Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter PHY-140 December 2013 TO: Physicians Participating in MassHealth FROM: Kristin L. Thorn, Medicaid Director RE: Physician Manual (Revisions to MassHealth Regulations-Affordable Care Act) This letter transmits revised regulations and an updated Subchapter 6 of the Physician Manual. The revised regulations and Subchapter 6 implement changes in coverage for acupuncture and the diagnosis of infertility. These changes were prompted by requirements of the Affordable Care Act regarding coverage of Essential Health Benefits. These regulations are effective January 1, 2014. The revised Subchapter 6 is effective for dates of service on or after January 1, 2014. MassHealth Website This transmittal letter and attached pages are available on the MassHealth website at www.mass.gov/masshealth. Questions If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Physician Manual Pages iv, iv-a, 4-1, 4-2, 4-7, 4-8, 4-33 through 4-42, 4-45, 4-46, and 6-1 through 6-24 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Physician Manual Pages iv, 4-1, 4-2, 4-7, 4-8, 4-39, and 4-40 — transmitted by Transmittal Letter PHY-124 Page iv-a — transmitted by Transmittal Letter PHY-131 Pages 4-33 and 4-34 — transmitted by Transmittal Letter PHY-111 Pages 4-35 through 4-38 — transmitted by Transmittal Letter PHY-122 Pages 4-41 and 4-42 — transmitted by Transmittal Letter PHY-135 Pages 4-45 and 4-46 — transmitted by Transmittal Letter PHY-137 Pages 6-1 through 6-24 — transmitted by Transmittal Letter PHY-139 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Physician Manual Transmittal Letter PHY-140 Date 01/01/14 4. Program Regulations Part 1. General Information 433.401: Definitions ............................................................................................................ 4-1 433.402: Eligible Members .................................................................................................. 4-6 433.403: Provider Eligibility ............................................................................................... 4-6 433.404: Nonpayable Circumstances ................................................................................... 4-7 433.405: Maximum Allowable Fees .................................................................................... 4-8 433.406: Individual Consideration ....................................................................................... 4-8 433.407: Service Limitations: Medical and Radiology Services ........................................ 4-9 433.408: Prior Authorization ................................................................................................ 4-10 433.409: Recordkeeping (Medical Records) Requirements ................................................. 4-11 433.410: Report Requirements ............................................................................................. 4-13 433.411: Child and Adolescent Needs and Strengths (CANS) Data Reporting ................... 4-13 433.412: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services ........ 4-13 Part 2. Medical Services 433.413: Office Visits: Service Limitations ........................................................................ 4-14 433.414: Hospital Emergency Department and Outpatient Department Visits .................... 4-14 433.415: Hospital Services: Service Limitations and Screening Requirements .................. 4-15 433.416: Nursing Facility Visits: Service Limitations ........................................................ 4-15 433.417: Home Visits: Service Limitations ........................................................................ 4-15 433.418: Consultations: Service Limitations ....................................................................... 4-16 433.419: Nurse Midwife Services ....................................................................................... 4-16 433.420: Obstetric Services: Introduction ........................................................................... 4-17 433.421: Obstetric Services: Global-Fee Method of Payment ............................................ 4-17 (130 CMR 433.422 and 433.423 Reserved) 433.424: Obstetric Services: Fee-for-Service Method of Payment .................................... 4-20 433.425: Ophthalmology Services ...................................................................................... 4-20 433.426: Audiology Services: Service Limitations ............................................................ 4-21 433.427: Allergy Testing: Service Limitations ................................................................... 4-21 433.428: Psychiatry Services: Introduction ........................................................................ 4-22 433.429: Psychiatry Services: Scope of Services ................................................................ 4-23 433.430: Dialysis: Service Limitations .............................................................................. 4-26 433.431: Physical Medicine: Service Limitations ............................................................... 4-26 433.432: Other Medical Procedures .................................................................................... 4-26 433.433: Nurse Practitioner Services .................................................................................. 4-27 433.434: Physician Assistant Services ................................................................................ 4-28 433.435: Tobacco Cessation Services ................................................................................. 4-30 433.436: Radiology Services: Introduction ........................................................................ 4-32 433.437: Radiology Services: Service Limitations ............................................................ 4-32 433.438: Clinical Laboratory Services: Introduction ......................................................... 4-33 433.439: Clinical Laboratory Services: Service Limitations .............................................. 4-33 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv-a Physician Manual Transmittal Letter PHY-140 Date 01/01/14 4. Program Regulations (cont.) 433.440: Pharmacy Services: Acupuncture ......................................................................... 4-34 433.441: Pharmacy Services: Prescription Requirements ................................................... 4-35 433.442: Pharmacy Services: Covered Drugs and Medical Supplies .................................. 4-36 433.443: Pharmacy Services: Limitations on Coverage of Drugs ....................................... 4-37 433.444: Pharmacy Services: Insurance Coverage .............................................................. 4-38 433.445: Pharmacy Services: Prior Authorization .............................................................. 4-39 433.446: Pharmacy Services: Member Copayments ........................................................... 4-40 433.447: Pharmacy Services: Payment ............................................................................... 4-40 (130 CMR 433.448 Reserved) 433.449: Fluoride Varnish Services ..................................................................................... 4-41 (130 CMR 433.450 Reserved) Part 3. Surgery Services 433.451: Surgery Services: Introduction ............................................................................ 4-41 433.452: Surgery Services: Payment .................................................................................. 4-42 (130 CMR 433.453 Reserved) 433.454: Anesthesia Services .............................................................................................. 4-44 433.455: Abortion Services ................................................................................................. 4-45 433.456: Sterilization Services: Introduction ..................................................................... 4-46 433.457: Sterilization Services: Informed Consent ........................................................... 4-47 433.458: Sterilization Services: Consent Form Requirements ............................................ 4-48 433.459: Hysterectomy Services ......................................................................................... 4-49 (130 CMR 433.460 through 433.465 Reserved) Part 4. Other Services 433.466: Durable Medical Equipment and Medical/Surgical Supplies: Introduction ....................................................................................................... 4-51 433.467: Durable Medical Equipment and Medical/Surgical Supplies: Prescription Requirements .................................................................................................... 4-51 433.468: Durable Medical Equipment and Medical/Surgical Supplies: Prior- Authorization Requirements ............................................................................. 4-52 433.469: Oxygen and Respiratory Therapy Equipment ...................................................... 4-52 433.470: Transportation Services ........................................................................................ 4-53 433.471: Therapy, Speech and Hearing Clinic, and Amputee Clinic Services ................... 4-54 433.472: Mental Health Services ......................................................................................... 4-55 (130 CMR 433.473 through 433.475 Reserved) 433.476: Alternatives to Institutional Care: Introduction ................................................... 4-58 433.477: Alternatives to Institutional Care: Adult Foster Care .......................................... 4-58 433.478: Alternatives to Institutional Care: Home Health Services ................................... 4-58 433.479: Alternatives to Institutional Care: Private Duty Nursing Services ...................... 4-59 433.480: Alternatives to Institutional Care: Adult Day Health Services ............................ 4-59 433.481: Alternatives to Institutional Care: Independent Living Programs ....................... 4-60 433.482: Alternatives to Institutional Care: Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) .......................................................................... 4-60 433.483: Alternatives to Institutional Care: Day Habilitation Centers ............................... 4-61 433.484: The Massachusetts Special Education Law (Chapter 766) ................................... 4-61 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-1 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 Part 1. General Information 433.401: Definitions The following terms used in 130 CMR 433.000 have the meanings given in 130 CMR 433.401 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 433.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 433.000 and in 130 CMR 450.000: Administrative and Billing Regulations. Acupuncture – the insertion of metal needles through the skin at certain points on the body, with or without the use of herbs, with or without the application of an electric current, and with or without the application of heat to the needles, skin, or both. Adult Office Visit – a medical visit by a member 21 years of age or older to a physician's office or to a hospital outpatient department. Child and Adolescent Needs and Strengths (CANS) – a tool that provides a standardized way to organize information gathered during behavioral-health clinical assessments. A Massachusetts version of the tool has been developed and is intended to be used as a treatment decision support tool for behavioral-health providers serving MassHealth members younger than 21 years old. Community-Based Physician – any physician, excluding interns, residents, fellows, and house officers, who is not a hospital-based physician. Consultant – a licensed physician whose practice is limited to a specialty and whose written advice or opinion is requested by another physician or agency in the evaluation or treatment of a member's illness or disability. Consultation – a visit made at the request of another physician. Controlled Substance – a drug listed in Schedule II, III, IV, V, or VI of the Massachusetts Controlled Substances Act (M.G.L. c. 94C). Cosmetic Surgery – a surgical procedure that is performed for the exclusive purpose of altering appearance and is unrelated to physical disease or defect, or traumatic injury. Couple Therapy – therapeutic services provided to a couple for whom the disruption of their marriage, family, or relationship is the primary reason for seeking treatment. Diagnostic Radiology Service – a radiology service intended to identify an injury or illness. Domiciliary – for use in the member's place of residence, including a long-term-care facility. Drug – a substance containing one or more active ingredients in a specified dosage form and strength. Each dosage form and strength is a separate drug. Emergency Admission Service – a complete history and physical examination by a physician of a member admitted to a hospital to treat an emergency medical condition, when definitive care of the member is assumed subsequently by another physician on the day of admission. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-2 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 Emergency Medical Condition – a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of the member or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in §1867(e)(1)(B) of the Social Security Act, 42 U.S.C. §1395dd(e)(1)(B). Emergency Services – medical services that are furnished by a provider that is qualified to furnish such services, and are needed to evaluate or stabilize an emergency medical condition. Family Planning – any medically approved means, including diagnosis, treatment, and related counseling, that helps individuals of childbearing age, including sexually active minors, to determine the number and spacing of their children. Family Therapy – a session for simultaneous treatment of two or more members of a family. Group Therapy – application of psychotherapeutic or counseling techniques to a group of persons, most of whom are not related by blood, marriage, or legal guardianship. High-Risk Newborn Care – care of a full-term newborn with a critical medical condition or of a premature newborn requiring intensive care. Home or Nursing Facility Visit – a visit by a physician to a member at a residence, nursing facility, extended care facility, or convalescent or rest home. Hospital-Based Entity – any entity that contracts with a hospital to provide medical services to members on the same site as the hospital's inpatient facility or hospital-licensed health center. Hospital-Based Physician – any physician, excluding interns, residents, fellows, and house officers, who contracts with a hospital to provide services to members on the same site as the hospital's inpatient facility or hospital-licensed health center. Hospital-Licensed Health Center – a facility that (1) operates under a hospital's license but is not physically attached to the hospital; (2) operates within the fiscal, administrative, and clinical management of the hospital; (3) provides services to patients solely on an outpatient basis; (4) meets all regulatory requirements for participation in MassHealth as a hospital-licensed health center; and (5) is enrolled with the MassHealth agency as a hospital-licensed health center with a separate hospital-licensed health center MassHealth provider number. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-7 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 (4) The physician practices outside a 50-mile radius of the Massachusetts border and obtains prior authorization from the MassHealth agency before providing a nonemergency service. Prior authorization will be granted only for services that are not available from comparable resources in Massachusetts, that are generally accepted medical practice, and that can be expected to benefit the member significantly. To request prior authorization, the out-of-state physician or the referring physician must send the MassHealth agency a written request detailing the proposed treatment and naming the treatment facility (see the instructions for requesting prior authorization in Subchapter 5 of the Physician Manual). The MassHealth agency will notify the member, the physician, and the proposed treatment facility of its decision. If the request is approved, the MassHealth agency will assist in any arrangements needed for transportation. 433.404: Nonpayable Circumstances (A) The MassHealth agency does not pay a physician for services provided under any of the following circumstances. (1) The services were provided by a physician who individually or through a group practice has contractual arrangements with an acute, chronic, or rehabilitation hospital, medical school, or other medical institution that involve a salary, compensation in kind, teaching, research, or payment from any other source, if such payment would result in dual compensation for professional, supervisory, or administrative services related to member care. (2) The services were provided by a physician who is an attending, visiting, or supervising physician in an acute, chronic, or rehabilitation hospital but who is not legally responsible for the management of the member's case with respect to medical, surgery, anesthesia, laboratory, or radiology services. (3) The services were provided by a physician who is a salaried intern, resident, fellow, or house officer. 130 CMR 433.404 does not apply to a salaried physician when the physician supplements his or her income by providing services during off-duty hours on premises other than those of the institution that pays the physician a salary, or through which the physician rotates as part of his or her training. (4) The services were provided in a state institution by a state-employed physician or physician consultant. (5) Under comparable circumstances, the physician does not customarily bill private patients who do not have health insurance. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-8 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 (B) The MassHealth agency does not pay a physician for performing, administering, or dispensing any experimental, unproven, cosmetic, or otherwise medically unnecessary procedure or treatment, specifically including, but not limited to, sex-reassignment surgery, thyroid cartilage reduction surgery, and any other related surgeries and treatments, including pre- and post-sex-reassignment surgery hormone therapy. Notwithstanding the preceding sentence, the MassHealth agency will continue to pay for post-sex-reassignment surgery hormone therapy for which it had been paying immediately prior to May 15, 1993. (C) The MassHealth agency does not pay a physician for the treatment of male or female infertility (including, but not limited to, laboratory tests, drugs, and procedures associated with such treatment); however, MassHealth does pay a physician for the diagnosis of male or female infertility. (D) The MassHealth agency does not pay a physician for otherwise payable service codes when those codes are used to bill for circumstances that are not payable pursuant to 130 CMR 433.404. 433.405: Maximum Allowable Fees The MassHealth agency pays for physician services with rates set by the Executive Office of Health and Human Services (EOHHS), subject to the conditions, exclusions, and limitations set forth in 130 CMR 433.000. EOHHS fees for physician services are contained in the following chapters of the Code of Massachusetts Regulations: (A) 114.3 CMR 14.00: Dental Services (B) 101 CMR 315.00: Vision Care Services and Ophthalmic Services (C) 114.3 CMR 16.00: Surgery and Related Anesthesia Services (D) 101 CMR 317.00: Medicine (E) 114.3 CMR 18.00: Radiology (F) 114.3 CMR 20.00: Clinical Laboratory Services 433.406: Individual Consideration (A) The MassHealth agency has designated certain services in Subchapter 6 of the Physician Manual as requiring individual consideration. This means that the MassHealth agency will establish the appropriate rate for these services based on the standards and criteria set forth in 130 CMR 433.406(B). Providers claiming payment for any service requiring individual consideration must submit with such claim a report that includes a detailed description of the service, and is accompanied by supporting documentation that may include, but is not limited to, an operative report, pathology report, or in the case of a purchase, a copy of the supplier's invoice. The MassHealth agency does not pay claims for services requiring individual consideration unless it is satisfied that the report and documentation submitted by the provider are adequate to support the claim. See 130 CMR 433.410 for report requirements. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-33 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 (D) Duplicate Services. Two or more identical diagnostic or therapeutic radiology services performed on one day for a member by one or more physicians are payable only if sufficient documentation for each is shown in the member's medical record. (E) Interventional Radiology. If interventional radiology services are performed by two providers, the professional component is divided equally into surgical and interpretative components. 433.438: Clinical Laboratory Services: Introduction Clinical laboratory services necessary for the diagnosis, treatment, and prevention of disease and for the maintenance of the health of a member are payable under MassHealth. (A) Provider Eligibility. The MassHealth agency pays for laboratory tests only when they are performed on a member by a physician or by an independent clinical laboratory certified by Medicare. (B) Payment. (1) Except for the circumstance described in 130 CMR 433.438(B)(2), the MassHealth agency pays a physician only for laboratory tests performed in the physician’s office. If a physician uses the services of an independent clinical laboratory, the MassHealth agency pays only the laboratory for services provided for a member. (2) A physician may bill the MassHealth agency for laboratory services provided on a fee-for-service basis by the state laboratory of the Massachusetts Department of Public Health. (C) Information with Specimen. A physician who sends a specimen to an independent clinical laboratory participating in MassHealth must also send the following: (1) a signed request for the laboratory services to be performed; (2) the member's MassHealth identification number; and (3) the physician's name, address, and provider number. 433.439: Clinical Laboratory Services: Service Limitations (A) Specimen Collections. The MassHealth agency does not pay a physician for routine specimen collection and preparation for the purpose of clinical laboratory analysis (for example, venipunctures; urine, fecal, and sputum samples; Pap smears; cultures; and swabbing and scraping for removal of tissue). However, the MassHealth agency will pay a physician who collects, centrifuges, and mails a specimen to a laboratory for analysis once per member specimen, regardless of the number of tests to be performed on that specimen. (B) Professional Component of Laboratory Services. The MassHealth agency does not pay a physician for the professional component of a clinical laboratory service. The MassHealth agency pays a physician for the professional component of an anatomical service (for example, bone marrow analysis or analysis of a surgical specimen). (C) Calculations. The MassHealth agency does not pay a physician for calculations such as red cell indices, A/G ratio, creatinine clearance, and those ratios calculated as part of a profile. Payment for laboratory services includes payment for all aspects involved in an assay. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-34 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 (D) Profile (or Panel) Tests. (1) A profile or panel test is defined as any group of tests, whether performed manually, automatedly, or semiautomatedly, that is ordered for a specified member on a specified day and has at least one of the following characteristics. (a) The group of tests is designated as a profile or panel by the physician performing the tests. (b) The group of tests is performed by the physician at a usual and customary fee that is lower than the sum of the physician's usual and customary fees for the individual tests in that group. (2) In no event may a physician bill or be paid separately for each of the tests included in a profile test when a profile test has either been performed by that physician or requested by an authorized person. (E) Forensic Services. The MassHealth agency does not pay for tests performed for forensic purposes or any purpose other than those described in 130 CMR 433.438, including but not limited to: (1) tests performed to establish paternity; (2) tests performed pursuant to, or in compliance with, a court order (for example, monitoring for drugs of abuse); and (3) post-mortem examinations. 