Commonwealth of Massachusetts 
Executive Office of Health and Human Services 
Office of Medicaid 
www.mass.gov/masshealth 
 


 
MassHealth 
Transmittal Letter CHC-99  
December 2013 
 
 TO: Community Health Centers Participating in MassHealth 
 
FROM: Kristin L. Thorn, Medicaid Director  
 
 RE: Community Health Center Manual (Revisions to MassHealth Regulations-Affordable Care Act) 
 
This letter transmits revised regulations and an updated Subchapter 6 of the Community Health Center Manual. 
 
The revised regulations and Subchapter 6 implement changes in coverage for acupuncture and the diagnosis of infertility. These changes were prompted by requirements of the Affordable Care Act regarding coverage of Essential Health Benefits.  
 
These regulations are effective January 1, 2014. The revised Subchapter 6 is effective for dates of service on or after January 1, 2014. 
 
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, email 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.) 
 
Community Health Center Manual 
 
Pages 4-1, 4-2, 4-11, 4-12, and 4-27 through 4-30 
Pages iv-a and 6-1 through 6-18 
OBSOLETE MATERIAL 
(The pages listed here are no longer in effect.) 
 
Community Health Center Manual 
 
Page iv-a — transmitted by Transmittal Letter CHC-82 
  
Pages 4-1, 4-2, 4-11, and 4-12 — transmitted by Transmittal Letter CHC-74 
Pages 4-27 and 4-28 — transmitted by Transmittal Letter CHC-93 
Pages 6-1 through 6-18 — transmitted by Transmittal Letter CHC-98 

 
 
Commonwealth of Massachusetts MassHealth 
Provider Manual Series 
 
 
Community Health Center Manual 
 Subchapter Number and Title 
Table of Contents 
 Page 
iv-a 
 
Transmittal Letter 
CHC-99 
 Date 
01/01/14 
 

 
4. Program Regulations (cont.) 
 
405.451: 
 Electrocardiogram (EKG) Services: 
 Introduction ............................................. 
 4-23 
 
405.452: 
 Electrocardiogram (EKG) Services: 
 Eligibility to Provide Services ................. 
 4-23 
 
405.453: 
 Electrocardiogram (EKG) Services: 
 Payment Limitations ................................ 
 4-23 
 
(130 CMR 405.454 through 405.460 Reserved) 
 
405.461: 
 Audiology Services: 
 Introduction     ...................................................................... 
 4-24 
 
405.462: 
 Audiology Services: 
 Eligibility to Provide Services ......................................... 
 4-24 
 
405.463: 
 Audiology Services: 
 Payment Limitations ........................................................ 
 4-24 
 
(130 CMR 405.464 and 405.465 Reserved) 
 

405.466: Pharmacy Services: Participation in the 340B Drug-Pricing Program for 
Outpatient CHC Pharmacies ................................................................................. 4-25 
405.467: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services .................... 4-25 
(130 CMR 405.468 through 405.470 Reserved) 
405.471: Optional Reimbursable Services ................................................................................ 4-26 
405.472: Tobacco-Cessation Services ...................................................................................... 4-26 
405.473: Fluoride Varnish Services .......................................................................................... 4-27 
405.474: Acupuncture............................................................................................................... 4-28 
(130 CMR 405.475 through 405.495 Reserved) 
405.496: Utilization Management Program .............................................................................. 4-29 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
4.  Program Regulations 
  (130 CMR 405.000) 
 Page 
4-1 
 
Community Health Center Manual 
 Transmittal Letter 
CHC-99 
 Date 
01/01/14 
 

 
405.401:  Introduction 
 
 All community health centers participating in MassHealth must comply with the regulations governing MassHealth, including but not limited to 130 CMR 405.000 and 130 CMR 450.000. 
 
405.402:  Definitions 
 
 The following terms used in 130 CMR 405.000 have the meanings given in 130 CMR 405.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 405.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 405.000 and in 130 CMR 450.000: Administrative and Billing Regulations. 
 
340B Covered Entities — facilities and programs eligible to purchase discounted drugs through a program established by Section 340B of Public Health Law 102-585, the Veterans Health Act of 1992. 
 
340B Drug-Pricing Program — a program established by Section 340B of Public Health Law  102-585, the Veterans Health Act of 1992, permitting certain grantees of federal agencies access to reduced cost drugs for their patients. 
 
Acupuncture — the insertion of metal needles through the skin at certain points on the body, with or without the use of herbs, with or without the application of an electric current, and with or without the application of heat to the needles, skin, or both. 
 
Family Practitioner — a licensed physician who is board-eligible or board-certified in family practice. A family practitioner provides continuous, accessible medical care with emphasis on the family unit that combines appreciation of both the biomedical and psychosocial dimensions of illness. The family practitioner assumes responsibility for and provides most of the member’s health care, and coordinates the member’s total health needs. 
 
Freestanding Clinic — any institution licensed as a clinic by the Massachusetts Department of Public Health pursuant to M.G.L. c. 111, s. 51 that is not part of a hospital and that possesses its own legal identity, maintains its own patient records, and administers its own budget and personnel. Such institutions include community health centers and mental health centers. 
 
Group Clinic Visit — a session conducted by a physician, physician assistant, nurse practitioner, or registered nurse to introduce preventive medicine approaches to personal health and safety and to present self-help and personal management information concerning family medicine, adult medicine, sex education, and chronic illness. Tobacco cessation group clinic visits may be provided by MassHealth-qualified tobacco cessation counseling providers as defined in 130 CMR 405.472. 
 
Health Practitioner — an individual who can diagnose and treat medical problems whether by authority of his or her own license or by the delegated authority of a licensed medical professional. 
 
