Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter PHY-132 December 2011 TO: Physicians Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Physician Manual (2011 HCPCS Updates) This letter transmits revisions to the laboratory service codes in the Physician Manual. The Centers for Medicare & Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) codes for 2011. The revised Subchapter 6 is effective for dates of service on or after December 1, 2011. For dates of service on or after December 1, 2011, you must use the new codes in order to obtain reimbursement. Drug Screen Service Codes Effective December 1, 2011, MassHealth will no longer pay for drug screen Service Codes 80100 (Drug screen, qualitative; multiple drug classes chromatographic method, each procedure) and 80101 (Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class). Drug screen services should now be reported using Service Code G0431 (Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter) or G0434 (Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter). G0431 and G0434 are bundled codes that pay a single fee for the drug screen services being provided at the patient encounter regardless of the number of drug classes being tested. Providers should not routinely bill for the quantification of drug classes (e.g., chemistry section 82000-84999 or therapeutic drug assay section 80150- 80299) being tested as part of the drug screen service. Providers should bill only for the quantification of drug classes being tested as part of a drug screen service or a confirmatory drug test if there is a positive screen for one or more drug classes being tested. Standing Order Requests Providers are reminded that MassHealth issued revised regulations about standing order requests made to independent clinical laboratories via Transmittal Letter LAB-35, issued in March 2010. These amendments pertain to standing order requests, information required for written requests for laboratory services, record keeping requirements, conditions relating to authorized prescribers, and EPSDT services. As part of these changes, MassHealth established that standing order requests made by authorized prescribers to a MassHealth independent clinical lab to perform most services must not exceed 180 days and for substance abuse testing must not exceed 30 days. Please review all the updated regulations transmitted via Transmittal Letter LAB-35. MassHealth Transmittal Letter PHY-132 December 2011 Page 2 Fluoride Treatment (D1206) MassHealth has adopted the clinical guidelines of the American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA) for topical fluoride treatment. MassHealth pays for fluoride treatment only once per member per three-month period. Fee Schedule If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy (DHCFP) regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of DHCFP regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The regulation title for laboratory services is 114.3 CMR 20.00: Clinical Laboratory Services. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth. Questions If you have any questions about 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 vi and 6-1 through 6-20 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Physician Manual Page vi — transmitted by Transmittal Letter PHY-129 Pages 6-1 through 6-20 — transmitted by Transmittal Letter PHY-130 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Physician Manual Transmittal Letter PHY-132 Date 12/01/11 6. Service Codes Introduction ................................................................................ ................................................... 6-1 Nonpayable CPT Codes ................................................................................ ................................. 6-1 Codes That Have Special Requirements or Limitations................................................................. 6-4 Payable HCPCS Level II Service Codes........................................................................... ............. 6-11 Modifiers ................................................................................ ....................................................... 6-18 Appendix A. Directory ................................................................................ .................................. A-1 Appendix B. Enrollment Centers ................................................................................ .................. B-1 Appendix C. Third-Party-Liability Codes ................................................................................ .... C-1 Appendix D. (Reserved) Appendix E. Admission Guidelines ................................................................................ .............. E-1 Appendix F. (Reserved) Appendix G. (Reserved) Appendix H. (Reserved) Appendix I. Utilization Management Program ............................................................................ I-1 Appendix J. (Reserved) Appendix K. Teaching Physicians ................................................................................ ................ K-1 Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity Schedules ........... W-1 Appendix X. Family Assistance Copayments and Deductibles..................................................... X-1 Appendix Y. EVS Codes/Messages ................................................................................ .............. Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes.............................................................. Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 601 Introduction MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) 2011 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 MassHealth regulations at 130 CMR 433.000 and 450.000, except for those codes listed in Section 602 of this subchapter, Category II codes ending in F, and Category III codes ending in T. In addition, 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 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 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 15825 21120 33930 38215 11922 15826 21121 33933 41870 11950 15828 21122 33940 41872 11951 15829 21123 33944 43752 11952 15847 21125 36415 43842 11954 15876 21127 36416 43843 15775 15877 21245 36468 43845 15776 15878 21246 36469 44132 15780 15879 21248 36591 44715 15781 17340 21249 36592 47133 15782 17360 22526 36598 47143 15783 17380 22527 38204 47144 15786 19316 22841 38207 47145 15787 19324 22856 38208 48160 15788 19325 22861 38209 48550 15789 19355 22864 38210 48551 15792 19396 32491 38211 50300 15793 20930 32850 38212 50323 15819 20936 32855 38213 50325 15824 20985 32856 38214 51701 1Commonwealth of Massachusetts MassHealth Provider Manual Series Physician Manual Subchapter Number and Title 6. Service Codes Page 6-2 Transmittal Letter PHY-132 Date 12/01/11 602 Nonpayable CPT Codes (cont.) 51702 76497 86305 89255 90647 54900 76498 86890 89257 90648 54901 77336 86891 89258 90654 55200 77370 86910 89259 90665 55300 77371 86911 89260 90669 55400 77372 86927 89261 90670 55870 77373 86930 89264 90680 55970 77401 86931 89268 90698 55980 77402 86932 89272 90700 58321 77403 86945 89280 90701 58322 77404 86950 89281 90702 58323 77406 86960 89290 90708 58345 77407 86965 89291 90710 58350 77408 86985 89300 90712 58750 77409 87150 89310 90720 58752 77411 87153 89320 90721 58760 77412 87493 89321 90723 58970 77413 87900 89322 90743 58974 77414 87901 89325 90744 58976 77416 87903 89329 90748 59070 77417 87904 89330 90845 59072 77418 88000 89331 90865 59412 77421 88005 89335 90875 59897 77422 88007 89342 90876 61630 77423 88012 89343 90880 61635 77520 88014 89344 90885 61640 77522 88016 89346 90889 61641 77523 88020 89352 90901 61642 77525 88025 89353 90911 62287 77790 88027 89354 90940 63043 78267 88028 89356 90989 63044 78268 88029 89398 90993 65760 78351 88036 90281 90997 65765 80100 88037 90283 90999 65767 80101 88040 90284 91132 65771 80104 88045 90287 91133 69090 80500 88099 90384 92314 71552 80502 88125 90386 92315 72159 82075 88333 90389 92316 72198 82962 88334 90396 92317 73225 83987 88738 90586 92325 74263 84061 88749 90633 92352 75571 84145 89250 90634 92353 76140 84431 89251 90644 92354 76390 84830 89253 90645 92355 76496 86079 89254 90646 92358 1Commonwealth of Massachusetts MassHealth Provider Manual Series Physician Manual Subchapter Number and Title 6. Service Codes Page 6-3 Transmittal Letter PHY-132 Date 12/01/11 602 Nonpayable CPT Codes (cont.) 92371 95967 97755 99148 99380 92531 95992 97810 99149 99401 92532 96000 97811 99150 99402 92533 96001 97813 99172 99403 92534 96002 97814 99190 99404 92548 96003 98940 99191 99406 92559 96004 98941 99192 99408 92560 96040 98942 99241 99409 92561 96101 98943 99242 99411 92562 96102 98960 99243 99412 92564 96103 98961 99244 99420 92597 96105 98962 99245 99429 92605 96111 98966 99251 99441 92606 96116 98967 99252 99442 92613 96118 98968 99253 99443 92615 96119 98969 99254 99444 92617 96120 99001 99255 99450 92630 96125 99002 99288 99455 92633 96150 99024 99315 99456 93660 96151 99026 99316 99500 93668 96152 99027 99339 99501 93770 96153 99053 99340 99502 93786 96154 99056 99354 99503 94005 96155 99058 99355 99504 94015 96376 99060 99356 99505 94644 96567 99071 99357 99506 94645 96902 99075 99358 99507 95012 96904 99078 99359 99509 95052 97005 99080 99360 99510 95120 97006 99082 99363 99511 95125 97014 99090 99364 99512 95130 97537 99091 99366 99601 95131 97545 99100 99367 99602 95132 97546 99116 99368 99605 95133 97597 99135 99374 99606 95134 97598 99140 99375 99607 95824 97602 99143 99377 95965 97605 99144 99378 95966 97606 99145 99379 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-4 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 603 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 centrifuges 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 Behavioral Health Screening Modifiers to indicate whether a behavioral health need was identified. 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. 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-5 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 603 Codes That Have Special Requirements or Limitations (cont.) Service Code and Req. or Limit 01999 IC 11920 PA 11921 PA 15431 IC 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 19318 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 21155 PA 21159 PA 21160 PA 21172 PA 21175 PA 21188 PA 21193 PA 21194 PA 21195 PA 21196 PA Service Code and Req. or Limit 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 21260 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-6 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 603 Codes That Have Special Requirements or Limitations (cont.) Service Code and Req. or Limit 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 Service Code and Req. or Limit 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-7 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 603 Codes That Have Special Requirements or Limitations (cont.) Service Code and Req. or Limit Service Code and Req. or Limit 49999 IC 58554 HI-1 50549 IC 58565 CS-18 or CS-21 50949 IC 58570 HI-1 51925 HI-1 58571 HI-1 51999 IC 58572 HI-1 53899 IC 58573 HI-1 54400 PA 58578 IC 54401 PA 58579 IC 54405 PA 58600 CS-18 or CS-21 54440 IC 58605 CS-18 or CS-21 54699 IC 58611 CS-18 or CS-21 55250 CS-18 or CS-21 58615 CS-18 or CS-21 55450 CS-18 or CS-21 58661 CS-18 or CS-21 55559 IC 58670 CS-18 or CS-21 55899 IC 58671 CS-18 or CS-21 56800 PA 58679 IC 56805 IC 58951 HI-1 57335 IC 58956 HI-1 58150 HI-1 58999 IC 58152 HI-1 59135 HI-1 58180 HI-1 59525 HI-1 58200 HI-1 59840 CPA-2 (first trimester) 58210 HI-1 59841 CPA-2 (first trimester) 58240 HI-1 59850 CPA-2 (second trimester, third 58260 HI-1 trimester in hospital only) 58262 HI-1 59851 CPA-2 (second trimester, third 58263 HI-1 trimester in hospital only) 58267 HI-1 59852 CPA-2 (second trimester, third 58270 HI-1 trimester in hospital only) 58275 HI-1 59855 CPA-2 58280 HI-1 59856 CPA-2 58285 HI-1 59857 CPA-2 58290 HI-1 59898 IC 58291 HI-1 59899 IC 58292 HI-1 60659 IC 58293 HI-1 60699 IC 58294 HI-1 64650 PA 58541 HI-1 64653 PA 58542 HI-1 64999 IC 58543 HI-1 65757 IC 58544 HI-1 66999 IC 58548 HI-1 67299 IC 58550 HI-1 67399 IC 58552 HI-1 67599 IC 58553 HI-1 67900 PA Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-8 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 603 Codes That Have Special Requirements or Limitations (cont.) Service Code and Req. or Limit Service Code and Req. or Limit 67901 PA 88399 IC 67902 PA 89240 IC 67903 PA 90288 IC 67904 PA 90291 IC 67906 PA 90296 IC 67908 PA 90378 PA; IC 67999 IC 90393 PA; IC 68399 IC 90399 IC 68899 IC 90476 IC 69300 PA 90477 IC 69399 IC 90581 IC 69710 IC 90632 Covered for adults ....; available 69799 IC free of charge through the 69930 