433.440: Acupuncture (A) Introduction. MassHealth members are eligible to receive acupuncture for the treatment of pain as described in 130 CMR 433.440(C), for use as an anesthetic as described in 130 CMR 433.454(C), and for use for detoxification as described in 130 CMR 418.406(C)(3): Acupuncture Detoxification. (B) General. 130 CMR 433.440 applies specifically to physicians and licensed practitioners of acupuncture. (C) Acupuncture for the Treatment of Pain. MassHealth provides a total of 20 sessions of acupuncture for the treatment of pain per member per year without prior authorization. If the member’s condition, treatment, or diagnosis changes, the member may receive more sessions of medically-necessary acupuncture treatment with prior authorization. (D) Provider Qualifications for Acupuncture. (1) Qualified Providers. (a) Physicians (b) Other practitioners who are licensed in acupuncture by the Massachusetts Board of Registration in Medicine under 243 CMR 5.00: The Practice of Acupuncture. (2) Supervising physicians must ensure that acupuncture practitioners for whom the physician will submit claims, possess the appropriate training, credentials, and licensure. (E) Conditions of Payment. The MassHealth agency pays physicians, physician employers of an acupuncturist (in accordance with 130 CMR 433.401(F)), independent nurse practitioners licensed in acupuncture, or independent nurse midwives licensed in acupuncture for acupuncture services when the: (1) services are limited to the scope of practice authorized by state law or regulation (including but not limited to 243 CMR 5.00: The Practice of Acupuncture); Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 433.000) Page 4-35 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 (2) the acupuncturist has a current license or certificate of registration from the Massachusetts Board of Registration in Medicine; and (3) services are provided pursuant to a supervisory arrangement with a physician. (F) Acupuncture Claims Submissions. (1) Physicians, independent nurse practitioners licensed in acupuncture, and independent nurse midwives licensed in acupuncture may submit claims for acupuncture services when they provide those services directly to MassHealth members or as an exception to 130 CMR 450.301(A) when a licensed practitioner under the supervision of a physician provides those services directly to MassHealth members. See Subchapter 6 of the Physician Manual for service code descriptions and billing requirements. (2) For MassHealth members receiving services under any of the acupuncture codes on the same date of service as an office visit, the physician, independent nurse practitioner licensed in acupuncture, or independent nurse midwife licensed in acupuncture may bill for either an office visit or the acupuncture code, but may not bill for both an office visit and the acupuncture code for the same member on the same date when the office visit and the acupuncture services are performed in the same location. This limitation does not apply to a significant, separately identifiable office visit provided by the same provider on the same day of the acupuncture service. 433.441: Pharmacy Services: Prescription Requirements (A) Legal Prescription Requirements. The MassHealth agency pays for prescription drugs, over- the-counter drugs, and items listed on the Non-Drug Product List only if the pharmacy has in its possession a prescription that meets all requirements for a legal prescription under all applicable federal and state laws and regulations. Each prescription, for drugs in Schedules II through V must contain the prescriber’s unique DEA number. For Schedule VI drugs, if the prescriber has no DEA registration number, the prescriber’s Massachusetts Controlled Substance Registration number must appear on the prescription. (B) Emergencies. When the pharmacist determines that an emergency exists, the MassHealth agency will pay a pharmacy for at least a 72-hour, nonrefillable supply of the drug in compliance with state and federal regulations. Emergency dispensing to a MassHealth member who is enrolled in the Controlled Substance Management Program (CSMP) must comply with 130 CMR 406.442(C)(2). (C) Refills. (1) The MassHealth agency does not pay for prescription refills that exceed the specific number authorized by the prescriber. (2) The MassHealth agency pays for a maximum of 11 monthly refills, except in circumstances described at 130 CMR 433.441(C)(3), or where the MassHealth Drug List specifically limits the number of refills, duration of the prescription, or both. (3) The MassHealth agency pays for more than 11 refills within a 12-month period if such refills are for less than a 30-day supply and have been prescribed and dispensed in accordance with 130 CMR 433.441(D). (4) The MassHealth agency does not pay for any refill dispensed after one year from the date of the original prescription. (5) The absence of an indication to refill by the prescriber renders the prescription nonrefillable. (6) The MassHealth agency does not pay for any refill without an explicit request from a Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 433.000) Page 4-36 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 member or caregiver for each filling event. The possession by a provider of a prescription with remaining refills authorized does not in itself constitute a request to refill the prescription. (D) Quantities. (1) Days’ Supply Limitations. The MassHealth agency requires that all drugs be prescribed in a 30-day supply, unless the drug is available only in a larger minimum package size, except as specified in 130 CMR 433.441(D)(2). (2) Exceptions to Days’ Supply Limitations. (a) The MassHealth agency allows exceptions to the limitations described in 130 CMR 433.441(D)(1) for the following products: (i) drugs in therapeutic classes that are commonly prescribed for less than a 30-day supply, including but not limited to antibiotics and analgesics; (ii) drugs that, in the prescriber's professional judgment, are not clinically appropriate for the member in a 30-day supply; (iii) drugs that are new to the member, and are being prescribed for a limited trial amount, sufficient to determine if there is an allergic or adverse reaction or lack of effectiveness. The initial trial amount and the member's reaction or lack of effectiveness must be documented in the member's medical record; (iv) drugs packed in such a way that the smallest quantity that may be dispensed is larger than a 30-day supply (for example, inhalers, ampules, vials, eye drops, and other sealed containers not intended by the manufacturer to be opened by any person other than the end user of the product); (v) drugs in topical dosage forms that do not allow the pharmacist to accurately predict the rate of the product’s usage (for example, lotions or ointments); (vi) products generally dispensed in the original manufacturer’s packaging (for example, fluoride preparations, prenatal vitamins, and over-the-counter drugs); and (vii) methylphenidate and amphetamine prescribed in 60-day supplies; (b) Drugs paid for by a member’s primary insurance carrier that are dispensed in up to a 90-day supply when the MassHealth agency pays any portion of the claim, including the copayment portion or deductible, may be dispensed in up to a 90-day supply. (c) Drugs used for family planning may be dispensed in up to a 90-day supply. (E) Prescription-Splitting. Providers must not split prescriptions by filling them for a period or quantity less than that specified by the provider. For example, a prescription written for a single 30-day supply may not be split into three 10-day supplies. The MassHealth agency considers prescription-splitting to be fraudulent. (See 130 CMR 450.238(B)(6).) (F) Excluded, Suspended, or Terminated Clinicians. The MassHealth agency does not pay for prescriptions written by clinicians (1) who have been excluded from participation based on a notice by the U.S. Department of Health and Human Services Office of Inspector General; or (2) whom the MassHealth agency has suspended, terminated, or denied admission into its program for any other reason. 433.442: Pharmacy Services: Covered Drugs and Medical Supplies (A) Drugs. The MassHealth Drug List specifies the drugs that are payable under MassHealth. In addition, the following rules apply. (1) Prescription Drugs. The MassHealth agency pays only for prescription drugs that are approved by the U.S. Food and Drug Administration and manufactured by companies that have signed rebate agreements with the U.S. Secretary of Health and Human Services Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-37 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 pursuant to 42 U.S.C. 1396r-8. Payment is calculated in accordance with DHCFP regulations at 114.3 CMR 31.00: Prescribed Drugs. (2) Over-the-Counter Drugs. Payment by the MassHealth agency for over-the-counter drugs is calculated in accordance with DHCFP regulations at 114.3 CMR 31.00: Prescribed Drugs. (B) Non-drug Products Paid Through POPS. (1) The MassHealth agency pays through POPS, only for those products not classified as drugs that are listed on the non-drug product section of the MassHealth Drug List. (2) Non-drug Product List. Payment for these items is in accordance with rates published in the Division of Health Care Finance and Policy regulations at 114.3 CMR 22.00: Durable Medical Equipment, Oxygen, and Respiratory Therapy Equipment and 101 CMR 317.00: Medicine. The MassHealth Non-Drug Product List also specifies which of the included products require prior authorization. 433.443: Pharmacy Services: Limitations on Coverage of Drugs (A) Interchangeable Drug Products. The MassHealth agency pays no more for a brand-name interchangeable drug product than its generic equivalent, unless (1) the prescriber has requested and received prior authorization from the MassHealth agency for a nongeneric multiple-source drug (see 130 CMR 433.444); and (2) the prescriber has written on the face of the prescription in the prescriber's own handwriting the words "brand name medically necessary" under the words "no substitution" in a manner consistent with applicable state law. These words must be written out in full and may not be abbreviated. (B) Drug Exclusions. The MassHealth agency does not pay for the following types of prescription or over-the-counter drugs or drug therapy. (1) Cosmetic. The MassHealth agency does not pay for any drug used for cosmetic purposes or for hair growth. (2) Cough and Cold. The MassHealth agency does not pay for any drug used solely for the symptomatic relief of coughs and colds, including but not limited to, those that contain an antitussive or expectorant as a major ingredient, unless dispensed to a member who is a resident in a nursing facility or an intermediate care facility for the mentally retarded (ICF/MR). (3) Fertility. The MassHealth agency does not pay for any drug used to promote male or female fertility. (4) Obesity Management. The MassHealth agency does not pay for any drug used for the treatment of obesity. (5) Less-Than-Effective Drugs. The MassHealth agency does not pay for any drug products (including identical, similar, or related drug products) that the U.S. Food and Drug Administration has proposed, in a Notice of Opportunity for Hearing (NOOH), to withdraw from the market because they lack substantial evidence of effectiveness for all labeled indications. (6) Experimental and Investigational Drugs. The MassHealth agency does not pay for any drug that is experimental, medically unproven, or investigational in nature. (7) Drugs for Sexual Dysfunction. The MassHealth agency does not pay for any drug when used for the treatment of male or female sexual dysfunction. (C) Service Limitations. (1) MassHealth covers drugs that are not explicitly excluded under 130 CMR 433.443(B). The limitations and exclusions in 130 CMR 433.443(B) do not apply to medically necessary Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-38 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 drugs for MassHealth Standard enrollees under age 21. The MassHealth Drug List specifies the drugs that are payable under MassHealth. Any drug that does not appear on the MassHealth Drug List requires prior authorization, as set forth in 130 CMR 433.000. The MassHealth Drug List can be viewed online at www.mass.gov/druglist, and copies may be obtained upon request. (See 130 CMR 450.303: Prior Authorization.) (2) The MassHealth agency does not pay for the following types of drugs or drug therapy without prior authorization: (a) immunizing biologicals and tubercular (TB) drugs that are available free of charge through local boards of public health or through the Massachusetts Department of Public Health (DPH); (b) nongeneric multiple-source drugs; and (c) drugs related to sex-reassignment surgery, specifically including but not limited to, presurgery and postsurgery hormone therapy. The MassHealth agency, however, will continue to pay for post sex-reassignment surgery hormone therapy for which it had been paying immediately prior to May 15, 1993. (3) The MassHealth agency does not pay any additional fees for dispensing drugs in a unit- dose distribution system. (4) The MassHealth agency does not pay for any drug prescribed for other than the FDA- approved indications as listed in the package insert, except as the MassHealth agency determines to be consistent with current medical evidence. (5) The MassHealth agency does not pay for any drugs that are provided as a component of a more comprehensive service for which a single rate of pay is established in accordance with 130 CMR 450.307: Unacceptable Billing Practices. 