Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

TO:      Physicians Participating in MassHealth FROM:      Beth Waldman, Acting Commissioner RE:      Physician Manual (2003 HCPCS Codes)

MASSHEALTH
TRANSMITTAL LETTER PHY-97
November 2003

This letter transmits a revised Subchapter 6 of the Physician Manual. The Division has replaced the remaining MassHealth local codes with HCPCS (Healthcare Common Procedure Coding System) codes to comply with HIPAA (the Health Insurance Portability and Accountability Act of 1996).
Providers should use this revised Subchapter 6 along with the American Medical Association Current Procedural Terminology (CPT) 2003 code book and Ingenix’s HCPCS Level II 2003 code book. Because the Division pays for most of the Centers for Medicare and Medicaid Services HCPCS codes, Subchapter 6 of the Physician Manual is structured to list only:
 •	CPT codes that are not payable under MassHealth;
 •	CPT codes that have special limitations or requirements, such as prior authorization, individual consideration, or attachment requirements; and
 •	Level II HCPCS codes that are payable under MassHealth and have special limitations or requirements, such as prior authorization, individual consideration, or attachment requirements
In addition, pursuant to 130 CMR 450.144(A), a physician may request prior authorization for any medically necessary service for a member under 21 years of age, even if it is listed as not payable in Subchapter 6 of the Physician Manual.
How to Obtain a Physician Fee Schedule
Providers who want to obtain a fee schedule may purchase Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). Providers must contact them first to find out the price of the publication. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for medicine is 114.3 CMR 17.00: Medicine. The regulation title for surgery and anesthesia is 114.3 CMR 16.00: Surgery and Related Anesthesia Care. The regulation title for radiology is 114.3 CMR 18.00: Radiology. The regulation title for laboratory is 114.3 CMR 20.00: Laboratory.

Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr

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

MASSHEALTH
TRANSMITTAL LETTER PHY-97 November 2003 Page 2
Effective Date
The new codes listed in Subchapter 6 are available for dates of service on or after November 1, 2003. Please Note: Providers may use either the new or obsolete service codes for dates of service from November 1, 2003, through December 31, 2003. Providers must use the new service codes for dates of service on or after January 1, 2004.
Administration of VFC Vaccine
The Omnibus Budget Reconciliation Act (OBRA) of 1993 created the Vaccine for Children (VFC) Program to increase vaccine coverage levels nationwide by providing vaccines free of charge to VFC-eligible children. VFC vaccines are distributed by the Department of Public Health free of change and are, therefore, not payable under MassHealth.
The MassHealth local service code for the administration of VFC vaccines for individuals 18 years of age and under (X5552) is obsolete. Providers billing for the administration of a VFC vaccine may do so by appending the modifier SL to the appropriate CPT vaccine administration code (90471 or 90473).
Providers who administer multiple VFC vaccines will be paid only for a single VFC administration payment.
Allergen Immunotherapy
The MassHealth local codes for allergen immunotherapy (X0410, X0411, and X0412) have been replaced by CPT codes 95144, 95145, 95146, 95147, 95148, 95149, 95165, 95170, and 95199. Providers billing for these services should use the most applicable of these CPT codes.
The fee schedule for professional services for the supervision of preparation and provision of antigens for allergen immunotherapy as listed in 114 CMR 17:00 are based on a single one cc dose.
When a provider dilutes a multi-dose vial (for example, by taking one cc aliquot from a multi-dose vial and mixing it with nine ccs of diluent), providers should not bill an additional amount for the diluent. The diluent, number of antigens, or number of vials is not the billing unit. Providers are allowed to bill for each one cc of aliquot prepared.
A maximum number of 20 doses (units) can be billed. If a patient’s dosage is adjusted to more or fewer doses than originally anticipated, the physician may not make changes to the number of doses for which he or she bills. The number of doses anticipated at the time that the antigen is prepared is the number of doses that must be billed. This policy is in effect for all antigens, including venoms.
Checking for the efficiency of, and any reactions to, allergen immunotherapy injections is not considered a separately identifiable service. It is included in the payment for the injection.
Physicians providing both an allergy injection (95115 or 95117) and an antigen or antigen preparation service (95144 through 95170) may bill for both services.

MASSHEALTH
TRANSMITTAL LETTER PHY-97 November 2003 Page 3
Influenza Vaccinations
MassHealth pays providers for influenza vaccinations that were not obtained free of charge from the Massachusetts Department of Public Health or any other source. For dates of service before November 1, 2003, providers must bill for the vaccine, toxoid service code (90749), and provide a copy of the manufacturer’s invoice showing the provider’s acquisition cost. For dates of service on or after November 1, 2003, providers must bill for providing this vaccine using one of the following CPT codes: 90657, 90658, 90659, or 90660. Service Code 90660 requires prior authorization and is payable by individual consideration.
Injectable and Infusible Drugs Administered in a Physician’s Office
The MassHealth local code for the distribution of injectable or infusible drugs requiring prior authorization (X3333) is obsolete. Providers billing for these services should use the most applicable Level II HCPCS code listed in Subchapter 6, Section 604, of the Physician Manual.
Providers billing for injectable and infusible drugs not requiring prior authorization must use the most applicable Level II HCPCS code instead of CPT code 99070. Claims for these services submitted with Service Code 99070 instead of the applicable Level II HCPCS code will be denied with error code 062 (inappropriate service code for service billed).
Family Planning Services
Providers billing for family planning services must use the most applicable service code listed in Subchapter 6 of the Physician Manual. The MassHealth local code for family planning injections/medications (X1069) is obsolete. Providers billing for injections/ medications related to family planning services not listed in Subchapter 6 must use Service Code J3490 (unclassified drugs) with modifier FP. Failure to use this modifier will result in a denied claim. Providers must use this modifier in addition to checking the Family Planning indicator on the claim form or its electronic equivalent.
Emergency Department Screening
The MassHealth local code for emergency department screening (X5591) is obsolete. Providers billing for these services should use Service Code T1023.
Mid-Level Practitioner Modifiers
Modifiers R3, R4, R5, S1, S2, S3, W5, W6, and W7 are obsolete. Providers billing for services performed by a non-independent mid-level practitioner under the employing physician’s MassHealth servicing provider number should apply modifier SA (nurse practitioner), HN (physician assistant), or SB (nurse midwife) to the service code. Independent nurse practitioners and nurse midwives who are currently enrolled with MassHealth under their own provider number should not use modifier SA or SB.

