Commonwealth of Massachusetts
Executive Office of Health and Human Services 
Office of Medicaid 
600 Washington Street
Boston, MA  02111
 www.mass.gov/masshealth 
MASSHEALTH 
TRANSMITTAL LETTER STR-14
January 2005 
TO: Sterilization Clinics Participating in MassHealth 
FROM: Beth Waldman, Medicaid Director  

RE: Sterilization Clinic Manual (Revisions to Service Codes and Descriptions) 
This letter transmits revisions to the service codes and descriptions in Subchapter 6 of the Sterilization Clinic Manual.  A new service code has been added (58565).  The revisions are effective for dates of service on or after January 1, 2005. 
If you wish to obtain a fee schedule, you may purchase Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or directly from the Division of Health Care Finance and Policy (see addresses and telephone numbers below).  You must contact them first to find out the price of the regulation.  The Division of Health Care Finance and Policy also has the regulations available on disk and on their Web site.  The regulation title is 114.3 CMR 16.00:  Surgery and Related Anesthesia Care and 114.3 CMR 20.00:  Laboratory. 

Massachusetts State Bookstore 	Division of Health Care Finance and Policy 	
State House, Room 116 	Two Boylston Street 	
Boston, MA 02133 	Boston, MA 02116 	
Telephone:  617-727-2834 	Telephone:  617-988-3100 	
 www.mass.gov/sec/spr	 www.mass.gov/dhcfp 	

Providers with questions about the information in this transmittal letter may contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231. 

NEW MATERIAL 
(The pages listed here contain new or revised language.) 

            Sterilization Clinic Manual

                Pages 6-1 and 6-2 

OBSOLETE MATERIAL 
             (The pages listed here are no longer in effect.) 

             Sterilization Clinic Manual 

                  Pages 6-1and 6-2 – transmitted by Transmittal Letter STR-13 

Commonwealth of Massachusetts 
Division of Medical Assistance 
Provider Manual Series	SUBCHAPTER NUMBER AND TITLE 
6  SERVICE CODES AND DESCRIPTIONS		PAGE 
6-1	
STERILIZATION CLINIC MANUAL	TRANSMITTAL LETTER 
STR-14		DATE 01/01/05	

601 Introduction 
	(A) The maximum allowable fee for a sterilization service payable to licensed ambulatory sterilization clinics is the fee listed in the applicable Division of Health Care Finance and Policy fee schedule or the provider’s usual fee or charge, whichever is less. 
	(B) Sterilization services include at least the following:  preoperative evaluation and counseling, laboratory services, anesthesia, and postoperative care. 
	(C) All claims for sterilization services must have a completed Consent for Sterilization (CS-18 or  CS-21) form attached to the claim form (see 130 CMR 485.409). 

602 Service Codes and Descriptions 
The following services include local anesthesia or intravenous sedation and all physician and clinic  services. 
Service 
Code 		Service Description 
55250 		Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen 
examination(s) (S.P.) 
55450 		Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) 
58565 		Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by 
                          placement of permanent implants  
58600 		Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or 
                          bilateral 
58670 		Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 
58671 		with occlusion of oviducts by device (e.g., band, clip, or Falope ring) 

This publication contains codes that are copyrighted by the American Medical Association.  Certain terms used in the service descriptions for HCPCS codes are defined in the Current Procedural Terminology (CPT) code book. 

Commonwealth of Massachusetts 
Division of Medical Assistance 
Provider Manual Series	SUBCHAPTER NUMBER AND TITLE 
6  SERVICE CODES AND DESCRIPTIONS		PAGE
 6-2	
STERILIZATION CLINIC MANUAL	TRANSMITTAL LETTER
 STR-14		DATE 01/01/05	

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