Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter AOH-28 June 2012 TO: Acute Outpatient Hospital Providers Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Acute Outpatient Hospital Manual (2012 HCPCS) This letter transmits revisions to the service codes in the Acute Outpatient Hospital Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) codes for 2012. The revised Subchapter 6 is effective for dates of service on or after January 1, 2012. This letter also updates billing information for acute outpatient hospitals (AOH), including their hospital-licensed health centers and other provider-based satellites. Service Codes for Subchapter 6 Subchapter 6 applies only when billing for services that are paid, either according to the Payment Amount Per Episode (PAPE) methodology, or according to the Division of Health Care Finance and Policy (DHCFP) clinical laboratory fee schedule (114.3 CMR 20.00). Providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2012, or Ingenix HCPCs Level II Codebook for the service code descriptions. An AOH provider may request prior authorization (PA) for any medically necessary service reimbursable under the federal Medicaid Act, in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5), for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in the Acute Outpatient Hospital Manual or other provider manuals referred to in this transmittal letter. Subchapter 6 (Other Provider Manuals) For services provided by AOHs that are not paid according to the PAPE methodology, or according to the DHCFP clinical laboratory fee schedule, AOHs must refer to the MassHealth provider manuals listed below to determine which services are payable and which are not payable. These provider manuals are available on the MassHealth website at www.mass.gov/masshealth. MassHealth Transmittal Letter AOH-28 June 2012 Page 2 Adult Day Health – AOHs billing for adult day health services must enroll in the Adult Day Health Program and refer to Subchapter 6 of the Adult Day Health Manual. Adult Foster Care – AOHs billing for adult foster care services must enroll in the Adult Foster Care Program and refer to Subchapter 6 of the Adult Foster Care Manual. Ambulance Services – AOHs billing for ambulance services must enroll in the Transportation Program and refer to Subchapter 6 of the Transportation Manual. Dental Services – AOHs billing for dental services must refer to Subchapter 6 of the Dental Manual except when the conditions in 130 CMR 420.430(A) or (D) apply. In those instances, AOHs should refer to Subchapter 6 of the Acute Outpatient Hospital Manual. Early Intervention Services – AOHs billing for early intervention program services must enroll in the Early Intervention Program and refer to Subchapter 6 of the Early Intervention Program Manual. Hearing Aid Dispensing – AOHs billing for the dispensing of hearing aids must refer to Subchapter 6 of the Hearing Instrument Specialist Manual. Home Health Services – AOHs billing for home health services must enroll in the Home Health Program and refer to Subchapter 6 of the Home Health Agency Manual. Pharmacy Services – 340B qualified AOHs using contract pharmacies and 340B pharmacies with retail licenses must refer to the MassHealth Pharmacy Manual. Physician Services – AOHs billing for hospital-based physician or entity services must refer to Subchapter 6 of the Physician Manual. Psychiatric Day Treatment Services – AOHs billing for psychiatric day treatment services must enroll in the Psychiatric