MASSHEALTH
TRANSMITTAL LETTER PHY-97 November 2003 Page 4
EPSDT Billing Instruction
The modifiers used to indicate services provided under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program (EP, Y3, R4, R5, S2, S3, W6, and W7) are obsolete. Providers billing for EPSDT services should bill using Service Code S0302 (completed early and periodic screening, diagnosis and treatment (EPSDT) service) in addition to the appropriate preventive medicine service code (99381 through 99385 or 99391 through 99395). Providers billing for EPSDT services performed by a non-independent mid-level practitioner under the employing physician’s servicing provider number should apply the appropriate mid-level modifier to the preventive medicine code. No modifier should be applied to Service Code S0302.
Crosswalk
Attached is a crosswalk from the obsolete MassHealth local service codes to the new national service codes and modifiers for the revised Subchapter 6.
Questions
Providers with questions about the information in this transmittal letter may contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.
Maintenance Note: Transmittal Letter PHY-92, dated July 2002, failed to instruct providers to remove pages 5.3-25 through 5.3-30, transmitted by Transmittal Letter PHY-89. These now outdated pages contain service code modifiers that have since been updated and moved to Subchapter 6 of the Physician Manual. If these pages are still included in your copy of the Physician Manual, please remove them.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Physician Manual
Pages vi and 6-1 through 6-18
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Physician Manual
Page vi – transmitted by Transmittal Letter PHY-92
Pages 6-1 through 6-14 – transmitted by Transmittal Letter PHY-94

Attachment for Transmittal Letter PHY-97
November 2003
Page 1
Physician Program Service Code Crosswalk
Effective for dates of service beginning November 1, 2003

Obsolete Code-Modifier	Obsolete Code Description	New Code - Modifier	New Code Description	Comments	
X0410	Allergenic extract, single-unit-dose, administered by either the preparer or dispenser of the extract	95144	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single dose vial(s) (specify number of vials)		
		95165	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)		
X0411	Preparation of a multi-dose vial of allergenic extract, for dispensing and administration by another physician.	95165	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)		
X0412	Stinging insect venom(s) (I.C.)	95145	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); single stinging insect venom		
		95146	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; two single stinging insect venoms		
		95147	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; three single stinging insect venoms		
		95148	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; four single stinging insect venoms		
		95149	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; five single stinging insect venoms		
		95170	Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; whole body extract of biting insect or other arthropod (specify number of doses)		
X0415	Palivizumab (Synagis) supplied in a physician’s office. This code requires prior authorization. (I.C.) (P.A.)	90378	Respiratory syncytial virus immune globulin (RSV-IgIM), for intramuscular use, 50 mg, each	Palivzumab (Synagis) continues to require prior authorization.	
X1051             Diaphragm (including
applicator and contraceptive cream or jelly)	A4266	Diaphragm for contraceptive use             Includes applicator
and cream or jelly.	
X1052	Condoms (three)	A4267	Contraceptive supply, condom, male,     Bill per condom, not each                                                               per package.	
X1054	Contraceptive jelly	A4269	Contraceptive supply, spermicide (e.g., foam, gel), each	Bill per package/tube.	

Attachment for Transmittal Letter PHY-97
November 2003
Page 2

Obsolete Code-Modifier	Obsolete Code Description	New Code - Modifier	New Code Description	Comments	
X1056	Contraceptive cream	A4269          Contraceptive supply, spermicide            Bill per package/tube. (e.g., foam, gel), each	
X1057	Vaginal contraceptive film (three)	A4269	Contraceptive supply, spermicide            Bill per package of (e.g., foam, gel), each                               film.	
X1058	Contraceptive foam	A4269	Contraceptive supply, spermicide            Bill per package/tube. (e.g., foam, gel), each	
X1059	Female condoms with lubricant (three)	A4268	Contraceptive supply, condom, female, each	Bill per condom, not per package.	
X1060	Female condoms with lubricant (six)	A4268          Contraceptive supply, condom, female, each	Bill per condom, not per package.	
X1061	Contraceptive suppositories (package of 12)	A4269          Contraceptive supply, spermicide (e.g., foam, gel), each	Bill per package, not per suppository.	
X1063	Cervical sponges (three)	A4269	Contraceptive supply, spermicide (e.g., foam, gel), each	Bill per package, not per sponge.	
X1069	Medications and injectables related to family planning services, with the exception of Rho(D) human immune globulin and contraceptive injectables, such as Depo Provera (The Division will pay for the items listed under Service Code X1069 at the provider’s cost.) (I.C.)	J3490-FP	Unclassified drugs (service provided as part of Medicaid family planning program) (use for medications and injectibles related to family planning services, with the exception of Rho(D) human immune globulin, and contraceptive injectables such as Depo-Provera, items for which the Division will pay the provider's cost) (I.C.)	Providers must use both the FP modifier and the Family Planning Indicator on the claim form.
Failure to use the FP modifier will result in a denied claim.
Providers should not apply modifier FP when billing for an unclassified drug that is not used for family planning purposes.	
X3333	Injectable and infusible drugs and devices supplied in a physician's office that require prior authorization (I.C.) (P.A.)	Most appropriate
Level II HCPCS code		Providers must use the most appropriate “J,” “Q,” or “S” code (some of which may require PA).	
X5539	Emergency psychiatry service (per 30 minute unit, four units maximum per date of service)	H2011	Crisis intervention service, per 15 minutes		
X5552	Administration of VFC pediatric vaccines for individuals 18 years and under (not for use in conjunction with an office visit or other outpatient visit)	90471-SL	Immunization administration (includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections); one vaccine (single or combination vaccine/toxoid)	Failure to us Modifier SL will result in an inappropriate fee.
Providers that administer multiple VFC vaccines will only be paid for a single VFC administration payment.
The administration of a vaccination is not payable in conjunction with an office visit or other outpatient visit.	

Attachment for Transmittal Letter PHY-97
November 2003
Page 3

Obsolete Code-Modifier	Obsolete Code Description	New Code - Modifier	New Code Description	Comments	
		90473-SL	Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/ toxoid)	Failure to us Modifier SL will result in an inappropriate fee.
Providers that administer multiple VFC vaccines will only be paid for a single VFC administration payment.
The administration of a vaccination is not payable in conjunction with an office visit or other outpatient visit.	
X5911	Emergency department screening for determination of level of care	T1023	Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol, per encounter		
EP	Initial well-child visit provided by a physician, independent nurse practitioner, or independent nurse midwife in accordance with the EPSDT Schedule. To identify a well-child office visit provided by a physician, independent nurse practitioner, or independent nurse midwife as an initial health assessment (screening), add the modifier EP to the appropriate preventive medicine service code. Refer to 130 CMR 433.433(C) for the definition of independent nurse practitioner.	S0302	Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to code for appropriate evaluation and management service.)	Providers billing for EPSDT services should bill using Service Code S0302 in addition to the appropriate preventive medicine service code (99381-99385 or 99391-99395).	
R3	Non-independent nurse practitioner services. To identify services provided by a non-independent nurse practitioner who is employed by a physician, add the modifier R3 to the end of the appropriate service code. Refer to 130 CMR 433.433(D) for the definition of non-independent nurse practitioner.	SA	Nurse practitioner rendering service in collaboration with a physician	Independent nurse practitioners that are currently enrolled with MassHealth under their own provider number should not use modifier SA.	

