Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER PHY-110 May 2006 TO: Physicians Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Physician Manual (Revisions to Service Codes in Subchapter 6) This letter transmits a revised Subchapter 6 of the Physician Manual. MassHealth has removed the following codes from Section 602 (Nonpayable CPT Codes) and added them to Section 603 (Codes That Have Special Requirements or Limitations) to indicate that they require prior authorization: 19370 19371 In addition, MassHealth has removed the prior-authorization requirement from the following codes: 19330 19340 19342 19357 19361 19364 19366 19367 19368 19369 19380 21181 21182 21183 21184 42140 51715 53850 53852 54240 54250 67923 67924 87999 These revisions are effective for dates of service on or after April 1, 2006. MASSHEALTH TRANSMITTAL LETTER PHY-110 May 2006 Page 2 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 Physician Manual Pages vi and 6-1 through 6-16 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Physician Manual Page vi — transmitted by Transmittal Letter PHY-103 Pages 6-1 through 6-12, 6-15, and 6-16 — transmitted by Transmittal Letter PHY-105 Pages 6-13 and 6-14 — transmitted by Transmittal Letter PHY-108 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page Vi Physician Manual Transmittal Letter PHY-110 Date 04/01/06 6. SERVICE CODES Introduction 6-1 Nonpayable CPT Codes 6-1 Codes That Have Special Requirements or Limitations 6-4 HCPCS Level II Service Codes 6-10 Modifiers 6-15 Appendix A. DIRECTORY A-1 Appendix B. ENROLLMENT CENTERS B-1 Appendix C. THIRD-PARTY-LIABILITY CODES C-1 Appendix D. (Reserved) Appendix E. ADMISSION GUIDELINES E-1 Appendix F. (Reserved) Appendix G. (Reserved) Appendix H. (Reserved) Appendix I. UTILIZATION MANAGEMENT PROGRAM I-1 Appendix J. (Reserved) Appendix K. TEACHING PHYSICIANS K-1 Appendix L. (Reserved) Appendix W. EPSDT SERVICES: MEDICAL PROTOCOL AND PERIODICITY SCHEDULE Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES X-1 Appendix Y. REVS CODES/MESSAGES Y-1 Appendix Z. EPSDT SERVICES LABORATORY CODES Z-1 601 Introduction MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2005 code book for the service codes and service descriptions when billing for services provided to MassHealth members. MassHealth pays for all medicine, radiology, surgery, and anesthesia CPT codes in effect at the time of service, subject to all conditions and limitations described in the MassHealth 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 MassHealth does not pay for services billed under the following codes. 0003T 0008T 0010T 0016T 0017T 0018T 0019T 0020T 0021T 0023T 0024T 0026T 0027T 0028T 0029T 0030T 0031T 0032T 0033T 0034T 0035T 0036T 0037T 0038T 0039T 0040T 0041T 0042T 0043T 0044T 0045T 0046T 0047T 0048T 0049T 0050T 0051T 0052T 0053T 0054T 0055T 0056T 0058T 0059T 0060T 0061T 0062T 0063T 0064T 0065T 0066T 0067T 0068T 0069T 0070T 0071T 0072T 0073T 0074T 0075T 0076T 0077T 0078T 0079T 0080T 0081T 0082T 0083T 0084T 0085T 0086T 0087T 0088T 10040 11922 11950 11951 11952 11954 15775 15776 15780 15781 15782 15783 15786 15787 15788 15789 15792 15793 15810 15811 15819 15824 15825 15826 15828 15829 15876 15877 15878 15879 17340 17360 17380 19316 19324 19325 19355 19396 20930 20936 21120 21121 21122 21123 21125 21127 21245 21246 21248 21249 22841 32491 32850 32855 32856 33930 33933 33944 33940 36415 36416 36468 36469 36540 37765 37766 38204 38207 38208 38209 38210 38211 38212 38213 38214 38215 41870 41872 43752 43842 43843 43845 44132 44715 47133 47143 47144 47145 48160 48550 48551 50300 50323 50325 51701 51702 