HIV Pre-Test Counseling Visit — a face-to-face meeting at the CHC between the member and a physician, physician assistant, nurse practitioner, registered nurse, or counselor (working under the supervision of one of the aforementioned) for the purpose of providing counseling before HIV testing. Providers will offer information on risk factors and implications of both positive and negative test results, in accordance with established protocols of the Massachusetts Department of Public Health. 
Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
4.  Program Regulations 
  (130 CMR 405.000) 
 Page 
4-2 
 
Community Health Center Manual 
 Transmittal Letter 
CHC-99 
 Date 
01/01/14 
 

 
HIV Post-Test Counseling Visit — a face-to-face meeting at the CHC between the member and a physician, physician assistant, nurse practitioner, registered nurse, or counselor (working under the supervision of one of the aforementioned) for the purpose of providing counseling after HIV testing. Such counseling will include information about the implications of positive and negative test results, risk-reduction techniques, partner notification, and referral to medical and support services, in accordance with established protocols of the Massachusetts Department of Public Health. 
 
Home Visit — a face-to-face meeting between a member and a physician, physician assistant, nurse practitioner, or registered nurse in the member's residence for examination, diagnosis, or treatment. 
 
Hospital Visit — a face-to-face meeting between a member and a physician, physician assistant, nurse practitioner, or registered nurse when the member has been admitted to a hospital by a physician on the CHC's staff. 
 
Individual Medical Visit — a face-to-face meeting at the CHC between a member and a physician, physician assistant, nurse practitioner, or registered nurse for medical examination, diagnosis, or treatment. 
 
Individual Mental Health Visit — a face-to-face meeting at the CHC between a member and a psychiatrist for mental health examination and diagnosis. 
 
Institutionalized Individual — for purposes of 130 CMR 405.428 through 405.430, an individual who is: 
(1)  involuntarily confined or detained, under a civil or criminal statute in a correctional or rehabilitative facility, including a psychiatric hospital or other facility for the care and treatment of mental illness; or 
(2)  confined, under a voluntary commitment, in a psychiatric hospital or other facility for the care and treatment of mental illness. 
 
Mentally Incompetent Individual — for purposes of 130 CMR 405.428 through 405.430, an individual who has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes that include the ability to consent to sterilization. 
 
Nursing Facility Visit — a visit by a physician, physician assistant, nurse practitioner, or registered nurse to a member who has been admitted to a nursing facility, extended care facility, or convalescent or rest home. 
 
Primary or Elective Care — medical care required by individuals or families that is appropriate for the maintenance of health and the prevention of illness. This care includes but is not limited to physical examination, diagnosis and management of illness, ongoing health maintenance, accident prevention, and referral when necessary. This care does not require the specialized resources of a hospital emergency department. 
 
 
 
 
 
Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
4.  Program Regulations 
  (130 CMR 405.000) 
 Page 
4-11 
 
Community Health Center Manual 
 Transmittal Letter 
CHC-99 
 Date 
01/01/14 
 

 
405.416:  Quality Assessment Program 
 
(A)  A CHC must have in effect a program for internal quality assessment that is based on written policies, standards, and procedures, and that includes the following: 
(1)  a review of the CHC's performance including, but not limited to, adequacy of recordkeeping, referral procedures and follow-up, medication review, quality of patient care, and identification of deficient areas of performance; 
(2)  recommendations for correcting any deficiencies identified in the review; and 
(3)  a review of any such corrective action. 
 
(B)  These reviews must be conducted at least twice a year by a committee composed of the professional services director, representatives of each professional discipline on the CHC's staff, consumers, and, if possible, health professionals not employed at the CHC. Activities of the committee must be documented in minutes or a report and made available to the MassHealth agency upon request. 
 
405.417:  Maximum Allowable Fees 
 
 The Executive Office of Health and Human Services (EOHHS) determines the maximum allowable fees for CHC services in accordance with 101 CMR 304.00: Rates for Community Health Centers.   
 
405.418:  Nonreimbursable Services 
 
(A)  MassHealth does not pay a CHC for performing, administering, or dispensing experimental, unproven, or otherwise medically unnecessary procedures or treatments, specifically including, but not limited to, sex-reassignment surgery, thyroid cartilage reduction and any other related surgeries and treatments including pre- and post-sex-reassignment surgery hormone therapy.  Notwithstanding the preceding sentence, MassHealth continues to pay for post-sex-reassignment surgery hormone therapy for which it had been paying immediately prior to May 15, 1993. 
 
(B)  MassHealth does not pay a CHC for the treatment of male or female infertility (including, but not limited to, laboratory tests, drugs, and procedures associated with such treatment); however, MassHealth does pay a CHC for the diagnosis of male or female infertility. 
 
(130 CMR 405.419 and 405.420 Reserved) 
 
 
 
 
 
 
 
 
 
 
 
 
 
Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
4.  Program Regulations 
  (130 CMR 405.000) 
 Page 
4-12 
 
Community Health Center Manual 
 Transmittal Letter 
CHC-99 
 Date 
01/01/14 
 

 
405.421:  Visits:  Service Limitations 
 
 The following restrictions and limitations apply to visits as defined in 130 CMR 405.402. 
 
(A)  Individual Medical Visit.  An individual medical visit may not be used for mental health services or for HIV pre- or post-test counseling visits.  
 
(B)  Individual Mental Health Visit.  An individual mental health visit conducted by a person other than a psychiatrist (for example, a psychologist, nurse, physician assistant, social worker, or counselor) is not reimbursable. An individual mental health visit must be for the sole purpose of examination and diagnosis, and must not include mental health treatment. 
 
(C)  Group Clinic Visit.  All instructional group sessions for members must be carried out by a physician, nurse practitioner, registered nurse, or physician assistant. A group visit conducted by other kinds of professionals (for example, social workers, counselors, or nutritionists) is not reimbursable as a group clinic visit. These limitations do not apply to group clinic visits for tobacco cessation. 
 
(D)  HIV Pre- and Post-Test Counseling Visits.  The CHC may be reimbursed for a maximum of two HIV pre-test counseling and two HIV post-test counseling visits per member per test. A maximum of four pre-test counseling visits and four post-test counseling visits per calendar year per member are reimbursable. 
 
(E)  Home Visit.  A home visit must be used to deliver episodic care in the member's home when a health practitioner has determined that it is not advisable for the member to visit the CHC. The medical record must document the reasons for a home visit. A house-bound member with chronic medical and nursing care needs must be referred to a Medicare-certified home health agency. 
 
