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 CHC-83 January 2009 TO: Community Health Centers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Community Health Center Manual (2009 HCPCS) This letter transmits revisions to the service codes and descriptions in Subchapter 6 of the Community Health Center Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) for 2009. These changes are included in the attached Subchapter 6 of the Community Health Center Manual and are effective for dates of service on or after January 1, 2009. Please Note: 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 CHC provider 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 the Community Health Center Manual. For more information about payment, you may download the Division of Health Care Finance and Policy (DHCFP) 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 DHCFP (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 titles are as follows: 114.3 CMR 18.00: Radiology; 114.3 CMR 20.00: Clinical Laboratory Services; 114.3 CMR 4.00: Rates for Community Health Centers; 114.3 CMR 17.00: Medicine. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp Vaccines Provided in a Community Health Center Vaccines supplied by the Massachusetts Department of Public Health (DPH) free of charge are not reimbursable by MassHealth. MassHealth reimburses community health centers for vaccines not supplied by DPH, as listed in Subchapter 6, Section 604, of the Community Health Center Manual. Information regarding the availability of DPH-supplied vaccines can be found on the following DPH Web sites: http://www.mass.gov/dph http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/vaccine_availability_adult.pdf http://www.mass.gov/Eeohhs2/docs/dph/cdc/immunization/vaccine_availability_childhood.pdf Reminder to Use a Modifier When Billing for Behavioral Health Screening Tools The administration and scoring of standardized behavioral-health screening tools selected from the approved menu of tools found in Appendix W of your provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. Service Code 96110 must be accompanied by one of the modifiers listed in Section 612 to indicate whether a behavioral-health need was identified. “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. In the future, failure to include a modifier when billing Service Code 96110 will result in denial of the claim. 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.) Community Health Center Manual Pages vi, 6-17, 6-18, 6-21, 6-22, 6-33 through 6-36, 6-39, 6-40, and 6-51 through 6-74 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Community Health Center Manual Pages vi, 6-17, 6-18, 6-21, 6-22, 6-33 through 6-36, 6-39, 6-40, and 6-51 through 6-72 — transmitted by Transmittal Letter CHC-80 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page vi Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 6. Service Codes and Descriptions Introduction and Explanation of Abbreviations............................................................................ 6-1 Radiology Service Codes and Descriptions.................................................................................. 6-1 Laboratory Service Codes and Descriptions................................................................................. 6-23 Visit Service Codes and Descriptions........................................................................................... 6-61 Obstetrics and Surgery Service Codes and Descriptions.............................................................. 6-69 Nurse-Midwife Service Codes and Descriptions.......................................................................... 6-70 Audiology Service Codes and Descriptions................................................................................. 6-70 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment Service Codes and Descriptions......................................................................... 6-71 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Tests Service Codes and Descriptions................................................... 6-71 Tobacco Cessation Service Codes and Descriptions.................................................................... 6-71 Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes and Descriptions............................................................................................. 6-72 Behavioral Health Screening Tool Service Codes and Descriptions............................................ 6-73 Appendix A. Directory....................................................................................................................... A-1 Appendix B. Enrollment Centers........................................................................................................ B-1 Appendix C. Third-Party-Liability Codes.......................................................................................... C-1 Appendix D. Reserved Appendix E. Utilization Management Program.................................................................................. E-1 Appendix F. Admission Guidelines.................................................................................................... F-1 Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule..................................... W-1 Appendix X. Family Assistance Copayment and Deductibles........................................................... X-1 Appendix Y. REVS/Codes Messages................................................................................................. Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes................................................................... Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-17 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description Hyperthermia Hyperthermia is used only as an adjunct to radiation therapy or chemotherapy. 77600 Hyperthermia, externally generated; superficial (i.e., heating to a depth of four cm or less) 77605 deep (i.e., heating to depths greater than four cm) 77610 Hyperthermia generated by interstitial probe(s); five or fewer interstitial applicators 77615 more than five interstitial applicators Clinical Intracavitary Hyperthermia Clinical intracavitary hyperthermia is used only as an adjunct to radiation therapy or chemotherapy. 