI-1
47136	PA		58292	HI-1
47379	IC		58293	HI-1
47399	IC		58294	HI-1
47579	IC		58541	HI-1
47999	IC		58542	HI-1
48554	PA		58543	HI-1
48999	IC		58544	HI-1

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-8	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit                         Service Code and Req. or Limit

58548	HI-1	65757	IC
58550	HI-1	66999	IC
58552	HI-1	67299	IC
58553	HI-1	67399	IC
58554	HI-1	67599	IC
58565	CS-18 or CS-21	67900	PA
58570	HI-1	67901	PA
58571	HI-1	67902	PA
58572	HI-1	67903	PA
58573	HI-1	67904	PA
58578	IC	67906	PA
58579	IC	67908	PA
58600	CS-18 or CS-21	67999	IC
58605	CS-18 or CS-21	68399	IC
58611	CS-18 or CS-21	68899	IC
58615	CS-18 or CS-21	69300	PA
58661	CS-18 or CS-21	69399	IC
58670	CS-18 or CS-21	69710	IC
58671	CS-18 or CS-21	69799	IC
58679	IC	69930	PA
58951	HI-1	69949	IC
58956	HI-1	69979	IC
58999	IC	74261	PA
59135	HI-1	74262	PA
59525	HI-1	76499	IC
59840	CPA-2 (first trimester)	76999	IC
59841	CPA-2 (first trimester)	77058	PA
59850	CPA-2 (second trimester, third	77059	PA
	trimester in hospital only)	77299	IC
59851	CPA-2 (second trimester, third	77399	IC
	trimester in hospital only)	77499	IC
59852	CPA-2 (second trimester, third	77799	IC
	trimester in hospital only)	78099	IC
59855	CPA-2	78199	IC
59856	CPA-2	78299	IC
59857	CPA-2	78399	IC
59898	IC	78499	IC
59899	IC	78599	IC
60659	IC	78699	IC
60699	IC	78799	IC
64650	PA	78999	IC
64653	PA	79999	IC
64999	IC	81099	IC
		84999	IC

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-9	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	
603 Codes That Have Special Requirements or Limitations (cont.)

Service Code and Req. or Limit	Service Code and Req. or Limit	
85999	IC	90668	IC	
86849	IC	90676	IC	
86999	IC	90681	IC; Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.	
87999	IC		
	
88199	IC	

88299	IC	

88384	IC	

88399	IC	90690	IC	
89240	IC	90692	IC	
90288	IC	90693	IC	
90291	IC	90696	IC	
90296	IC	90707	Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.	
90378	PA; IC		
	
90393	PA; IC	

90399	IC	

90476	IC	

90477	IC	90713	Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.	
90581	IC		
	
90632	Covered for adults ≥ 19; available free of charge through the Massachusetts Immunization Program for children under 19	

	
	90715	Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.	
90636	years of age. 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.	

	

	

	90716	Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.	

		
	
90650	Covered for female members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.	

	

	

	90719	IC	

	90725	IC	

	90727	IC	
90654	IC; Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.	         90732 	Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.	

	
90661	IC	

90662	IC	
		
90664	IC	

90666	IC	

90667	IC	

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-10	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	

603 Codes That Have Special Requirements or Limitations (cont.)		
Service Code and Req. or Limit	Service Code and Req. or Limit	
90734	IC; Covered for members ≥ 19;	93299	IC	
	available free of charge through	93745	IC	

	the Massachusetts Immunization	93799	IC	

	Program for children under 19	93998	IC	

	years of age.	94772	IC	
90736	IC; PA is required for members less	94774	IC	
	than age 50	94775	IC	
90738	IC	94776	IC	
90749	IC	94777	IC	
90867	IC	94799	IC	
90868	IC	95199	IC	
90899	IC	95803	IC	
90935	For hospitalized member only; not for chronic maintenance	95999	IC	

