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 LAB-31 December 2007 TO: Independent Clinical Laboratories Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Independent Clinical Laboratory Manual (Revised Service Codes and Description) This letter transmits revisions to service codes and descriptions contained in the Independent Clinical Laboratory Manual. The revised Subchapter 6 is effective for dates of service on or after October 1, 2007. Claims already submitted with October 2007 dates of service do not need to be resubmitted. Updated Fee Schedule The Division of Health Care Finance and Policy (DHCFP) has updated its regulations governing independent clinical laboratories, effective for dates of service on or after October 1, 2007. To obtain a fee schedule, you may download these regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of the DHCFP regulations from either the Massachusetts State Bookstore or 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 paper copy of the publication. The regulation title for laboratory services is 114.3 CMR 20.00: Clinical Laboratory Services. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.goc/sec/sprDivision of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp Code Replacement Among other changes, Service Code G0001 has been deleted from Subchapter 6. Effective for dates of service on or after October 1, 2007, providers must bill for this service using the following replacement code: P9604 Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing home bound patient; prorated trip charge. Claims already paid using Service Code G0001 for dates of service on or after October 1, 2007 do not need to be resubmitted. Providers billing with Service Code P9604 should report two units signifying the trip to and from the patient’s location. MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth. Questions If you have any questions about 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.) Independent Clinical Laboratory Manual Pages 6-29 through 6-36 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Independent Clinical Laboratory Manual Pages 6-29 through 6-36 — transmitted by Transmittal Letter LAB-28 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-29 Independent Clinical Laboratory Manual Transmittal Letter LAB-31 Date 10/01/07 601 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 87651 Streptococcus, group A, amplified probe technique 87652 Streptococcus, group A, quantification 87653 Streptococcus, group B, amplified probe technique 87660 Trichomonas vaginalis, direct probe technique 87797 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism 87798 amplified probe technique, each organism 87799 quantification, each organism 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87801 amplified probe(s) technique 87802 Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group B 87803 Clostridium difficile toxin A 87804 Influenza 87807 respiratory syncytial virus 87808 Trichomonas vaginalis 87810 Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis 87850 Neisseria gonorrhoeae 87880 Streptococcus, group A 87899 not otherwise specified 87900 Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics 87901 Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV 1, reverse transcriptase and protease 87902 Hepatitis C virus 87903 Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; first through 10 drugs tested 87904 each additional drug tested (List separately in addition to code for primary procedure.) (Use 87904 in conjunction with 87903.) 87999 Unlisted microbiology procedure (I.C.) (P.A.) ANATOMIC PATHOLOGY Cytopathology 88104 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation 88106 simple filter method with interpretation 88107 smears and simple filter preparation with interpretation 88108 Cytopathology, concentration technique, smears and interpretation (e.g., Saccomanno technique) 88112 Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal 88130 Sex chromatin identification; Barr bodies 88140 peripheral blood smear, polymorphonuclear drumsticks Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-30 Independent Clinical Laboratory Manual Transmittal Letter LAB-31 Date 10/01/07 601 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description Codes 88141-88155 and 88164-88167 are used to report cervical or vaginal screening by various methods and to report physician interpretation services. Use codes 88150-88154 to report Pap smears that are examined using non-Bethesda reporting. Use codes 88164-88167 to report Pap smears that are examined using the Bethesda System of reporting. Use codes 88142-88143 to report specimens collected in fluid medium with automated thin layer preparation that are examined using any system of reporting (Bethesda or non-Bethesda). Within each of these three code families choose the one code that describes the screening method(s) used. Codes 88141 and 88155 should be reported in addition to the screening code chosen when the additional services are provided. 88141 Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician (List separately in addition to code for technical service.) 