(F)  Treatments or Procedures.  The CHC may bill for a visit, a treatment, or a procedure, but may not bill for more than one of these services provided to the same member on the same date when the services are performed in the same location. This limitation does not apply to tobacco cessation counseling services provided by a physician or other qualified staff member under the supervision of a physician on the same day as a visit. Examples of treatments or procedures are a vasectomy or an amniocentesis. 
 
(G)  Urgent Care.  The MassHealth agency pays an enhanced fee for urgent care when such care is provided at the CHC Monday through Friday from 5:00 P.M. to 6:59 A.M., and from Saturday at 7:00 A.M. through Monday at 6:59 A.M.  
 
405.422:  Obstetric Services:  Introduction 
 
(A)  MassHealth offers two methods of payment for obstetric services:  the fee-for-service method and the global-fee method. Fee for service requires submission of claims for services as they are performed and is available for covered obstetric services. The global-fee method is available only when the conditions in 130 CMR 405.423 are met.   
 
 
 
Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
4.  Program Regulations 
  (130 CMR 405.000) 
 Page 
4-27 
 
Community Health Center Manual 
 Transmittal Letter 
CHC-99 
 Date 
01/01/14 
 

 
  biological, psychological, and social causes of tobacco dependence; and 
  (iii)  a review of evidence-based treatment strategies and the advantages and disadvantages of each strategy; 
   (b)  collaborative development of a treatment plan that uses evidence-based strategies to assist the member to attempt to quit, to continue to abstain from tobacco, and to prevent relapse, including: 
  (i)  identification of personal risk factors for relapse and incorporation into the treatment plan; 
 (ii)  strategies and coping skills to reduce relapse risk; and 
 (iii)  a plan for continued aftercare following initial treatment; and 
(c)  information and advice on the benefits of nicotine replacement therapy or other proven pharmaceutical or behavioral adjuncts to quitting smoking, including: 
 (i)  the correct use, efficacy, adverse events, contraindications, known side effects, and exclusions for all tobacco dependence medications; and 
 (ii)  the possible adverse reactions and complications related to the use of pharmacotherapy for tobacco dependence.  
    
 (C)  Provider Qualifications for Tobacco Cessation Counseling Services. 
  (1) Qualified Personnel. 
   (a) Physicians, registered nurses, nurse practitioners, nurse midwives, and physician assistants may provide tobacco cessation counseling services without additional experience or training in tobacco cessation counseling services. 
   (b) All other providers of tobacco cessation counseling services must be under the  supervision of a physician, and must complete a course of training in tobacco cessation counseling by a degree-granting institution of higher education with a minimum of eight hours of instruction.   
  (2) Supervision of Tobacco Cessation Counseling Services.  A physician must supervise all nonphysician providers of tobacco cessation counseling services. 
 
(D) Tobacco Cessation Services:  Claims Submission.  A CHC may submit claims for tobacco  


cessation counseling services that are provided by physicians, nurse practitioners, registered nurses, nurse midwives, physician assistants, and MassHealth-qualified tobacco cessation counselors according to 130 CMR 405.472(B) and (C). See Subchapter 6 of the Community Health Center Manual for service codes.   
 
405.473:  Fluoride Varnish Services 
 
(A)  Eligible Members.  Members must be younger than 21 years old to be eligible for the application of fluoride varnish.  
   
 (B)  Qualified Personnel.  Physicians, nurse practitioners, registered nurses, licensed practical nurses, physician assistants, and medical assistants may apply fluoride varnish subject to the limitation of state law. To qualify to apply fluoride varnish, the individual must complete a MassHealth-approved training on the application of fluoride varnish, maintain proof of completion of the training, and provide such proof to the MassHealth agency upon request.  
 
 
 
Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
4.  Program Regulations 
  (130 CMR 405.000) 
 Page 
4-28 
 
Community Health Center Manual 
 Transmittal Letter 
CHC-99 
 Date 
01/01/14 
 

 
(C)  Billing for a Medical Visit and Fluoride Varnish Treatment or Procedure. A CHC may bill for fluoride varnish services provided by a physician or a qualified staff member as listed in  
130 CMR 405.473(B) under the supervision of a physician. The CHC may bill for a medical visit in addition to the fluoride varnish application only if fluoride varnish was not the sole service, treatment, or procedure provided during the visit. The dental enhancement fee may not be billed for a fluoride varnish application separately or in addition to a medical visit.  
 
(D)  Claims Submission.  A CHC may submit claims for fluoride varnish services that are provided by physicians, nurse practitioners, registered nurses, licensed practical nurses, physician assistants, and medical assistants according to 130 CMR 405.473(C). See Subchapter 6 of the Community Health Center Manual for service codes. 
 
405.474: Acupuncture Services 
 
(A) Introduction. MassHealth members are eligible to receive acupuncture services in CHCs for the treatment of pain as described in 130 CMR 405.474(C). Please see 130 CMR 433.454(C): Acupuncture  as an Anesthetic for use of acupuncture as an anesthetic, and 130 CMR 418.406(C): Substance Abuse Outpatient Counseling Programs for use of acupuncture for detoxification.   

(B) General. 130 CMR 405.474 applies specifically to physicians and other licensed practitioners of acupuncture in a CHC. In general however, subject to the limitations of state law, the requirements elsewhere in 130 CMR 405.000 that apply to a CHC, also apply to licensed practitioners of acupuncture, such as service limitations, recordkeeping, report requirements, and prior-authorization requirements. 


 
(C) Acupuncture for the Treatment of Pain. MassHealth provides a total of 20 sessions of acupuncture for the treatment of pain per member per year without prior authorization. If the member’s condition, treatment, or diagnosis changes, the member may be able to receive more sessions of medically-necessary acupuncture treatment with prior authorization. 


 
(D) Provider Qualifications for Acupuncture. 

(1) Qualified Providers. 

(a) Physicians 

(b) Other providers who are licensed in acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00: The Practice of Acupuncture. 


(2) Acupuncture Providers in CHCs. CHCs must ensure that acupuncture providers for whom the CHC will submit claims possess the appropriate training, credentials, and licensure.  