Day Treatment Program and refer to Subchapter 6 of the Psychiatric Day Treatment Program Manual. Vision Care Materials Dispensing – AOHs billing for the dispensing of ophthalmic materials must refer to Subchapter 6 of the Vision Care Manual. For more information on the reimbursement for AOH services, providers should refer to the Hospital Rate Year (HRY) 2010 Acute Hospital Request for Application (RFA). Hospitals can locate the HRY 2010 RFA at www.comm-pass.com. If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The specific regulation title for acute outpatient services is Clinical Laboratory Services: 114.3 CMR 20.00. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp MassHealth Transmittal Letter AOH-28 June 2012 Page 3 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 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.) Acute Outpatient Hospital Manual Pages 6-1 through 6-14 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Pages 6-1 through 6-12 — transmitted by Transmittal Letter AOH-26 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Acute Outpatient Hospital Manual Transmittal Letter AOH-28 Date 01/01/12 601 Introduction MassHealth providers must refer to the official list of HCPCS codes and descriptions posted on the Centers for Medicare & Medicaid Services website at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. For a list of billable revenue codes, please refer to Appendix F of the Acute Outpatient Hospital Manual. CPT Codes MassHealth pays for services billed using all medicine, radiology, laboratory, surgery, and anesthesia CPT codes in effect at the time of service, except for those codes listed in Section 602 of this subchapter, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. Level II HCPCS Codes MassHealth pays for services billed using only those Level II HCPCS codes listed in Section 603 of this subchapter that are in effect at the time of service, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. Early and Periotic Screening, Diagnosis and Treatment Services (EPSDT) An acute outpatient hospital provider may request prior authorization (PA) for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Acute Outpatient Hospital Manual. 602 Nonpayable CPT Codes MassHealth does not ordinarily pay for services billed under the following codes and code ranges. 0001F 0052T 0101T 0142T 0051T 0005F 0053T 0102T 0143T 0052T 0012F 0071T 0103T 0155T 0053T 0014F 0072T 0104T 0156T 0071T 0015F 0073T 0105T 0157T 0072T 4002F 0075T 0106T 0158T 0073T 4006F 0076T 0107T 0159T 0075T 4009F 0078T 0108T 0160T 0076T 4011F 0079T 0109T 0161T 0078T 0016T 0080T 0110T 0163T 0079T 0017T 0081T 0111T 0016T 0080T 0019T 0085T 0123T 0017T 0081T 0030T 0092T 0124T 0019T 0085T 0042T 0095T 0126T 0030T 0092T 0048T 0098T 0130T 0042T 0095T 0050T 0099T 0140T 0048T 0098T 0051T 0100T 0141T 0050T 0099T Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-2 Transmittal Letter AOH-28 Date 01/01/12 602 Nonpayable CPT Codes (cont.) 0100T 0187T 15829 21123 21616 0101T 0188T 15847 21125 21620 0102T 0189T 15876 21127 21627 0103T 0190T 15877 21141 21630 0104T 0191T 15878 21142 21632 0105T 0192T 15879 21143 21705 0106T 0193T 16036 21145 21740 0107T 0195T 17340 21146 21750 0108T 0196T 17360 21147 21810 0109T 0197T 17380 21151 21825 0110T 0198T 19271 21154 22010 0111T 0199T 19272 21155 22015 0123T 0200T 19305 21159 22110 0124T 0201T 19306 21160 22112 0126T 0202T 19316 21172 22114 0130T 0203T 19324 21179 22116 0140T 0204T 19325 21180 22206 0141T 0205T 19355 21182 