88142 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision 88143 with manual screening and rescreening under physician supervision 88147 Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision 88148 screening by automated system with manual rescreening under physician supervision 88150 Cytopathology, slides, cervical or vaginal; manual screening under physician supervision 88152 with manual screening and computer-assisted rescreening under physician supervision 88153 with manual screening and rescreening under physician supervision 88154 with manual screening and computer-assisted rescreening using cell selection and review under physician supervision 88155 Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (e.g., maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code(s) for other technical and interpretation services.) 88160 Cytopathology, smears, any other source; screening and interpretation 88161 preparation, screening, and interpretation 88162 extended study involving over five slides and/or multiple stains 88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision 88165 with manual screening and rescreening under physician supervision 88166 with manual screening and computer-assisted rescreening under physician supervision 86167 with manual screening and computer-assisted rescreening using cell selection and review under physician supervision 88172 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s) 88173 interpretation and report 88174 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by automated system, under physician supervision 88175 with screening by automated system and manual rescreening or review, under physician supervision 88182 Flow cytometry; cell cycle or DNA analysis Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-31 Independent Clinical Laboratory Manual Transmittal Letter LAB-31 Date 10/01/07 601 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 88184 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker 88185 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (list separately in addition to code for first marker) (report 88185 in conjunction with 88184) 88187 Flow cytometry, interpretation; 2 to 8 markers 88188 Flow cytometry, interpretation; 9 to 15 markers 88189 Flow cytometry, interpretation; 16 or more markers 88199 Unlisted cytopathology procedure (I.C.) Cytogenetic Studies 88230 Tissue culture for non-neoplastic disorders; lymphocyte 88233 skin or other solid tissue biopsy 88235 amniotic fluid or chorionic villus cells 88237 Tissue culture for neoplastic disorders; bone marrow, blood cells 88239 solid tumor 88240 Cryopreservation, freezing and storage of cells, each cell line 88241 Thawing and expansion of frozen cells, each aliquot 88245 Chromosome analysis for breakage syndromes; baseline Sister Chromatid Exchange (SCE), 20-25 cells 88248 baseline breakage, score 50-100 cells, count 20 cells, 2 karyotypes, (e.g., for ataxia telangiectasia, Fanconi anemia, fragile X) 88249 score 100 cells, clastogen stress (e.g., diepoxybutane, mitomycin C, ionizing radiation, UV radiation) 88261 Chromosome analysis; count 5 cells, 1 karyotype, with banding 88262 count 15-20 cells, 2 karyotypes, with banding 88263 count 45 cells for mosaicism, 2 karyotypes, with banding 88264 analyze 20-25 cells 88267 Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with banding 88269 Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, 1 karyotype, with banding 88271 Molecular cytogenetics; DNA probe, each (e.g., FISH) 88272 chromosomal in situ hybridization, analyze 3-5 cells (e.g., for derivatives and markers) 88273 chromosomal in situ hybridization, analyze 10-30 cells (e.g., for microdeletions) 88274 interphase in situ hybridization, analyze 25-99 cells 88275 interphase in situ hybridization, analyze 100-300 cells 88280 Chromosome analysis; additional karyotypes, each study 88283 additional specialized banding technique (e.g., NOR, C-banding) 88285 additional cells counted, each study 88289 additional high resolution study 88291 Cytogenetics and molecular cytogenetics, interpretation and report 88299 Unlisted cytogenetic study (I.C.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-32 Independent Clinical Laboratory Manual Transmittal Letter LAB-31 Date 10/01/07 601 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description SURGICAL PATHOLOGY Complete descriptions for codes 88300 through 88309 are listed in the American Medical Association’s Current Procedural Terminology (CPT) code book. 88300 Level I - surgical pathology, gross examination only 88302 Level II - surgical pathology, gross and microscopic examination 88304 Level III - surgical pathology, gross and microscopic examination 88305 Level IV - surgical pathology, gross and microscopic examination 88307 Level V - surgical pathology, gross and microscopic examination 88309 Level VI - surgical pathology, gross and microscopic examination 88311 Decalcification procedure (List separately in addition to code for surgical pathology examination.) 88312 Special stains (List separately in addition to code for primary service); Group I for microorganisms (e.g., Gridley, acid fast, methenamine silver), each 88313 Group II, all other (e.g., iron, trichrome), except immunocytochemistry and immunoperoxidase stains, each 88314 histochemical staining with frozen section(s) 88318 Determinative histochemistry to identify chemical components (e.g., copper, zinc) 88319 Determinative histochemistry or cytochemistry to identify enzyme constituents, each 88342 Immunohistochemistry (including tissue immunoperoxidase), each antibody 88346 Immunofluorescent study, each antibody; direct method 88347 indirect method 88348 Electron microscopy; diagnostic 88349 scanning 88355 Morphometric analysis; skeletal muscle 88356 nerve 88358 tumor (eg, DNA ploidy) 88360 Morphometric analysis, tumor immunohistochemistry, (e.g., Her-2/neu, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody, manual 88361 using computer-assisted technology 88362 Nerve teasing preparations 88365 In situ hybridization (e.g, FISH), each probe 88367 Morphometric analysis, in situ hybridization (quantitative or semiquantitative), each probe, using computer-assisted technology 88368 manual 88371 Protein analysis of tissue by Western Blot, with interpretation and report 88372 immunological probe for band identification, each 88380 Microdissection (e.g., mechanical, laser capture) (I.C.) 88384 Array-based evaluation of multiple molecular probes; 11 through 50 probes 88385 51 through 250 probes 88386 251 through 500 probes 88399 Unlisted surgical pathology procedure (I.C.