Attachment for Transmittal Letter PHY-97
November 2003
Page 4

Obsolete Code-Modifier	Obsolete Code Description	New Code - Modifier	New Code Description	Comments	
R4	Initial well-child visit provided by a non-independent nurse practitioner in accordance with the EPSDT Schedule. To identify a well-child office visit provided by a non-independent nurse practitioner (employed by a physician) as an initial health assessment (screening), add the modifier R4 to the end of the appropriate preventive medicine service code. Refer to 130 CMR 433.433(D) for the definition of non-independent nurse practitioner.	S0302	Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to code for appropriate evaluation and management service.)	Providers billing for EPSDT services should bill using Service Code S0302 in addition to the appropriate preventative medicine service code (99381-99385 or 99391-99395).
Modifier SA should be applied to the preventive medicine service code if a non-independent nurse practitioner performed the EPSDT service. No modifier should be applied to S0302.	
R5	Subsequent well-child visit provided by a non-independent nurse practitioner in accordance with the EPSDT Schedule. To identify a well-child office visit provided by a non-independent nurse practitioner (employed by a physician) as a subsequent health assessment (screening), add the modifier R5 to the end of the appropriate preventive medicine service code. Refer to 130 CMR 433.433(D) for the definition of non-independent nurse practitioner.	S0302	Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to code for appropriate evaluation and management service.)	Providers billing for EPSDT services should bill using Service Code S0302 in addition to the appropriate preventive medicine service code (99381-99385 or 99391-99395).
Modifier SA should be applied to the preventive medicine service code if a non-independent nurse practitioner performed the EPSDT service. No modifier should be applied to S0302.	
S1	Physician assistant services. To identify services provided by a physician assistant employed by a physician or group practice, add the modifier S1 to the end of the appropriate service code.	HN	Bachelor’s degree level (Use to indicate Physician Assistant.)		
S2	Initial well-child visit provided by a physician assistant in accordance with the EPSDT Schedule. To identify a well-child office visit provided by physician assistant as an initial health assessment (screening), add the modifier S2 to the end of the appropriate preventive medicine service code.	S0302	Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to code for appropriate evaluation and management service.)	Providers billing for EPSDT services should bill using Service Code S0302 in addition to the appropriate preventive medicine service code (99381-99385 or 99391-99395).
Modifier HN should be applied to the preventive medicine service code if a physician assistant performed the EPSDT service.   No modifier should be applied to S0302.	

Attachment for Transmittal Letter PHY-97
November 2003
Page 5

Obsolete Code-Modifier	Obsolete Code Description	New Code - Modifier	New Code Description	Comments	
S3	Subsequent well-child visit provided by a physician assistant in accordance with the EPSDT Schedule. To identify a well-child office visit provided by a physician assistant as a subsequent health assessment (screening), add the modifier S3 to the end of the appropriate preventive medicine service code.	S0302	Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to code for appropriate evaluation and management service.)	Providers billing for EPSDT services should bill using Service Code S0302 in addition to the appropriate preventive medicine service code (99381-99385 or 99391-99395).
Modifier HN should be applied to the preventive medicine service code if a physician assistant performed the EPSDT service.   No modifier should be applied to S0302.	
W5	Non-independent nurse midwife services. To identify services provided by a non-independent nurse midwife who is employed by a physician, add the modifier W5 to the end of the appropriate service code. Refer to 130 CMR 433.419(D) for definition of non-independent nurse midwife.	SB	Nurse midwife	Independent Nurse Midwives that are currently enrolled with MassHealth under his or her own provider number should not use modifier SB.	
W6	Initial well-child visit provided by a non-independent nurse midwife in accordance with the EPSDT Schedule. To identify a well-child office visit provided by a non-independent nurse midwife (employed by a physician) as an initial health assessment (screening), add the modifier W6 to the end of the appropriate preventive medicine service code. Refer to 130 CMR 433.419(D) for the definition of non-independent nurse midwife.	S0302	Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to code for appropriate evaluation and management service.)	Providers billing for EPSDT services should bill using Service Code S0302 in addition to the appropriate preventive medicine service code (99381-99385 or 99391-99395).
Modifier SB should be applied to the preventive medicine service code if a non-independent nurse practitioner performed the EPSDT service. No modifier should be applied to S0302.	

Attachment for Transmittal Letter PHY-97
November 2003
Page 6

Obsolete Code-Modifier	Obsolete Code Description	New Code - Modifier	New Code Description	Comments	
W7	Subsequent well-child visit provided by a non-independent nurse midwife in accordance with the EPSDT Schedule. To identify a well-child office visit provided by a non-independent nurse midwife (employed by a physician) as a subsequent health assessment (screening), add the modifier W7 to the end of the appropriate preventive medicine service code. Refer to 130 CMR 433.419(D) for the definition of non-independent nurse midwife.	S0302	Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to code for appropriate evaluation and management service.)	Providers billing for EPSDT services should bill using Service Code S0302 in addition to the appropriate preventive medicine service code (99381-99385 or 99391-99395).
Modifier SB should be applied to the preventive medicine service code if a non-independent nurse practitioner performed the EPSDT service. No modifier should be applied to S0302.	
Y3	Subsequent well-child visit provided by a physician, independent nurse practitioner, or independent nurse midwife in accordance with the EPSDT Schedule. To identify a well-child office visit provided by a physician, independent nurse practitioner, or independent nurse midwife as a subsequent health assessment (screening), add the modifier Y3 to the end of the appropriate preventive medicine service code. Refer to 130 CMR 433.433(C) for the definition of independent nurse practitioner. Refer to 130 CMR 433.419(C) for the definition of independent nurse midwife.	S0302	Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to code for appropriate evaluation and management service.)	Providers billing for EPSDT services should bill using Service Code S0302 in addition to the appropriate preventative medicine service code (99381-99385 or 99391-99395).	

Modifier	Description	Comments	
W8	Emergency treatment in a nursing facility. To identify a visit to a nursing facility for emergency treatment, add the modifier W8 to the end of the nursing facility visit service code.	Modifier deleted, no longer in use.	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
vi	

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	

6.   SERVICE CODES
DIRECTORY
ENROLLMENT CENTERS THIRD-PARTY-LIABILITY CODES
Appendix A. Appendix B. Appendix C. Appendix D. Appendix E. Appendix F. Appendix G. Appendix H. Appendix I. Appendix J. Appendix K. Appendix L. Appendix W.
Appendix X. Appendix Y. Appendix Z.
 601	Introduction 	
 602	Nonpayable CPT Codes 	
 603	Codes That Have Special Requirements or Limitations 	
 604	HCPCS Level II Service Codes 	
 605	Modifiers 	

(Reserved)
ADMISSION GUIDELINES 	
(Reserved) (Reserved) (Reserved) UTILIZATION MANAGEMENT PROGRAM

(Reserved)
TEACHING PHYSICIANS

NONLEGEND DRUGS 	
EPSDT SERVICES: MEDICAL PROTOCOL AND PERIODICITY SCHEDULE
FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES 	

REVS CODES/MESSAGES

EPSDT SERVICES LABORATORY CODES

6-1
6-1
6-4
6-12
6-17
A-1 B-1 C-1
E-1
I-1
K-1 L-1
X-1 Y-1 Z-1

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

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
601 Introduction
MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2003 code book for the service codes and service descriptions when billing for services provided to MassHealth members. The Division pays for all medicine, radiology, surgery, and anesthesia CPT codes in effect at the time of service, subject to all conditions and limitations described in the Division’s regulations at 130 CMR 433.000 and 450.000, except for those codes listed in Section 602 of this subchapter. In addition, a physician may request prior authorization for any medically necessary service for a member under 21 years of age.
 •	Section 602 lists CPT service codes that are not payable under MassHealth.
 •	Section 603 lists service codes that have special requirements or limitations. Beside each service code in Section 603 is an explanation of the requirement or limitation.
 •	Section 604 lists Level II HCPCS codes that are payable under MassHealth.
•	Section 605 lists service code modifiers payable under MassHealth.
602 Nonpayable CPT Codes
The Division does not pay for services billed under the following codes.