54900 54901 55200 55300 55400 55870 55970 55980 58321 58322 58323 58345 58350 58750 58752 58760 58970 58974 58976 59070 59072 59412 59897 62287 63043 63044 65760 65765 65767 65771 69090 71552 72159 72198 73225 76082 76083 76093 76094 76140 76150 76350 76390 76400 76496 76497 76498 77336 77370 77401 77402 77403 77404 77406 77407 77408 77409 77411 77412 77413 77414 77416 77417 77418 77520 77522 77523 77525 77790 78267 78268 78351 78890 78891 80500 80502 82075 82962 84061 84830 86079 86585 86890 86891 86910 86911 86927 86930 86931 86932 86945 86950 86965 86985 87901 87903 87904 88000 88005 88007 88012 88014 88016 88020 88025 88027 88028 88029 88036 88037 88040 88045 88099 88125 89250 89251 89253 89254 89255 89257 89258 89259 89260 89261 89264 89268 89272 89280 89281 89290 89291 89300 89310 89320 89321 89325 89329 89330 89335 89342 89343 89344 89346 89352 89353 89354 89356 90281 90283 90287 90379 90384 90386 90389 90396 90586 90633 90634 90636 90645 90646 90647 90648 90669 90680 90698 90700 90701 90702 90708 90710 90712 90715 90718 90720 90721 90723 90744 90748 90845 90865 90875 90876 90880 90885 90889 90901 90911 90939 90940 90989 90993 90997 90999 91132 91133 92314 92315 92316 92317 92325 92330 92335 92352 92353 92354 92355 92358 92371 92390 92391 92392 92393 92395 92396 92510 92531 92532 92533 92534 92548 92559 92560 92561 92562 92564 92597 92605 92606 92613 92615 92617 93660 93668 93760 93762 93770 93784 93786 93788 93790 94015 95052 95120 95125 95130 95131 95132 95133 95134 95824 95965 95966 95967 96000 96001 96002 96003 96004 96100 96105 96110 96111 96115 96117 96150 96151 96152 96153 96154 96155 96567 96902 97005 97006 97014 97537 97545 97546 97597 97598 97602 97605 97606 97755 97802 97803 97804 97810 97811 97813 97814 98940 98941 98942 98943 99001 99002 99024 99026 99027 99056 99058 99071 99075 99078 99080 99082 99090 99091 99100 99116 99135 99140 99141 99142 99172 99190 99191 99192 99271 99272 99273 99274 99275 99288 99315 99316 99354 99355 99356 99357 99358 99359 99360 99361 99362 99371 99372 99373 99374 99375 99377 99378 99379 99380 99401 99402 99403 99404 99411 99412 99420 99429 99450 99455 99456 99500 99501 99502 99503 99504 99505 99506 99507 99509 99510 99511 99512 99601 99602 603 Codes That Have Special Requirements or Limitations The following service codes 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. 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 OT >20: Prior authorization is required for more than 20 occupational therapy visits in a 12-month period. PA for PT >20: Prior authorization is required for more than 20 physical therapy visits, regardless of modality, in a 12-month period. PA for ST >35: Prior authorization is required for more than 35 speech/language therapy visits in a 12-month period. PA: 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. 01999 IC 11920 PA 11921 PA 15820 PA 15821 PA 15822 PA 15823 PA 15831 PA 15832 PA 15833 PA 15834 PA 15835 PA 15836 PA 15837 PA 15838 PA 15839 PA 15999 IC 17999 IC 19140 PA 19318 PA 19328 PA 19350 PA 19370 PA 19371 PA 19499 IC 20999 IC 21076 PA 21077 PA 21079 PA 21080 PA 21081 PA 21082 PA 21083 PA 21084 PA 21085 PA 21086 PA 21087 PA 21088 IC; PA 21089 IC; PA 21137 PA 21138 PA 21139 PA 21141 PA 21142 PA 21143 PA 21145 PA 21146 PA 21147 PA 21150 PA 21151 PA 21154 PA 21155 PA 21159 PA 21160 PA 21172 PA 21175 PA 21179 PA 21180 PA 21188 PA 21193 PA 21194 PA 21195 PA 21196 PA 21198 PA 21206 PA 21208 PA 21209 PA 21210 PA 21215 PA 21230 PA 21235 PA 21240 PA 21242 PA 21243 PA 21244 PA 21247 PA 21255 PA 21256 PA 21260 PA 21261 PA 21263 PA 21267 PA 21268 PA 21270 PA 21275 PA 21280 