(E)   Conditions of Payment.  The MassHealth agency pays the CHC for services of an acupuncturist (in accordance with 130 CMR 405.474(F)) when the:  
 (1)  services are limited to the scope of practice authorized by state law or regulation (including but not limited to 243 CMR 5.00: The Practice of Acupuncture);  
(2)  the acupuncturist has a current license or certificate of registration from the Massachusetts Board of Registration in Medicine; and  
(3)  services are provided pursuant to a supervisory arrangement with a physician. 
 
(F)  Acupuncture Claims Submissions. 
(1) Community health centers (CHCs) may submit claims for acupuncture services when they are provided to MassHealth members by physicians or when a licensed provider under the supervision of a physician provides those services directly to MassHealth members. See  


Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
4.  Program Regulations 
  (130 CMR 405.000) 
 Page 
4-29 
 
Community Health Center Manual 
 Transmittal Letter 
CHC-99 
 Date 
01/01/14 
 

 
Subchapter 6 of the Community Health Center Manual for service code descriptions and billing requirements. 
(2) For MassHealth members receiving services under any of the acupuncture codes on the same date of service as an office visit, the CHC may bill for either an office visit or the acupuncture code, but may not bill for both an office visit and the acupuncture code for the same member on the same date when the office visit and the acupuncture services are performed in the same location. This limitation does not apply to a significant, separately identifiable office visit provided by the same CHC on the same day of the acupuncture service.  


 
(130 CMR 405.475 through 405.495 Reserved) 
 
405.496:  Utilization Management Program  
 
 The MassHealth agency pays for procedures and hospital stays that are subject to the Utilization Management Program only if the applicable requirements of the program as described in 130 CMR 450.207 through 450.209 are satisfied. Appendix E of the Community Health Center Manual describes the information that must be provided as part of the review process. 
 
REGULATORY AUTHORITY 
 
 130 CMR 405.000:  M.G.L. c. 118E, §§ 7 and 12. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
 Subchapter Number and Title 
4.  Program Regulations 
  (130 CMR 405.000) 
 Page 
4-30 
 
Community Health Center Manual 
 Transmittal Letter 
CHC-99 
 Date 
01/01/14 
 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
This page is reserved. 
 
 
 
 
 

601  Introduction and Explanation of Abbreviations  
 
MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 405.000 and 450.000. A community health center may request prior authorization (PA) 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 Subchapter 6 of the Community Health Center Manual. 
 
For complete descriptions of the service codes listed in Subchapter 6, MassHealth providers must refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).  
 
The following abbreviations are used in Subchapter 6. 
(A) PA indicates that service-specific prior authorization is required (see 130 CMR 450.303). 

(B) IC indicates that the claim will receive individual consideration to determine payment. A descriptive report must accompany the claim (see 130 CMR 450.271). 

(C) SP indicates that the procedure is commonly performed as part of a total service and does not usually warrant a separate fee. The procedure must be performed separately to receive the separate fee. 

(D) CS-18 or CS-21 indicates that a completed Sterilization Consent Form (CS-18 for members aged 18 through 20; CS-21 form for members aged 21 and older) must be submitted. See 130 CMR 405.428 through 405.430 for more information. 

(E) HI-1: A completed Hysterectomy Information Form must be submitted. 


 
602  Payable Radiology Service Codes 
 
This section lists radiology service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
 
70030 
70100 
70110 
70120 
70130 
70134 
70140 
70150 
70160 
70190 
70200 
70210 
70220 
70240 
70250 
70260 
70300 
70310 
70320 
70328 
70330 
70332 
70336  
70350 
70355 
70360 
70370 
70371 
70373 
70380 
70390 
70450 
70460 
70470 
70480 
70481 
70482 
70486 
70487 
70488 
70490 
70491 
70492 
70540 
70542 
70543 
70544 
70545 
70546 
70547 
70548 
70549 
70551 
70552  
70553 
70554 
70555 
71010 
71015 
71020 
71021 
71022 
71023 
71030 
71034 
71035 
71100 
71101 
71110 
71111 
71120 
71130 
71550 
71551 
71555 
72010 
72020 
72040 
72050 
72052 
72069 
72070 
72072 
72074 
72080 
72090 
72100 
72110 
72114 
72120 
72125 
72126 
72127 
72128 
72129 
72130 
72131 
72132 
72133 
72141 
72142    
72146   
72147    
72148   
72149   
72156  
72157    
72158    
72170 
72190   
72192   
72193 
72194    
72195 
72196   
72197 
72200  
72202   
72220  
72240   
72255   
72265   
72270   
72275  
72285 
72291  
72292 
72295 
73000 
73010 
73020 
73030 
73040 
73050 
73060 
73070 
73080 
73085 
73090 
73092 
73100 
73110 
73115 
73120 
73130 
73140 
73200 
73201 
73202 
73218 
73219 
73220 
73221 
73222 
73223 
73500 
73510 
73520 
73525 
73530 
73540 
73550 
73560 
73562 
73564 
73565 
73580 
73590 
73592 
73600 
73610 
73615 
73620 
73630 
73650 
73660 
73700 
73701 
73702 
73718 
73719 
73720 
73721 
73722 
73723 
73725 
74000 
74010 
74020 
74022 
74150 
74160 
74170 
74174 
74176 
74177 
74178 
74181 
74182 
74183 
74185 
74190 
74210 
74220 
74230 
74235 
74240 
74245 
74246  
74247 
74249   
74250 
74251 
74260  
74261 (PA)      
74262 (PA)             
74270 
74280   
74283 
74290 
74291   
74300 
74301  
74305 
74320 
74327 
74330 
74340   
74355 
74400  
74410 
74415 
74420 
74425  
74430 
74440 
74445 
74450 
74455 
74470 
74475 
74480 
74485 
74710 
74740 
74742 
74775 
75557  
75559  
75561  
75563 
75565  
75572 
75573   
75574 
75600 
75605 
75625 
75630 
75658 
75705 
75710 
75716 
75726 
75731 
75733 
75736 
75741 
75743 
75746 
75756 
75774 
75791 
75801 
75803 
75805 
75807 
75809 
75810 
75820 
75822 
75825 
75827 
75831 
75833 
75840 
75842 
75860 
75870 
75872 
75880 
75885 
75887 
75889 
75891 
75893 
75898 
75901 
75902  
75945   
75946  
76000 
76001 
76010 
76080 
76098 
76100 
76101 
76102 
76120 
76125 
76376 
76377 
76380 
76499 (IC) 
76506 
76510 
76511 
76512 
76513 
76514 
76516 
76519 
76529 
76536 
76604 
76645 
76700 
76705 
76770 
76775 
76776 
76800 
76801  
76802 
76805  
76810  
76811   
76812  
76813   
76814 
76815 
76816 
76817 
76818 
76820 
76821 
76825 
76826 
76827 
76828 
76830 
76831 
76856  
76857 
76870 
76872 
76873 
76881 
76882 
76885  
76886 
76937 
76942 
76945 
76946 
76948 
76950 
76965 
76970 
76977 
76999 (IC) 
77001  
77002  
77003 
77011        
77012        
77013        
77014        
77021        
77022      
77051   
77052   
77053      
77054        
77055        
77056 
77057   
77058 (PA) 
77059 (PA)      
77071        
77072        
77073        
77074        
77075   
77076        
77077    
77078   
77080    
77081 
77082 
77421 
78012 
78013 
78014 
78015 
78016 
78018 
78020 
78070 
78071 
78072 
78075 
78099 (IC) 
78102 
78103 
78104  
78110  
78111 
78120  
78121 
78122  
78130 
78135 
78140 
78185 
78190 
78191 
78195 
78199 (IC) 
78201 
78202 
78205 
78206 
78215 
78216 
78226 
78227 
78230 
78231 
78232 
78258 
78261 
78262 
78264 
78270 
78271 
78272 
78278 
78282 (IC) 
78290 
78291 
78299 (IC) 
78300 
78305 
78306 
78315 
78320  
78350  
78399 (IC) 
78414 (IC) 
78428 
78445 
78451  
78452  
78453  
78454 
78456  
78457   
78458 
78459  
78466  
78468    
78469 
78472   
78473    
78481  
78483 
78491 
78492  
78494 
78496 
78499 (IC)  
78579 
78580 
78582 
78597 
78598 
78599 (IC)  
78600 
78601 
78605 
78607  
78608 
78609 
78610 
78630  
78635 
78645 
78647  
78650 
78660 
78699 (IC)  
78700 
78701 
78707 
78708 
78709 
78710  
78725 
78730  
78740  
78761 
78799 (IC) 
78800  
78801 
78802 
78803  
78804 
78805 
78806 
78807 
78808 
78811  
78812 
78813 
78814  
78815 
78816 
78999 (IC) 
G0202  
G0204  
G0206 
 