433.444: Pharmacy Services: Insurance Coverage (A) Managed Care Organizations. The MassHealth agency does not pay pharmacy claims for services to MassHealth members enrolled in a MassHealth managed care organization (MCO) that provides pharmacy coverage through a pharmacy network or otherwise, except for family planning pharmacy services provided by a non-network provider to a MassHealth MCO enrollee (where such provider otherwise meets all prerequisites for payment for such services). A pharmacy that does not participate in the MassHealth member’s MCO must instruct the MassHealth member to take his or her prescription to a pharmacy that does participate in such MCO. To determine whether the MassHealth member belongs to an MCO, pharmacies must verify member eligibility and scope of services through POPS before providing service in accordance with 130 CMR 450.107: Eligible Members and the MassHealth Card and 450.117: Managed Care Participation. (B) Other Health Insurance. When the member’s primary carrier has a preferred drug list, the prescriber must follow the rules of the primary carrier first. The provider may bill the MassHealth agency for the primary insurer’s member copayment for the primary carrier’s preferred drug without regard to whether the MassHealth agency generally requires prior authorization, except in cases where the drug is subject to a pharmacy service limitation pursuant to 130 CMR 433.443(C)(2)(a) and (c). In such cases, the prescriber must obtain prior authorization from the MassHealth agency in order for the pharmacy to bill the MassHealth agency for the primary insurer’s member copayment. For additional information about third party liability, see 130 CMR 450.101 et seq. (C) Medicare Part D. (1) Overview. Except as otherwise required in 130 CMR 406.414(C)(2) and (3), for MassHealth members who have Medicare, the MassHealth agency does not pay for any Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-39 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 Medicare Part D drugs, or for any cost-sharing obligations (including premiums, copayments, and deductibles) for Medicare Part D drugs, whether or not the member has actually enrolled in a Medicare Part D drug plan. Medications excluded from the Medicare Part D drug program continue to be covered for MassHealth members eligible for Medicare, if they are MassHealth-covered medications. (2) Medicare Part D One-Time Supplies. The MassHealth agency pays for one-time supplies of prescribed medications if the medication is a MassHealth-covered medication and the MassHealth member would otherwise be entitled to MassHealth pharmacy benefits but for being eligible for Medicare prescription drug coverage. MassHealth prior authorization does not apply to such one-time supplies. The MassHealth agency pays for the one-time supplies in all instances in which the pharmacist cannot bill a Medicare Part D prescription drug plan at the time the prescription is presented. The MassHealth agency pays for a one-time 72-hour supply of prescribed medications. (3) Cost-Sharing Assistance for MassHealth Members Enrolled in a Medicare Part D Prescription Drug Plan. For the purpose of 130 CMR 433.444(C)(3)(a) and (b), the “applicable MassHealth copayment” is the copayment the MassHealth member would pay for prescription drugs if the drugs were covered by MassHealth and not covered by Medicare Part D. MassHealth members who are enrolled in a Medicare Part D prescription drug plan and are charged a copayment or deductible in excess of the member’s applicable MassHealth copayment for a drug that MassHealth would otherwise cover, must pay the applicable MassHealth copayment and the MassHealth agency pays the difference between the applicable MassHealth copayment and the amount charged by the Medicare Part D prescription drug plan. 433.445: Pharmacy Services: Prior Authorization (A) Prescribers must obtain prior authorization from the MassHealth agency for drugs identified by the MassHealth agency in accordance with 130 CMR 450.303. If the limitations on covered drugs specified in 130 CMR 433.442(A) and 433.443(A) and (C) would result in inadequate treatment for a diagnosed medical condition, the prescriber may submit a written request, including written documentation of medical necessity, to the MassHealth agency for prior authorization for an otherwise noncovered drug. (B) All prior-authorization requests must be submitted in accordance with the instructions for requesting prior authorization in Subchapter 5 of the Physician Manual. If the MassHealth agency approves the request, it will notify the pharmacy and the member. (C) The MassHealth agency will authorize at least a 72-hour emergency supply of a prescription drug to the extent required by federal law. (See 42 U.S.C. 1396r-8(d)(5).) The MassHealth agency acts on requests for prior authorization for a drug within a time period consistent with federal regulations. (D) Prior authorization does not waive any other prerequisites to payment such as, but not limited to, member eligibility or requirements of other health insurers. (E) The MassHealth Drug List specifies the drugs that are payable under MassHealth. Any drug that does not appear on the MassHealth Drug List requires prior authorization, as set forth in 130 CMR 406.000. MassHealth evaluates the prior-authorization status of drugs on an ongoing basis, and updates the MassHealth Drug List accordingly. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-40 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 433.446: Pharmacy Services: Member Copayments Under certain conditions, the MassHealth agency requires that members make a copayment to the dispensing pharmacy for each original prescription and for each refill for all drugs (whether prescription or over-the-counter) covered by MassHealth. The copayment requirements are detailed in 130 CMR 450.130. 433.447: Pharmacy Services: Payment Drugs and biologicals dispensed in the office are payable, subject to the service limitations at 130 CMR 433.404, 433.406, and 433.443. The MassHealth agency does not pay a physician separately for drugs that are considered routine and integral to the delivery of a physician’s professional services in the course of diagnosis or treatment. Such drugs are commonly provided without charge or are included in the physician’s fee for the service. The MassHealth agency does not pay separately for any oral drugs dispensed in the office for which the physician has not requested and received prior authorization from the MassHealth agency, with the exception of oral vaccines and oral radiopharmaceuticals, which do not require prior authorization. Claims for drugs and biologicals that are listed in Subchapter 6 of the Physician Manual must include the name of the drug or biological, strength, dosage, and number of units dispensed. A copy of the invoice showing the actual acquisition cost must be attached to the claim form for drugs and/or biologicals that are listed as requiring individual consideration in Subchapter 6 of the Physician Manual, and must include the National Drug Code (NDC). Claims without this information are denied. The MassHealth agency does not pay for a biological if the Massachusetts Department of Public Health distributes the biological free of charge. Payment for drugs may be claimed in addition to an office visit. (130 CMR 433.448 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-41 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 433.449: Fluoride Varnish Services (A) Eligible Members. Members must be younger than 21 years old to be eligible for the application of fluoride varnish. (B) Qualified Personnel. Physicians, nurse practitioners, registered nurses, licensed practical nurses, physician assistants, and medical assistants may apply fluoride varnish subject to the limitations of state law. To qualify to apply fluoride varnish, the individual must complete a MassHealth-approved training on the application of fluoride varnish, maintain proof of completion of the training, and provide such proof to the MassHealth agency upon request. (C) Billing for an Office Visit and Fluoride Varnish Treatment or Procedure. A physician may bill for fluoride varnish services provided by the physician or a qualified staff member as listed in 130 CMR 433.449(B) under the supervision of a physician. The physician may bill for an office visit, in addition to the fluoride varnish application, only if fluoride varnish was not the sole service, treatment, or procedure provided during the visit. (D) Claims Submission. Physicians and independent nurse practitioners may submit claims for fluoride varnish services when they provide those services directly to MassHealth members. These are the only MassHealth provider types who may bill for this service independently under 130 CMR 433.449. A physician may also submit claims for fluoride varnish services that are provided by nurse practitioners, registered nurses, licensed practical nurses, physician assistants, and medical assistants according to 130 CMR 433.449(C). See Subchapter 6 of the Physician Manual for service codes. (130 CMR 433.450 Reserved) Part 3. Surgery Services 433.451: Surgery Services: Introduction (A) Provider Eligibility. The MassHealth agency pays a physician for surgery only if the physician is scrubbed and present in the operating room during the major portion of the operation. (See 130 CMR 433.421(B)(2) for the single exception to this requirement.) (B) Nonpayable Services. The MassHealth agency does not pay for (1) any experimental, unproven, cosmetic, or otherwise medically unnecessary procedure or treatment. This specifically includes, but is not limited to, sex-reassignment surgery, thyroid cartilage reduction surgery, and any other related surgeries; (2) the treatment of male or female infertility (including, but not limited to, laboratory tests, drugs, and procedures associated with such treatment); however, MassHealth does pay for the diagnosis of male or female infertility; (3) reconstructive surgery, unless the MassHealth agency determines, pursuant to a request for prior authorization, the service is medically necessary to correct, repair, or ameliorate the physical effects of physical disease or defect, or traumatic injury; (4) services billed under codes listed in Subchapter 6 of the Physician Manual as not payable; (5) services otherwise identified in MassHealth regulations at 130 CMR 433.000 or 450.000 as not payable; and (6) services billed with otherwise covered service codes when such codes are used to bill for nonpayable circumstances as described in 130 CMR 433.404. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4. Program Regulations (130 CMR 433.000) Page 4-42 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 (C) Definitions. The following terms have the meanings given for purposes of 130 CMR 433.451 and 433.452, unless otherwise indicated. (1) Complications Following Surgery – all additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room. (2) Evaluation and Management (E/M) Services – visits and consultations furnished by physicians in various settings and of various complexities as defined in the Evaluation and Management section of the American Medical Association’s Current Procedural Terminology (CPT) code book. (3) Intraoperative Services – intraoperative services that are normally a usual and necessary part of a surgical procedure. (4) Major Surgery – a surgery for which the Centers for Medicare & Medicaid Services (CMS) determines the preoperative period is one day and the postoperative period is 90 days. (5) Minor Surgery – a surgery for which CMS determines the preoperative period is zero days and the postoperative period is zero or 10 days. (6) Postoperative Period – (a) The postoperative period for major surgery is 90 days. (b) The postoperative period for minor surgery and endoscopies is zero or 10 days. (7) Postoperative Visits – follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery. (8) Postsurgical Pain Management – postsurgical pain management by the surgeon, including supplies. (9) Preoperative Period – (a) The preoperative period for major surgery is one day. (b) The preoperative period for minor surgery is zero days. (10) Preoperative Visits – preoperative visits after the decision is made to operate, beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures. 433.452: Surgery Services: Payment Surgical services and other invasive procedures are listed in the surgery and medicine section of the American Medical Association’s Current Procedural Terminology (CPT) code book. The MassHealth agency pays for all medicine and surgery CPT codes in effect at the time of service, except for those codes listed in Section 602 of Subchapter 6 of the Physician Manual, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 433.000 and 450.000. (A) Visit and Treatment/Procedure on Same Day in Same Location. The MassHealth agency pays a physician for either a visit or a treatment/procedure, whichever fee is greater. The MassHealth agency does not pay for both a preoperative evaluation and management visit, and a treatment/procedure provided to a member on the same day when they are performed in the same location. For minor surgeries and endoscopies, the MassHealth agency does not pay separately for an evaluation and management service on the same day as the surgery or endoscopy. For payment information about obstetrical care, refer to 130 CMR 433.421. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 433.000) Page 4-45 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 (3) Submitting Claims for Certified Registered Nurse-Anesthetists. As an exception to 130 CMR 450.301(A), a physician or group practice who is an employer of or who contracts with a CRNA, may submit claims for services provided by a CRNA, but only if such services are provided in accordance with 130 CMR 450.301(B). Only one provider may claim payment for the services provided by the CRNA. (C) Acupuncture as an Anesthetic. The MassHealth agency pays for acupuncture as a substitute for conventional surgical anesthesia. 433.455: Abortion Services (A) Payable Services. (1) The MassHealth agency pays for an abortion service if both of the following conditions are met: (a) the abortion is a medically necessary abortion, or the abortion is performed upon a victim of rape or incest when such rape or incest has been reported to a law enforcement agency or public health service within 60 days of the incident; and (b) the abortion is performed in accordance with M.G.L. c. 112, §§12K through 12U, except as provided under 130 CMR 433.455(C)(2). (2) For the purposes of 130 CMR 433.455, a medically necessary abortion is one that, according to the medical judgment of a licensed physician, is necessary in light of all factors affecting the woman's health. (3) Unless otherwise indicated, all abortions referred to in 130 CMR 433.455 are payable abortions as defined in 130 CMR 433.455(A)(1) and (2). (B) Assurance of Member Rights. A provider must not use any form of coercion in the provision of abortion services. The MassHealth agency, any provider, or any agent or employee of a provider must not mislead any member into believing that a decision to have or not to have an abortion will adversely affect the member's entitlement to benefits or services for which the member would otherwise be eligible. The MassHealth agency has strict requirements for confidentiality of member records for abortion services as well as for all other medical services covered by MassHealth. (C) Locations in Which Abortions May Be Performed. Abortions must be performed in compliance with the following. (1) First-Trimester Abortion. A first-trimester abortion must be performed by a licensed and qualified physician in a clinic licensed by the Department of Public Health to perform surgical services, or in a hospital licensed by the Department of Public Health to perform medical and surgical services. (2) Second-Trimester Abortion. A second-trimester abortion must be performed by a licensed and qualified physician only in a hospital licensed by the Department of Public Health to perform medical and surgical services; provided, however, that up to and including the 18th week of pregnancy, a second-trimester abortion may be performed in a clinic that meets the requirements of 130 CMR 433.455(C)(1) where the attending physician certifies in the medical record that, in his or her professional judgment, a nonhospital setting is medically appropriate in the specific case. (3) Third-Trimester Abortion. A third-trimester abortion must be performed by a licensed and qualified physician only in a hospital licensed by the Department of Public Health to perform abortions and to provide facilities for obstetric services. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 433.000) Page 4-46 Physician Manual Transmittal Letter PHY-140 Date 01/01/14 (D) Certification for Payable Abortion Form. All physicians must complete a Certification for Payable Abortion (CPA-2) form and retain the form in the member’s record. (Instructions for obtaining the Certification for Payable Abortion form are in Appendix A of all provider manuals.) To identify those abortions that meet federal reimbursement standards, specified in 42 CFR 449.100 through 449.109, the MassHealth agency must secure on the CPA-2 form the certifications described in 130 CMR 433.455(D)(1), (2), and (3), when applicable. For all medically necessary abortions not included in 130 CMR 433.455(D)(1), (2), or (3), the certification described in 130 CMR 433.455(D)(4) is required on the CPA-2 form. The physician must indicate on the CPA-2 form which of the following circumstances is applicable, and must complete that portion of the form with the appropriate signatures. (1) Life of the Mother Would Be Endangered. The attending physician must certify that, in the physician’s professional judgment, the life of the mother would be endangered if the pregnancy were carried to term. (2) Severe and Long-Lasting Damage to Mother's Physical Health. The attending physician and another physician must each certify that, in his or her professional judgment, severe and long-lasting damage to the mother's physical health would result if the pregnancy were carried to term. At least one of the physicians must also certify that he or she is not an "interested physician," defined herein as one whose income is directly or indirectly affected by the fee paid for the performance of the abortion; or who is the spouse of, or another relative who lives with, a physician whose income is directly or indirectly affected by the fee paid for the performance of the abortion. (3) Victim of Rape or Incest. The physician is responsible for submitting with the claim form signed documentation from a law enforcement agency or public health service certifying that the person upon whom the procedure was performed was a victim of rape or incest that was reported to the agency or service within 60 days of the incident. (A public health service is defined as either an agency of the federal, state, or local government that provides health or medical services, or a rural health clinic, provided that the agency's principal function is not the performance of abortions.) The documentation must include the date of the incident, the date the report was made, the name and address of the victim and of the person who made the report (if different from the victim), and a statement that the report included the signature of the person who made the report. (4) Other Medically Necessary Abortions. The attending physician must certify that, in his or her medical judgment, for reasons other than those described in 130 CMR 433.455(D)(1), (2), and (3), the abortion performed was necessary in light of all factors affecting the mother's health. 433.456: Sterilization Services: Introduction (A) Covered Services. The MassHealth agency pays for a sterilization service provided to an eligible member only if all of the following conditions are met. (1) The member has voluntarily given informed consent for the sterilization procedure in the manner and at the time described in 130 CMR 433.457, and such consent is documented in the manner described in 130 CMR 433.458. (2) The member is at least 18 years old at the time consent is obtained. (3) The member is not mentally incompetent or institutionalized. 601 Introduction MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2013 code book for the descriptions for the service codes when billing for services provided to MassHealth members. MassHealth pays for all medicine, radiology, surgery, and anesthesia CPT codes in effect at the time of service, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 433.000 and 450.000, except for those codes listed in Section 602 of this subchapter, CPT Category II codes ending in F, and CPT Category III codes ending in T. A physician may request prior authorization 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 Physician Manual. . Section 602 lists CPT codes that are not payable under MassHealth. . Section 603 lists CPT codes that have special requirements or limitations. Beside each service code in Section 603 is an explanation of the requirement or limitation. . Section 604 lists Level II HCPCS codes that are payable under MassHealth. . Section 605 lists service code modifiers allowed under MassHealth. 602 Nonpayable CPT Codes Regardless of nonpayable status, a physician may request prior authorization for any medically necessary service for a MassHealth Standard or CommonHealth member younger than 21 years of age. MassHealth does not pay for services billed under the following codes. 