	96110	Developmental screening, with interpretation and report, per standardized instrument form. 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.	
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	96379	IC	
92312	PA; includes supply of lenses	96549	IC	
92313	PA; includes supply of lenses	96999	IC	
92326	PA	97001	PA for PT >20	
92499	IC	97002	PA for PT >20	
92506	PA for ST >35	97003	PA for OT >20	
92507	PA for ST >35	97004	PA for OT >20	
92508	PA for ST >35	97010	PA for PT >20	
92526	PA for ST >35	97012	PA for PT >20	
92588	IC	97016	PA for PT >20	
92610	PA for ST >35	97018	PA for PT >20	
92700	IC	97022	PA for PT >20	
92992	IC	97024	PA for PT >20	
92993	IC	97026	PA for PT >20	
93229	IC	97028	PA for PT >20	

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-11	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	

603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit
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	
SO190	(IC) Mifepristone, oral, 200 mcg	
SO191	(IC) Misoprostol, oral, 200 mcg	

604 Payable 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 website 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 (once
per three-month period)

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604 Payable HCPCS Level II Service Codes (cont.)
Service
Code	Service Description
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
G0431	Drug screen qualitative; multiple drug classes by high complexity test method (e.g.,
immunoassay, enzyme assay), per patient encounter
G0434	Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or
moderate complexity test, per patient encounter
J0129	Injection, abatacept, 10 mg (PA)
J0131	Injection, acetaminophen, 10 mg (IC)
J0135	Injection, adalimumab, 20 mg (PA)
J0171	Injection, Adrenalin, epinephrine, 0.1 mg (IC)
J0215	Injection, alefacept, 0.5 mg (PA)
J0221	Injection, alglucosidase alfa (Lumizyme), 10 mg (PA) (IC)
J0256	Injection, alpha 1-proteinase inhibitor–human, 10 mg
J0257	Injection, alpha 1 proteinase inhibitor (human) (GLASSIA), 10 mg (IC)
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
J0476	Injection, baclofen, 50 mcg for intrathecal trial
J0490	Injection, belimumab, 10 mg (PA) (IC)
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)
J0588	Injection, incobotulinumtoxinA, 1 unit (PA) (IC)
J0592	Injection, buprenorphine HCl, 0.1 mg

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604 Payable HCPCS Level II Service Codes (cont.)

Service Code

Service Description

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
J0715	Injection, ceftizoxime sodium, per 500 mg (PA) (IC)
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
J0840	Injection, crotalidae polyvalent immune fab (ovine), up to 1 g (IC)
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)
J0897	Injection, denosumab, 1 mg (PA) (IC)
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, 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

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604 Payable HCPCS Level II Service Codes (cont.)
Service
Code	Service Description
J1557	Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg
(PA) (IC)
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 (PA)
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
J1725	Injection, hydroxyprogesterone caproate, 1 mg (PA) (IC)
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
J2248	Injection, micafungin sodium, 1 mg
J2250	Injection, midazolam HCl, per 1 mg
J2265	Injection, minocycline HCl, 1 mg (IC)
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

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604 Payable HCPCS Level II Service Codes (cont.)

Service Code

Service Description

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
J2507	Injection, pegloticase, 1 mg (PA) (IC)
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)
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

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604 Payable HCPCS Level II Service Codes (cont.)
Service
Code	Service Description
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
J7131	Hypertonic saline solution, 1 ml (IC)
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)
J7326	Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose (PA) (IC)
J7335	Capsaicin 8% patch, per 10 sq cm (PA) (IC)
J7599	Immunosuppressive drug, not otherwise specidfied (IC)
J7608	Acetylcysteine, inhalation solution, FDA-approved final product, noncompounded,
administered through DME, unit-dose form, per g

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604 Payable HCPCS Level II Service Codes (cont.)
Service
Code	Service Description
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
J7665	Mannitol, administered through an inhaler, 5 mg (IC)
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)
J8561	Everolimus, oral, 0.25 mg (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
J9043	Injection, cabazitaxel, 1 mg (PA) (IC)
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
J9179	Injection, eribulin mesylate, 0.1 mg (PA) (IC)
J9181	Injection, etoposide, 10 mg

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604 Payable HCPCS Level II Service Codes (cont.)
Service
Code	Service Description
J9190	Injection, fluorouracil, 500 mg
J9201	Injection, gemcitabine HC1, 200 mg
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)
J9228	Injection, ipilimumab, 1 mg (IC)
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

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	Transmittal Letter
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604 Payable HCPCS Level II Service Codes (cont.)