0001T	0030T	15780	19316	36416	
0002T	0031T	15781	19324	36468	
0003T	0032T	15782	19325	36469	
0005T	0033T	15783	19355	36540	
0006T	0034T	15786	19370	41870	
0007T	0035T	15787	19371	41872	
0008T	0036T	15788	19396	43752	
0009T	0037T	15789	20930	43842	
0010T	0038T	15792	20936	43843	
0012T	0039T	15793	21120	44132	
0013T	0040T	15810	21121	44133	
0014T	0041T	15811	21122	44135	
0016T	0042T	15819	21123	44136	
0017T	0043T	15824	21125	47133	
0018T	0044T	15825	21127	48160	
0019T	10040	15826	21245	48550	
0020T	11920	15828	21246	50300	
0021T	11921	15829	21248	51701	
0023T	11922	15876	21249	51702	
0024T	11950	15877	22841	54900	
0025T	11951	15878	32491	54901	
0026T	11952	15879	32850	55200	
0027T	11954	17340	33930	55300	
0028T	15775	17360	33940	55400	
0029T	15776	17380	36415	55870	

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

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
602 Nonpayable CPT Codes (cont.)

55970	77331	86931	90281	91133	
55980	77332	86932	90283	92314	
58321	77333	86945	90287	92315	
58322	77334	86950	90379	92316	
58323	77336	86965	90384	92317	
58345	77370	86985	90386	92325	
58350	77399	87901	90389	92330	
58750	77401	87903	90396	92335	
58752	77402	87904	90586	92340	
58760	77403	88000	90633	92341	
58970	77404	88005	90634	92342	
58974	77406	88007	90636	92352	
58976	77407	88012	90645	92353	
59412	77408	88014	90646	92354	
62287	77409	88016	90647	92355	
63043	77411	88020	90648	92358	
63044	77412	88025	90669	92370	
65760	77413	88027	90680	92371	
65765	77414	88028	90700	92390	
65767	77416	88029	90701	92391	
65771	77417	88036	90702	92392	
69090	77418	88037	90708	92393	
71552	77520	88040	90710	92395	
72159	77522	88045	90712	92396	
72198	77523	88099	90718	92510	
73225	77525	88125	90720	92531	
76085	77790	89250	90721	92532	
76093	78267	89251	90723	92533	
76094	78268	89252	90744	92534	
76140	78351	89253	90748	92548	
76150	78890	89254	90845	92559	
76350	78891	89255	90865	92560	
76390	80500	89256	90875	92561	
76400	80502	89257	90876	92562	
76496	82075	89258	90880	92564	
76497	82962	89259	90885	92597	
76498	84061	89260	90889	93660	
77300	84830	89261	90901	93668	
77301	86079	89264	90911	93760	
77305	86585	89300	90939	93762	
77310	86890	89310	90940	93770	
77315	86891	89320	90989	93784	
77321	86910	89321	90993	93786	
77326	86911	89325	90997	93788	
77327	86927	89329	90999	93790	
77328	86930	89330	91132	94015	

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

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
602 Nonpayable CPT Codes (cont.)

95052	98940	99371	99565	
95120	98941	99372	99566	
95125	98942	99373	99567	
95130	98943	99374	99568	
95131	99001	99375	99569	
95132	99002	99377		
95133	99024	99378		
95134	99025	99379		
95824	99026	99380		
95965	99027	99401		
95966	99056	99402		
95967	99058	99403		
96000	99071	99404		
96001	99075	99411		
96002	99078	99412		
96003	99080	99420		
96004	99082	99429		
96100	99090	99450		
96105	99091	99455		
96110	99100	99456		
96111	99116	99500		
96115	99135	99501		
96117	99140	99502		
96150	99141	99503		
96151	99142	99504		
96152	99172	99505		
96153	99190	99506		
96154	99191	99507		
96155	99192	99509		
96567	99271	99510		
96902	99272	99511		
97005	99273	99512		
97006	99274	99551		
97014	99275	99552		
97139	99288	99553		
97530	99315	99554		
97537	99316	99555		
97545	99354	99556		
97546	99355	99557		
97601	99356	99558		
97602	99357	99559		
97780	99358	99560		
97781	99359	99561		
97802	99360	99562		
97803	99361	99563		
97804	99362	99564		

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

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
603 Codes That Have Special Requirements or Limitations
The following service codes are payable by MassHealth, subject to all conditions and limitations in the Division’s regulations at 130 CMR 433.000 and 450.000, but require specific attachments or prior authorization, or have other specific instructions or limitations. Refer to Section 604 for specific requirements or limitations for HCPCS Level II.
Legend:
*: Available free of charge through the Massachusetts Immunization Program for children under 19
years of age. Centrifuging required: Service Code 99000 may be used only to pay a physician who centrifuges
and mails a specimen to a laboratory for analysis. (See 130 CMR 433.439.) Covered for adults ≥ 19: This code is payable only for adults aged 19 or older. CPA-2: A completed Certification of Payable Abortion Form must be completed. See 130 CMR
450.234 through 450.260 and 130 CMR 433.455 for more information. CS-18: A completed Sterilization Consent Form (for members aged 18 through 20) must be
completed. See 130 CMR 450.234 through 450.260 and 130 CMR 433.456 through 433.458 for
more information. CS-21: A completed Sterilization Consent Form (for members aged 21 and older) must be
completed. See 130 CMR 450.234 through 450.260 and 130 CMR 433.456 through 433.458 for
more information. HI-1: A completed Hysterectomy Information Form must be completed. See 130 CMR 450.234
through 450.260 and 130 CMR 433.459 for more information. IC: Claim requires individual consideration. See 130 CMR 433.406 for more information. PA for OMT >20: Prior authorization is required for more than 20 osteopathic manipulative 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: Service requires prior authorization. See 130 CMR 433.408 for more information. Urgent Care Only: Service Codes 99050, 99052, and 99054 may be used only for urgent care
provided in the office after hours, in addition to the basic service.