22207 0142T 0206T 19361 21183 22208 0143T 0207T 19364 21184 22210 0155T 00100 19367 21188 22212 0156T through 19368 21193 22214 0157T 01999 19369 21194 22216 0158T 10040 19396 21196 22220 0159T 11004 20660 21245 22224 0160T 11005 20661 21246 22226 0161T 11006 20664 21247 22318 0163T 11008 20802 21248 22319 0164T 11922 20805 21249 22325 0165T 11950 20808 21255 22326 0166T 11951 20816 21256 22328 0167T 11952 20824 21268 22526 0168T 11954 20827 21343 22527 0169T 15756 20838 21344 22532 0171T 15757 20930 21346 22533 0172T 15758 20931 21347 22534 0173T 15781 20936 21348 22548 0174T 15782 20937 21366 22554 0175T 15783 20938 21386 22556 0176T 15786 20955 21387 22558 0177T 15787 20956 21395 22585 0178T 15788 20957 21422 22590 0179T 15789 20962 21423 22595 0180T 15792 20969 21431 22600 0181T 15793 20970 21432 22610 0182T 15819 20985 21433 22630 0183T 15824 21045 21435 22632 0184T 15825 21120 21436 22800 0185T 15826 21121 21510 22802 0186T 15828 21122 21615 22804 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-3 Transmittal Letter AOH-28 Date 01/01/12 602 Nonpayable CPT Codes (cont.) 22808 26992 27236 27557 31800 22810 27005 27240 27558 31805 22812 27025 27244 27580 32035 22818 27030 27245 27590 32036 22819 27036 27248 27591 32095 22830 27054 27253 27592 32100 22840 27070 27254 27596 32110 22841 27071 27258 27598 32120 22842 27075 27259 27645 32124 22843 27076 27268 27646 32140 22844 27077 27269 27702 32141 22845 27078 27280 27703 32150 22846 27079 27282 27712 32151 22847 27090 27284 27715 32160 22848 27091 27286 27724 32200 22849 27120 27290 27725 32225 22850 27122 27295 27727 32310 22852 27125 27303 27880 32320 22855 27130 27365 27881 32402 22856 27132 27445 27882 32440 22857 27134 27447 27886 32442 22861 27137 27448 27888 32445 22862 27138 27450 28800 32480 22864 27140 27454 28805 32482 22865 27146 27455 31225 32484 23200 27147 27457 31230 32486 23210 27151 27465 31290 32488 23220 27156 27466 31291 32491 23332 27158 27468 31360 32500 23472 27161 27470 31365 32501 23900 27165 27472 31367 32503 23920 27170 27477 31368 32504 24900 27175 27479 31370 32540 24920 27176 27485 31375 32650 24930 27177 27486 31380 32651 24931 27178 27487 31382 32652 24940 27179 27488 31390 32653 25900 27181 27495 31395 32654 25905 27185 27506 31584 32655 25909 27187 27507 31587 32656 25915 27215 27511 31725 32657 25920 27217 27513 31760 32658 25924 27218 27514 31766 32659 25927 27222 27519 31770 32660 26551 27226 27535 31775 32661 26553 27227 27536 31780 32662 26554 27228 27540 31781 32663 26556 27232 27556 31786 32664 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-4 Transmittal Letter AOH-28 Date 01/01/12 602 Nonpayable CPT Codes (cont.) 32665 33320 33511 33720 33875 32800 33321 33512 33722 33877 32810 33322 33513 33724 33880 32815 33330 33514 33726 33881 32820 33332 33516 33730 33883 32850 33335 33517 33732 33884 32851 33400 33518 33735 33886 32852 33401 33519 33736 33889 32853 33403 33521 33737 33891 32854 33404 33522 33750 33910 32855 33405 33523 33755 33915 32856 33406 33530 33762 33916 32900 33410 33533 33764 33917 32905 33411 33534 33766 33920 32906 33412 33535 33767 33922 32940 33413 33536 33768 33924 32997 33414 33542 33770 33925 33015 33415 33545 33771 33926 33020 33416 33548 33774 33930 33025 33417 33572 33775 33933 33030 33420 33600 33776 33935 33031 33422 33602 33777 33940 33050 33425 33606 33778 33944 33120 33426 33608 33779 33945 33130 33427 33610 33780 33960 33140 33430 33611 33781 33961 33141 33460 33612 33782 33967 33202 33463 33615 33783 33968 33203 33464 