77620 Hyperthermia generated by intracavitary probe(s) Clinical Brachytherapy 77750 Infusion or instillation of radioelement solution (includes three months follow-up care) 77761 Intracavitary radiation source application; simple 77762 intermediate 77763 complex 77776 Interstitial radiation source application; simple 77777 intermediate 77778 complex 77785 Remote afterloading high dose rate radionuclide brachytherapy; 1 channel 77786 2-12 channels 77787 over 12 channels 77789 Surface application of radiation source 77799 Unlisted procedure, clinical brachytherapy (I.C.) NUCLEAR MEDICINE DIAGNOSTIC Endocrine System 78000 Thyroid uptake; single determination 78001 multiple determinations 78003 stimulation, suppression or discharge (not including initial uptake studies) 78006 Thyroid imaging, with uptake; single determination 78007 multiple determinations 78010 Thyroid imaging; only 78011 with vascular flow Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-18 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description 78015 Thyroid carcinoma metastases imaging; limited area (e.g., neck and chest only) 78016 with additional studies (e.g., urinary recovery) 78018 whole body 78020 Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure.) 78070 Parathyroid imaging 78075 Adrenal imaging, cortex and/or medulla 78099 Unlisted endocrine procedure, diagnostic nuclear medicine (I.C.) Hematopoietic, Reticuloendothelial and Lymphatic System 78102 Bone marrow imaging; limited area 78103 multiple areas 78104 whole body 78110 Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling 78111 multiple samplings 78120 Red cell volume determination (separate procedure); single sampling 78121 multiple samplings 78122 Whole blood volume determination, including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique) 78130 Red cell survival study 78135 differential organ/tissue kinetics (e.g., splenic and/or hepatic sequestration) 78140 Labeled red cell sequestration, differential organ/tissue (e.g., splenic and/or hepatic) 78185 Spleen imaging only, with or without vascular flow 78190 Kinetics, study of platelet survival, with or without differential organ/tissue localization 78191 Platelet survival study 78195 Lymphatics and lymph nodes imaging 78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine (I.C.) Gastrointestinal System 78201 Liver imaging; static only 78202 with vascular flow 78205 Liver imaging (SPECT) 78206 with vascular flow 78215 Liver and spleen imaging; static only 78216 with vascular flow 78220 Liver function study with hepatobiliary agents, with serial images 78223 Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative measurement of gallbladder function 78230 Salivary gland imaging 78231 with serial images 78232 Salivary gland function study Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-21 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description Nervous System 78600 Brain imaging, less than four static views 78601 with vascular flow 78605 Brain imaging, minimum four static views 78607 Brain imaging, tomographic (SPECT) 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation 78609 perfusion evaluation 78610 Brain imaging, vascular flow only 78630 Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography 78635 ventriculography 78645 shunt evaluation 78647 tomographic (SPECT) 78650 Cerebrospinal fluid leakage detection and localization 78660 Radiopharmaceutical dacryocystography 78699 Unlisted nervous system procedure, diagnostic nuclear medicine (I.C.) Genitourinary System 78700 Kidney imaging; static only 78701 with vascular flow 78707 Kidney imaging with vascular flow and function; single study without pharmacological intervention 78708 single study, with pharmacological intervention (e.g., angiotensin converting enzyme inhibitor and/or diuretic) 78709 multiple studies, with and without pharmacological intervention (e.g., angiotensin converting enzyme inhibitor and/or diuretic) 78710 Kidney imaging, tomographic (SPECT) 78725 Kidney function study, non-imaging radioisotopic study 78730 Urinary bladder residual study 78740 Ureteral reflux study (radiopharmaceutical voiding cystogram) 78761 with vascular flow 78799 Unlisted genitourinary procedure, diagnostic nuclear medicine (I.C.) Other Procedures 78800 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area 78801 multiple areas 78802 whole body, single day imaging 78803 tomographic (SPECT) 78804 whole body, requiring two or more days imaging 78805 Radiopharmaceutical localization of inflammatory process; limited area Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-22 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 602 Radiology Service Codes and Descriptions (cont.) Service Code Service Description 78806 whole body 78807 tomographic (SPECT) 78808 Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (eg, parathyroid adenoma) 78811 Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) 78812 skull base to mid-thigh 78813 whole body 78814 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) 78815 skull base to mid-thigh 78816 whole body 78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine (I.C.) THERAPEUTIC 79005 Radiopharmaceutical therapy, by oral administration 79101 Radiopharmaceutical therapy, by intravenous administration 79200 Radiopharmaceutical therapy by intracavitary administration 79300 Radiopharmaceutical therapy by interstitial radioactive colloid administration 79403 Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion 79440 Radiopharmaceutical therapy, by intra-articular administration 79999 Radiopharmaceutical therapy, unlisted procedure (I.C.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-33 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 83088 Histamine 83090 Homocystine 83150 Homovanillic acid (HVA) 83491 Hydroxycorticosteroids, 17- (17-OHCS) 83497 Hydroxyindolacetic acid, 5- (HIAA) 83498 Hydroxyprogesterone, 17-d 83499 Hydroxyprogesterone, 20- 83500 Hydroxyproline; free 83505 total 83516 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or semiquantitative; multiple step method 83518 single step method (e.g., reagent strip) 83519 Immunoassay, analyte, quantitative; by radiopharmaceutical technique (e.g., RIA) 83520 not otherwise specified 83525 Insulin; total 83527 free 83528 Intrinsic factor 83540 Iron 83550 Iron-binding capacity 83570 Isocitric dehydrogenase (IDH) 83582 Ketogenic steroids, fractionation 83586 Ketosteroids, 17- (17-KS); total 83593 fractionation 83605 Lactate (lactic acid) 83615 Lactate dehydrogenase (LD), (LDH); 83625 isoenzymes, separation and quantitation 83630 Lactoferrin, fecal, qualitative 83631 quantitative 83632 Lactogen, human placental (HPL) human chorionic somatomammotropin 83633 Lactose, urine; qualitative 83634 quantitative 83655 Lead 83661 Fetal lung maturity assessment; lecithin sphingomyelin (L/S) ratio 83662 foam stability test 83663 fluorescence polarization 83664 lamellar body density 83670 Leucine aminopeptidase (LAP) 83690 Lipase 83695 Lipoprotein (a) 83700 Lipoprotein, blood, electrophoretic separation and quantitation 83701 High resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (e.g., electrophoresis, ultracentrifugation) 83704 Quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (e.g., by nuclear magnetic resonance spectroscopy) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-34 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 83719 direct measurement, VLDL cholesterol 83721 direct measurement, LDL cholesterol 83727 Luteinizing-releasing factor (LRH) 83735 Magnesium 83775 Malate dehydrogenase 83785 Manganese 83788 Mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere specified; qualitative, each specimen 83789 quantitative, each specimen 83805 Meprobamate 83825 Mercury, quantitative 83835 Metanephrines 83840 Methadone 83857 Methemalbumin 83858 Methsuximide 83864 Mucopolysaccharides, acid; quantitative 83866 screen 83872 Mucin, synovial fluid (Ropes test) 83873 Myelin basic protein, cerebrospinal fluid 83874 Myoglobin 83876 Myeloperoxidase (MPO) 83880 Natriuretic peptide 83883 Nephelometry, each analyte not elsewhere specified 83885 Nickel 83887 Nicotine Molecular Diagnostics The series of codes 83890-83912 is intended for use with molecular diagnostic techniques for analysis of nucleic acids. These services are coded by procedure rather than analyte. Code separately for each procedure used in an analysis. For example, a procedure requiring isolation of DNA, restriction endonuclease digestion, electrophoresis, and nucleic acid probe amplification would be coded 83890, 83892, 83894, and 83898. 