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

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

01999	IC	21088	IC; PA	
15820	PA	21089	IC; PA	
15821	PA	21110	IC	
15822	PA	21137	PA	
15823	PA	21138	PA	
15831	IC; PA	21139	PA	
15832	IC; PA	21141	PA	
15833	IC; PA	21142	PA	
15834	IC; PA	21143	PA	
15835	IC; PA	21145	PA	
15836	IC; PA	21146	PA	
15837	IC; PA	21147	PA	
15838	IC; PA	21150	PA	
15839	IC; PA	21151	PA	
15999	IC	21154	PA	
17999	IC	21155	PA	
19140	PA	21159	PA	
19318	PA	21160	PA	
19328	PA	21172	PA	
19330	PA	21175	PA	
19340	PA	21179	PA	
19342	PA	21180	PA	
19350	PA	21181	PA	
19357	PA	21182	PA	
19361	PA	21183	PA	
19364	PA	21184	PA	
19366	PA	21188	PA	
19367	PA	21193	PA	
19368	PA	21194	PA	
19369	PA	21195	PA	
19380	PA	21196	PA	
19499	IC	21198	PA	
20999	IC	21206	PA	
21076	IC; PA	21208	PA	
21077	IC; PA	21209	PA	
21079	IC; PA	21210	PA	
21080	IC; PA	21215	PA	
21081	IC; PA	21230	PA	
21082	IC; PA	21235	PA	
21083	IC; PA	21240	PA	
21084	IC; PA	21242	PA	
21085	IC; PA	21243	PA	
21086	IC; PA	21244	PA	
21087	IC; PA	21247	PA	

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

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

21255	PA	31899	IC	
21256	PA	32851	PA	
21260	PA	32852	PA	
21261	PA	32853	PA	
21263	PA	32854	PA	
21267	PA	32999	IC	
21268	PA	33924	IC	
21270	PA	33935	PA	
21275	PA	33945	PA	
21280	PA	33979	IC	
21282	PA	33980	IC	
21295	PA	33999	IC	
21296	PA	36299	IC	
21299	IC; PA	36470	PA	
21499	IC	36471	PA	
21742	IC	37501	IC	
21743	IC	37799	IC	
21899	IC	38129	IC	
22899	IC	38204	IC	
22999	IC	38205	PA	
23929	IC	38206	IC	
24940	IC	38207	IC; PA	
24999	IC	38208	IC; PA	
25915	IC	38209	IC; PA	
25999	IC	38210	IC; PA	
26989	IC	38211	IC; PA	
27299	IC	38212	IC; PA	
27599	IC	38213	IC; PA	
27899	IC	38214	IC; PA	
28360	IC	38215	IC; PA	
28899	IC	38230	PA	
29799	IC	38240	PA	
29800	PA	38241	PA	
29804	PA	38242	PA	
29999	IC	38589	IC	
30400	PA	38999	IC	
30410	PA	39499	IC	
30420	PA	39599	IC	
30430	PA	40799	IC	
30435	PA	40840	PA	
30450	PA	40842	PA	
30999	IC	40843	PA	
31299	IC	40844	PA	
31599	IC	40845	PA	

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

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

40899	IC	50549	IC	
41599	IC	50949	IC	
41820	IC; PA	51597	HI-1	
41821	IC	51715	PA	
41822	IC	51925	HI-1	
41823	IC	52327	PA	
41828	IC	53850	PA	
41850	IC	53852	PA	
41899	IC	53899	IC	
42140	PA	54240	PA	
42280	PA	54250	PA	
42281	PA	54400	PA	
42299	IC	54401	PA	
42699	IC	54405	PA	
42999	IC	54440	IC	
43289	IC	54699	IC	
43496	IC	55250	CS-18 or CS-21	
43499	IC	55450	CS-18 or CS-21	
43659	IC	55559	IC	
43846	PA	55899	IC	
43847	PA	56800	PA	
43848	PA	56805	IC; PA	
43999	IC	57335	IC; PA	
44238	IC	58150	HI-1	
44239	IC	58152	HI-1	
44799	IC	58180	HI-1	
44899	IC	58200	HI-1	
44979	IC	58210	HI-1	
45999	IC	58240	HI-1	
46999	IC	58260	HI-1	
47134	IC; PA	58262	HI-1	
47135	IC; PA	58263	HI-1	
47136	IC; PA	58267	HI-1	
47379	IC	58270	HI-1	
47399	IC	58275	HI-1	
47579	IC	58280	HI-1	
47999	IC	58285	HI-1	
48554	PA	58290	HI-1	
48556	PA	58291	HI-1	
48999	IC	58292	HI-1	
49329	IC	58293	HI-1	
49659	IC	58294	HI-1	
49906	IC	58550	HI-1	
49999	IC	58552	HI-1	

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

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

58553	HI-1		67909	PA	
58554	HI-1		67911	PA	
58578	IC		67916	PA	
58579	IC		67917	PA	
58600	CS-18 or	CS-21	67923	PA	
58605	CS-18 or	CS-21	67924	PA	
58611	CS-18 or	CS-21	67961	PA	
58615	CS-18 or	CS-21	67966	PA	
58661	CS-18 or	CS-21	67971	PA	
58670	CS-18 or	CS-21	67973	PA	
58671	CS-18 or	CS-21	67974	PA	
58679	IC		67975	PA	
58951	HI-1		67999	IC	
58999	IC		68399	IC	
59135	HI-1		68899	IC	
59525	HI-1		69300	PA	
59840	CPA-2; (first trimester)	69399	IC	
59841	CPA-2; (first trimester)	69710	IC	
59850	CPA-2; (second trimester, third	69799	IC	
	trimester in hospital only)	69930	PA	
59851	CPA-2; (second trimester, third	69949	IC	
	trimester in hospital only)	69979	IC	
59852	CPA-2; (second trimester, third	70336	PA	
	trimester in hospital only)	71555	IC	
59855	CPA-2		73725	IC	
59856	CPA-2		74185	IC	
59857	CPA-2		75556	IC	
59898	IC		76380	IC	
59899	IC		76496	IC	
60659	IC		76497	IC	
60699	IC		76498	IC	
64999	IC		76499	IC	
66990	IC		76999	IC	
66999	IC		77299	IC	
67299	IC		77399	IC	
67399	IC		77499	IC	
67599	IC		77799	IC	
67900	PA		78099	IC	
67901	PA		78172	IC	
67902	PA		78199	IC	
67903	PA		78282	IC	
67904	PA		78299	IC	
67906	PA		78399	IC	
67908	PA		78414	IC	

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

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

78459	IC	86922	IC	
78491	IC	86999	IC	
78492	IC	87255	IC	
78499	IC	87267	IC	
78599	IC	87271	IC	
78608	IC	87999	IC; PA	
78609	IC	88174	IC	
78699	IC	88175	IC	
78799	IC	88180	IC	
78810	IC	88182	IC	
78990	IC	88199	IC	
78999	IC	88299	IC	
79300	IC	88399	IC	
79420	IC	89055	IC	
79900	IC	89399	IC	
79999	IC	90288	IC	
80103	IC	90291	IC	
80406	IC	90296	IC	
81099	IC	90371	Covered for adults > 17	
82154	IC	90378	IC, PA	
83527	IC	90393	IC	
83880	IC	90399	IC	
83937	IC	90473	IC	
84140	IC	90474	IC	
84143	IC	90476	IC	
84302	IC	90477	IC	
84449	IC	90581	IC	
84466	IC	90632	Covered for adults > 17	
84586	IC	90660	IC, PA	
84999	IC	90665	IC	
85004	IC	90690	IC	
85032	IC	90692	IC	
85049	IC	90693	IC	
85380	IC	90707	Covered for adults > 17	
85999	IC	90713	Covered for adults > 17	
86341	IC	90716	Covered for adults > 17	
86359	IC	90719	IC	
86849	IC	90725	IC	
86850	IC	90727	IC	
86860	IC	90732	Covered for adults > 17	
86870	IC	90749	IC, PA	
86901	IC	90799	IC	
86920	IC	90899	IC	
86921	IC			

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-10	

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit	Service Code and Req. or Limit