33617 33786 33970 33236 33465 33619 33788 33971 33237 33468 33641 33800 33973 33238 33470 33645 33802 33974 33243 33471 33647 33803 33975 33250 33472 33660 33813 33976 33251 33474 33665 33814 33977 33254 33475 33670 33820 33978 33255 33476 33675 33822 33979 33256 33478 33676 33824 33980 33257 33496 33677 33840 33981 33258 33500 33681 33845 33982 33259 33501 33684 33851 33983 33261 33502 33688 33852 34001 33265 33503 33690 33853 34051 33266 33504 33692 33860 34151 33300 33505 33694 33861 34401 33305 33506 33697 33863 34451 33310 33507 33702 33864 34502 33315 33510 33710 33870 34800 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-5 Transmittal Letter AOH-28 Date 01/01/12 602 Nonpayable CPT Codes (cont.) 34802 35271 35540 35701 38780 34803 35276 35548 35721 39000 34804 35281 35549 35741 39010 34805 35301 35551 35800 39200 34806 35302 35556 35820 39220 34808 35303 35558 35840 39499 34812 35304 35560 35870 39501 34813 35305 35563 35901 39502 34820 35306 35565 35905 39503 34825 35311 35566 35907 39520 34826 35331 35571 36415 39530 34830 35341 35583 36416 39531 34831 35351 35585 36468 39540 34832 35355 35587 36469 39541 34833 35361 35600 36591 39545 34834 35363 35601 36592 39560 34900 35371 35606 36598 39561 35001 35372 35612 36660 39599 35002 35390 35616 36822 41130 35005 35400 35621 36823 41135 35013 35450 35623 37140 41140 35021 35452 35626 37145 41145 35022 35454 35631 37160 41150 35045 35456 35636 37180 41153 35081 35480 35637 37181 41155 35082 35481 35638 37182 41870 35091 35482 35642 37215 41872 35092 35483 35645 37616 42426 35102 35501 35646 37617 42845 35103 35506 35647 37618 42894 35111 35508 35650 37660 42953 35112 35509 35651 37765 42961 35121 35510 35654 37766 42971 35122 35511 35656 37788 43045 35131 35512 35661 38100 43100 35132 35516 35663 38101 43101 35141 35518 35665 38102 43107 35142 35521 35666 38115 43108 35151 35522 35671 38380 43112 35152 35523 35681 38381 43113 35182 35525 35682 38382 43116 35189 35526 35683 38562 43117 35211 35531 35691 38564 43118 35216 35533 35693 38724 43121 35221 35536 35694 38746 43122 35241 35537 35695 38747 43123 35246 35538 35697 38765 43124 35251 35539 35700 38770 43135 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-6 Transmittal Letter AOH-28 Date 01/01/12 602 Nonpayable CPT Codes (cont.) 43300 43770 44140 44721 47010 43305 43771 44141 44800 47015 43310 43772 44143 44820 47100 43312 43773 44144 44850 47120 43313 43774 44145 44899 47122 43314 43775 44146 44900 47125 43320 43800 44147 44950 47130 43324 43810 44150 44955 47133 43325 43820 44151 44960 47135 43326 43825 44155 45110 47136 43330 43832 44156 45111 47140 43331 43840 44157 45112 47141 43340 43842 44158 45113 47142 43341 43843 44160 45114 47143 43350 43845 44187 45116 47144 43351 43846 44188 45119 47145 43352 43847 44202 45120 47146 43360 43848 44203 45121 47147 43361 43850 44204 45123 47300 43400 43855 44205 45126 47350 43401 43860 44210 45130 47360 43405 43865 44211 45135 47361 43410 43880 44212 45136 47362 43415 43881 44227 45395 47380 43420 43882 44300 45397 47381 43425 44005 44310 45400 47400 43460 44010 44314 45402 47420 43496 44015 44316 45540 47425 43500 44020 44320 45550 47460 43501 44021 44322 45562 47480 43502 44025 44345 45563 47550 43520 44050 44346 45800 47570 43605 44055 44602 45805 47600 43610 44110 44603 45820 47605 43611 44111 44604 45825 47610 43620 44120 44605 46705 47612 43621 44121 44615 46710 47620 43622 44125 44620 46712 47700 43631 44126 44625 46715 47701 43632 44127 44626 46716 47711 43633 44128 44640 46730 47712 43634 