83890 Molecular diagnostics; molecular isolation or extraction 83891 isolation or extraction of highly purified nucleic acid 83892 enzymatic digestion 83893 dot/slot blot production 83894 separation by gel electrophoresis (e.g., agarose, polyacrylamide) 83896 nucleic acid probe, each 83897 nucleic acid transfer (e.g., Southern, Northern) 83898 amplification, target, each nucleic acid sequence 83900 amplification, target, multiplex, first two nucleic acid sequences Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-35 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 83901 amplification, target, multiplex, each additional nucleic acid sequence beyond two (List separately in addition to code for primary procedure) 83902 reverse transcription 83903 mutation scanning, by physical properties (e.g., single strand conformational polymorphisms (SSCP), heteroduplex, denaturing gradient gel electrophoresis (DGGE), RNA’ase A), single segment, each 83904 mutation identification by sequencing, single segment, each segment 83905 mutation identification by allele specific transcription, single segment, each segment 83906 mutation identification by allele specific translation, single segment, each segment 83907 lysis of cells prior to nucleic acid extraction (e.g., stool specimens, paraffin embedded tissue 83908 amplification, signal, each nucleic acid sequence 83909 separation and identification by high resolution technique (e.g., capillary electrophoresis) 83912 interpretation and report 83914 Mutation identification by enzymatic ligation or primer extension, single segment, each segment (e.g., oligonucleotide ligation assay (OLA), single base chain extension (SBCE), or allele- specific primer extension (ASPE)) 83915 Nucleotidase 5- 83916 Oligoclonal immune (oligoclonal bands) 83918 Organic acids; total, quantitative, each specimen 83919 qualitative, each specimen 83921 Organic acid, single, quantitative 83925 Opiates (e.g., morphine, meperidine) 83930 Osmolality; blood 83935 urine 83937 Osteocalcin (bone g1a protein) 83945 Oxalate 83950 Oncoprotein, HER-2/neu 83951 des-gamma-carboxy-prothrombin (DCP) 83970 Parathormone (parathyroid hormone) 83986 pH, body fluid, except blood 83992 Phencyclidine (PCP) 83993 Calprotectin, fecal 84022 Phenothiazine 84030 Phenylalanine (PKU), blood 84035 Phenylketones, qualitative 84060 Phosphatase, acid; total 84066 prostatic 84075 Phosphatase, alkaline 84078 heat stable (total not included) 84080 isoenzymes 84081 Phosphatidylglycerol 84085 Phosphogluconate, 6-, dehydrogenase, RBC 84087 Phosphohexose isomerase 84100 Phosphorus inorganic (phosphate); Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-36 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 84105 urine 84106 Porphobilinogen, urine; qualitative 84110 quantitative 84119 Porphyrins, urine; qualitative 84120 quantitation and fractionation 84126 Porphyrins, feces; quantitative 84127 qualitative 84132 Potassium; serum 84133 urine 84134 Prealbumin 84135 Pregnanediol 84138 Pregnanetriol 84140 Pregnenolone 84143 17-hydroxypregnenolone 84144 Progesterone 84146 Prolactin 84150 Prostaglandin, each 84152 Prostate specific antigen (PSA); complexed (direct measurement) 84153 total 84154 free 84155 Protein, total, except by refractometry; serum 84156 urine 84157 other source (e.g., synovial fluid, cerebrospinal fluid) 84160 Protein, total, by refractometry, any source 84163 Pregnancy-associated plasma protein-A (PAPP-A) (I.C.) 84165 Protein, electrophoretic fractionation and quantitation, serum 84166 electrophoretic fractionation and quantitation, other fluids with concentration (e.g., urine, CSF) 84181 Western Blot, with interpretation and report, blood or other body fluid 84182 Western Blot, with interpretation and report, blood or other body fluid, immunological probe for band identification, each 84202 Protoporphyrin, RBC; quantitative 84203 screen 84206 Proinsulin 84207 Pyridoxal phosphate (vitamin B-6) 84210 Pyruvate 84220 Pyruvate kinase 84228 Quinine 84233 Receptor assay; estrogen 84234 progesterone 84235 endocrine, other than estrogen or progesterone (specify hormone) 84238 non-endocrine (specify receptor) 84244 Renin 84252 Riboflavin (vitamin B-2) 84255 Selenium 84260 Serotonin Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-39 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 85048 leukocyte (WBC), automated 85049 platelet, automated 85055 Reticulated platelet assay 85060 Blood smear, peripheral, interpretation by physician with written report 85097 Bone marrow, smear interpretation 85130 Chromogenic substrate assay 85170 Clot retraction 85175 Clot lysis time, whole blood dilution 85210 Clotting; factor II, prothrombin, specific 85220 factor V (AcG or proaccelerin), labile factor 85230 factor VII (proconvertin, stable factor) 85240 factor VIII (AHG), one stage 85244 factor VIII related antigen 85245 factor VIII, VW factor, ristocetin cofactor 85246 factor VIII, VW factor antigen 85247 factor VIII, von Willebrand factor, multimetric analysis 85250 factor IX (PTC or Christmas) 85260 factor X (Stuart-Prower) 85270 factor XI (PTA) 85280 factor XII (Hageman) 85290 factor XIII (fibrin stabilizing) 85291 factor XIII (fibrin stabilizing), screen solubility 85292 prekallikrein assay (Fletcher factor assay) 85293 high molecular weight kininogen assay (Fitzgerald factor assay) 85300 Clotting inhibitors or anticoagulants; antithrombin III, activity 85301 antithrombin III, antigen assay 85302 protein C, antigen 85303 protein C, activity 85305 protein S, total 85306 protein S, free 85307 Activated Protein C (APC) resistance assay 85335 Factor inhibitor test 85337 Thrombomodulin 85345 Coagulation time; Lee and White 85347 activated 85348 other methods 85360 Euglobulin lysis 85362 Fibrin(ogen) degradation (split) products (FDP) (FSP); agglutination slide; semiquantitative 85366 paracoagulation 85370 quantitative 85378 Fibrin degradation products, D-dimer; qualitative or semiquantitative 85379 quantitative 85380 ultrasensitive (e.g., for evaluation for venous thromboembolism), qualitative or semiquantitative 85384 Fibrinogen; activity 85385 antigen 85390 Fibrinolysins or coagulopathy screen, interpretation and report Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-40 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 85396 Coagulation/fibrinolysis assay, whole blood (e.g., viscoelastic clot assessment), including use of any pharmacologic additive(s), as indicated, including interpretation and written report, per day 85397 Coagulation and fibrinolysis, functional activity, not otherwise specified (eg, ADAMTS-13), each analyte 85400 Fibrinolytic factors and inhibitors; plasmin 85410 alpha-2 antiplasmin 85415 plasminogen activator 85420 