PA 21282 PA 21295 PA 21296 PA 21299 IC; PA 21499 IC 21742 IC 21743 IC 21899 IC 22899 IC 22999 IC 23929 IC 24940 IC 24999 IC 25999 IC 26989 IC 27299 IC 27599 IC 27899 IC 28899 IC 29799 IC 29800 PA 29804 PA 29999 IC 30400 PA 30410 PA 30420 PA 30430 PA 30435 PA 30450 PA 30999 IC 31299 IC 31599 IC 31899 IC 32851 PA 32852 PA 32853 PA 32854 PA 32999 IC 33935 PA 33945 PA 33999 IC 36299 IC 36470 PA 36471 PA 37501 IC 37799 IC 38129 IC 38205 PA 38230 PA 38240 PA 38241 PA 38242 PA 38589 IC 38999 IC 39499 IC 39599 IC 40799 IC 40840 PA 40842 PA 40843 PA 40844 PA 40845 PA 40899 IC 41599 IC 41820 IC; PA 41821 IC 41850 IC 41899 IC 42280 PA 42281 PA 42299 IC 42699 IC 42999 IC 43289 IC 43499 IC 43644 PA 43645 PA 43659 IC 43846 PA 43847 PA 43848 PA 43999 IC 44133 IC; PA 44135 IC; PA 44136 IC; PA 44137 IC 44238 IC 44239 IC 44799 IC 44899 IC 44979 IC 45999 IC 46999 IC 47135 PA 47136 PA 47140 PA 47141 PA 47142 PA 47379 IC 47399 IC 47579 IC 47999 IC 48554 PA 48556 PA 48999 IC 49329 IC 49659 IC 49906 IC 49999 IC 50549 IC 50949 IC 51597 HI-1 51925 HI-1 53899 IC 54400 PA 54401 PA 54405 PA 54440 IC 54699 IC 55250 CS-18 or CS-21 55450 CS-18 or CS-21 55559 IC 55899 IC 56800 PA 56805 IC; PA 57335 IC; PA 58150 HI-1 58152 HI-1 58180 HI-1 58200 HI-1 58210 HI-1 58240 HI-1 58260 HI-1 58262 HI-1 58263 HI-1 58267 HI-1 58270 HI-1 58275 HI-1 58280 HI-1 58285 HI-1 58290 HI-1 58291 HI-1 58292 HI-1 58293 HI-1 58294 HI-1 58550 HI-1 58552 HI-1 58553 HI-1 58554 HI-1 58565 CS-18 or CS-21 58578 IC 58579 IC 58600 CS-18 or CS-21 58605 CS-18 or CS-21 58611 CS-18 or CS-21 58615 CS-18 or CS-21 58661 CS-18 or CS-21 58670 CS-18 or CS-21 58671 CS-18 or CS-21 58679 IC 58951 HI-1 58956 HI-1 58999 IC 59135 HI-1 59525 HI-1 59840 CPA-2 (first trimester) 59841 CPA-2 (first trimester) 59850 CPA-2 (second trimester, third trimester in hospital only) 59851 CPA-2 (second trimester, third trimester in hospital only) 59852 CPA-2 (second trimester, third trimester in hospital only) 59855 CPA-2 59856 CPA-2 59857 CPA-2 59898 IC 59899 IC 60659 IC 60699 IC 64999 IC 66999 IC 67299 IC 67399 IC 67599 IC 67900 PA 67901 PA 67902 PA 67903 PA 67904 PA 67906 PA 67908 PA 67909 PA 67911 PA 67916 PA 67917 PA 67961 PA 67966 PA 67971 PA 67973 PA 67974 PA 67975 PA 67999 IC 68399 IC 68899 IC 69300 PA 69399 IC 69710 IC 69799 IC 69930 PA 69949 IC 69979 IC 70336 PA 75556 IC 76499 IC 76999 IC 77299 IC 77399 IC 77499 IC 77799 IC 78099 IC 78199 IC 78299 IC 78399 IC 78499 IC 78599 IC 78608 IC 78609 IC 78699 IC 78799 IC 78999 IC 79999 IC 81099 IC 82045 IC 82656 IC 83009 IC 83630 IC 84163 IC 84999 IC 85999 IC 86064 IC 86379 IC 86587 IC 86849 IC 86999 IC 87807 IC 87999 IC 88199 IC 88299 IC 88380 IC 88399 IC 89230 IC 89240 IC 90288 IC 90291 IC 90296 IC 90371 Covered for adults >17 90378 IC; PA 90393 IC, PA 90399 IC 90467 IC 90468 IC 90473 IC 90474 IC 90476 IC 90477 IC 90581 IC 90632 Covered for adults >17 90660 IC; PA 90665 IC 90690 IC 90692 IC 90693 IC 90707 Covered for adults >17 90713 Covered for adults >17 90716 Covered for adults ??? 90719 IC 90725 IC 90727 IC 90734 IC 90749 IC 90799 IC 90899 IC 90935 For hospitalized member only; not for chronic maintenance 90937 For hospitalized member only; not for chronic maintenance 90945 For hospitalized member only; not for chronic maintenance 90947 For hospitalized member only; not for chronic maintenance 91110 PA 91123 IC 91299 IC 92065 PA 92250 PA 92310 PA 92311 PA; includes supply of lenses 92312 PA; includes supply of lenses 92313 PA; includes supply of lenses 92326 PA 92499 IC 92506 PA for ST >35 92507 PA for ST >35 92508 PA for ST >35 92526 PA for ST >35 92610 PA for ST >35 92700 IC 92992 IC 