44130 44650 46735 47715 43635 44132 44660 46740 47720 43640 44133 44661 46742 47721 43641 44135 44680 46744 47740 43644 44136 44700 46746 47741 43645 44137 44715 46748 47760 43752 44139 44720 46751 47765 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-7 Transmittal Letter AOH-28 Date 01/01/12 602 Nonpayable CPT Codes (cont.) 47780 49428 50526 51580 56631 47785 49605 50540 51585 56632 48000 49606 50545 51590 56633 47801 49610 50546 51595 56634 47802 49611 50547 51596 56637 47900 49900 50548 51597 56640 48000 49904 50600 51701 57110 48001 49905 50605 51702 57111 48020 49906 50610 51800 57112 48100 50010 50620 51820 57270 48105 50040 50630 51840 57280 48120 50045 50650 51841 57296 48140 50060 50660 51845 57305 48145 50065 50700 51860 57307 48146 50070 50715 51865 57308 48148 50075 50722 51900 57311 48150 50100 50725 51920 57531 48152 50120 50727 51925 57540 48153 50125 50728 51940 57545 48154 50130 50740 51960 58140 48155 50135 50750 51980 58146 48160 50205 50760 53415 58150 48400 50220 50770 53448 58152 48500 50225 50780 54125 58180 48510 50230 50782 54135 58200 48520 50234 50783 54332 58210 48540 50236 50785 54336 58240 48545 50240 50800 54390 58267 48547 50250 50810 54411 58275 48548 50280 50815 54417 58280 48551 50290 50820 54430 58285 48552 50300 50825 54535 58293 48554 50320 50830 54650 58400 48556 50323 50840 55605 58410 49000 50325 50845 55650 58520 49002 50327 50860 55801 58540 49010 50328 50900 55810 58548 49020 50329 50920 55812 58605 49040 50340 50930 55815 58611 49060 50360 50940 55821 58700 49062 50365 51060 55831 58720 49203 50370 51525 55840 58740 49204 50380 51530 55842 58750 49205 50400 51550 55845 58752 49215 50405 51555 55862 58760 49220 50500 51565 55865 58822 49255 50520 51570 55866 58825 49425 50525 51575 56630 58940 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-8 Transmittal Letter AOH-28 Date 01/01/12 602 Nonpayable CPT Codes (cont.) 58943 61120 61533 61606 62115 58950 61140 61534 61607 62116 58951 61150 61535 61608 62117 58952 61151 61536 61609 62120 58953 61154 61536 61610 62121 58954 61156 61537 61611 62140 58956 61210 61538 61612 62141 58957 61250 61539 61613 62142 58958 61253 61540 61615 62143 58960 61304 61541 61616 62145 58970 61305 61542 61618 62146 58974 61312 61543 61619 62147 58976 61313 61544 61624 62148 59070 61314 61545 61630 62161 59072 61315 61546 61635 62162 59120 61316 61548 61640 62163 59121 61320 61550 61641 62164 59130 61321 61552 61642 62165 59135 61322 61556 61680 62180 59136 61323 61557 61682 62190 59140 61332 61558 61684 62192 59325 61333 61559 61686 62200 59350 61340 61563 61690 62201 59412 61343 61564 61692 62220 59514 61345 61566 61697 62223 59525 61440 61567 61698 62256 59620 61450 61570 61700 62258 59630 61458 61571 61702 62287 59850 61460 61575 61703 63043 59851 61470 61576 61705 63044 59852 61480 61580 61708 63050 59855 61490 61581 61710 63051 59856 61500 61582 61711 63076 59857 61501 61583 61735 63077 59897 61510 61584 61750 63078 60254 61512 61585 61751 63081 60270 61514 61586 61760 63082 60505 61516 61590 61850 63085 60521 61517 61591 61860 63086 60522 61518 61591 61863 63087 60540 61519 61592 61864 63088 60545 61520 61595 61867 63090 60600 61521 61596 61868 63091 60605 61522 61597 61870 63101 60650 61524 61598 61875 63102 61105 61526 61600 62005 63103 61107 61530 61601 62010 63170 61108 61531 61605 62100 63172 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-9 Transmittal Letter AOH-28 Date 01/01/12 602 Nonpayable CPT Codes (cont.) 63173 63704 80100 81270 81400 63180 63706 80101 