plasminogen, except antigenic assay 85421 plasminogen, antigenic assay 85441 Heinz bodies; direct 85445 induced, acetyl phenylhydrazine 85460 Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; differential lysis (Kleihauer-Betke) 85461 rosette 85475 Hemolysin, acid 85520 Heparin assay 85525 Heparin neutralization 85530 Heparin-protamine tolerance test 85536 Iron stain, peripheral blood 85540 Leukocyte alkaline phosphatase with count 85547 Mechanical fragility, RBC 85549 Muramidase 85555 Osmotic fragility, RBC; unincubated 85557 incubated 85576 Platelet; aggregation (in vitro), each agent 85597 Platelet neutralization 85610 Prothrombin time 85611 substitution, plasma fractions, each 85612 Russell viper venom time (includes venom); undiluted 85613 diluted 85635 Reptilase test 85651 Sedimentation rate, erythrocyte; non-automated 85652 automated 85660 Sickling of RBC, reduction 85670 Thrombin time; plasma 85675 titer 85705 Thromboplastin inhibition; tissue 85730 Thromboplastin time, partial (PTT); plasma or whole blood 85732 substitution, plasma fractions, each 85810 Viscosity 85999 Unlisted hematology and coagulation procedure (I.C.) IMMUNOLOGY 86000 Agglutinins, febrile (e.g., Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain spotted fever, scrub typhus), each antigen 86001 Allergen specific IgG; quantitative or semiquantitative, each allergen Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-51 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 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 87809 adenovirus 87810 Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis 87850 Neisseria gonorrhoeae 87880 Streptococcus, group A 87899 not otherwise specified 87902 Hepatitis C virus 87905 Infectious agent enzymatic activity other than virus (eg, sialidase activity in vaginal fluid) 87999 Unlisted microbiology procedure (I.C.) ANATOMIC PATHOLOGY Cytopathology 88104 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation 88106 filter method only with interpretation 88107 smears and filter preparation with interpretation 88108 Cytopathology, concentration technique, smears and interpretation (e.g., Saccomanno technique) 88112 Cytopathology, selective cellular enhancement technique with interpretation (e.g., liquid based slide preparation method), except cervical or vaginal 88130 Sex chromatin identification; Barr bodies 88140 peripheral blood smear, polymorphonuclear drumsticks Codes 88141-88155, 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-52 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 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 reported 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 88180 Flow cytometry; each cell surface, cytoplasmic or nuclear 88182 cell cycle or DNA analysis 88184 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker 88185 each additional marker (List separately in addition to code for first marker) 88187 Flow cytometry, interpretation; two to 8 markers 88188 nine to 15 markers 88189 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-53 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 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, two 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 five cells, one karyotype, with banding 88262 count 15-20 cells, two karyotypes, with banding 88263 count 45 cells for mosaicism, two karyotypes, with banding 88264 analyze 20-25 cells 88267 Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, one karyotype, with banding 88269 Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, one karyotype, with banding 88271 Molecular cytogenetics; DNA probe, each (e.g., FISH) 88272 chromosomal in situ hybridization, analyze three to five 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.) 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-54 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 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 (e.g., 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 semi-quantitative) 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 (i.e., sample preparation of microscopically identified target); laser capture 88381 manual 88384 Array-based evaluation of multiple molecular probes; 11 through 50 probes (I.C.) 88385 51 through 250 probes 88386 251 through 500 probes 88399 Unlisted surgical pathology procedure (I.C.) 88720 Bilirubin, total, transcutaneous 88740 Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin 88741 methemoglobin 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 semiquantitative 89060 Crystal identification by light microscopy with or without polarizing lens analysis, 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 89105 collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-55 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 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 89225 Starch granules, feces 89230 Sweat collection by iontopheresis 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, continous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-56 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 93227 physician review and interpretation 93228 Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report 93229 technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports (I.C.) 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 93279 Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and selected optimal permanent programmed values with physician analysis, review and report; single lead pacemaker system 93280 dual lead pacemaker system 93281 multiple lead pacemaker system 93282 single lead implantable cardioverter-defibrillator system 93283 dual lead implantable cardioverter-defibrillator system 93284 multiple lead implantable cardioverter-defibrillator system 93285 implantable loop recorder system 93286 Peri-procedural device evaluation and programming of device system parameters before or after a surgery, procedure, or test with physician analysis, review and report; single, dual, or multiple lead pacemaker system 93287 single, dual, or multiple lead implantable cardioverter-defibrillator system 93288 Interrogation device evaluation (in person) with physician analysis, review and report, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead pacemaker system 93289 single, dual, or multiple lead implantable cardioverter-defibrillator system, including analysis of heart rhythm derived data elements 93290 implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-57 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 93291 implantable loop recorder system, including heart rhythm derived data analysis 93292 wearable defibrillator system 93293 Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with or without magnet application with physician analysis, review and report(s), up to 90 days 93294 Interrogation device evaluation(s) (remote) up to 90 days; single, dual, or multiple lead pacemaker system with interim physician analysis, review(s) and report(s) 93295 single, dual, or multiple lead implantable cardioverter-defibrillator system with interim physician analysis, review(s) and report(s) 93296 single, dual, or multiple lead pacemaker system or implantable