 
 
 
603  Payable Laboratory Service Codes 
 
This section lists laboratory service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
 
80047 
80048 
80050 
80051 
80053 
80055 
80061 
80069 
80074 
80076 
80102 
80103 
80150 
80152 
80154 
80156 
80157 
80158 
80160 
80162 
80164 
80166 
80168 
80170 
80172 
80173 
80174 
80176 
80178 
80182 
80184 
80185 
80186 
80188 
80190 
80192 
80194 
80195 
80196 
80197 
80198 
80200 
80201 
80202 
80299 
80400 
80402 
80406 
80408 
80410 
80412 
80414 
80415 
80416 
80417 
80418 
80420 
80422 
80424 
80426 
80428 
80430 
80432 
80434 
80435 
80436 
80438 
80439 
80440 
81000  
81001 
81002   
81003 
81005  
81007 
81015  
81020 
81025  
81050  
81099 (IC) 
81161 
81479 (IC) 
81500 
81503 
81506 
81508 
81509 
81510 
81511 
81512 
81599 
82000   
82003   
82009   
82010   
82013   
82016   
82017  
82024   
82030   
82040   
82042   
82043   
82044   
82045   
82055   
82085   
82088   
82101   
82103   
82104   
82105   
82106 
82107   
82108   
82120   
82127   
82128   
82131   
82135   
82136   
82139   
82140   
82143   
82145   
82150   
82154   
82157 
82160 
82163 
82164 
82172 
82175 
82180 
82190 
82205 
82232 
82239 
82240 
82247 
82248 
82252 
82261 
82270 
82271 
82272 
82274 
82286 
82300 
82306 
82308 
82310 
82330 
82331 
82340 
82355 
82360 
82365 
82370 
82373 
82374 
82375 
82376 
82378 
82379 
82380 
82382 
82383 
82384 
82387 
82390 
82397 
82415 
82435 
82436 
82438 
82441 
82465 
82480 
82482 
82485 
82486 
82487 
82488 
82489 
82491 
82492 
82495 
82507 
82520 
82523 
82525 
82528 
82530 
82533 
82540 
82541 
82542 
82543 
82544 
82550 
82552 
82553 
82554 
82565 
82570 
82575 
82585 
82595 
82600 
82607 
82608 
82610 
82615 
82626 
82627 
82633 
82634 
82638 
82646 
82649 
82651 
82652 
82654 
82656 
82657 
82658 
82664 
82666 
82668 
82670 
82671 
82672 
82677 
82679 
82690 
82693 
82696 
82705 
82710 
82715 
82725 
82726 
82728 
82731 
82735 
82742 
82746 
82747 
82757 
82759 
82760 
82775 
82776 
82777 
82784 
82785 
82787 
82800 
82803 
82805 
82810 
82820 
82930 
82938 
82941 
82943 
82945 
82946 
82947 
82948 
82950 
82951 
82952 
82953 
82955 
82960 
82963 
82965 
82975 
82977 
82978 
82979 
82980 
82985 
83001 
83002 
83003 
83008 
83009 
83010 
83012 
83013 
83014 
83015  
83018 
83020 
83021 
83026 
83030 
83033  
83036 
83037 
83045 
83050 
83051 
83055 
83060 
83065 
83068 
83069 
83070 
83071 
83080 
83088  
83090 
83150  
83491  
83497  
83498  
83499  
83500  
83505   
83516  
83518   
83519   
83520   
83525  
83527 
83528  
83540  
83550  
83570 
83582 
83586 
83593 
83605 
83615 
83625 
83630 
83631 
83632 
83633 
83634 
83655 
83661 
83662 
83663 
83664 
83670 
83690 
83695 
83698 
83700 
83701 
83704 
83718 
83719 
83721 
83727 
83735 
83775 
83785 
83788 
83789 
83805 
83825 
83835  
83840 
83857  
83858  
83861  
83864  
83866  
83872 
83873 
83874 
83876  
83880 
83883 
83885 
83887 
83915 
83916 
83918 
83919 
83921 
83925 
83930 
83935 
83937 
83945 
83950 
83951 
83970 
83986 
83992 
83993 
84022 
84030 
84035 
84060 
84066 
84075 
84078 
84080 
84081 
84085 
84087 
84100 
84105 
84106 
84110 
84112 
84119 
84120 
84126 
84127 
84132  
84133 
84134  
84135  
84138  
84140  
84143  
84144  
84146  
84150  
84152  
84153  
84154  
84155  
84156  
84157 
84160  
84163 
84165 
84166 
84181  
84182  
84202  
84203 
84206  
84207 
84210 
84220 
84228  
84233 
84234  
84235  
84238 
84244  
84252 
84255  
84260  
84270  
84275 
84285  
84295 
84300  
84302  
84305 
84307  
84311 
84315  
84375  
84376 
84377  
84378 
84379  
84392  
84402  
84403  
84425 
84430  
84432 
84436  
84437  
84439  
84442  
84443  
84445  
84446  
84449  
84450  
84460  
84466   
84478  
84479  
84480  
84481  
84482  
84484  
84485  
84488  
84490  
84510  
84512  
84520  
84525  
84540  
84545  
84550 
84560  
84577  
84578  
84580  
84583  
84585  
84586 
84588  
84590 
84591 
84597  
84600  
84620  
84630  
84681  
84702  
84703  
84704  
84999 (IC)  
85002  
85004  
85007  
85008  
85009  
85013  
85014  
85018  
85025  
85027  
85032  
85041  
85044  
85045  
85046  
85048  
85049 
85055  
85060  
85097  
85130  
85170  
85175   
85210  
85220  
85230  
85240  
85244  
85245  
85246  
85247  
85250  
85260  
85270  
85280  
85290  
85291  
85292  
85293  
85300  
85301 
85302  
85303  
85305  
85306  
85307 
85335  
85337  
85345  
85347  
85348  
85360  
85362  
85366 
85370  
85378  
85379  
85380  
85384 
85385  
85390 
85396  
85397   
85400  
85410  
85415  
85420  
85421  
85441  
85445  
85460  
85461  
85475  
85520  
85525  
85530  
85536  
85540  
85547  
85549  
85555  
85557  
85576  
85597  
85598  
85610  