92993 IC 93745 IC 93799 IC 94642 IC 94772 IC 94799 IC 95199 IC 95999 IC 96545 IC 96549 IC 96999 IC 97001 PA for PT >20 97002 PA for PT >20 97003 PA for OT >20 97004 PA for OT >20 97010 PA for PT >20 97012 PA for PT >20 97016 PA for PT >20 97018 PA for PT >20 97020 PA for PT >20 97022 PA for PT >20 97024 PA for PT >20 97026 PA for PT >20 97028 PA for PT >20 97032 PA for PT >20 97033 PA for PT >20 97034 PA for PT >20 97035 PA for PT >20 97036 PA for PT >20 97039 PA for PT >20 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 97140 PA for PT >20 97150 PA for PT >20 97504 PA for OT >20 97520 PA for OT >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 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 99052 Urgent care only 99054 Urgent care only 99070 IC; excluding family planning supplies, such as trays, used in the collection of specimens 99195 For hematologic disorders only 99199 IC 99296 IC 99344 IC 99345 IC 99350 IC 99499 IC 99600 IC 604 HCPCS Level II Service Codes This section lists Level II HCPCS codes that are payable under MassHealth. Refer to the Centers for Medicare and Medicaid Web site at www.cms.gov/medicare/hcpcs for more detailed descriptions when billing for Level II HCPCS codes provided to MassHealth members. Service Code Service Description A4261 Cervical cap for contraceptive use (IC) A4266 Diaphragm for contraceptive use A4267 Contraceptive supply, condom, male, each A4268 Contraceptive supply, condom, female, each A4269 Contraceptive supply, spermicide (e.g., foam, gel), each A4641 Supply of radiopharmaceutical diagnostic imaging agent, not otherwise classified (IC) A9500 Supply of radiopharmaceutical diagnostic imaging agent, technetiumTc 99m sestamibi, per dose (IC) A9502 Supply of radiopharmaceutical diagnostic imaging agent technetiumTc 99m tetrofosmin, per unit dose (IC) A9503 Supply of radiopharmaceutical diagnostic imaging agent technetiumTc 99m medronate, up to 30 millicurie (IC) A9505 Supply of radiopharmaceutical diagnostic imaging agent thallous chloride T1-201, per millicurie (IC) H2011 Crisis intervention service, per 15 minutes J0128 Injection, abarelix, 10 mg (PA) J0135 Injection, adalimumab, 20 mg (PA) J0215 Injection, alefacept, 0.5 mg (PA) J0256 Injection, alpha 1-proteinase inhibitor–human, 10 mg J0295 Injection, ampicillin sodium / sulbactam sodium, per 1.5 g J0456 Injection, azithromycin, 500 mg J0475 Injection, baclofen, 10 mg J0476 Injection, baclofen, 50 mcg for intrathecal trial J0530 Injection, penicillin G benzathine and penicillin G procaine, up to 600,000 units J0540 Injection, penicillin G benzathine and penicillin G procaine, up to 1,200,000 units J0550 Injection, penicillin G benzathine and penicillin G procaine, up to 2,400,000 units J0560 Injection, penicillin G benzathine, up to 600,000 units J0570 Injection, penicillin G benzathine, up to 1,200,000 units J0580 Injection, penicillin G benzathine, up to 2,400,000 units J0585 Botulinum toxin type A, per unit (PA) J0587 Botulinum toxin type B, per 100 units (PA) J0640 Injection, leucovorin calcium, per 50 mg J0694 Injection, cefoxitin sodium, 1 g J0696 Injection, ceftriaxone sodium, per 250 mg J0697 Injection, sterile cefuroxime sodium, per 750 mg J0702 Injection, betamethasone acetate and betamethasone sodium phosphate, per 3 mg J0704 Injection, betamethasone sodium phosphate, per 4 mg J0780 Injection, prochlorperazine, up to 10 mg J0880 Injection, darbepoetin alfa, 5 mcg (PA) J0900 Injection, testosterone enanthate and estradiol valerate, up to 1 cc J1020 Injection, methylprednisolone acetate, 20 mg J1030 Injection, methylprednisolone