cardioverter-defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results 93297 Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system, including analysis of 1 or more recorder physiologic cardiovascular data elements from all internal and external sensors, physician analysis, review(s) and report(s) 93298 implantable loop recorder system, including analysis of recorded heart rhythm data, physician analysis, review(s) and report(s) 93299 implantable cardiovascular monitor system or implantable loop recorder system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results (I.C.) 93306 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography 93351 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically reduced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision 93352 Use of echocardiographic contrast agent during stress echocardipgraphy (List separately in addition to code for primary procedure) Other Vascular Studies 93701 Bioimpedance, thoracic, electrical 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) 93745 Initial set-up and programming by a physician of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient instruction in wearing system and patient reporting of problems or events (I.C.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-58 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description Other Procedures 93797 Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) 93798 with continuous ECG monitoring (per session) 93799 Unlisted cardiovascular service or procedure (I.C.) NONINVASIVE VASCULAR DIAGNOSTIC STUDIES Cerebrovascular Arterial Studies 93875 Noninvasive physiologic studies of extracranial arteries, complete bilateral study (e.g., periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis) (S.P. to 93880 and 93882) 93880 Duplex scan of extracranial arteries; complete bilateral study 93882 unilateral or limited study 93886 Transcranial Doppler study of the intracranial arteries; complete study 93888 limited study Extremity Arterial Studies (Including Digits) 93922 Noninvasive physiologic studies of upper or lower extremity arteries, single level, bilateral (e.g., ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement) (S.P. to 93924, 93925, 93926, 93930, and 93931) 93923 Noninvasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (e.g., segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests, measurements with reactive hyperemia) (S.P. to 93924, 93925, 93926, 93930, and 93931) 93924 Noninvasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study (S.P. to 93925, 93926, 93930, and 93931) 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 93926 unilateral or limited study 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 93931 unilateral or limited study Extremity Venous Studies (Including Digits) 93965 Noninvasive physiologic studies of extremity veins, complete bilateral study (e.g., Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography) (S.P. to 93970 and 93976) 93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study 93971 unilateral or limited study Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-59 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description Visceral and Penile Vascular Studies 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study 93976 limited study (S.P. to 93975) 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study (S.P. to 93975) 93979 unilateral or limited study (S.P. to 93975) 93980 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study 93981 follow-up or limited study (S.P. to 93980) Extremity Arterial—Venous Studies 93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) PULMONARY 94002 Ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day 94003 hospital inpatient/observation, each subsequent day 94004 nursing facility, per day 94010 Spirometry, including graphic record, total and timed vital capacity, expiratory flow rate measurement(s), with or without maximal voluntary ventilation (S.P. to 94060, 94070, and 94620) 94014 Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, transmission of spirometric tracing, data capture, analysis of transmitted data, periodic recalibration, and physician review and interpretation 94016 physician review and interpretation only 94060 Bronchodilation responsiveness, spirometry as in 94010, pre- and post-bronchodilator administration (S.P. to 94070 and 94620) 94070 Bronchospasm provocation evaluation, multiple spirometric determinations as in 94010,with administered agents (e.g., antigen(s), cold air, methacholine) 94150 Vital capacity, total (separate procedure) (S.P. to 94010, 94060, 94070, and 94620) 94200 Maximum breathing capacity, maximal voluntary ventilation (S.P. to 94010, 94060, 94070, and 94620) 94240 Functional residual capacity or residual volume: helium method, nitrogen open circuit method, or other method 94250 Expired gas collection, quantitative, single procedure (separate procedure) 94260 Thoracic gas volume 94350 Determination of maldistribution of inspired gas: multiple breath nitrogen washout curve including alveolar nitrogen or helium equilibration time 94360 Determination of resistance to airflow, oscillatory or plethysmographic methods 94370 Determination of airway closing volume, single breath tests 94375 Respiratory flow volume loop (S.P. to 94010, 94060, and 94070) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-60 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 603 Laboratory Service Codes and Descriptions (cont.) Service Code Service Description 94400 Breathing response to CO2 (CO2 response curve) 94450 Breathing response to hypoxia (hypoxia response curve) 94620 Pulmonary stress testing; simple (e.g., 6-minute walk test, prolonged exercise test for bronchospasm with pre- and post-spirometry and oximetry) 94621 complex (including measurements of CO2 production, O2 uptake, and electrocardiographic recordings) 94640 Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) 94642 Aerosol inhalation of pentamidine for pneumocystis carinii pneumonia treatment or prophylaxis 94660 Continuous positive airway pressure ventilation (CPAP), initiation and management 94662 Continuous negative pressure ventilation (CNP), initiation and management 94664 Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device 94667 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; initial demonstration and/or evaluation 94668 subsequent 94680 Oxygen uptake, expired gas analysis; rest and exercise, direct, simple (S.P. to 94620) 94681 including CO2 output, percentage oxygen extracted (S.P. to 94620 and 94680) 94690 rest, indirect (separate procedure) (S.P. to 94620) 94720 Carbon monoxide diffusing capacity (e.g., single breath, steady state) (S.P. to 94725) 94725 Membrane diffusion capacity 94750 Pulmonary compliance study (e.g., plethysmography, volume and pressure measurements) (with report only) (S.P. to 94010, 94060, 94070, and 94620) 94760 Noninvasive ear or pulse oximetry for oxygen saturation; single determination (no professional component) (S.P. to 94620) 94761 multiple determinations (e.g., during exercise) (no professional component) (S.P. to 94620) 94762 by continuous overnight monitoring (separate procedure) (no professional component) (S.P. to 