85611  
85612  
85613  
85635  
85651  
85652  
85660  
85670  
85675  
85705  
85730  
85732  
85810  
85999 (IC)  
86000  
86001  
86003  
86005  
86021  
86022  
86023  
86038  
86039  
86060  
86063  
86140 
86141 
86146 
86147 
86148 
86152 
86153 
86155 
86156 
86157 
86160 
86161 
86162 
86171 
86185 
86200 
86215 
86225 
86226 
86235 
86243 
86255 
86256 
86277 
86280 
86294 
86300 
86301 
86304 
86308 
86309 
86310  
86316  
86317  
86318  
86320  
86325  
86327  
86329  
86331  
86332  
86334  
86335 
86336 
86337 
86340 
86341  
86343 
86344 
86352  
86353 
86355 
86356 
86357 
86359  
86360 
86361 
86367 
86376 
86378  
86382  
86384 
86386 
86403 
86406 
86430 
86431 
86480  
86481 
86485 
86486  
86490  
86510  
86590 
86592 
86593 
86602 
86603 
86606 
86609 
86611 
86612 
86615 
86617 
86618 
86619 
86622 
86625 
86628 
86631 
86632 
86635 
86638 
86641 
86644 
86645 
86648 
86651 
86652 
86653 
86654 
86658 
86663 
86664 
86665 
86666 
86668 
86671 
86674 
86677 
86682 
86684 
86687 
86688 
86689 
86692 
86694 
86695 
86696 
86698 
86701 
86702 
86703 
86704 
86705 
86706 
86707 
86708 
86709 
86710 
86711 
86713 
86717 
86720 
86723 
86727 
86729 
86732 
86735 
86738 
86741 
86744 
86747 
86750 
86753 
86756 
86757 
86759 
86762 
86765 
86768 
86771 
86774 
86777 
86778 
86780 
86784 
86787 
86788 
86789 
86790 
86793 
86800 
86803 
86804 
86805 
86806 
86807 
86808 
86812 
86813 
86816 
86817 
86821 
86822 
86825 
86826 
86828 
86829 
86830 
86831 
86832 
86833 
86834 
86835 
86849 (IC)  
86850  
86860  
86870  
86880 
86885 
86886 
86900 
86901  
86902  
86904 
86905 
86906 
86920  
86921  
86922  
86923  
86940 
86941 
86970 
86971 
86972 
86975 
86976 
86977 
86978 
86999 (IC)  
87001 
87003 
87015  
87040  
87045 
87046 
87070 
87071 
87073 
87075 
87076 
87077 
87081 
87084  
87086 
87088 
87101  
87102  
87103 
87106 
87107 
87109 
87110 
87116 
87118 
87140 
87143  
87147 
87149 
87152 
87158 
87164 
87166 
87168 
87169 
87172 
87176 
87177 
87181 
87184  
87185  
87186  
87187  
87188 
87190 
87197  
87205  
87206 
87207 
87209  
87210 
87220 
87230 
87250 
87252 
87253 
87254  
87255 
87260 
87265 
87267  
87269 
87270 
87271  
87272 
87273 
87274 
87275 
87276 
87277 
87278 
87279 
87280 
87281 
87283 
87285 
87290 
87299 
87300 
87301 
87305 
87320 
87324  
87327 
87328 
87329 
87332 
87335 
87336 
87337 
87338 
87339 
87340 
87341 
87350 
87380 
87385 
87389 
87390 
87391 
87400 
87420 
87425 
87427 
87430 
87449 
87450 
87451 
87470 
87471 
87472 
87475 
87476 
87477 
87480 
87481 
87482 
87485 
87486 
87487 
87490 
87491 
87492 
87495 
87496 
87497 
87498  
87500 
87501 
87502 
87503  
87510 
87511 
87512 
87515 
87516 
87517 
87520 
87521 
87522 
87525 
87526 
87527 
87528 
87529 
87530 
87531 
87532 
87533 
87534 
87535 
87536 
87537 
87538 
87539 
87540 
87541 
87542 
87550 
87551 
87552 
87555 
87556 
87557 
87560 
87561 
87562 
87580 
87581 
87582 
87590 
87591 
87592 
87620 
87621 
87622 
87631 
87632 
87633 
87640 
87641 
87650 
87651 
87652 
87653 
87660 
87797  
87798 
87799 
87800  
87801 
87802 
87803 
87804 
87807 
87808 
87809 
87810 
87850 
87880 
87899 
87900 
87901 
87902 
87903 
87904 
87905 
87906  
87910 
87912 
87999 (IC) 
88104 
88106 
88108  
88112 
88120 
88121 
88130 
88140 
88141  
88142 
88143 
88147 
88148 
88150 
88152 
88153 
88154 
88155 
88160 
88161 
88162 
88164  
88165 
88166 
86167 
88172  
88173 
88174  
88175 
88177  
88182 
88184 
88185  
88187 
88188 
88189 
88199 (IC) 
88230 
88233 
88235 
88237 
88239 
88240 
88241 
88245 
88248 
88249 
88261 
88262 
88263 
88264 
88267 
88269 
88271 
88272 
88273 
88274 
88275 
88280 
88283 
88285 
88289 
88291 
88299 (IC) 
88300 
88302 
88304 
88305 
88307 
88309 
88311  
88312  
88313 
88314  
88319 
88342  
88346 
88347 
88348 
88349 
88355 
88356 
88358 
88360 
88361 
88362 
88363 
88365 
88367  
88368 
88371 
88372 
88375 
88380 
88381 
88387 
88388  
88399 (IC) 
88720 
88740 
88741  
89049 
89050 
89051 
89055 
89060  
89125 
89160 
89190 
89220  
89230 
89240 (IC) 
89300 
89310 
89320 
93000 
93005 
93010 
93015 
93016 
93017 
93018 
93024 
93040 
93041 
93042 
93224 
93225  
93226  
93227  
93228 
93229 (IC) 
93268 
93270 
93271 
93272  
93278 
93303 
93304 
93306 
93307 
93308 
93312 
93313 
93314 
93315 
93316 
93317 
93318 
93320 
93321 
93325 
93350  
93351 
93352  
93724  
93740 
93745 (IC)  
93784 
93786 
93788 
93790 
93797  
93798 
93799 (IC)  
93880 
93882 
93886 
93888 
93890 
93893 
93922 
93923 
93924 
93925 
93926 
93930 
93931 
93965  
93970 
93971 
93975 
93976  
93978  
93979  
93980 
93981  
93990 
93998 (IC) 
95950 
95951 
95953 
95956 
G0027 
G0431 
G0434 
P9604 
 