PA Massachusetts Immunization 69949 IC Program for children under 19 69979 IC years of age. 74261 PA 90636 IC 74262 PA 90649 Covered for members aged 19 to 26; 76499 IC available free of charge through 76999 IC the Massachusetts Immunization 77058 PA Program for children under 19 77059 PA years of age. 77299 IC 90650 Covered for members aged 19 to 26; 77399 IC available free of charge through 77499 IC the Massachusetts Immunization 77799 IC Program for children under 19 78099 IC years of age. 78199 IC 90661 IC 78299 IC 90662 IC 78399 IC 90663 IC 78499 IC 90664 IC 78599 IC 90666 IC 78699 IC 90667 IC 78799 IC 90668 IC 78999 IC 90676 IC 79999 IC 90681 IC; Covered for members ..19; 81099 IC available free of charge through 84999 IC the Massachusetts Immunization 85999 IC Program for children under 19 86849 IC years of age. 86999 IC 90690 IC 87999 IC 90692 IC 88199 IC 90693 IC 88299 IC 90696 IC 88384 IC Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-9 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 603 Codes That Have Special Requirements or Limitations (cont.) Service Code and Req. or Limit 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. 90718 IC 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 60 90738 IC 90749 IC 90867 IC 90868 IC 90899 IC 90935 For hospitalized member only; not for chronic maintenance Service Code and Req. or Limit 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 92610 PA for ST >35 92700 IC 92992 IC 92993 IC 93229 IC 93299 IC 93745 IC 93799 IC 94772 IC 94774 IC 94775 IC 94776 IC 94777 IC 94799 IC 95199 IC 95803 IC 95999 IC Commonwealth of Massachusetts MassHealth Provider Manual Series Physician Manual Subchapter Number and Title 6. Service Codes Page 6-10 Transmittal Letter PHY-132 Date 12/01/11 603 Codes That Have Special Requirements or Limitations (cont.) Service Code and Req. or Limit 96110 Developmental testing; limited (e.g., Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report; 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 Service Code and Req. or Limit 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-11 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 604 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 Web site 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) 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) 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) J0135 Injection, adalimumab, 20 mg (PA) J0171 Injection, Adrenalin, epinephrine, 0.1 mg (IC) 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-12 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 604 HCPCS Level II Service Codes (cont.) Service Code Service Description 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 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) 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 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 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) 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 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 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-13 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 604 HCPCS Level II Service Codes (cont.) Service Code Service Description 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 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 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 J1740 Injection, ibandronate sodium, 1 mg (PA) J1743 Injection, idursulfase, 1 mg (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 J2248 Injection, micafungin sodium, 1 mg J2250 Injection, midazolam HCl, per 1 mg J2270 Injection, morphine sulfate, up to 10 mg Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-14 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 604 HCPCS Level II Service Codes (cont.) Service Code Service Description 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 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) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-15 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 604 HCPCS Level II Service Codes (cont.) Service Code Service Description 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 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) J7335 Capsaicin 8% patch, per 10 sq cm (PA) (IC) 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) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-16 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 604 HCPCS Level II Service Codes (cont.) Service Code Service Description 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 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 J9001 Injection, doxorubicin HCl, all lipid formulations, 10 mg 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 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 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-17 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 604 HCPCS Level II Service Codes (cont.) Service Code Service Description 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) 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 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-18 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 604 HCPCS Level II Service Codes (cont.) Service Code Service Description 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) 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. Modifier Modifer Description 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 FP Service provided as part of family planning program 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.) 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.) 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.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-19 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 605 Modifiers (cont.) Modifier Modifier Description 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).) 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 114.3 CMR 17.04 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 Modifer 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. “Behavioralhealth 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-20 Physician Manual Transmittal Letter PHY-132 Date 12/01/11 605 Modifiers (cont.) Modifier Modifer 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) HA Service Code 90801 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.