90935	For hospitalized member only; not	97003	PA for PT >20	
	for chronic maintenance	97004	PA for PT >20	
90937	For hospitalized member only; not	97010	PA for PT >20	
	for chronic maintenance	97012	PA for PT >20	
90945	For hospitalized member only; not	97016	PA for PT >20	
	for chronic maintenance	97018	PA for PT >20	
90947	For hospitalized member only; not	97020	PA for PT >20	
	for chronic maintenance	97022	PA for PT >20	
90999	IC	97024	PA for PT >20	
91123	IC	97026	PA for PT >20	
91299	IC	97028	PA for PT >20	
92065	IC; PA	97032	PA for PT >20	
92250	PA	97033	PA for PT >20	
92310	PA	97034	PA for PT >20	
92311	PA; includes supply of lenses	97035	PA for PT >20	
92312	PA; includes supply of lenses	97036	PA for PT >20	
92313	IC; PA; includes supply of lenses	97039	IC; PA for PT >20	
92326	PA	97110	PA for PT >20	
92499	IC	97112	PA for PT >20	
92605	IC; PA	97113	IC; PA for PT >20	
92606	IC	97116	PA for PT >20	
92610	PA	97124	PA for PT >20	
92611	PA	97140	PA for PT >20	
92613	IC	97150	PA for PT >20	
92615	IC	97504	PA for PT >20	
92617	IC	97520	PA for PT >20	
92700	IC	97532	PA for PT >20	
92953	IC	97533	PA for PT >20	
93799	IC	97535	PA for PT >20	
94642	IC	97542	PA for PT >20	
94772	IC	97799	IC	
94799	IC	98925	PA for OMT >20	
95071	IC	98926	PA for OMT >20	
95199	IC, PA	98927	PA for OMT >20	
95875	IC	98928	PA for OMT >20	
95999	IC	98929	PA for OMT >20	
96423	IC	98928	IC	
96425	IC	98929	IC	
96545	IC	98940	IC	
96549	IC	98941	IC	
96913	IC	98942	IC	
96999	IC	98943	IC	
97001	PA for PT >20	99000	Centrifuging requi	
97002	PA for PT >20	99050	Urgent care only	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-11	

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
603 Codes That Have Special Requirements or Limitations (cont.)
Service Code and Req. or Limit
99052	Urgent care only
99054	Urgent care only
99070	IC; excluding family planning
supplies and supplies, such as
trays, used in the collection of
specimens
 99185	IC
 99186	IC
99195	For hematologic disorders only
99199	IC
 99289	IC
 99290	IC 99296	IC

 99298	IC
 99299	IC
99344	IC
99345	IC
99350	IC
99499	IC
99600	IC

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-12	

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
604 HCPCS Level II Service Codes
This	section lists Level II HCPCS codes that are payable under MassHealth. MassHealth providers must
refer	to Ingenix’s HCPCS Level II 2003 code book for more detailed descriptions when billing for Level
II HCPCS codes provided to MassHealth members.
Service	Service
Code	Description
A4261	Cervical cap for contraceptive use (IC)
A4266	Diaphragm for contraceptive use
A4267	Contraceptive supply, condom, male, each
A4268	Contraceptive supply, condom, female, each
A4269	Contraceptive supply, spermicide (e.g., foam, gel), each
H2011	Crisis intervention service, per 15 minutes
J0170	Injection, adrenalin, epinephrine, up to 1 ml ampule (IC)
J0256	Injection, alpha 1- proteinase inhibitor – human, 10 mg (IC)
J0270	Injection, alprostadil, 1.25 mcg (PA) (IC)
J0290	Injection, ampicillin sodium 500 mg (IC)
J0295	Injection, ampicillin sodium / sulbactam sodium, per 1.5 g (IC)
J0456	Injection, azithromycin, 500 mg (IC)
J0460	Injection, atropine sulfate, up to 0.3 mg (IC)
J0475	Injection, baclofen, 10 mg (PA) (IC)
J0476	Injection, baclofen, 50 mcg for intrathecal trial (PA) (IC)
J0530	Injection, penicillin G benzathine and penicillin G procaine, up to 600,000 units (IC)
J0540	Injection, penicillin G benzathine and penicillin G procaine, up to 1,200,000 units (IC)
J0550	Injection, penicillin G benzathine and penicillin G procaine, up to 2,400,000 units (IC)
J0560	Injection, penicillin G benzathine, up to 600,000 units (IC)
J0570	Injection, penicillin G benzathine, up to 1,200,000 units (IC)
J0580	Injection, penicillin G benzathine, up to 2,400,000 units (IC)
J0585	Botulinum toxin type A, per unit (PA) (IC)
J0587	Botulinum toxin type B, per 100 units (PA) (IC)
J0640	Injection, leucovorin calcium, per 50 mg (IC)
J0690	Injection, cefazolin sodium, 500 mg (IC)
J0694	Injection, cefoxitin sodium, 1 g (IC)
J0696	Injection, ceftriaxone sodium, per 250 mg (IC)
J0697	Injection, sterile cefuroxime sodium, per 750 mg (IC)
J0702	Injection, betamethasone acetate and betamethasone sodium phosphate, per 3 mg (IC)
J0704	Injection, betamethasone sodium phosphate, per 4 mg (IC)
J0780	Injection, prochlorperazine, up to 10 mg (IC)
J0880	Injection, darbepoetin alfa, 5 mcg (PA) (IC)
J0900	Injection, testosterone enanthate and estradiol valerate, up to 1 cc (IC)
J1020	Injection, methylprednisolone acetate, 20 mg (IC)
J1030	Injection, methylprednisolone acetate, 40 mg (IC)
J1040	Injection, methylprednisolone acetate, 80 mg (IC)
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 (IC)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-13	