 
 
 
604  Payable Visit and Vaccine Service Codes 
  
This section lists visit and vaccine service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
 
When claiming payment for visits or vaccines, a CHC must bill according to the following service codes. A visit during which a member sees more than one professional for the same medical problem or general purpose must be claimed as only one visit. (See 130 CMR 405.421 for other requirements.)  
(A) The following visit and associated service codes have special requirements or limitations. 


Service 
Code       Modifier  Special Requirement or Limitation     
 
D1206   Covered for children under age 21. The CHC may bill for a medical visit in addition to the fluoride varnish application only if fluoride varnish was not the sole service, treatment, or procedure provided during the visit. 
D9450  Use only for dental enhancement fee. This code may only be billed once per date of service for each member receiving dental services on that date. The dental enhancement fee may not be billed for a fluoride varnish application separately or in addition to a medical visit. 
J3490  Use for injectable and infusible drugs and devices supplied in the clinic. Do not use for medications and injectables related to family planning services. (IC) 
T1015  Use for individual medical visit. 
T1015 HQ Use for group clinic visit. 

604  Payable Visit and Vaccine Service Codes (cont.) 
 
Service 
Code       Modifier  Special Requirement or Limitation     
90899 Use for individual mental health visit. (IC) 
99050 Use for urgent care Monday through Friday from 5:00 P.M. to 6:59 A.M., and Saturday 7:00 A.M. to Monday 6:59 A.M. This code may be billed in addition to the individual medical visit. 
99402 Use for HIV counseling visits. 
(B) This section lists evaluation and management visit service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 


 
99218 
99219 
99220 
99221  
99222    
99223 
99224 
99225  
99226 
99231  
99232 
99233 
99304  
99305  
99306  
99307  
99308  
99309  
99310 
99324  
99325  
99326  
99327 
99334  
99335  
99336  
99337 
99341   
99342  
99343  
99345 (IC) 
99347   
99348  
99349  
99350 (IC) 
99460 
99462
  
The following vaccine administration service codes are payable in addition to the evaluation and management visit service codes in this Section 604(B), provided that the vaccine administration is a medically necessary, separately identifiable service.  Under these circumstances, the CHC may append modifier 25 to the evaluation and management visit service code.  See MassHealth All Provider Bulletin 236 for additional information.  
 
90460 
90461 
90471 
90472 
90473 
90474 
 
(C) The following vaccine service codes have special requirements or limitations. 
 
