Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER PHY-100 May 2004 TO: Physicians Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Physician Manual (2004) HCPCS Codes This letter transmits a revised Subchapter 6 of the Physician Manual. Providers should use this revised Subchapter 6 along with the American Medical Association Current Procedural Terminology (CPT) 2004 code book. Subchapter 6 of the Physician Manual contains the following information: • CPT codes that are not payable under MassHealth (all other CPT codes in the CPT 2004 code book are payable, subject to all limitations and conditions of payment in MassHealth’s regulations at 130 CMR 433.000 and 450.000); • CPT codes that have special limitations or requirements, such as prior authorization, individual consideration, or attachment requirements; and • Level II HCPCS codes that are payable under MassHealth and have special limitations or requirements, such as prior authorization, individual consideration, or attachment requirements. In addition, pursuant to 130 CMR 450.144(A), a physician may request prior authorization for any medically necessary service for a member under 21 years of age, even if it is listed as not payable in Subchapter 6 of the Physician Manual. How to Obtain a Physician Fee Schedule Providers who want to obtain a fee schedule may purchase 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). Providers must contact them first to find out the price of the publication. The Division of Health Care Finance and Policy also has the regulations available on disk. The regulation title for medicine is 114.3 CMR 17.00: Medicine. The regulation title for surgery and anesthesia is 114.3 CMR 16.00: Surgery and Related Anesthesia Care. The regulation title for radiology is 114.3 CMR 18.00: Radiology. The regulation title for laboratory is 114.3 CMR 20.00: Laboratory. Massachusetts State Bookstore Division of Health Care Finance and Policy State House, Room 116 Two Boylston Street Boston, MA 02133 Boston, MA 02116 Telephone: 617-727-2834 Telephone: 617-988-3100 www.mass.gov/sec/spr www.mass.gov/dhcfp MASSHEALTH TRANSMITTAL LETTER PHY-100 May 2004 Page 2 Effective Date The new codes listed in Subchapter 6 are available for dates of service on or after April 30, 2004. Please Note: Providers may use either the new or obsolete service codes for dates of service from April 30, 2004 through June 30, 2004. Providers must use the new service codes for dates of service on or after July 1, 2004. Mid-Level Provider/EPSDT Modifiers As conveyed in Transmittal Letter PHY-97 (November 2003), the modifiers used to indicate that the code billed was performed by a nonindependent nurse practitioner (SA), nonindependent nurse midwife (W5), or physician assistant (S1) were replaced. Effective for dates of service beginning November 1, 2003, providers are instructed to use modifier SA (nonindependent nurse practitioner), SB (nonindependent nurse midwife), and HN (physician assistant) when billing for these services. The modifiers used to indicate EPSDT services (EP, R4, R5, S2, S3, W6, and W7) were also replaced. Effective for dates of service beginning November 1, 2003, providers are instructed to bill CPT add-on code S0302 in addition to the appropriate preventive medicine CPT code (99381-99387; 99391-99397) to indicate the preventive visit billed was an EPSDT service. Providers must also apply modifier SA, SB, or HN to the appropriate preventive medicine CPT code if the services were performed by a nonindependent nurse practitioner, nonindependent nurse midwife, or physician assistant. Please Note: Independent nurse practitioners and nurse midwives billing under their own provider numbers should not use modifier SA or SB. The use of these modifiers could result in a reduction in your reimbursement or a claim denial. Global Payment MassHealth eliminated