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
604 HCPCS Level II Service Codes (cont.)
Service	Service
Code	Description
J1070	Injection, testosterone cypionate, up to 100 mg (IC)
J1080	Injection, testosterone cypionate, 1 cc, 200 mg (IC)
J1094	Injection, dexamethasone acetate, 1 mg (IC)
J1100	Injection, dexamethasone sodium phosphate, 1 mg (IC)
J1160	Injection, digoxin, up to 0.5 mg (IC)
J1170	Injection, hydromorphone, up to 4 mg (IC)
J1200	Injection, diphendydramine HCl, up to 50 mg (IC)
J1260	Injection, dolasetron mesylate, 10 mg (IC)
J1320	Injection, amitriptyline HCl, up to 20 mg (IC)
J1438	Injection, etanercept, 25 mg (PA) (IC)
J1440	Injection, filgrastim (G-CSF), 300 mcg (PA) (IC)
J1441	Injection, filgrastim (G-CSF), 480 mcg (PA) (IC)
J1460	Injection, gamma globulin, intramuscular, 1 cc (IC)
J1470	Injection, gamma globulin, intramuscular, 2 cc (IC)
J1480	Injection, gamma globulin, intramuscular, 3 cc (IC)
J1490	Injection, gamma globulin, intramuscular, 4 cc (IC)
J1500	Injection, gamma globulin, intramuscular, 5 cc (IC)
J1510	Injection, gamma globulin, intramuscular, 6 cc (IC)
J1520	Injection, gamma globulin, intramuscular, 7 cc (IC)
J1530	Injection, gamma globulin, intramuscular, 8 cc (IC)
J1540	Injection, gamma globulin, intramuscular, 9 cc (IC)
J1550	Injection, gamma globulin, intramuscular, 10 cc (IC)
J1563	Injection, immune globulin, intravenous, 1 g (PA) (IC)
J1564	Injection, immune globulin, 10 mg (PA) (IC)
J1626	Injection, granisetron HCl, 100 mcg (IC)
J1630	Injection, haloperidol, up to 5 mg (IC)
J1644	Injection, heparin sodium, per 1,000 units (IC)
J1650	Injection, enoxaparin sodium, 10 mg (IC)
J1655	Injection, tinzaparin sodium, 1000 IU (IC)
J1670	Injection, tetanus immune globulin, human, up to 250 units
J1700	Injection, hydrocortisone acetate, up to 25 mg (IC)
J1710	Injection, hydrocortisone sodium phosphate, up to 50 mg (IC)
J1720	Injection, hydrocortisone sodium succinate, up to 100 mg (IC)
J1745	Injection, infliximab, 10 mg (PA) (IC)
J1750	Injection, iron dextran, 50 mg (IC)
J1790	Injection, droperidol, up to 5 mg (IC)
J1800	Injection, propranolol HCl, up to 1 mg (IC)
J1815	Injection, insulin, per 5 units (IC)
J1885	Injection, ketorolac, tromethamine, per 15 mg (IC)
J1890	Injection, cephalothin sodium, up to 1 g (IC)
J1940	Injection, furosemide, up to 20 mg (IC)
J1950	Injection, leuprolide acetate (for depot suspension), per 3.75 mg (PA) (IC)
J1956	Injection, levofloxacin, 250 mg (IC)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
PHYSICIAN MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES	PAGE
6-14	

	TRANSMITTAL LETTER
PHY-97	DATE
11/01/03	
604 HCPCS Level II Service Codes (cont.)
Service	Service
Code	Description
J1990	Injection, chlordiazepoxide HCl, up to 100 mg (IC)
J2000	Injection, lidocaine HCl, 50 cc (IC)
J2060	Injection, lorazepam, 2 mg (IC)
J2150	Injection, mannitol, 25% in 50 ml (IC)
J2175	Injection, meperidine HCl, per 100 mg (IC)
J2250	Injection, midazolam HCl, per 1 mg (IC)
J2270	Injection, morphine sulfate, up to 10 mg (IC)
J2271	Injection, morphine sulfate, 100 mg (IC)
J2275	Injection, morphine sulfate (preservative-free sterile solution), per 10 mg (IC)
J2300	Injection, nalbuphine HCl, per 10 mg (IC)
J2310	Injection, naloxone HCl, per 1 mg (IC)
J2405	Injection, ondansetron HCl, per 1 mg (IC)
J2430	Injection, pamidronate disodium, per 30 mg (IC)
J2440	Injection, papaverine HC1, up to 60 mg (IC)
J2510	Injection, penicillin G procaine, aqueous, up to 600,000 units (IC)
J2515	Injection, pentobarbital sodium, per 50 mg (IC)
J2560	Injection, phenobarbital sodium, up to 120 mg (IC)
J2650	Injection, prednisolone acetate, up to 1 ml (IC)
J2675	Injection, progesterone, per 50 mg (IC)
J2760	Injection, phentolamine mesylate, up to 5 mg (IC)
J2765	Injection, metoclopramide HCl, up to 10 mg (IC)
J2780	Injection, ranitidine HCl, 25 mg (IC)
J2788	Injection, Rho d immune globulin, human, minidose, 50 mcg
J2790	Injection, Rho d immune globulin, human, full dose, 300 mcg
J2792	Injection, Rho d immune globulin, intravenous, human, solvent detergent, 100 IU
J2820	Injection, sargramostim (GM-CSF), 50 mcg (PA) (IC)
J2916	Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg (IC)
J2920	Injection, methylprednisolone sodium succinate, up to 40 mg (IC)
J2930	Injection, methylprednisolone sodium succinate, up to 125 mg (IC)
J2940	Injection, somatrem, 1 mg (PA) (IC)
J2941	Injection, somatropin, 1 mg (PA) (IC)
J3010	Injection, fentanyl citrate, 0.1 mg (IC)
J3030	Injection, sumatriptan succinate, 6 mg (IC)
J3120	Injection, testosterone enanthate, up to 100 mg (IC)
J3130	Injection, testosterone enanthate, up to 200 mg (IC)
J3230	Injection, chlorpromazine HCl, up to 50 mg (IC)
J3250	Injection, trimethobenzamide HCl, up to 200 mg (IC)
J3301	Injection, triamcinolone acetonide, per 10 mg (IC)
J3302	Injection, triamcinolone diacetate, per 5 mg (IC)
J3303	Injection, triamcinolone hexacetonide, per 5 mg (IC)
J3360	Injection, diazepam, up to 5 mg (IC)
J3395	Injection, verteporfin, 15 mg (IC)
J3410	Injection, hydroxyzine HCl, up to 25 mg (IC)

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604 HCPCS Level II Service Codes (cont.)
Service	Service
Code	Description
J3420	Injection, vitamin B-12 cyanocobalamin, up to 1,000 mcg (IC)
J3430	Injection, phytonadione (vitamin K), per 1 mg (IC)
J3475	Injection, magnesium sulphate, per 500 mg (IC)
J3487	Injection, zoledronic acid, 1 mg (IC)
J3490	Unclassified drugs (PA) (IC)
J3490-FP   Unclassified drugs (service provided as part of Medicaid family planning program) (Use for
medications and injectibles related to family planning services, with the exception of Rho(D) human immune globulin, and contraceptive injectables such as Depo-Provera, items for which the Division will pay the provider's costs) (IC)
J3590	Unclassified biologics (PA) (IC)
J7030	Infusion, normal saline solution, 1,000 cc (IC)
J7040	Infusion, normal saline solution, sterile (500 ml = 1 unit) (IC)
J7042	5% dextrose/normal saline (500 ml = 1 unit) (IC)
J7050	Infusion, normal saline solution, 250 cc (IC)
J7060	5% dextrose/water (500 ml = 1 unit) (IC)
J7070	Infusion, D-5-W, 1,000 cc (IC)
J7317	Sodium hyaluronate, per 20 to 25 mg dose for intra-articular injection (PA) (IC)
J7320	Hylan G-F 20, 16 mg, for intra-articular injection (PA) (IC)
J7599	Immunosuppressive drug, NOC (PA) (IC)
J9000	Doxorubicin HCl, 10 mg (IC)
J9001	Doxorubicin HCl, all lipid formulations, 10 mg (IC)
J9031	BCG live (intravesical), per instillation
J9040	Bleomycin sulfate, 15 units (IC)
J9045	Carboplatin, 50 mg (IC)
J9060	Cisplatin, powder or solution, per 10 mg (IC)
J9062	Cisplatin, 50 mg (IC)
J9070	Cyclophosphamide, 100 mg (IC)
J9080	Cyclophosphamide, 200 mg (IC)
J9090	Cyclophosphamide, 500 mg (IC)
J9091	Cyclophosphamide, 1 g (IC)
J9092	Cyclophosphamide, 2 g (IC)
J9093	Cyclophosphamide, lyophilized, 100 mg (IC)
J9094	Cyclophosphamide, lyophilized, 200 mg (IC)
J9095	Cyclophosphamide, lyophilized, 500 mg (IC)
J9096	Cyclophosphamide, lyophilized, 1 g (IC)
J9097	Cyclophosphamide, lyophilized, 2 g (IC)
J9130	Dacarbazine, 100 mg (IC)
J9140	Dacarbazine, 200 mg (IC)
J9170	Docetaxel, 20 mg (IC)
J9181	Etoposide, 10 mg (IC)
J9182	Etoposide, 100 mg (IC)
J9190	Fluorouracil, 500 mg (IC)
J9201	Gemcitabine HC1, 200 mg (IC)