10040 11922 11950 11951 11952 11954 15775 15776 15780 15781 15782 15783 15786 15787 15788 15789 15792 15793 15819 15824 15825 15826 15828 15829 15847 15876 15877 15878 15879 17340 17360 17380 19355 19396 20930 20936 20985 21120 21121 21122 21123 21245 21246 21248 21249 22526 22527 22841 22856 22861 22864 32491 32850 32855 32856 33930 33933 33940 33944 36415 36416 36468 36469 36591 36592 36598 38204 38207 38208 38209 38210 38211 38212 38213 38214 38215 41870 41872 43206 43252 43752 43842 43843 43845 44132 44705 44715 47133 47143 47144 47145 48160 48550 48551 50300 50323 50325 54900 54901 55200 55300 55400 55870 55970 55980 58321 58322 58323 58345 58350 58750 58752 58760 58970 58974 58976 59070 59072 59412 59897 61630 61635 61640 61641 61642 62287 63043 63044 65760 65765 65767 65771 69090 71552 72159 72198 73225 74263 75571 76140 76390 76496 76497 76498 77336 77370 77371 77372 77373 77401 77402 77403 77404 77406 77407 77408 77409 77411 77412 77413 77414 77416 77417 77418 77422 77423 77424 77425 77520 77522 77523 77525 77790 78267 78268 78351 80100 80101 80104 80500 80502 81200 81201 81202 81203 81205 81206 81207 81808 81209 81210 81211 81212 81213 81214 81215 81216 81217 81220 81221 81222 81223 81224 81225 81226 81227 81228 81229 81235 81240 81241 81242 81243 81244 81245 81250 81251 81252 81253 81254 81255 81256 81257 81260 81261 81262 81263 81264 81265 81266 81267 81270 81275 81280 81281 81282 81290 81291 81292 81293 81294 81295 81296 81297 81298 81299 81300 81301 81302 81303 81304 81310 81315 81316 81317 81318 81319 81321 81322 81323 81324 81325 81326 81330 81331 81332 81340 81341 81342 81350 81355 81370 81371 81372 81373 81374 81375 81376 81377 81378 81379 81380 81381 81382 81383 81400 81401 81402 81403 81404 81405 81406 81407 81408 81500 81503 81506 81508 81509 81510 81511 81512 81599 82075 82962 83987 84061 84145 84431 84830 86079 86305 86890 86891 86910 86911 86927 86930 86931 86932 86945 86950 86960 86965 86985 87150 87153 87493 87900 87901 87903 87904 88000 88005 88007 88012 88014 88016 88020 88025 88027 88028 88029 88036 88037 88040 88045 88099 88125 88333 88334 88738 88749 89250 89251 89253 89254 89255 89257 89258 89259 89260 89261 89264 89268 89272 89280 89281 89290 89291 89321 89322 89325 89329 89330 89331 89335 89342 89343 89344 89346 89352 89353 89354 89356 89398 90281 90283 90284 90287 90384 90386 90389 90396 90586 90633 90634 90644 90645 90646 90647 90648 90669 90680 90698 90700 90702 90708 90710 90712 90720 90721 90723 90743 90744 90748 90845 90863 90865 90875 90876 90880 90885 90889 90901 90911 90940 90989 90993 90997 90999 91112 91132 91133 92314 92315 92316 92317 92325 92352 92353 92354 92355 92358 92371 92531 92532 92533 92534 92548 92559 92560 92561 92562 92564 92597 92605 92606 92613 92615 92617 92630 92633 93660 93668 93770 93786 94005 94015 94644 94645 95012 95052 95120 95125 95130 95131 95132 95133 95134 95824 95965 95966 95967 95992 96000 96001 96002 96003 96004 96040 96101 96102 96103 96105 96111 96116 96118 96119 96120 96125 96150 96151 96152 96153 96154 96155 96376 96567 96902 96904 97005 97006 97014 97537 97545 97546 97755 98940 98941 98942 98943 98960 98961 98962 98966 98967 98968 98969 99001 99002 99024 99026 99027 99053 99056 99058 99060 99071 99075 99078 99080 99082 99090 99091 99100 99116 99135 99140 99143 99144 99145 99148 99149 99150 99172 99190 99191 99192 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99288 99315 99316 99339 99340 99354 99355 99356 99357 99358 99359 99360 99363 99364 99366 99367 99368 99374 99375 99377 99378 99379 99380 99401 99402 99403 99404 99406 99408 99409 99411 99412 99420 99429 99441 99443 99444 99450 99442 99455 99456 99485 99486 99487 99488 99489 99495 99496 99500 99501 99502 99503 99504 99505 99506 99507 99509 99510 99511 99512 99601 99602 99605 99606 99607 603 Codes That Have Special Requirements or Limitations The service codes in this section are payable by MassHealth, subject to all conditions and limitations in MassHealth regulations at 130 CMR 433.000 and 450.000, but require specific attachments or prior authorization, or have other specific instructions or limitations. Refer to Section 604 for specific requirements or limitations for HCPCS Level II codes. Legend Centrifuging required: Service Code 99000 may be used only to pay a physician who centri- fuges and mails a specimen to a laboratory for analysis. (See 130 CMR 433.439.) Covered for members . 12: This code is payable only for members aged 12 years or older; available free of charge through the Massachusetts Immunization Program for children under 12 years of age. Covered for members 19 to 26: This code is payable only for members aged 19 to 26 years; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. Covered for members birth to 21: This code is payable only for members aged birth to 21 years; used to claim for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your provider manual, must be accompanied by modifiers found in Section 605 under Modifiers for Behavioral Health Screening. Covered for members .. 19.. This code is payable only for members aged 19 or older; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. CPA-2: A completed Certification of Payable Abortion Form must be completed for all induced abortions, except medically induced abortions. See 130 CMR 450.234 through 450.260 and 130 CMR 433.455 for more information. CS-18: A completed Sterilization Consent Form (for members aged 18 through 20) must be completed. See 130 CMR 450.234 through 450.260 and 130 CMR 433.456 through 433.458 for more information. CS-21: A completed Sterilization Consent Form (for members aged 21 and older) must be completed. See 130 CMR 450.234 through 450.260 and 130 CMR 433.456 through 433.458 for more information. HI-1: A completed Hysterectomy Information Form must be completed. See 130 CMR 450.234 through 450.260 and 130 CMR 433.459 for more information. IC: Claim requires individual consideration. See 130 CMR 433.406 for more information. PA for OMT > 20: Prior authorization is required for more than 20 osteopathic manipulative therapy visits in a 12-month period. PA for OT > 20: Prior authorization is required for more than 20 occupational therapy visits in a 12-month period. PA for PT > 20: Prior authorization is required for more than 20 physical therapy visits, regardless of modality, in a 12-month period. PA for ST > 35: Prior authorization is required for more than 35 speech/language therapy visits in a 12-month period. PA for Units > 8: Prior authorization is required for claims submitted with greater than 8 units on a given date of service. PA: Service requires prior authorization. See 130 CMR 433.408 for more information. Urgent Care Only: Service Codes 99050 and 99051 may be used only for urgent care provided in the office after hours, in addition to the basic service. Service Code and Req. or Limit Service Code and Req. or Limit 01999 IC 11920 PA 11921 PA 15820 PA 15821 PA 15822 PA 15823 PA 15830 PA 15832 PA 15833 PA 15834 PA 15835 PA 15836 PA 15837 PA 15838 PA 15839 PA 15999 IC 17999 IC 19300 PA 19316 PA 19318 PA 19324 PA 19325 PA 19328 PA 19350 PA 19499 IC 20999 IC 21085 PA 21088 IC 21089 IC 21137 PA 21138 PA 21139 PA 21146 PA 21147 PA 21150 PA 21151 PA 21154 PA 21155 PA 21159 PA 21160 PA 21172 PA 21175 PA 21188 PA 21193 PA 21194 PA 21195 PA 21196 PA 21198 PA 21206 PA 21208 PA 21209 PA 21210 PA 21215 PA 21230 PA 21235 PA 21240 PA 21242 PA 21243 PA 21244 PA 21247 PA 21255 PA 21256 PA 21299 PA; IC 21499 IC 21742 IC 21743 IC 21899 IC 22857 PA 22862 PA 22865 PA 22899 IC 22999 IC 23929 IC 24940 IC 24999 IC 25999 IC 26989 IC 27299 IC 27599 IC 27899 IC 28890 PA 28899 IC 29799 IC 29800 PA 29804 PA 29999 IC 30400 PA 30410 PA 30420 PA 30430 PA 30435 PA 30450 PA 30999 IC 31299 IC 31599 IC 31899 IC 32851 PA 32852 PA 32853 PA 32854 PA 32999 IC 33935 PA 33945 PA 33981 IC 33982 IC 33983 IC 33999 IC 36299 IC 36470 PA 36471 PA 37501 IC 37799 IC 38129 IC 38230 PA 38240 PA 38241 PA 38242 PA 38589 IC 38999 IC 39499 IC 39599 IC 40799 IC 40840 PA 40842 PA 40843 PA 40844 PA 40845 PA 40899 IC 41599 IC 41820 PA; IC 41821 IC 41850 IC 41899 IC 42280 PA 42281 PA 42299 IC 42699 IC 42999 IC 43289 IC 43499 IC 43644 PA 43645 PA 43647 PA; IC 43648 IC 43659 IC 43770 PA 43771 PA 43772 PA 43773 PA 43774 PA 43775 PA 43846 PA 43847 PA 43848 PA 43881 PA; IC 43882 IC 43886 PA 43887 PA 43888 PA 43999 IC 44133 IC 44135 PA; IC 44136 PA; IC 44238 IC 44799 IC 44899 IC 44979 IC 45499 IC 45999 IC 46999 IC 47135 PA 47136 PA 47379 IC 47399 IC 47579 IC 47999 IC 48554 PA 48999 IC 49329 IC 49659 IC 49906 IC 49999 IC 50549 IC 50949 IC 51925 HI-1 51999 IC 53899 IC 54400 PA 54401 PA 54405 PA 54440 IC 54699 IC 55250 CS-18 or CS-21 55450 CS-18 or CS-21 55559 IC 55899 IC 56800 PA 56805 IC 57335 IC 58150 HI-1 58152 HI-1 58180 HI-1 58200 HI-1 58210 HI-1 58240 HI-1 58260 HI-1 58262 HI-1 58263 HI-1 58267 HI-1 58270 HI-1 58275 HI-1 58280 HI-1 58285 HI-1 58290 HI-1 58291 HI-1 58292 HI-1 58293 HI-1 58294 HI-1 58541 HI-1 58542 HI-1 58543 HI-1 58544 HI-1 58548 HI-1 58550 HI-1 58552 HI-1 58553 HI-1 58554 HI-1 58565 CS-18 or CS-21 58570 HI-1 58571 HI-1 58572 HI-1 58573 HI-1 58578 IC 58579 IC 58600 CS-18 or CS-21 58605 CS-18 or CS-21 58611 CS-18 or CS-21 58615 CS-18 or CS-21 58661 CS-18 or CS-21 58670 CS-18 or CS-21 58671 CS-18 or CS-21 58679 IC 58951 HI-1 58956 HI-1 58999 IC 59135 HI-1 59525 HI-1 59840 CPA-2 (first trimester) 59841 CPA-2 (first trimester) 59850 CPA-2 (second trimester, third trimester in hospital only) 59851 CPA-2 (second trimester, third trimester in hospital only) 59852 CPA-2 (second trimester, third trimester in hospital only) 59855 CPA-2 59856 CPA-2 59857 CPA-2 59898 IC 59899 IC 60659 IC 60699 IC 64650 PA 64653 PA 64999 IC 65757 IC 66999 IC 67299 IC 67399 IC 67599 IC 67900 PA 67901 PA 67902 PA 67903 PA 67904 PA 67906 PA 67908 PA 67999 IC 68399 IC 68899 IC 69300 PA 69399 IC 69710 IC 69799 IC 69930 PA 69949 IC 69979 IC 74261 PA 74262 PA 76499 IC 76999 IC 77058 PA 77059 PA 77299 IC 77399 IC 77499 IC 77799 IC 78099 IC 78199 IC 78299 IC 78399 IC 78499 IC 78599 IC 78699 IC 78799 IC 78999 IC 79999 IC 81099 IC 81479 IC 84999 IC 85999 IC 86152 IC 86153 IC 86849 IC 86999 IC 87999 IC 88199 IC 88299 IC 88384 IC 88399 IC 89240 IC 90288 IC 90291 IC 90296 IC 90378 PA; IC 90393 PA; IC 90399 IC 90476 IC 90477 IC 90581 IC 90632 Covered for adults . . .. ; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90636 IC 90649 Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90650 Covered for female members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90653 IC; Covered for members = 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90654 IC; Covered for members = 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90661 IC 90662 IC 90664 IC 90666 IC 90667 IC 90668 IC 90670 IC; Covered for members .. 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90672 IC; Covered for members > 19 < 49; available free-of-charge through the Massachusetts Immunization Program for children under 19 years of age. 90676 IC 90681 IC; Covered for members . . 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90690 IC 90692 IC 90693 IC 90696 IC 90707 Covered for members .. 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90713 Covered for members .. 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90715 Covered for members . 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90716 Covered for members .. 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90719 IC 90725 IC 90727 IC 90732 Covered for members .. 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90734 IC; Covered for members .. 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90736 IC; PA is required for members less than age 50 90738 IC 90739 IC; Covered for members = 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90749 IC 90867 IC 90868 IC 90899 IC 90935 For hospitalized member only; not for chronic maintenance 90937 For hospitalized member only; not for chronic maintenance 90945 For hospitalized member only; not for chronic maintenance 90947 For hospitalized member only; not for chronic maintenance 90952 IC 90953 IC 91110 PA 91111 PA 91299 IC 92065 PA 92250 PA 92310 PA; includes supply of lenses 92311 PA; includes supply of lenses 92312 PA; includes supply of lenses 92313 PA; includes supply of lenses 92326 PA 92499 IC 92506 PA for ST >35 92507 PA for ST >35 92508 PA for ST >35 92526 PA for ST >35 92588 IC 92610 PA for ST >35 92700 IC 92992 IC 92993 IC 93229 IC 93299 IC 93745 IC 93799 IC 93998 IC 94772 IC 94774 IC 94775 IC 94776 IC 94777 IC 94799 IC 95199 IC 95803 IC 95999 IC 96110 Developmental screening, with interpretation and report, per standardized instrument form. Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; must be accompanied by modifiers found in Section 605 under Behavioral Health Screening Modifiers to indicate whether a behavioral health need was identified. 