94620) 94770 Carbon dioxide, expired gas determination by infrared analyzer (with report only) (S.P. to 94620) 94772 Circadian respiratory pattern recording (pediatric pneumogram), 12 to 24 hour continuous recording, infant (I.C.) 94774 Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate per 30-day period of time; includes monitor attachment, download of data, physician review, interpretation, and preparation of a report (I.C.) 94775 monitor attachment only (includes hook-up, initiation of recording and disconnection) (I.C.) 94776 monitoring, download of information, receipt of transmission(s) and analyses by computer only (I.C.) 94777 physician review, interpretation, and preparation of report only (I.C.) 94799 Unlisted pulmonary service or procedure (I.C.) SUPPLEMENTARY 99000 Handling and/or conveyance of specimen for transfer from the physician’s office to a laboratory – centrifuging required Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-61 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 604 Visit Service Codes and Descriptions When claiming payment for visits, 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.) Service Code Modifier Service Description CHC Visits 90632 Hepatitis A vaccine, adult dosage, for intramuscular use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90660 Influenza virus vaccine, live, for intranasal use (P.A.) 90707 Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90716 Varicella virus vaccine, live, for subcutaneous use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90732 Pneumoccal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) 90746 Hepatitis B vaccine, adult dosage, for intramuscular use (Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age) D1206 Topical fluoride varnish; therapeutic application for moderate-to-high caries risk patients. D9450 Case presentation, detailed and extensive treatment planning (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.) J3490 Unclassified drugs (Use for injectable and infusible drugs and devices supplied in the clinic. Do not use for medications and injectables related to family planning services.) (I.C.) T1015 Clinic visit/encounter, all-inclusive (Use for individual medical visit.) T1015 HQ Clinic visit/encounter, all-inclusive, group setting (Use for group clinic visit.) 90899 Unlisted psychiatric service or procedure (Use for individual mental health visit.) (I.C.) 99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g.. holidays, Saturday, and Sunday), in addition to basic service (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 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes (Use for HIV counseling visits.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-62 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description Hospital Inpatient Services 99221 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - detailed or comprehensive history; - detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity. 99222 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity. 99223 Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity. 99460 Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant Subsequent Hospital Care 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a problem focused interval history; - a problem focused examination; - medical decision making that is straightforward or of low complexity. 99232 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - an expanded problem focused interval history; - an expanded problem focused examination; - medical decision making of moderate complexity. 99233 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: - a detailed interval history; - a detailed examination; - medical decision making of high complexity. 99462 Subsequent hospital care, per day, for evaluation and management of normal newborn Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-63 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description HOSPITAL OBSERVATION SERVICES Initial Observation Care (New or Established Patient) 99218 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: - a detailed or comprehensive history; - a detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity. 99219 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of moderate complexity. 99220 Initial observation care, per day, for the evaluation and management of a patient, which requires these three key components: - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-64 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description Nursing Facility Services 99304 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components: - a detailed or comprehensive history - a detailed or comprehensive examination; and - medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver. 99305 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components: - a comprehensive history - a comprehensive examination; and - medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Physicians typically spend 35 minutes with the patient and/or family or caregiver. 99306 Initial nursing facility care, per day, for the evaluation and management of a patient which requires these three key components: - a comprehensive history - a comprehensive examination; and - medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver. Subsequent Nursing Facility Care 99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: -a problem focused interval history; -a problem focused examination; -straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the patient is stable, recovering, or improving. Physicians typically spend 10 minutes with the patient and/or family or caregiver. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-65 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: -an expanded problem-focused interval history; -an expanded problem-focused examination; -medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 15 minutes with the patient and/or family or caregiver. 99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: -a detailed interval history; -a detailed examination; -medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the patient has developed a significant complication or a significant new problem. Physicians typically spend 25 minutes with the patient and/or family or caregiver. 99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: -a comprehensive interval history; -a comprehensive examination; -medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 35 minutes with the patient and/or family or caregiver. DOMICILIARY, REST HOME (E.G., BOARDING HOME), OR CUSTODIAL CARE SERVICES New Patient 99324 Domicillary or rest home visit for the evaluation and management of a new patient, which requires these three key components: -a problem-focused history; -a problem-focused examination; and -straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of low severity. Physicians typically spend 20 minutes with the patient and/or family or caregiver. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-66 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 99325 Domicillary or rest home visit for the evaluation and management of a new patient, which requires these three components: -an expanded problem-focused history; -an expanded problem-focused examination; and -medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes with the patient and/or family or caregiver. 