global billing for services with a professional and technical component as stated in Transmittal Letter PHY-98 (January 2004). Effective for dates of service beginning February 1, 2004, physicians, nurse practitioners, and nurse midwives furnishing both the professional and technical components of a service must bill for these components separately to receive the equivalent of the global payment. To bill the professional component, providers must append modifier 26 to the appropriate service code. To bill the technical component, the provider must report the same service code on a second claim line and append modifier TC. For dates of service on or after February 1, 2004, services that have professional and technical components must be billed with a modifier. Claims for such services that are not billed with modifier 26 or TC will be denied with error code 135 (modifier required). This denial will be reflected with an adjustment reason code 04 and remarks M78 on the HIPAA-compliant 835 Health Care Claim Payment/Advice transaction. MASSHEALTH TRANSMITTAL LETTER PHY-100 May 2004 Page 3 Providers with questions about the information in this transmittal letter may contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231. NEW MATERIAL (The pages listed here contain new or revised language.) Physician Manual Pages 6-1 through 6-16 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Physician Manual Pages 6-1, 6-2, 6-5, 6-6, 6-7, 6-8, and 6-13 through 6-18 — transmitted by Transmittal Letter PHY-97 Pages 6-3, 6-4, and 6-9 through 6-12 — transmitted by Transmittal Letter PHY-99 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-1 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2004 code book for the service codes and service descriptions 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 the MassHealth regulations at 130 CMR 433.000 and 450.000, except for those codes listed in Section 602 of this subchapter. In addition, a physician may request prior authorization for any medically necessary service for a member under 21 years of age. • Section 602 lists CPT service codes that are not payable under MassHealth. • Section 603 lists service 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 payable under MassHealth. 602 Nonpayable CPT Codes MassHealth does not pay for services billed under the following codes. 0001T 0032T 15782 19325 36469 0003T 0033T 15783 19355 36540 0005T 0034T 15786 19370 37765 0006T 0035T 15787 19371 37766 0007T 0036T 15788 19396 38204 0008T 0037T 15789 20930 38207 0009T 0038T 15792 20936 38208 0010T 0039T 15793 21120 38209 0012T 0040T 15810 21121 38210 0013T 0041T 15811 21122 38211 0014T 0042T 15819 21123 38212 0016T 0043T 15824 21125 38213 0017T 0044T 15825 21127 38214 0018T 10040 15826 21245 38215 0019T 11920 15828 21246 41870 0020T 11921 15829 21248 41872 0021T 11922 15876 21249 43752 0023T 11950 15877 22841 43842 0024T 11951 15878 32491 43843 0026T 11952 15879 32850 44132 0027T 11954 17340 33930 44135 0028T 15775 17360 33940 47133 0029T 15776 17380 36415 48160 0030T 15780 19316 36416 48550 0031T 15781 19324 36468 50300 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-2 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 51701 51702 54900 54901 55200 55300 55400 55870 55970 55980 58321 58322 58323 58345 58350 58750 58752 58760 58970 58974 58976 59070 59072 59412 59897 62287 63043 63044 65760 65765 65767 65771 69090 71552 72159 72198 73225 76082 76083 76093 76094 76140 76150 76350 76390 76400 76496 76497 76498 77300 77301 77305 77310 77315 77321 77326 77327 77328 77331 77332 77333 77334 77336 77370 77399 77401 77402 77403 77404 77406 77407 77408 77409 77411 77412 77413 77414 77416 77417 77418 77520 77522 77523 77525 77790 78267 78268 78351 78890 78891 80500 80502 82075 82962 84061 84830 86079 86585 86890 86891 86910 86911 86927 86930 86931 86932 86945 86950 86965 86985 87901 