90632 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90649 Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90650  Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90653 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90654  Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC) 
90655 Only for privately purchased vaccine; vaccine must not otherwise be available free of charge through the Massachusetts Immunization Program. 
90656 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90657 Only for privately purchased vaccine; vaccine must not otherwise be available free of charge through the Massachusetts Immunization Program. 
90658      Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90660       Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90661      Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC) 
90662       Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC) 
90672 Covered for members aged 19 to 49; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC) 
90707 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90713  Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90715 Covered for adults > 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90716  Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90732  Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90733 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
90734 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC) 
90736  (IC); PA is required for members < age 60. 
90739 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.    
90746 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 
 
605  Payable Obstetrics Service Codes 
 
This section lists obstetrics service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
See 130 CMR 405.422 through 405.426 for other requirements. 
(A) Fee-for-Service Deliveries 


59409  
59410  
59414  
59514  
59515 
59525 (HI-1 form required) 
59612  
 
59614 
59620 
59622 
(B) Global Deliveries  


59400  
59510  
59610  
59618 
 
606  Payable Surgery Service Codes 
This section lists surgery service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
 
44955  
49255  
49320  
54057   
54150  
54160 
55250  
   (CS-18 or CS-21 required) (SP) 
55450  
   (CS-18 or CS-21 required) (SP)  
56420 
56440 
57240 
57250 
57260 
57520 
57522 
57700 
58120  
58140  
58146     
58150 (HI-1 form required) 
58180 (HI-1 form required) 
58353  
58541 (HI-1 form required) 
58543 (HI-1 form required) 
58544 (HI-1 form required) 
58555  
58558  
58560  
58561 
58600 (CS-18 or CS-21 required) 
58605  
   (CS-18 or CS-21 required) (SP) 
58611 (CS-18 or CS-21 required) 
58615 (CS-18 or CS-21 required) 
58660  
58661 (CS-18 or CS-21 required) 
58670 (CS-18 or CS-21 required) 
58671 (CS-18 or CS-21 required) 
58700  
58720 
58940 
59000 
59012 
59015 
59025 
59870 
 
 
 
 
 
 
   
  
 
 
  
  
 
 
607  Payable Nurse-Midwife Service Codes 
This section lists nurse-midwife service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
 
See 130 CMR 405.427 for requirements. When billing for delivery services performed by a nurse midwife, the provider must use a modifier.  
 
 
Service     
Code        Modifier Special Requirement or Limitation 
 
T1015 TH Use for a medical visit with a nurse midwife for a prenatal or postpartum service. 
59400   
59409  
59410  
59414  
59610  
59612  
59614
608  Payable Audiology Service Codes  
This section lists audiology service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
See 130 CMR 405.461 through 405.463 for other requirements. 
92551 
92552  
92553  
92567  
 
609  Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment Service   Codes  
This section lists Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
 
See 130 CMR 450.140 through 450.149 for other requirements. 
 
99381  
99382  
 
99383  
99384  
 
99385 
99391  
 
99392  
99393  
 
99394  
99395
 
610  Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Test Service Codes  
This section lists Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Test service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
 
92551  
92552  
92587  
99173  
 
611  Payable Tobacco Cessation Service Codes 
This section lists tobacco cessation service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
 
Service 
Code Modifier Special Requirement or Limitation 
 
99407               at least 30 minutes; eligible providers are physicians employed by community health centers. 
99407 HN at least 30 minutes; eligible providers are physician assistants employed by community health centers. 
99407 HQ  for an individual in a group setting, 60-90 minutes; eligible providers are physicians employed by community health centers. 
99407 SA at least 30 minutes; eligible providers are nurse practitioners employed by community health centers. 
99407 SB at least 30 minutes; eligible providers are nurse midwives employed by community health centers. 
99407 TD at least 30 minutes; eligible providers are registered nurses employed by community health centers. 
99407 TF intake assessment for an individual, at least 45 minutes; eligible providers are physicians employed by community health centers. 
99407 U1 at least 30 minutes; eligible providers are tobacco cessation counselors employed by community health centers. 
99407 U2 intake assessment for an individual, at least 45 minutes; eligible providers are nurse practitioner, nurse midwife, physician assistant, registered nurse, and tobacco cessation counselor. 
99407 U3 for an individual in a group setting, 60-90 minutes; eligible providers are nurse practitioners, nurse midwives, physician assistants, registered nurses, and tobacco cessation counselors. 
 
612  Payable Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes  
This section lists medical nutrition therapy and diabetes self-management training service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
 
G0108  
G0109  
G0270  
G0271 
97802   
97803   
97804  
 
613  Payable Behavioral Health Screening Tool Service Codes 
This section lists behavioral health screening tool service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
 
The administration and scoring of standardized behavioral-health screening tools selected from the approved menu of tools found in Appendix W of your MassHealth provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. 
 
Service 
Code     Modifier Special Requirement or Limitation 
 
96110 U1 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; with no behavioral health need identified* (Eligible providers are physicians employed by community health centers.) 
96110 U2 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; and behavioral health need identified* (Eligible providers are physicians employed by community health centers.) 
96110 U3 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; with no behavioral health need identified* (Eligible providers are nurse midwives employed by community health centers.) 
96110 U4 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; and behavioral health need identified* (Eligible providers are nurse midwives employed by community health centers.) 
96110 U5 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; with no behavioral health need identified* (Eligible providers are nurse practitioners employed by community health centers.) 
613  Payable Behavioral Health Screening Tool Service Codes (cont.) 
Service 
Code Modifier Special Requirement or Limitation 
96110 U6 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; and behavioral health need identified* (Eligible providers are nurse practitioners employed by community health centers.) 
96110 U7 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; with no behavioral health need identified* (Eligible providers are physician assistants employed by community health centers.) 
96110 U8 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; and behavioral health need identified* (Eligible providers are physician assistants employed by community health centers.) 
* “Behavioral health need identified” means the provider administering the screening tool, in his or her professional judgment, identifies a child with a potential behavioral health services need. 
614  Payable Acupuncture Service Codes 
This section lists acupuncture service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov). 
97810 
97811 
97813 
97814 
615  Modifiers 
The following service code modifiers are allowed for billing under MassHealth. 
Modifier Description 
24 Unrelated evaluation and management service by the same physician during 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 
615  Modifiers (cont.) 
Modifier Description 
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 
 
LT Left side (used to identify procedures performed on the left side of the body). 
RT Right side (used to identify procedures performed on the right side of the body). 
TC Technical Component 
 
The following modifiers are for Provider Preventable Conditions that are National Coverage Determinations 
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 codes are defined in the Current Procedural Terminology (CPT) code book. 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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