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-33 Independent Clinical Laboratory Manual Transmittal Letter LAB-31 Date 10/01/07 601 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description OTHER PROCEDURES 89049 Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including interpretation and report 89050 Cell count, miscellaneous body fluids (e.g., cerebrospinal fluid, joint fluid), except blood 89051 with differential count 89055 Leukocyte assessment, fecal, qualitative or semiqualitative 89060 Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine) 89100 Duodenal intubation and aspiration; single specimen (e.g., simple bile study or afferent loop culture) plus appropriate test procedure (I.C.) 89105 collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube 89125 Fat stain, feces, urine, or respiratory secretions 89130 Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology 89132 after stimulation 89135 Gastric intubation, aspiration, and fractional collections (e.g., gastric secretory study); one hour 89136 two hours 89140 two hours including gastric stimulation (e.g., histalog, pentagastrin) 89141 three hours, including gastric stimulation 89160 Meat fibers, feces 89190 Nasal smear for eosinophils 89220 Sputum, obtaining specimen, aerosol induced technique (separate procedure) (I.C.) 89225 Starch granules, feces 89230 Sweat collection by iontophoresis (I.C.) 89235 Water load test 89240 Unlisted miscellaneous pathology test (I.C.) MEDICINE CARDIOVASCULAR Cardiography 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005 tracing only, without interpretation and report 93010 interpretation and report only 93012 Telephonic transmission of post-symptom electrocardiogram rhythm strip(s), 24-hour attended monitoring, per 30-day period of time; tracing only 93014 physician review with interpretation and report only 93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-34 Independent Clinical Laboratory Manual Transmittal Letter LAB-31 Date 10/01/07 601 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 93016 physician supervision only, without interpretation and report only 93017 tracing only, without interpretation and report 93018 interpretation and report only 93024 Ergonovine provocation test 93040 Rhythm ECG, one to three leads; with interpretation and report 93041 tracing only without interpretation and report 93042 interpretation and report only 93224 Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation 93225 recording (includes hook-up, recording, and disconnection) 93226 scanning analysis with report 93227 physician review and interpretation 93230 Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; includes recording, microprocessor-based analysis with report, physician review and interpretation 93231 recording (includes hook-up, recording, and disconnection) 93232 microprocessor-based analysis with report 93233 physician review and interpretation 93235 Electrocardiographic monitoring for 24 hours by continuous computerized monitoring and non-continuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient activated; includes monitoring and real-time data analysis with report, physician review and interpretation 93236 monitoring and real-time data analysis with report 93237 physician review and interpretation 93268 Patient demand single or multiple event recording with presymptom memory loop, 24-hour attended monitoring, per 30-day period of time; includes transmission, physician review and interpretation 93278 Signal-averaged electrocardiography (SAECG), with or without ECG Other Vascular Studies 93724 Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings) 93731 Electronic analysis of dual-chamber pacemaker system (includes evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); without reprogramming 93732 with reprogramming 93734 Electronic analysis of single-chamber pacemaker system (includes evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); without reprogramming 93735 with reprogramming Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-35 Independent Clinical Laboratory Manual Transmittal Letter LAB-31 Date 10/01/07 601 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description Other Procedures 93799 Unlisted cardiovascular service or procedure (I.C.) SUPPLEMENTARY P9604 Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing-home-bound patients; prorated miles actually traveled S3820 Complete BRCA1 and BRCA2 gene sequence analysis for susceptibility to breast and ovarian cancer 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 MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-36 Independent Clinical Laboratory Manual Transmittal Letter LAB-31 Date 10/01/07 This page is reserved.