96379 IC 96549 IC 96999 IC 97001 PA for PT >20 97002 PA for PT >20 97003 PA for OT >20 97004 PA for OT >20 97010 PA for PT >20 97012 PA for PT >20 97016 PA for PT >20 97018 PA for PT >20 97022 PA for PT >20 97024 PA for PT >20 97026 PA for PT >20 97028 PA for PT >20 97032 PA for PT >20 97033 PA for PT >20 97034 PA for PT >20 97035 PA for PT >20 97036 PA for PT >20 97039 PA for PT >20; IC 97110 PA for PT >20 97112 PA for PT >20 97113 PA for PT >20 97116 PA for PT >20 97124 PA for PT >20 97139 PA for PT >20; IC 97140 PA for PT >20 97150 PA for PT >20 97530 PA for OT >20 97532 PA for OT >20 97533 PA for OT >20 97535 PA for OT >20 97542 PA for OT >20 97760 PA for OT >20 97761 PA for OT >20 97762 PA for OT >20 97799 IC 98925 PA for OMT >20 98926 PA for OMT >20 98927 PA for OMT >20 98928 PA for OMT >20 98929 PA for OMT >20 99000 Centrifuging required 99050 Urgent care only 99051 Urgent care only 99070 IC; excluding family planning supplies, such as trays, used in the collection of specimens 99174 PA 99195 For hematologic disorders only 99199 IC 99499 IC 99600 IC 604 Payable HCPCS Level II Service Codes This section lists Level II HCPCS codes that are payable under MassHealth. Refer to the Centers for Medicare & Medicaid Services website at www.cms.gov/medicare/hcpcs for more detailed descriptions when billing for Level II HCPCS codes provided to MassHealth members. Service Code Service Description A4261 Cervical cap for contraceptive use (IC) A4266 Diaphragm for contraceptive use A4267 Contraceptive supply, condom, male, each A4268 Contraceptive supply, condom, female, each A4269 Contraceptive supply, spermicide (e.g., foam, gel), each A4641 Radiopharmaceutical, diagnostic, not otherwise classified (IC) A4648 Tissue marker, implantable, any type, each (IC) A9500 Technetium Tc-99m sestamibi, diagnostic, per study dose (IC) A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose (IC) A9503 Technetium Tc-99m medronate, diagnostic, per study, up to 30 millicuries (IC) A9505 Thallium T1-201 thallous chloride, diagnostic, per millicurie (IC) A9512 Technetium Tc-99m pertechnetate, diagnostic, per millicurie (IC) A9537 Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries (IC) D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients (once per three-month period) G0027 Semen analysis: presence and/or mobility of sperm excluding Huhner G0105 Colorectal cancer screening; colonoscopy on individual at high risk G0108 Diabetes outpatient self-management training services, individual, per 30 minutes G0109 Diabetes outpatient self-management training services, group session (two or more), per 30 minutes G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0202 Screening mammography, producing direct digital image, bilateral, all views G0204 Diagnostic mammography, producing direct digital image, bilateral, all views G0206 Diagnostic mammography, producing direct digital image, unilateral, all views 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 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 G0431 Drug screen qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter G0434 Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter J0129 Injection, abatacept, 10 mg (PA) J0131 Injection, acetaminophen, 10 mg (IC) J0135 Injection, adalimumab, 20 mg (PA) J0171 Injection, Adrenalin, epinephrine, 0.1 mg (IC) J0178 Injection, aflibercept, 1 mg (PA) J0215 Injection, alefacept, 0.5 mg (PA) J0221 Injection, alglucosidase alfa (Lumizyme), 10 mg (PA) (IC) J0256 Injection, alpha 1-proteinase inhibitor–human, 10 mg J0257 Injection, alpha 1 proteinase inhibitor (human) (GLASSIA), 10 mg (IC) J0290 Injection, ampicillin sodium, 500 mg J0295 Injection, ampicillin sodium/sulbactam sodium, per 1.5 g J0348 Injection, anidulafungin, 1 mg J0456 Injection, azithromycin, 500 mg J0461 Injection, atropine sulfate, 0.01 mg J0475 Injection, baclofen, 10 mg J0476 Injection, baclofen, 50 mcg for intrathecal trial J0485 Injection, belatacept, 1 mg (PA) J0490 Injection, belimumab, 10 mg (PA) (IC) J0558 Injection, penicillin G benzathine and penicillin G procaine, 100,000 units (IC) J0561 Injection, penicillin G benzathine, 100,000 units (IC) J0585 Injection onabotulinumtoxinA, 1 unit (PA) J0586 Injection, abobotulinumtoxinA, 5 units (PA) J0587 Injection rimabotulinumtoxinB, 100 units (PA) J0588 Injection, incobotulinumtoxinA, 1 unit (PA) (IC) J0592 Injection, buprenorphine HCl, 0.1 mg J0597 Injection, C-1 esterase inhibitor (human), Berinert, 10 units (IC) J0598 Injection, C1 esterase inhibitor (human), Cinryze, 10 units (PA) J0638 Injection, canakinumab, 1 mg (PA) (IC) J0640 Injection, leucovorin calcium, per 50 mg J0690 Injection, cefazolin sodium, 500 mg J0694 Injection, cefoxitin sodium, 1 g J0696 Injection, ceftriaxone sodium, per 250 mg J0697 Injection, sterile cefuroxime sodium, per 750 mg J0702 Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg J0715 Injection, ceftizoxime sodium, per 500 mg (PA) (IC) J0716 Injection, centruroides immune f(ab)2, up to 120 milligrams (IC) J0718 Injection, certolizumab pegol, 1 mg (PA) J0775 Injection, collagenase, clostridium histolyticum, 0.01 mg (PA) (IC) J0780 Injection, prochlorperazine, up to 10 mg J0833 Injection, cosyntropin, not otherwise specified, 0.25 mg J0834 Injection, cosyntropin (Cortrosyn), 0.25 mg J0840 Injection, crotalidae polyvalent immune fab (ovine), up to 1 g (IC) J0881 Injection, darbepoetin alfa, 1 mcg (non-ESRD use) (PA) J0882 Injection, darbepoetin alfa, 1 mcg (for ESRD on dialysis) (PA) J0885 Injection, epoetin alfa (for non-ESRD use), 1000 units (PA) J0886 Injection, epoetin alfa, 1000 units (for ESRD on dialysis) (PA) J0890 Injection, peginesatide, 0. 1 mg (for esrd on dialysis) (PA) J0897 Injection, denosumab, 1 mg (PA) (IC) J0900 Injection, testosterone enanthate and estradiol valerate, up to 1 cc (IC) J1020 Injection, methylprednisolone acetate, 20 mg J1030 Injection, methylprednisolone acetate, 40 mg J1040 Injection, methylprednisolone acetate, 80 mg J1050 Injection, medroxyprogesterone acetate, 1 mg J1060 Injection, testerone cypionate and estradiol cypionate, up to 1 ml J1070 Injection, testosterone cypionate, up to 100 mg J1080 Injection, testosterone cypionate, 1 cc, 200 mg J1094 Injection, dexamethasone acetate, 1 mg J1100 Injection, dexamethosone sodium phosphate, 1 mg J1160 Injection, digoxin, up to 0.5 mg J1170 Injection, hydromorphone, up to 4 mg J1200 Injection, diphenhydramine HCl, up to 50 mg J1260 Injection, dolasetron mesylate, 10 mg J1290 Injection, ecallantide, 1 mg (IC) J1300 Injection, eculizumab, 10 mg (IC) J1320 Injection, amitriptyline HCl, up to 20 mg (IC) J1438 Injection, etanercept, 25 mg (PA) J1440 Injection, filgrastim (G-CSF), 300 mcg J1441 Injection, filgrastim (G-CSF), 480 mcg J1460 Injection, gamma globulin, intramuscular, 1 cc J1557 Injection, immune globulin, (Gammaplex), intravenous, nonlyophilized (e.g., liquid), 500 mg (PA) (IC) J1559 Injection, immune globulin (Hizentra), 100 mg (PA) (IC) J1561 Injection, immune globulin, (Gamunex), intravenous, nonlyophilized (e.g., liquid), 500 mg J1562 Injection, immune globulin, (Vivaglobin), 100 mg (PA) J1566 Injection, immune globulin, intravenous, lyophilized (e.g., powder), not otherwise specified, 500 mg (PA) J1569 Injection, immune globulin (Gammagard liquid), intravenous, nonlyophilized (e.g., liquid), 500 mg (PA) J1571 Injection, hepatitis B immune globulin (Hepagam B), intramuscular, 0.5 ml J1580 Injection, garamycin, gentamicin, up to 80 mg J1599 Injection, immune globulin, intravenous, nonlyophilized (e.g., liquid), not otherwise specified, 500 mg (PA) (IC) J1626 Injection, granisetron HCl, 100 mcg J1630 Injection, haloperidol, up to 5 mg J1650 Injection, enoxaparin sodium, 10 mg J1655 Injection, tinzaparin sodium, 1000 IU J1670 Injection, tetanus immune globulin, human, up to 250 units J1710 Injection, hydrocortisone sodium phosphate, up to 50 mg (IC) J1720 Injection, hydrocortisone sodium succinate, up to 100 mg J1725 Injection, hydroxyprogesterone caproate, 1 mg (PA) (IC) J1740 Injection, ibandronate sodium, 1 mg (PA) J1743 Injection, idursulfase, 1 mg (IC) J1744 Injection, icatibant, 1 mg (PA) (IC) J1745 Injection, infliximab, 10 mg (PA) J1750 Injection, iron dextran, 50 mg J1786 Injection, imiglucerase, 10 units (PA) (IC) J1790 Injection, droperidol, up to 5 mg J1800 Injection, propranolol HCl, up to 1 mg J1826 Injection, interferon beta-1a, 30 mcg (IC) J1885 Injection, ketorolac, tromethamine, per 15 mg J1890 Injection, cephalothin sodium, up to 1 g (IC) J1950 Injection, leuprolide acetate (for depot suspension), per 3.75 mg (PA) J1956 Injection, levofloxacin, 250 mg J1990 Injection, chlordiazepoxide HCl, up to 100 mg J2060 Injection, lorazepam, 2 mg J2150 Injection, mannitol, 25% in 50 ml J2175 Injection, meperidine HCl, per 100 mg J2212 Injection, methylnaltrexone, 0. 1 mg (IC) (PA) J2248 Injection, micafungin sodium, 1 mg J2250 Injection, midazolam HCl, per 1 mg J2265 Injection, minocycline HCl, 1 mg (IC) J2270 Injection, morphine sulfate, up to 10 mg J2271 Injection, morphine sulfate, 100 mg J2275 Injection, morphine sulfate (preservative-free sterile solution), per 10 mg J2300 Injection, nalbuphine HCl, per 10 mg J2310 Injection, naloxone HCl, per 1 mg J2315 Injection, naltrexone, depot form, 1 mg (PA) J2323 Injection, natalizumab, 1 mg J2355 Injection, oprelvekin, 5 mg (PA) J2357 Injection, omalizumab, 5 mg (PA) J2358 Injection, olanzapine, long-acting, 1 mg (PA) (IC) J2405 Injection, ondansetron HCl, per 1 mg J2426 Injection, paliperidone palmitate extended release, 1 mg (PA) (IC) J2430 Injection, pamidronate disodium, per 30 mg J2440 Injection, papaverine HC1, up to 60 mg J2469 Injection, palonosetron HCl, 25 mcg J2503 Injection, pegaptanib sodium, 0.3 mg J2505 Injection, pegfilgrastim, 6 mg J2507 Injection, pegloticase, 1 mg (PA) (IC) J2510 Injection, penicillin G procaine, aqueous, up to 600,000 units J2515 Injection, pentobarbital sodium, per 50 mg J2550 Injection, promethazine HCl, up to 50 mg J2560 Injection, phenobarbital sodium, up to 120 mg J2562 Injection, plerixafor, 1 mg J2675 Injection, progesterone, per 50 mg J2680 Injection, fluphenazine decanoate, up to 25 mg J2760 Injection, phentolamine mesylate, up to 5 mg J2778 Injection, ranibizumab, 0.1 mg J2785 Injection, regadenoson, 0.1 mg J2788 Injection, Rho D immune globulin, human, minidose, 50 mcg J2790 Injection, Rho D immune globulin, human, full dose, 300 mcg J2792 Injection, Rho D immune globulin, intravenous, human, solvent detergent, 100 IU J2793 Injection, rilonacept, 1 mg (PA) J2794 Injection, risperidone, long acting, 0.5 mg J2796 Injection, romiplostim, 10 mcg (PA) J2820 Injection, sargramostim (GM-CSF), 50 mcg J2910 Injection, aurothioglucose, up to 50 mg (IC) J2916 Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg J2920 Injection, methylprednisolone sodium succinate, up to 40 mg J2930 Injection, methylprednisolone sodium succinate, up to 125 mg J2940 Injection, somatrem, 1 mg (PA) (IC) J2941 Injection, somatropin, 1 mg (PA) J3010 Injection, fentanyl citrate, 0.1 mg J3030 Injection, sumatriptan succinate, 6 mg J3095 Injection, telavancin, 10 mg (PA) (IC) J3110 Injection, teriparatide, 10 mcg (PA) (IC) J3120 Injection, testosterone enanthate, up to 100 mg J3130 Injection, testosterone enanthate, up to 200 mg J3230 Injection, chlorpromazine HCl, up to 50 mg J3240 Injection, thyrotropin alpha, 0.9 mg. provided in 1.1 mg vial J3243 Injection, tigecycline, 1 mg J3250 Injection, trimethobenzamide HCl, up to 200 mg J3262 Injection, tocilizumab, 1 mg (PA) (IC) J3301 Injection, triamcinolone acetonide, not otherwise specified, 10 mg J3302 Injection, triamcinolone diacetate, per 5 mg J3303 Injection, triamcinolone hexacetonide, per 5 mg J3357 Injection, ustekinumab, 1 mg (PA) (IC) J3360 Injection, diazepam, up to 5 mg J3385 Injection, velaglucerase alfa, 100 units (PA) (IC) J3396 Injection, verteporfin, 0.1 mg J3410 Injection, hydroxyzine HCl, up to 25 mg J3411 Injection, thiamine HCI, 100 mg J3430 Injection, phytonadione (vitamin K), per 1 mg J3487 Injection, zoledronic acid (Zometa), 1 mg J3490 Unclassified drugs (IC) J3490-FP Unclassified drugs (service provided as part of Medicaid family planning program) (Use for medications and injectables related to family planning services, with the exception of Rho (D) human immune globulin, and contraceptive injectables such as Depo-Provera, items for which MassHealth will pay the provider's costs.) (IC) J3590 Unclassified biologics (IC) J7030 Infusion, normal saline solution, 1,000 cc J7060 5% dextrose/water (500 ml = 1 unit) J7070 Infusion, D-5-W, 1,000 cc J7131 Hypertonic saline solution, 1 ml (IC) J7178 Injection, human fibrinogen concentrate, 1 mg (IC) J7302 Levonorgestrel-releasing intrauterine contraceptive system, 52 mg (IC) J7303 Contraceptive supply, hormone containing vaginal ring, each (IC) J7304 Contraceptive supply, hormone containing patch, each (IC) J7307 Etonogestrel (contraceptive) implant system, including implant and supplies (IC) J7309 Methyl aminolevulinate (MAL) for topical administration, 16.8%, 1 g (IC) J7312 Injection, dexamethasone, intravitreal implant, 0.1 mg (IC) J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose (PA) J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose (PA) J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose (PA) J7325 Hyaluronan or derivative, Synvisc or Synvisc-One for intra-articular injection, 1 mg (PA) J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose (PA) (IC) J7335 Capsaicin 8% patch, per 10 sq cm (PA) (IC) J7527 Everolimus, oral, 0. 