99326 Domicillary or rest home visit for the evaluation and management of a new patient, which requires these three key components: -a detailed history; -a detailed examination; and -medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate severity. Physicians typically spend 45 minutes with the patient and/or family or caregiver. 99327 Domicillary or rest home visit for the evaluation and management of a new patient, which requires these three key components: -a comprehensive history; -a comprehensive examination; and -medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of high severity. Physicians typically spend 60 minutes with the patient and/or family or caregiver. Established Patient 99334 Domicillary or rest home visit for the evaluation and management of an established patient, which requires at least two these three key components: -a problem-focused interval history; -a problem-focused examination; -straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of self-limited or minor. Physicians typically spend 15 minutes with the patient and/or family or caregiver. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-67 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 99335 Domicillary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three components: -an expanded problem-focused interval history; -an expanded problem-focused examination; -medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of low to moderate severity. Physicians typically spend 25 minutes with the patient and/or family or caregiver. 99336 Domicillary or rest home visit for the evaluation and management of an established patient, which requires at least two of these three components: -a detailed interval history; -a detailed examination; -medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes with the patient and/or family or caregiver. 99337 Domicillary or rest home visit for the evaluation and management of an established patient, which requires these three components: -a comprehensive interval history; -a comprehensive examination; -medical decision making of moderate to high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Physicians typically spend 60 minutes with the patient and/or family or caregiver. Home Services New Patient 99341 Home visit for the evaluation and management of a new patient, which requires these three key components: -a problem focused history; -a problem focused examination; and -straightforward medical decision making. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-68 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 604 Visit Service Codes and Descriptions (cont.) Service Code Modifier Service Description 99342 Home visit for the evaluation and management of a new patient, which requires these three key components: -an expanded problem focused history; -an expanded problem focused examination; and -medical decision making of low complexity. 99343 Home visit for the evaluation and management of a new patient, which requires these three key components: -a detailed history; -a detailed examination; and -medical decision making of moderate complexity. 99345 Home visit for the evaluation and management of a new patient, which requires these three key components: -a comprehensive history; -a comprehensive examination; and -medical decision making of high complexity. (I.C.) Established Patient 99347 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: -a problem focused interval history; -a problem focused examination; -straightforward medical decision making. 99348 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: -an expanded problem focused interval history; -an expanded problem focused examination; -medical decision making of low complexity. 99349 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: -a detailed interval history; -a detailed examination; -medical decision making of moderate complexity. 99350 Home visit for the evaluation and management of an established patient, which requires at least two of these three key components: -a comprehensive interval history; -a comprehensive examination; -medical decision making of moderate to high complexity. (I.C.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-69 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 605 Obstetrics and Surgery Service Codes and Descriptions See 130 CMR 405.422 for other requirements. Service Code Service Description Fee-for-Service Deliveries 59409 Vaginal delivery only (with or without episiotomy and /or forceps 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care 59414 Delivery of placenta (separate procedure) 59515 Cesarean delivery only; including postpartum care 59525 Subtotal or total hysterectomy after cesarean delivery (List separately in addition to 59510 or 59515.) (Hysterectomy Information (HI-1) form required) 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59614 including postpartum care 59620 Cesarean delivery only, following attempted vaginal delivery after previous cesarean delivery 59622 including postpartum care Global Deliveries 59400 Routine obstetric care, including antepartum care, vaginal delivery (with or without episiotomy and/or forceps) and postpartum care 59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery 59618 Routine obstetric care, including antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery Surgery Services 54150 Circumcision, using clamp or other device; newborn 54160 Circumcision, surgical excision other than clamp, device or dorsal slit; newborn 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) (Consent for Sterilization Form (CS-18 or CS-21) required) (S.P.) 55450 Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) (Consent for Sterilization Form (CS-18 or CS-21) required) (S.P.) 58600 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral (Consent for Sterilization Form (CS-18 or CS-21) required) 58605 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, postpartum, unilateral or bilateral, during same hospitalization (separate procedure) (Consent for Sterilization Form (CS-18 or CS-21) required) (S.P.) 58611 Ligation or transection of fallopian tube(s) when done at the time of cesarean section or intra- abdominal surgery (not a separate procedure) (Consent for Sterilization Form (CS-18 or CS-21) required) (List separately in addition to code for primary procedure.