87903 87904 88000 88005 88007 88012 88014 88016 88020 88025 88027 88028 88029 88036 88037 88040 88045 88099 88125 89250 89251 89253 89254 89255 89257 89258 89259 89260 89261 89264 89268 89272 89280 89281 89290 89291 89300 89310 89320 89321 89325 89329 89330 89335 89342 89343 89344 89346 89352 89353 89354 89356 90281 90283 90287 90379 90384 90386 90389 90396 90586 90633 90634 90636 90645 90646 90647 90648 90669 90680 90698 90700 90701 90702 90708 90710 90712 90715 90718 90720 90721 90723 90744 90748 90845 90865 90875 90876 90880 90885 90889 90901 90911 90939 90940 90989 90993 90997 90999 91132 91133 92314 92315 92316 92317 92325 92330 92335 92352 92353 92354 92355 92358 92371 92390 92391 92392 92393 92395 92396 92510 92532 92533 92534 92548 92559 92560 96105 92561 92562 92564 92597 92605 92606 92613 92615 92617 93660 93668 93760 93762 93770 93784 93786 93788 93790 94015 95052 95120 95125 95130 95131 95132 95133 95134 95824 95965 95966 95967 96000 96001 96002 96003 96004 96100 96110 96111 96115 96117 96150 96151 96152 99091 99100 96154 96153 96155 96902 97005 97006 97014 97139 97530 97537 97545 97546 96567 97601 97602 97755 97780 97781 97802 97803 97804 98940 98941 98942 98943 99001 99002 99024 99026 99027 99056 99058 99071 99075 99078 99080 99090 99116 99135 99140 99141 99142 99172 99190 99455 99456 99191 99192 99271 99272 99273 99274 99275 99288 99315 99316 99354 99355 99356 99357 99358 99359 99360 99361 99362 99371 99372 99373 99374 99375 99377 99378 99379 99380 99401 99402 99403 99404 99411 99412 99420 99429 99450 99500 99501 99502 99503 99504 99505 99506 99507 99509 99510 99511 99512 99601 99602 The following service codes 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. • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-3 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-4 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 Legend: *: Available free of charge through the Massachusetts Immunization Program for children under 19 years of age. Centrifuging required: Service Code 99000 may be used only to pay a physician who centrifuges and mails a specimen to a laboratory for analysis. (See 130 CMR 433.439.) Covered for adults = 19: This code is payable only for adults aged 19 or older. CPA-2: A completed Certification of Payable Abortion Form must be completed. 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 >8: Prior authorization is required for more than eight osteopathic manipulative therapy visits in a 12-month period. PA for OT >8: Prior authorization is required for more than eight occupational therapy visits in a 12-month period. PA for PT >8: Prior authorization is required for more than eight physical therapy visits, regardless of modality, in a 12-month period. PA for ST >15: Prior authorization is required for more than 15 speech/language therapy visits in a 12-month period. PA: Service requires prior authorization. See 130 CMR 433.408 for more information. Urgent Care Only: Service Codes 99050, 99052, and 99054 may be used only for urgent care provided in the office after hours, in addition to the basic service. • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-5 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 01999 IC 21088 IC; PA 15820 PA 21089 IC; PA 15821 PA 21137 PA 15822 PA 21138 PA 15823 PA 21139 PA 15831 PA 21141 PA 15832 PA 21142 PA 15833 PA 21143 PA 15834 PA 21145 PA 15835 PA 21146 PA 15836 PA 21147 PA 15837 PA 21150 PA 15838 PA 21151 PA 15839 PA 21154 PA 15999 IC 21155 PA 17999 IC 21159 PA 19140 PA 21160 PA 19318 PA 21172 PA 19328 PA 21175 PA 19330 PA 21179 PA 19340 PA 21180 PA 19342 PA 21181 PA 19350 PA 21182 PA 19357 PA 21183 PA 19361 PA 21184 PA 19364 PA 21188 PA 19366 PA 21193 PA 19367 PA 21194 PA 19368 PA 21195 PA 19369 PA 21196 PA 19380 PA 21198 PA 19499 IC 21206 PA 20999 IC 21208 PA 21076 PA 21209 PA 21077 PA 21210 PA 21079 PA 21215 PA 21080 PA 21230 