81275 81401 63182 63707 80104 81280 81402 63185 63709 80502 81281 81403 63190 63710 81200 81282 81404 63191 63740 81205 81290 81405 63194 63752 81206 81291 81406 63195 64752 81207 81292 81407 63196 64755 81208 81293 81408 63197 64760 81209 81294 82075 63198 64809 81210 81295 82962 63199 64818 81211 81296 83987 63200 64866 81212 81297 84145 63250 64868 81213 81298 84431 63251 65273 81214 81299 84793 63252 65760 81215 81300 86079 63265 65765 81216 81301 86305 63266 65767 81217 81302 86352 63267 65771 81220 81303 86780 63268 65780 81221 81304 86825 63270 65781 81222 81310 86826 63271 65782 81223 81315 86890 63272 69090 81224 81316 86891 63273 69155 81225 81317 86910 63275 69535 81226 81318 86911 63276 69554 81227 81319 86927 63277 69950 81228 81330 86930 63278 71552 81229 81331 86931 63280 72159 81240 81332 86932 63281 72198 81241 81340 86960 63282 73225 81242 81341 86985 63283 74263 81243 81342 87150 63285 75571 81244 81350 87153 63286 75900 81245 81355 87493 63287 75952 81250 81370 87903 63290 75953 81251 81371 87904 63295 75954 81255 81372 88000 63300 75956 81256 81373 88005 63301 75957 81257 81374 88007 63302 75958 81260 81375 88012 63303 75959 81261 81376 88014 63304 76140 81262 81377 88016 63305 76496 81263 81378 88020 63306 76497 81264 81379 88025 63307 76498 81265 81380 88027 63308 78267 81266 81381 88028 63700 78268 81267 81382 88029 63702 78351 81268 81383 88036 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-10 Transmittal Letter AOH-28 Date 01/01/12 602 Nonpayable CPT Codes (cont.) 88037 90287 90876 94011 97811 88040 90379 90880 94012 97813 88045 90384 90885 94013 97814 88099 90386 90889 94015 98940 88125 90389 90901 94774 98941 88333 90396 90911 94775 98942 88334 90586 90940 94776 98943 88738 90633 90989 94777 98960 88749 90634 90993 95052 98961 89250 90644 90997 95120 98962 89251 90645 90999 95125 98966 89253 90646 91132 95130 98967 89254 90647 91133 95131 98968 89255 90648 92314 95132 98969 89257 90654 92315 95133 99000 89258 90665 92316 95134 99001 89259 90669 92317 95824 99002 89260 90670 92325 95965 99024 89261 90696 92352 95966 99026 89264 90698 92353 95967 99027 89268 90700 92354 95992 99050 89272 90701 92355 96000 99051 89280 90702 92358 96001 99053 89281 90708 92371 96002 99056 89290 90710 92531 96003 99058 89291 90712 92532 96004 99060 89300 90718 92533 96150 99071 89310 90720 92534 96151 99075 89320 90721 92540 96152 99078 89321 90723 92548 96153 99080 89322 90743 92550 96154 99082 89325 90744 92559 96155 99090 89329 90748 92560 96376 99091 89330 90816 92561 96567 99100 89331 90817 92562 96902 99116 89335 90818 92564 96904 99135 89342 90819 92570 97005 99140 89343 90821 92630 97006 99143 89344 90822 92633 97537 99144 89346 90823 92970 97545 99148 89352 90824 92971 97546 99149 89353 90826 92975 97597 99150 89354 90827 92992 97598 99172 89356 90828 92993 97602 99190 89398 90829 93660 97605 99191 90281 90845 93770 97606 99192 90283 90865 93786 97755 99199 90284 90875 94005 97810 99251 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-11 Acute Outpatient Hospital Manual Transmittal Letter AOH-28 Date 01/01/12 602 Nonpayable CPT Codes (cont.) 99252 99310 99347 99404 99503 99253 99315 99348 99406 99504 99254 99316 99349 99408 99505 99255 99318 99350 99409 99506 99288 99324 99354 99411 99507 99466 99325 99355 99412 99509 99467 99326 99356 99420 99510 99471 99327 99357 99429 99511 99472 99328 99358 99441 99512 99468 99334 99359 99442 99600 99469 99335 99360 99443 99601 99478 99336 99374 99444 99602 99479 99337 99375 99450 99605 