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604 HCPCS Level II Service Codes (cont.)
Service	Service
Code	Description
J9202	Goserelin acetate implant, per 3.6 mg (PA) (IC)
J9206	Irinotecan, 20 mg (IC)
J9212	Injection, interferon Alfacon-1, recombinant, 1 mcg (IC)
J9213	Interferon alfa-2A, recombinant, 3 million units (IC)
J9214	Interferon alfa-2B, recombinant, 1 million units (IC)
J9215	Interferon alfa-N3 (human leukocyte derived), 250,000 IU (IC)
J9216	Interferon gamma-1B, 3 million units (IC)
J9217	Leuprolide acetate (for depot suspension), 7.5 mg (PA) (IC)
J9218	Leuprolide acetate, per 1 mg (PA) (IC)
J9219	Leuprolide acetate implant, 65 mg (PA) (IC)
J9250	Methotrexate sodium, 5 mg (IC)
J9260	Methotrexate sodium, 50 mg (IC)
J9265	Paclitaxel, 30 mg (IC)
J9300	Gemtuzumab ozogamicin, 5 mg (IC)
J9310	Rituximab, 100 mg (IC)
J9355	Trastuzumab, 10 mg (IC)
J9360	Vinblastine sulfate, 1 mg (IC)
J9370	Vincristine sulfate, 1 mg (IC)
J9375	Vincristine sulfate, 2 mg (IC)
J9380	Vincristine sulfate, 5 mg (IC)
J9390	Vinorelbine tartrate, per 10 mg (IC)
J9999	NOC, antineoplastic drug (PA) (IC)
Q0136	Injection, epoetin alpha (for non ESRD use), per 1,000 units (PA) (IC)
Q4053	Injection, pegfilgrastim, per 6 mg, single dose vial (PA) (IC)
Q9920	Injection of EPO, per 1000 units, at patient HCT of 20 or less (PA) (IC)
Q9921	Injection of EPO, per 1000 units, at patient HCT of 21 (PA) (IC)
Q9922	Injection of EPO, per 1000 units, at patient HCT of 22 (PA) (IC)
Q9923	Injection of EPO, per 1000 units, at patient HCT of 23 (PA) (IC)
Q9924	Injection of EPO, per 1000 units, at patient HCT of 24 (PA) (IC)
Q9925	Injection of EPO, per 1000 units, at patient HCT of 25 (PA) (IC)
Q9926	Injection of EPO, per 1000 units, at patient HCT of 26 (PA) (IC)
Q9927	Injection of EPO, per 1000 units, at patient HCT of 27 (PA) (IC)
Q9928	Injection of EPO, per 1000 units, at patient HCT of 28 (PA) (IC)
Q9929	Injection of EPO, per 1000 units, at patient HCT of 29 (PA) (IC)
Q9930	Injection of EPO, per 1000 units, at patient HCT of 30 (PA) (IC)
Q9931	Injection of EPO, per 1000 units, at patient HCT of 31 (PA) (IC)
Q9932	Injection of EPO, per 1000 units, at patient HCT of 32 (PA) (IC)
Q9933	Injection of EPO, per 1000 units, at patient HCT of 33 (PA) (IC)
Q9934	Injection of EPO, per 1000 units, at patient HCT of 34 (PA) (IC)
Q9935	Injection of EPO, per 1000 units, at patient HCT of 35 (PA) (IC)
Q9936	Injection of EPO, per 1000 units, at patient HCT of 36 (PA) (IC)
Q9937	Injection of EPO, per 1000 units, at patient HCT of 37 ((PA) (IC)
Q9938	Injection of EPO, per 1000 units, at patient HCT of 38 (PA) (IC)

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604	HCPCS Level II Service Codes (cont.)
Service
Code        Description
Q9939	Injection of EPO, per 1000 units, at patient HCT of 39 (PA) (IC)
Q9940	Injection of EPO, per 1000 units, at patient HCT of 40 or above (PA) (IC)
R0070	Transportation of portable X-ray equipment and personnel to home or nursing home, per trip to
facility or location, one patient seen
50020	Injection, bupivicaine HCl, 30 ml (IC)
50021	Injection, ceftoperazone sodium, 1 gram (IC)
S0023	Injection, cimetidine HCl, 300 mg (IC)
S0028	Injection, famotidine, 20 mg (IC)
S0077	Injection, clindamycin phosphate, 300 mg (IC)
S0302	Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to
code for appropriate evaluation and management services) S4989       Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies (IC) S4993       Contraceptive pills for birth control T1023       Screening to determine the appropriateness of consideration of an individual for participation in a
specified program, project or treatment protocol, per encounter
605	Modifiers
The following service code modifiers are allowed for billing under MassHealth. See Subchapter 5 of the Physician Manual for billing instructions related to the use of modifiers.
26	Professional component
50	Bilateral procedure
51	Multiple procedures
54	Surgical care only
62	Two surgeons
66	Surgical team
80	Assistant surgeon
82	Assistant surgeon (when qualified resident surgeon not available)
99	Multiple modifiers
FP	Services provided as part of Medicaid Family Planning Program
HN	Bachelor’s degree level. (Use to indicate physician assistant.) (This modifier is to be applied to
service codes billed by a physician that were performed by a physician assistant employed by the physician or group practice.) SA  Nurse practitioner rendering service in collaboration with a physician. (This modifier is to be applied to service codes billed by a physician which were performed by a non-independent nurse practitioner employed by the physician or group practice.) (An independent nurse practitioner billing under his/her own individual provider number should not use this modifier.)

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605 Modifiers (cont.)
SB   Nurse midwife. (This modifier is to be applied to service codes billed by a physician which were performed by a non-independent nurse midwife employed by the physician or group practice.) (An independent nurse midwife billing under his/her own individual provider number should not use this modifier.)
SL   State supplied vaccine. (This modifier should only be applied to codes 90471 and 90473 to
identify vaccines administered under the Vaccine for Children Program (VFC) for individuals ages 18 and under.)
TC  Technical component. (The component of a service or procedure representing the cost of rent, equipment, utilities, supplies, administrative and technical salaries and benefits, and other overhead expenses of the service or procedures, excluding the physician’s professional component. When the technical component is reported separately the addition of modifier ‘-TC’ to the procedure code will allow the technical component allowable fee contained in 114.3 CMR 17.04 to be paid.)