PA 21081 PA 21235 PA 21082 PA 21240 PA 21083 PA 21242 PA 21084 PA 21243 PA 21085 PA 21244 PA 21086 PA 21247 PA 21087 PA 21255 PA 21256 PA 32853 PA 21260 PA 32854 PA 21261 PA 32999 IC 21263 PA 33935 PA 21267 PA 33945 PA 21268 PA 33999 IC 21270 PA 36299 IC 21275 PA 36470 PA 21280 PA 36471 PA 21282 PA 37501 IC 21295 PA 37799 IC 21296 PA 38129 IC 21299 IC; PA 38204 IC 21499 IC 38205 PA 21742 IC 38230 PA 21743 IC 38240 PA 21899 IC 38241 PA 22899 IC 38242 PA 22999 IC 38589 IC 23929 IC 38999 IC 24940 IC 39499 IC 24999 IC 39599 IC 25999 IC 40799 IC 26989 IC 40840 PA 27299 IC 40842 PA 27599 IC 40843 PA 27899 IC 40844 PA 28899 IC 40845 PA 29799 IC 40899 IC 29800 PA 41599 IC 29804 PA 41820 IC; PA 29999 IC 41821 IC 30400 PA 41850 IC 30410 PA 41899 IC 30420 PA 42140 PA 30430 PA 42280 PA 30435 PA 42281 PA 30450 PA 42299 IC 30999 IC 42699 IC 31299 IC 42999 IC 31599 IC 43289 IC 31899 IC 43499 IC 32851 PA 43659 IC 32852 PA 43846 PA 43847 PA 55250 CS-18 or CS-21 43848 PA 55450 CS-18 or CS-21 43999 IC 55559 IC 44133 IC; PA 55899 IC 44136 IC; PA 56800 PA 44238 IC 56805 IC; PA 44239 IC 57335 IC; PA 44799 IC 58150 HI-1 44899 IC 58152 HI-1 44979 IC 58180 HI-1 45999 IC 58200 HI-1 46999 IC 58210 HI-1 47135 PA 58240 HI-1 47136 PA 58260 HI-1 47140 PA 58262 HI-1 47141 PA 58263 HI-1 47142 PA 58267 HI-1 47379 IC 58270 HI-1 47399 IC 58275 HI-1 47579 IC 58280 HI-1 47999 IC 58285 HI-1 48554 PA 58290 HI-1 48556 PA 58291 HI-1 48999 IC 58292 HI-1 49329 IC 58293 HI-1 49659 IC 58294 HI-1 49906 IC 58550 HI-1 49999 IC 58552 HI-1 50549 IC 58553 HI-1 50949 IC 58554 HI-1 51597 HI-1 58578 IC 51715 PA 58579 IC 51925 HI-1 58600 CS-18 or CS-21 52327 PA 58605 CS-18 or CS-21 53850 PA 58611 CS-18 or CS-21 53852 PA 58615 CS-18 or CS-21 53899 IC 58661 CS-18 or CS-21 54240 PA 58670 CS-18 or CS-21 54250 PA 58671 CS-18 or CS-21 54400 PA 58679 IC 54401 PA 58951 HI-1 54405 PA 58999 IC 54440 IC 59135 HI-1 54699 IC 59525 HI-1 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-6 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series PHYSICIAN MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-7 TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-8 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 Service Code and Req. or Limit Service Code and Req. or Limit 59840 CPA-2 (first trimester) 69399 IC 59841 CPA-2 (first trimester) 69710 IC 59850 CPA-2 (second trimester, third 69799 IC trimester in hospital only) 69930 PA 59851 CPA-2 (second trimester, third 69949 IC trimester in hospital only) 69979 IC 59852 CPA-2 (second trimester, third 70336 PA trimester in hospital only) 75556 IC 59855 CPA-2 76499 IC 59856 CPA-2 76999 IC 59857 CPA-2 77299 IC 59898 IC 77499 IC 59899 IC 77799 IC 60659 IC 78099 IC 60699 IC 78199 IC 64681 IC 78299 IC 64999 IC 78399 IC 66999 IC 78499 IC 67299 IC 78599 IC 67399 IC 78608 IC 67599 IC 78609 IC 67900 PA 78699 IC 67901 PA 78799 IC 67902 PA 78990 IC 67903 PA 78999 IC 67904 PA 79900 IC 67906 PA 79999 IC 67908 PA 81099 IC 67909 PA 84999 IC 67911 PA 85999 IC 67916 PA 86849 IC 67917 PA 86999 IC 67923 PA 87999 IC; PA 67924 PA 88199 IC 67961 PA 88299 IC 67966 PA 88380 IC 67971 PA 88399 IC 67973 PA 89230 IC 67974 PA 89240 IC 67975 PA 90288 IC 67999 IC 90291 IC 68399 IC 90296 IC 68899 IC 90371 Covered for adults >17 69300 PA 90378 IC; PA • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series PHYSICIAN MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-9 TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 90393 IC 92506 PA for ST >15 90399 IC 92507 PA for ST >15 90473 IC 92508 PA for ST >15 90474 IC 92526 PA for ST >15 90476 IC 92610 PA for ST >15 90477 IC 92610 PA 90581 IC 92611 PA 90632 Covered for adults >17 92700 IC 90660 IC; PA 93799 IC 90665 IC 94642 IC 90690 IC 94772 IC 90692 IC 94799 IC 90693 IC 95071 IC 90707 Covered for adults >17 95199 IC; PA 90713 Covered for adults >17 95999 IC 90716 Covered for adults >17 96545 IC 