99480 99339 99377 99455 99606 99304 99340 99378 99456 99607 99305 99341 99379 99477 A4641 99306 99342 99380 99499 A9500 99307 99343 99401 99500 A9502 99308 99344 99402 99501 A9503 99309 99345 99403 99502 603 Payable Level II HCPCS Codes The following Level II HCPCS codes represent services that are covered by MassHealth when provided by AOHs, including hospital-licensed health centers (HLHCs) and other satellite clinics. A9505 J0215 J0640 J1055 J1566 A9512 J0221 J0690 J1056 J1569 A9537 J0256 J0694 J1060 J1571 G0105 J0257 J0696 J1070 J1580 G0108 J0290 J0697 J1080 J1599 G0109 J0295 J0702 J1094 J1626 G0121 J0348 J0715 J1100 J1630 G0202 J0456 J0718 J1160 J1650 G0204 J0461 J0775 J1170 J1655 G0206 J0475 J0780 J1200 J1670 G0270 J0476 J0833 J1260 J1710 G0271 J0490 J0834 J1290 J1720 G0378 J0558 J0840 J1300 J1725 G0379 J0561 J0881 J1320 J1740 G0424 J0585 J0882 J1438 J1743 G0431 J0586 J0885 J1440 J1745 G0434 J0587 J0886 J1441 J1750 J0129 J0588 J0897 J1460 J1786 J0131 J0592 J0900 J1557 J1790 J0135 J0597 J1020 J1559 J1800 J0171 J0598 J1030 J1561 J1826 J0207 J0638 J1040 J1562 J1885 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-12 Acute Outpatient Hospital Manual Transmittal Letter AOH-28 Date 01/01/12 603 Payable Level II HCPCS Codes (cont.) J1890 J2790 J7070 J9043 J9351 J1950 J2792 J7131 J9045 J9355 J1956 J2793 J7302 J9055 J9360 J1990 J2794 J7303 J9060 J9370 J2060 J2796 J7304 J9130 J9390 J2150 J2820 J7307 J9155 J9395 J2175 J2910 J7309 J9171 J9999 J2248 J2916 J7312 J9178 L8614 J2250 J2920 J7321 J9179 L8615 J2265 J2930 J7323 J9181 L8616 J2270 J2940 J7324 J9190 L8617 J2271 J2941 J7325 J9201 L8618 J2275 J3010 J7326 J9202 L8619 J2300 J3030 J7335 J9206 L8690 J2310 J3095 J7599 J9212 L8691 J2315 J3110 J7608 J9213 Q0081 J2323 J3120 J7614 J9214 Q0083 J2355 J3130 J7620 J9215 Q0084 J2357 J3230 J7626 J9216 Q4100 J2358 J3240 J7633 J9217 Q4101 J2405 J3243 J7639 J9218 Q4102 J2430 J3250 J7644 J9219 Q4103 J2440 J3262 J7665 J9228 Q4104 J2469 J3301 J7669 J9250 Q4105 J2503 J3302 J7676 J9260 Q4106 J2505 J3303 J7682 J9261 Q4107 J2507 J3357 J7686 J9263 Q4108 J2510 J3360 J7699 J9264 Q4110 J2515 J3385 J7799 J9265 Q4111 J2550 J3396 J8561 J9266 Q4112 J2560 J3410 J8562 J9293 Q4113 J2562 J3411 J9000 J9300 Q4114 J2675 J3430 J9001 J9302 Q4115 J2680 J3487 J9025 J9305 S0023 J2760 J3490 J9031 J9307 S0028 J2778 J3590 J9035 J9310 S0077 J2785 J7030 J9040 J9315 S0302 J2788 J7060 J9041 J9340 S2083 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-13 Acute Outpatient Hospital Manual Transmittal Letter AOH-28 Date 01/01/12 604 Modifiers 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 MassHealth 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 her or his professional judgment, identified a child with a potential behavioral health services need. 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 MassHealth provider manual with no behavioral health need identified. 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 MassHealth provider manual and behavioral-health need identified. 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. HQ Group counseling, at least 60-90 minutes TF Intermediate level of care, at least 45 minutes Modifier for Child and Adolescent Needs and Strengths (CANS) HA Service code 90801 must be accompanied by this modifier to indicate that the Child and Adolescent Needs and Strengths is included in the assessment. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-14 Acute Outpatient Hospital Manual Transmittal Letter AOH-28 Date 01/01/12 This page is reserved.