acetate, 40 mg J1040 Injection, methylprednisolone acetate, 80 mg J1055 Injection, medroxyprogesterone acetate for contraceptive use, 150 mg (150 mg Depo-Provera) (IC) J1056 Injection, medroxyprogesterone acetate/estradiol cypionate, 5 mg/25 mg (5 mg/25 mg Lunelle) (IC) J1060 Injection, testerone cypionate and estradiol cypionate, up to 1 ml J1070 Injection, testosterone cypionate, up to 100 mg J1080 Injection, testosterone cypionate, 1 cc, 200 mg J1094 Injection, dexamethasone, acetate, 1 mg J1100 Injection, dexamethosone sodium phosphate, 1 mg J1160 Injection, digoxin, up to 0.5 mg J1170 Injection, hydromorphone, up to 4 mg J1200 Injection, diphendydramine HCl, up to 50 mg J1260 Injection, dolasetron mesylate, 10 mg J1320 Injection, amitriptyline HCl, up to 20 mg J1438 Injection, etanercept, 25 mg (PA) J1440 Injection, filgrastim (G-CSF), 300 mcg (PA) J1441 Injection, filgrastim (G-CSF), 480 mcg (PA) J1460 Injection, gamma globulin, intramuscular, 1 cc J1470 Injection, gamma globulin, intramuscular, 2 cc J1480 Injection, gamma globulin, intramuscular, 3 cc J1490 Injection, gamma globulin, intramuscular, 4 cc J1500 Injection, gamma globulin, intramuscular, 5 cc J1510 Injection, gamma globulin, intramuscular, 6 cc J1520 Injection, gamma globulin, intramuscular, 7 cc J1530 Injection, gamma globulin, intramuscular, 8 cc J1540 Injection, gamma globulin, intramuscular, 9 cc J1550 Injection, gamma globulin, intramuscular, 10 cc J1563 Injection, immune globulin, intravenous, 1 g (PA) J1564 Injection, immune globulin, 10 mg (PA) 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 J1720 Injection, hydrocortisone sodium succinate, up to 100 mg J1745 Injection, infliximab, 10 mg (PA) J1750 Injection, iron dextran, 50 mg J1790 Injection, droperidol, up to 5 mg J1800 Injection, propranolol HCl, up to 1 mg J1885 Injection, ketorolac, tromethamine, per 15 mg J1890 Injection, cephalothin sodium, up to 1 g 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 J2250 Injection, midazolam HCl, per 1 mg J2270 Injection, morphine sulfate, up to 10 mg J2271 Injection, morphine sulfate, 100 mg J2275 Injection, morphine sulfate (preservative-free sterile solution), per 10 mg J2300 Injection, nalbuphine HCl, per 10 mg J2310 Injection, naloxone HCl, per 1 mg J2357 Injection, omalizumab, 5 mg (PA) J2405 Injection, ondansetron HCl, per 1 mg J2430 Injection, pamidronate disodium, per 30 mg J2440 Injection, papaverine HC1, up to 60 mg J2469 Injection, palonosetron, HCl, 25 mcg J2505 Injection, pegfilgrastim, 6 mg (PA) 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 J2675 Injection, progesterone, per 50 mg J2760 Injection, phentolamine mesylate, up to 5 mg J2765 Injection, metoclopramide HCl, up to 10 mg J2780 Injection, ranitidine HCl, 25 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 J2820 Injection, sargramostim (GM-CSF), 50 mcg (PA) J2910 Injection, aurothioglucose, up to 50 mg 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) J2941 Injection, somatropin, 1 mg (PA) J3030 Injection, sumatriptan succinate, 6 mg J3110 Injection, teriparatide, 10 mcg (PA) J3120 Injection, testosterone enanthate, up to 100 mg J3130 Injection, testosterone enanthate, up to 200 mg J3230 Injection, chlorpromazine HCl, up to 50 mg J3250 Injection, trimethobenzamide HCl, up to 200 mg J3301 Injection, triamcinolone acetonide, per 10 mg J3302 Injection, triamcinolone diacetate, per 5 mg J3303 Injection, triamcinolone hexacetonide, per 5 mg J3396 Injection, verteporfin, 0.1 mg J3410 Injection, hydroxyzine HCl, up to 25 mg J3487 Injection, zoledronic acid, 1 mg J3490 Unclassified drugs (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 MassHealth will pay the provider's costs.) (IC) J3590 Unclassified biologics (IC) J7030 Infusion, normal saline solution, 1,000 cc J7070 Infusion, D-5-W, 1,000 cc J7303 Contraceptive supply, hormone containing vaginal ring, each (IC) J7304 Contraceptive supply, hormone containing patch, each (IC) J7317 Sodium hyaluronate, per 20 to 25 mg dose for intra-articular injection (PA) J7320 Hylan G-F 20, 16 mg, for intra-articular injection (PA) J7599 Immunosuppressive drug, NOC (IC) J9000 Doxorubicin HCl, 10 mg J9001 Doxorubicin HCl, all lipid formulations, 10 mg J9031 BCG live (intravesical), per instillation J9035 Injection, bevacizumab, 10 mg J9040 Bleomycin sulfate, 15 units J9041 Injection, bortezomib, 0.1 mg J9045 Carboplatin, 50 mg J9055 Injection, cetuximab, 10 mg J9060 Cisplatin, powder or solution, per 10 mg J9062 Cisplatin, 50 mg J9070 Cyclophosphamide, 100 mg J9080 Cyclophosphamide, 200 mg J9090 Cyclophosphamide, 500 mg J9091 Cyclophosphamide, 1 g J9092 Cyclophosphamide, 2 g J9093 Cyclophosphamide, lyophilized, 100 mg J9094 Cyclophosphamide, lyophilized, 200 mg J9095 Cyclophosphamide, lyophilized, 500 mg J9096 Cyclophosphamide, lyophilized, 1 g J9097 Cyclophosphamide, lyophilized, 2 g J9130 Dacarbazine, 100 mg J9140 Dacarbazine, 200 mg J9170 Docetaxel, 20 mg J9181 Etoposide, 10 mg J9182 Etoposide, 100 mg J9190 Fluorouracil, 500 mg J9201 Gemcitabine HC1, 200 mg J9202 Goserelin acetate implant, per 3.6 mg (PA) J9206 Irinotecan, 20 mg J9212 Injection, interferon Alfacon-1, recombinant, 1 mcg J9213 Interferon alfa-2A, recombinant, 3 million units J9214 Interferon alfa-2B, recombinant, 1 million units J9215 Interferon alfa-N3 (human leukocyte derived), 250,000 IU J9216 Interferon gamma-1B, 3 million units J9217 Leuprolide acetate (for depot suspension), 7.5 mg (PA) J9218 Leuprolide acetate, per 1 mg (PA) J9219 Leuprolide acetate implant, 65 mg (PA) J9250 Methotrexate sodium, 5 mg J9260 Methotrexate sodium, 50 mg J9263 Injection, oxaliplatin, 0.5 mg J9265 Paclitaxel, 30 mg J9293 Injection, mitoxantrone HCL, per 5mg J9300 Gemtuzumab ozogamicin, 5 mg J9305 Injection, pemetrexed, 10 mg J9310 Rituximab, 100 mg J9355 Trastuzumab, 10 mg J9360 Vinblastine sulfate, 1 mg J9370 Vincristine sulfate, 1 mg J9375 Vincristine sulfate, 2 mg J9380 Vincristine sulfate, 5 mg J9390 Vinorelbine tartrate, per 10 mg J9395 Injection, fulvestrant, 25 mg (PA) J9999 NOC, antineoplastic drug (IC) Q0136 Injection, epoetin alpha (for non ESRD use), per 1,000 units (PA) R0070 Transportation of portable X-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen S0020 Injection, bupivicaine HCl, 30 ml S0021 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) S0162 Injection, efalizumab, 125 mg (IC), (PA) S0302 Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to code for appropriate evaluation and management services.) S2260 Induced abortion, 17 to 24 weeks, any surgical method (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 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.) RP Replacement and repair (This modifier should only be used with 92340, 92341, and 92342 to bill for the displacement of replacement lenses.) 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.) 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 Service codes 90465, 90467, 90471 and 90473 to identify vaccines administered under the Vaccine for Children Program (VFC) for individuals age 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 service code will let the technical component allowable fee contained in 114.3 CMR 17.04 be paid.)