90719 IC 96549 IC 90725 IC 96999 IC 90727 IC 97001 PA for PT >8 90732 Covered for adults >17 97002 PA for PT >8 90734 IC 97003 PA for OT >8 90749 IC; PA 97004 PA for OT >8 90799 IC 97010 PA for PT >8 90899 IC 97012 PA for PT >8 90935 For hospitalized member only; not for 97016 PA for PT >8 chronic maintenance 97018 PA for PT >8 90937 For hospitalized member only; not for 97020 PA for PT >8 chronic maintenance 97022 PA for PT >8 90945 For hospitalized member only; not for 97024 PA for PT >8 chronic maintenance 97026 PA for PT >8 90947 For hospitalized member only; not for 97028 PA for PT >8 chronic maintenance 97032 PA for PT >8 91110 PA 97033 PA for PT >8 91123 IC 97034 PA for PT >8 91299 IC 97035 PA for PT >8 92065 PA 97036 PA for PT >8 92250 PA 97039 IC; PA for PT >8 92310 PA 97110 PA for PT >8 92311 PA; includes supply of lenses 97112 PA for PT >8 92312 PA; includes supply of lenses 97113 IC; PA for PT >8 92313 PA; includes supply of lenses 97116 PA for PT >8 92326 PA 97124 PA for PT >8 92499 IC 97140 PA for PT >8 97150 PA for PT >8 97504 PA for OT >8 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-10 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 97520 PA for OT >8 97532 PA for OT >8 97533 PA for OT >8 97535 PA for OT >8 97542 PA for OT >8 97799 IC 98925 PA for OMT >8 98926 PA for OMT >8 98927 PA for OMT >8 98928 PA for OMT >8, IC 98929 PA for OMT >8, IC 99000 Centrifuging required 99050 Urgent care only 99052 Urgent care only 99054 Urgent care only 99070 IC; excluding family planning supplies, such as trays, used in the collection of specimens 99185 IC 99186 IC 99195 For hematologic disorders only 99199 IC 99289 IC 99290 IC 99296 IC 99298 IC 99299 IC 99344 IC 99345 IC 99350 IC 99499 IC 99600 IC This section lists Level II HCPCS codes that are payable under MassHealth. Refer to the Centers for Medicare and Medicaid Web site at www.cms.gov/medicare/hcpcs for more detailed descriptions when billing for Level II HCPCS codes provided to MassHealth members. • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-11 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 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 H2011 Crisis intervention service, per 15 minutes J0170 Injection, adrenalin, epinephrine, up to 1 ml ampule J0215 Injection, alefacept, 0.5 mg (PA) J0256 Injection, alpha 1- proteinase inhibitor – human, 10 mg J0290 Injection, ampicillin sodium 500 mg J0295 Injection, ampicillin sodium / sulbactam sodium, per 1.5 g J0456 Injection, azithromycin, 500 mg J0475 Injection, baclofen, 10 mg (PA) J0476 Injection, baclofen, 50 mcg for intrathecal trial (PA) J0530 Injection, penicillin G benzathine and penicillin G procaine, up to 600,000 units J0540 Injection, penicillin G benzathine and penicillin G procaine, up to 1,200,000 units J0550 Injection, penicillin G benzathine and penicillin G procaine, up to 2,400,000 units J0560 Injection, penicillin G benzathine, up to 600,000 units J0570 Injection, penicillin G benzathine, up to 1,200,000 units J0580 Injection, penicillin G benzathine, up to 2,400,000 units J0585 Botulinum toxin type A, per unit (PA) J0587 Botulinum toxin type B, per 100 units (PA) 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 and betamethasone sodium phosphate, per 3 mg J0704 Injection, betamethasone sodium phosphate, per 4 mg J0780 Injection, prochlorperazine, up to 10 mg J0880 Injection, darbepoetin alfa, 5 mcg (PA) J0900 Injection, testosterone enanthate and estradiol valerate, up to 1 cc J1020 Injection, methylprednisolone acetate, 20 mg J1030 Injection, methylprednisolone acetate, 40 mg J1040 Injection, methylprednisolone acetate, 80 mg J1055 Injection, medroxyprogesterone acetate for contraceptive use, 150 mg (150 mg Depo Provera) (IC) J1056 Injection, medroxyprogesterone acetate/estradiol cypionate, 5 mg/25 mg (5 mg/25 mg Lunelle) (IC) 