Service Code

Service Description

S0021	Injection, cefoperazone sodium, 1 g (IC)
S0023	Injection, cimetidine HCl, 300 mg
S0077	Injection, clindamycin phosphate, 300 mg
S0190 I.C.     Mifepristone, Oral, 200MG
S0191 I.C.     Misoprostol, Oral, 200MCG
S0199	Medically induced abortion by oral ingestion of medication including all associated services
and supplies (e.g., patient counseling, office visits confirmation of pregnancy by Hcg,
Ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of
abortion) except drugs
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)

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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   Modifier Description
24	Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period
25	Significant, separately identifiable evaluation and management service by the same
physician or other qualified health care professional on the same day of the procedure or other service
26	Professional component
50	Bilateral procedure
51	Multiple procedures 54	Surgical care only

57	Decision for surgery
58	Staged or related procedure or service by the same physician or other qualified health care
professional during the postoperative period
59	Distinct procedural service
62	Two surgeons
66	Surgical team
78	Unplanned return to the operating/procedure room by the same physician or other qualified
health care professional following initial procedure for a related procedure during the postoperative period
79	Unrelated procedure or service by the same physician or other qualified health care
professional during the postoperative period
80	Assistant surgeon
82	Assistant surgeon (when qualified resident surgeon not available)
91	Repeat clinical diagnostic laboratory test
99	Multiple modifiers
E1	Upper left, eyelid
E2	Lower left, eyelid
E3	Upper right, eyelid
E4	Lower right eyelid
F1	Left hand, second digit
F2	Left hand, third digit
F3	Left hand, fourth digit
F4	Left hand, fifth digit
F5	Right hand, thumb
F6	Right hand, second digit
F7	Right hand, third digit
F8	Right hand, fourth digit
F9	Right hand, fifth digit
FA	Left hand, thumb
FP	Service provided as part of family planning program

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605 Modifiers (cont.)
Modifier   Modifier Description
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.)
LC	Left circumflex coronary artery
LD	Left anterior descending coronary artery
LT	Left side (Used to identify procedures performed on the left side of the body.)
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.)
RC	Right coronary artery
RT	Right side (Used to identify procedures performed on the right side of the body.)
SA	Nurse practitioner rendering service in collaboration with a physician (This modifier is to be
applied to codes for services billed by a physician that 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 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).)
T1	Left foot, second digit
T2	Left foot, third digit
T3	Left foot, fourth digit
T4	Left foot, fifth digit
T5	Right foot, great toe
T6	Right foot, second digit
T7	Right foot, third digit
T8	Right foot, fourth digit
T9	Right foot, fifth digit
TA	Left foot, great toe
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 101 CMR 317.04 be paid.)

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-22	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	
605 Modifiers (cont.)
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   Modifier 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 physicial
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.
Modifier   Modifier 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.

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-23	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	
605 Modifiers (cont.)
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.
Modifiers for Provider Preventable Conditions That Are National Coverage Determinations
Modifier   Modifier Description
PA	Surgical or other invasive procedure on wrong body part
PB	Surgical or other invasive procedure on wrong patient
PC	Wrong surgery or other invasive procedure on patient
For more information on the use of these modifiers, see Appendix V of your provider manual.
This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS are defined in the Physician’s Current Procedural Terminology (CPT) code book.

Commonwealth of Massachusetts
MassHealth
Provider Manual Series	Subchapter Number and Title
6. Service Codes	Page
6-24	
Physician Manual	Transmittal Letter
PHY-138	Date
07/01/12	

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