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-70 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 605 Obstetrics and Surgery Service Codes and Descriptions (cont.) Service Code Modifier Service Description 58615 Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring), vaginal or suprapubic approach (Consent for Sterilization Form (CS-18 or CS-21) required) 58670 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) (Consent for Sterilization Form (CS-18 or CS-21) required) 58671 with occlusion of oviducts by device (e.g., band, clip, or Falope ring) (Consent for Sterilization Form (CS-18 or CS-21) required) 59000 Amniocentesis, any method 59012 Cordocentesis (intrauterine), any method 59015 Chorionic villus sampling, any method 59025 Fetal non-stress test 606 Nurse-Midwife Service Codes and Descriptions 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 Service Description T1015-TH Clinic visit/encounter, all-inclusive – obstetrical treatment/services, prenatal or postpartum (use for a medical visit with a nurse midwife for a prenatal or postpartum service) 59400 Routine obstetric care, including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care 59409 Vaginal delivery only (with or without episiotomy and/or forceps) 59410 Vaginal delivery only (with or without episiotomy and/or forceps); including postpartum care (Hysterectomy Information (HI-1) form required) 59414 Delivery of placenta (separate procedure) 59610 Routine obstetric care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous cesarean delivery 59612 Vaginal delivery only, after previous cesarean delivery (with or without episiotomy and/or forceps) 59614 including postpartum care 607 Audiology Service Codes and Descriptions See 130 CMR 405.461 through 405.463 for other requirements. Service Code Service Description 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only 92553 air and bone 92567 Tympanometry (impedance testing) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-71 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 608 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment Service Codes and Descriptions See 130 CMR 450.140 through 450.149 for other requirements. Service Code Service Description New Patient 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, new patient; infant (age younger than one year) 99382 early childhood (age one through four years) 99383 late childhood (age five through 11 years) 99384 adolescent (age 12 through 17 years) 99385 18 through 39 years Established Patient 99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; infant (age younger than one year) 99392 early childhood (age one through four years) 99393 late childhood (age five through 11 years) 99394 adolescent (age 12 through 17 years) 99395 18 through 39 years 609 Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Tests Service Codes and Descriptions Service Code Service Description 92551 Screening test, pure tone, air only 92552 Pure tone audiometry (threshold); air only 92587 Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) 99173 Screening test of visual acuity, quantitative, bilateral. 610 Tobacco Cessation Service Codes and Descriptions Service Code-Modifier Service Description 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). (Eligible providers are physicians employed by community health centers.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-72 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 610 Tobacco Cessation Service Codes and Descriptions (cont.) Service Code-Modifier Service Description 99407-HN Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). (Eligible providers are physicians employed by community health centers.) 99407-HQ Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (for an individual in a group setting, 60-90 minutes). (Eligible providers are physicians employed by community health centers.) 99407-SA Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). (Eligible providers are nurse practitioners employed by community health centers.) 99407-SB Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). (Eligible providers are nurse midwives employed by community health centers.) 99407-TD Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). (Eligible providers are registered nurses employed by community health centers.) 99407-TF Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (intake assessment for an individual, at least 45 minutes). (Eligible providers are physicians employed by community health centers.) 99407-U1 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (at least 30 minutes). Eligible providers are tobacco cessation counselors employed by community health centers.) 99407-U2 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (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 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes (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.) 611 Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes and Descriptions Service Code Service Description G0108 Diabetes self-management training services, individual, per 30 minutes G0109 Diabetes outpatient self-management training services, group session (two or more), per 30 minutes G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), individual, face-to-face with the patient, each 15 minutes Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-73 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 611 Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes and Descriptions (cont.) Service Code Service Description G0271 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease), group (two or more individuals), each 30 minutes 97802 Medical nutrition therapy, initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes 97803 reassessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 group (two or more individuals), each 30 minutes 612 Behavioral Health Screening Tool Service Codes and Descriptions The administration and scoring of standardized behavioral-health screening tools selected from the approved menu of tools found in Appendix W of your provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. Service Code-Modifier Service Description 96110-U1 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W with no behavioral health need identified* (eligible providers are physicians employed by community health centers) 96110-U2 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W and behavioral health need identified* (eligible providers are physicians employed by community health centers) 96110-U3 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W with no behavioral health need identified* (eligible providers are nurse midwives employed by community health centers) 96110-U4 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W and behavioral health need identified* (eligible providers are nurse midwives employed by community health centers) 96110-U5 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W with no behavioral health need identified* (eligible providers are nurse practitioners employed by community health centers) 96110-U6 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W and behavioral health need identified* (eligible providers are nurse practitioners employed by community health centers) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-74 Community Health Center Manual Transmittal Letter CHC-83 Date 01/01/09 612 Behavioral Health Screening Tool Service Codes and Descriptions (cont.) Service Code-Modifier Service Description 96110-U7 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W with no behavioral health need identified* (eligible providers are physician assistants employed by community health centers) 96110-U8 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W 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. 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.