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 J1160 Injection, digoxin, up to 0.5 mg J1170 Injection, hydromorphone, up to 4 mg J1200 Injection, diphendydramine HCl, up to 50 mg J1260 Injection, dolasetron mesylate, 10 mg J1320 Injection, amitriptyline HCl, up to 20 mg J1438 Injection, etanercept, 25 mg (PA) J1440 Injection, filgrastim (G-CSF), 300 mcg (PA) J1441 Injection, filgrastim (G-CSF), 480 mcg (PA) J1460 Injection, gamma globulin, intramuscular, 1 cc J1470 Injection, gamma globulin, intramuscular, 2 cc J1480 Injection, gamma globulin, intramuscular, 3 cc J1490 Injection, gamma globulin, intramuscular, 4 cc J1500 Injection, gamma globulin, intramuscular, 5 cc J1510 Injection, gamma globulin, intramuscular, 6 cc J1520 Injection, gamma globulin, intramuscular, 7 cc J1530 Injection, gamma globulin, intramuscular, 8 cc J1540 Injection, gamma globulin, intramuscular, 9 cc J1550 Injection, gamma globulin, intramuscular, 10 cc J1563 Injection, immune globulin, intravenous, 1 g (PA) J1564 Injection, immune globulin, 10 mg (PA) 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 J1720 Injection, hydrocortisone sodium succinate, up to 100 mg J1745 Injection, infliximab, 10 mg (PA) J1750 Injection, iron dextran, 50 mg J1790 Injection, droperidol, up to 5 mg J1800 Injection, propranolol HCl, up to 1 mg J1885 Injection, ketorolac, tromethamine, per 15 mg J1890 Injection, cephalothin sodium, up to 1 g 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 J2250 Injection, midazolam HCl, per 1 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 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-12 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-13 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 J2405 Injection, ondansetron HCl, per 1 mg J2430 Injection, pamidronate disodium, per 30 mg J2440 Injection, papaverine HC1, up to 60 mg J2505 Injection, prefilgrastim, 6 mg (PA) J2510 Injection, penicillin G procaine, aqueous, up to 600,000 units J2515 Injection, pentobarbital sodium, per 50 mg J2560 Injection, phenobarbital sodium, up to 120 mg J2675 Injection, progesterone, per 50 mg J2760 Injection, phentolamine mesylate, up to 5 mg J2765 Injection, metoclopramide HCl, up to 10 mg J2780 Injection, ranitidine HCl, 25 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 J2820 Injection, sargramostim (GM-CSF), 50 mcg (PA) J2910 Injection, aurothioglucose, up to 50 mg 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) J2941 Injection, somatropin, 1 mg (PA) J3030 Injection, sumatriptan succinate, 6 mg J3120 Injection, testosterone enanthate, up to 100 mg J3130 Injection, testosterone enanthate, up to 200 mg J3230 Injection, chlorpromazine HCl, up to 50 mg J3250 Injection, trimethobenzamide HCl, up to 200 mg J3301 Injection, triamcinolone acetonide, per 10 mg J3302 Injection, triamcinolone diacetate, per 5 mg J3303 Injection, triamcinolone hexacetonide, per 5 mg J3395 Injection, verteporfin, 15 mg J3410 Injection, hydroxyzine HCl, up to 25 mg J3430 Injection, phytonadione (vitamin K), per 1 mg J3487 Injection, zoledronic acid, 1 mg J3490 Unclassified drugs (PA) (IC) J3490-FP Unclassified drugs (service provided as part of Medicaid family planning program) (Use for medications and injectibles 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 (PA) (IC) J7030 Infusion, normal saline solution, 1,000 cc J7040 Infusion, normal saline solution, sterile (500 ml = 1 unit) J7042 5% dextrose/normal saline (500 ml = 1 unit) J7050 Infusion, normal saline solution, 250 cc J7060 5% dextrose/water (500 ml = 1 unit) J7070 Infusion, D-5-W, 1,000 cc J7317 Sodium hyaluronate, per 20 to 25 mg dose for intra-articular injection (PA) J7320 Hylan G-F 20, 16 mg, for intra-articular injection (PA) J7599 Immunosuppressive drug, NOC (PA) (IC) J9000 Doxorubicin HCl, 10 mg J9001 Doxorubicin HCl, all lipid formulations, 10 mg J9031 BCG live (intravesical), per