25 mg J7599 Immunosuppressive drug, not otherwise specidfied (IC) J7608 Acetylcysteine, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit-dose form, per g J7614 Levalbuterol, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose, 0.5 mg (PA) J7620 Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, noncompounded, administered through DME J7626 Budesonide, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, up to 0.5 mg J7633 Budesonide, inhalation solution, FDA-approved final product, noncompounded, administered through DME, concentrated form, per 0.25 mg (IC) J7639 Dornase alpha, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per mg J7644 Ipratropium bromide, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per mg J7665 Mannitol, administered through an inhaler, 5 mg (IC) J7669 Metaproterenol sulfate, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, per 10 mg J7676 Pentamidine isethionate, inhalation solution, compounded product, administered through DME, unit dose form, per 300 mg (IC) J7682 Tobramycin, inhalation solution, FDA-approved final product, noncompounded, unit dose form, administered through DME, per 300 mg J7686 Treprostinil, inhalation solution, FDA-approved final product, noncompounded, administered through DME, unit dose form, 1.74 mg (PA) (IC) J7699 NOC drugs, inhalation solution administered through DME (IC) J7799 NOC drugs, other than inhalation drugs, administered through DME (IC) J8562 Fludarabine phosphate, oral, 10 mg (IC) J9000 Injection, doxorubicin HCl, 10 mg J9002 Injection, doxorubicin hydrochloride, liposomal, doxil, 10 mg J9019 Injection, asparaginase (erwinaze), 1,000 iu (PA) J9025 Injection, azacitidine, 1 mg J9031 BCG (intravesical), per instillation J9035 Injection, bevacizumab, 10 mg J9040 Injection bleomycin sulfate, 15 units J9041 Injection, bortezomib, 0.1 mg J9042 Injection, brentuximab vedotin, 1 mg (PA) J9043 Injection, cabazitaxel, 1 mg (PA) (IC) J9045 Injection, carboplatin, 50 mg J9055 Injection, cetuximab, 10 mg J9060 Injection, cisplatin, powder or solution, 10 mg J9070 Injection, cyclophosphamide, 100 mg J9130 Dacarbazine, 100 mg J9155 Injection, degarelix, 1 mg (PA) J9171 Injection, docetaxel, 1 mg J9178 Injection, epirubicin HCl, 2 mg J9179 Injection, eribulin mesylate, 0.1 mg (PA) (IC) J9181 Injection, etoposide, 10 mg J9190 Injection, fluorouracil, 500 mg J9201 Injection, gemcitabine HC1, 200 mg J9202 Goserelin acetate implant, per 3.6 mg (PA) J9206 Injection, irinotecan, 20 mg J9212 Injection, interferon alfacon-1, recombinant, 1 mcg J9213 Injection, interferon, alfa-2a, recombinant, 3 million units J9214 Injection, interferon, alfa-2b, recombinant, 1 million units J9215 Injection, interferon alfa-N3 (human leukocyte derived), 250,000 IU (IC) J9216 Injection, interferon gamma-1-b, 3 million units J9217 Leuprolide acetate (for depot suspension), 7.5 mg (PA) J9218 Leuprolide acetate, per 1 mg (PA) J9219 Leuprolide acetate implant, 65 mg (PA) J9228 Injection, ipilimumab, 1 mg (IC) J9250 Methotrexate sodium, 5 mg J9260 Methotrexate sodium, 50 mg J9261 Injection, nelarabine, 50 mg (PA) J9263 Injection, oxaliplatin, 0.5 mg J9264 Injection, paclitaxel protein-bound particles, 1 mg J9265 Injection, paclitaxel, 30 mg J9293 Injection, mitoxantrone HCl, per 5 mg J9300 Injection, gemtuzumab ozogamicin, 5 mg J9302 Injection, ofatumumab, 10 mg (PA) (IC) J9305 Injection, pemetrexed, 10 mg J9307 Injection, pralatrexate, 1 mg (IC) J9310 Injection, rituximab, 100 mg (PA) J9315 Injection, romidepsin, 1 mg (PA) (IC) J9340 Injection, thiotepa, 15 mg J9351 Injection, topotecan, 0.1 mg (IC) J9355 Trastuzumab, 10 mg J9360 Injection, vinblastine sulfate, 1 mg J9370 Vincristine sulfate, 1 mg J9390 Injection vinorelbine tartrate, 10 mg J9395 Injection, fulvestrant, 25 mg (PA) J9999 Not otherwise classified, antineoplastic drugs (IC) Q4101 Apligraf, per sq cm Q4102 Oasis wound matrix, per sq cm Q4103 Oasis burn matrix, per sq cm Q4104 Integra bilayer matrix wound dressing (BMWD), per sq cm Q4106 Dermagraft, per sq cm Q4107 GRAFTJACKET, per sq cm Q4108 Integra matrix, per sq cm Q4110 PriMatrix, per sq cm S0020 Injection, bupivicaine HCl, 30 ml S0021 Injection, cefoperazone sodium, 1 g (IC) S0023 Injection, cimetidine HCl, 300 mg S0077 Injection, clindamycin phosphate, 300 mg S0190 I.C. Mifepristone, Oral, 200MG S0191 I.C. Misoprostol, Oral, 200MCG S0199 Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits confirmation of pregnancy by Hcg, Ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion) except drugs S0302 Completed early periodic screening diagnosis and treatment (EPSDT) service (or preventative pediatric healthcare screening and diagnosis (PPHSD) service) (List in addition to code for appropriate evaluation and management service.) S2260 Induced abortion, 17 to 24 weeks, (CPA-2) (second trimester, third trimester in hospital only) S4989 Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies (IC) S4993 Contraceptive pills for birth control T1023 Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project or treatment protocol, per encounter V2600 Hand held low vision aids and other nonspectacle-mounted aids (PA) (IC) V2610 Single lens, spectacle mounted low vision aids (PA) (IC) V2615 Telescopic and other compound lens system, including distance-vision telescopic, near-vision telescopes, and compound microscopic lens system (PA) (IC) V2799 Vision service, miscellaneous (PA) (IC) The following service code modifiers are allowed for billing under MassHealth. See Subchapter 5 of the Physician Manual for billing instructions related to the use of modifiers. Modifier Modifier Description 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service 26 Professional component 50 Bilateral procedure 51 Multiple procedures 54 Surgical care only 57 Decision for surgery 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period 59 Distinct procedural service 62 Two surgeons 66 Surgical team 78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period 80 Assistant surgeon 82 Assistant surgeon (when qualified resident surgeon not available) 91 Repeat clinical diagnostic laboratory test 99 Multiple modifiers E1 Upper left, eyelid E2 Lower left, eyelid E3 Upper right, eyelid E4 Lower right eyelid F1 Left hand, second digit F2 Left hand, third digit F3 Left hand, fourth digit F4 Left hand, fifth digit F5 Right hand, thumb F6 Right hand, second digit F7 Right hand, third digit F8 Right hand, fourth digit F9 Right hand, fifth digit FA Left hand, thumb FP Service provided as part of family planning program Modifier Modifier Description HN Bachelor’s degree level (Use to indicate physician assistant.) (This modifier is to be applied to codes for services billed by a physician that were performed by a physician assistant employed by the physician or group practice.) LC Left circumflex coronary artery LD Left anterior descending coronary artery LM Left main coronary artery LT Left side (Used to identify procedures performed on the left side of the body.) RB Replacement of a DME, orthotic, or prosthetic item furnished as part of a repair (This modifier should only be used with 92340, 92341, and 92342 to bill for the dispensing of replacement lenses.) RC Right coronary artery RI Ramus intermedius coronary artery RT Right side (Used to identify procedures performed on the right side of the body.) SA Nurse practitioner rendering service in collaboration with a physician (This modifier is to be applied to codes for services billed by a physician that were performed by a non- independent nurse practitioner employed by the physician or group practice.) (An independent nurse practitioner billing under his/her own individual provider number should not use this modifier.) SB Nurse midwife (This modifier is to be applied to codes for services billed by a physician that were performed by a non-independent nurse midwife employed by the physician or group practice.) (An independent nurse midwife billing under his/her own individual provider number should not use this modifier.) SL State-supplied vaccine (This modifier should only be applied to codes 90460, 90461, 90471, and 90473 to identify administration of vaccines provided at no cost by the Massachusetts Department of Public Health for individuals aged 18 years and under, including those administered under the Vaccine for Children Program (VFC).) T1 Left foot, second digit T2 Left foot, third digit T3 Left foot, fourth digit T4 Left foot, fifth digit T5 Right foot, great toe T6 Right foot, second digit T7 Right foot, third digit T8 Right foot, fourth digit T9 Right foot, fifth digit TA Left foot, great toe TC Technical component (The component of a service or procedure representing the cost of rent, equipment, utilities, supplies, administrative and technical salaries and benefits, and other overhead expenses of the service or procedures, excluding the physician’s professional component. When the technical component is reported separately the addition of modifier TC to the service code will let the technical component allowable fee contained in 101 CMR 317.04 be paid.) Modifiers for Tobacco-Cessation Services The following modifiers are used in combination with Service Code 99407 to report tobacco-cessation counseling. Service Code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) may also be billed without a modifier to report an individual smoking and tobacco-use cessation counseling visit of at least 30 minutes. Modifier Modifier Description HQ Group counseling, at least 60-90 minutes in duration, provided by a physician TD Individual counseling provided by a registered nurse (RN) TF Individual counseling, intermediate level of care (intake/assessment counseling, at least 45 minutes in duration) provided by a physician U1 Individual counseling services provided by a tobacco-cessation counselor U2 Individual intake/assessment counseling, at least 45 minutes in duration, provided by a nurse practitioner, nurse midwife, physician assistant, registered nurse, or a tobacco-cessation counselor, under the supervision of a physician U3 Group counseling, at least 60-90 minutes in duration, provided by a nurse practitioner, nurse midwife, physician assistant, registered nurse, or a tobacco-cessation counselor, under the supervision of a physician Modifiers for Behavioral Health Screening 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 below 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, identified a child with a potential behavioral health services need. Modifier Modifier Description U1 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified when administered by a physician, independent nurse midwife or independent nurse practitioner. U2 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified when administered by a physician, independent nurse midwife or independent nurse practitioner. U3 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified when administered by a nurse midwife employed by a physician. U4 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified when administered by a nurse midwife employed by a physician. U5 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified when administered by a nurse practitioner employed by a physician. U6 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified when administered by a nurse practitioner employed by a physician. U7 Completed behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual with no behavioral health need identified when administered by a physician assistant employed by a physician. U8 Completed a behavioral health screening using a standardized behavioral health screening tool selected from the approved menu of tools found in Appendix W of your provider manual and a behavioral health need was identified when administered by a physician assistant employed by a physician. Modifier for Child and Adolescent Needs and Strengths (CANS) Modifier Modifier Description HA Service Code 90791 must be accompanied by this modifier to indicate that the Child and Adolescent Needs and Strengths (CANS) is included in the psychiatric diagnostic interview examination. This modifier may be billed only by psychiatrists. Modifiers for Provider Preventable Conditions That Are National Coverage Determinations Modifier Modifier Description PA Surgical or other invasive procedure on wrong body part PB Surgical or other invasive procedure on wrong patient PC Wrong surgery or other invasive procedure on patient For more information on the use of these modifiers, see Appendix V of your provider manual. This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS are defined in the Physician’s Current Procedural Terminology (CPT) code book. This page is reserved.