instillation J9040 Bleomycin sulfate, 15 units J9045 Carboplatin, 50 mg J9060 Cisplatin, powder or solution, per 10 mg J9062 Cisplatin, 50 mg J9070 Cyclophosphamide, 100 mg J9080 Cyclophosphamide, 200 mg J9090 Cyclophosphamide, 500 mg J9091 Cyclophosphamide, 1 g J9092 Cyclophosphamide, 2 g J9093 Cyclophosphamide, lyophilized, 100 mg J9094 Cyclophosphamide, lyophilized, 200 mg J9095 Cyclophosphamide, lyophilized, 500 mg J9096 Cyclophosphamide, lyophilized, 1 g J9097 Cyclophosphamide, lyophilized, 2 g J9130 Dacarbazine, 100 mg J9140 Dacarbazine, 200 mg J9170 Docetaxel, 20 mg J9181 Etoposide, 10 mg J9182 Etoposide, 100 mg J9190 Fluorouracil, 500 mg J9201 Gemcitabine HC1, 200 mg J9202 Goserelin acetate implant, per 3.6 mg (PA) J9206 Irinotecan, 20 mg J9212 Injection, interferon Alfacon-1, recombinant, 1 mcg J9213 Interferon alfa-2A, recombinant, 3 million units J9214 Interferon alfa-2B, recombinant, 1 million units J9215 Interferon alfa-N3 (human leukocyte derived), 250,000 IU J9216 Interferon gamma-1B, 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) J9250 Methotrexate sodium, 5 mg J9260 Methotrexate sodium, 50 mg J9263 Injection, oxaliplatin, 0.5 mg J9265 Paclitaxel, 30 mg • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-14 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES AND DESCRIPTIONS PAGE 6-15 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 4/30/2004 J9300 Gemtuzumab ozogamicin, 5 mg J9310 Rituximab, 100 mg J9355 Trastuzumab, 10 mg J9360 Vinblastine sulfate, 1 mg J9370 Vincristine sulfate, 1 mg J9375 Vincristine sulfate, 2 mg J9380 Vincristine sulfate, 5 mg J9390 Vinorelbine tartrate, per 10 mg J9395 Trastuzumab, 10 mg (PA) J9999 NOC, antineoplastic drug (PA) (IC) Q0136 Injection, epoetin alpha (for non ESRD use), per 1,000 units (PA) R0070 Transportation of portable X-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen S0020 Injection, bupivicaine HCl, 30 ml S0021 Injection, ceftoperazone sodium, 1 gram (IC) S0023 Injection, cimetidine HCl, 300 mg S0028 Injection, famotidine, 20 mg S0077 Injection, clindamycin phosphate, 300 mg S0107 Injection, omalizumab, 25 mg (PA) S0302 Completed early periodic screening diagnosis and treatment (EPSDT) service (List in addition to code for appropriate evaluation and management services) S2260 Induced abortion, 17 to 24 weeks, any surgical method (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 605 Modifiers 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. 26 Professional component 50 Bilateral procedure 51 Multiple procedures 54 Surgical care only 62 Two surgeons 66 Surgical team 80 Assistant surgeon 82 Assistant surgeon (when qualified resident surgeon not available) 99 Multiple modifiers • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-16 PHYSICIAN MANUAL TRANSMITTAL LETTER PHY-100 DATE 04/30/2004 FP Services provided as part of Medicaid Family Planning Program HN Bachelor’s degree level. (Use to indicate physician assistant.) (This modifier is to be applied to service codes billed by a physician that were performed by a physician assistant employed by the physician or group practice.) RP Replacement and repair (This modifier should only be used with 92340, 92341, and 92342 to bill for the displacement of replacement lenses.) SA Nurse practitioner rendering service in collaboration with a physician. (This modifier is to be applied to service codes billed by a physician which 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 service codes billed by a physician which 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 Service codes 90471 and 90473 to identify vaccines administered under the Vaccine for Children Program (VFC) for individuals age 18 and under.) 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 procedure code will allow the technical component allowable fee contained in 114.3 CMR 17.04 to be paid.)