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 AOH-6 September 2004 TO: Acute Outpatient Hospitals and Hospital Licensed Health Centers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Acute Outpatient Hospital Manual (Revised Service Codes and Appendix F) This letter transmits revisions to the Acute Outpatient Hospital Manual. Appendix F, previously issued under Transmittal Letter AOH-5 (April 2004), contained several inaccurate allowable HCPCS ranges listed in the column “Allowable HCPCS.” • MassHealth has removed Service Code 87901 from the nonpayable codes list in Section 602 of Subchapter 6. • After review, MassHealth has determined that Service Codes 97139 and 97530 are payable effective September 1, 2004. They have been removed from the nonpayable codes list in Section 602 of Subchapter 6. MassHealth has corrected the ranges of allowable HCPCS and is reissuing the attached Appendix F in its entirety. All other conditions and information in Transmittal Letter AOH-5 remain in effect. 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.) Acute Outpatient Hospital Manual Pages 6-1, 6-2, and F-1 through F-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Pages 6-1, 6-2, and F-1 through F-6 — transmitted by Transmittal Letter AOH-5 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-1 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-6 DATE 09/01/04 601 Introduction MassHealth providers must refer to the official list of HCPCS codes and descriptions as posted on the Centers for Medicare and Medicaid Services Web site at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. Level I HCPCS Codes MassHealth pays for all medicine, radiology, laboratory, surgery, and anesthesia Level I HCPCS 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’s 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 all Level II HCPCS codes in effect at the time of service listed in Section 603 of this subchapter, subject to all conditions and limitations described in MassHealth’s regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. For a list of billable revenue codes and HCPCS billing combinations, please refer to Appendix F of the Acute Outpatient Hospital Manual. The list in Appendix F is to be used only as a guide. 602 Nonpayable Codes - Level I HCPCS MassHealth does not pay for services billed under the following codes. For members under age 21, MassHealth regulations at 130 CMR 450.144(A) allow providers to seek coverage when medically necessary, by requesting prior authorization. 0001F 0016T 0044T 11922 15825 21121 0002F 0017T 0045T 11950 15826 21122 0003F 0018T 0046T 11951 15828 21123 0004F 0019T 0047T 11952 15829 21125 0005F 0020T 0048T 11954 15876 21127 0006F 0021T 0049T 15775 15877 21245 0007F 0023T 0050T 15776 15878 21246 0008F 0030T 0051T 15780 15879 21248 0009F 0031T 0052T 15781 17340 21249 0010F 0032T 0053T 15782 17360 22841 0011F 0033T 0054T 15783 17380 32491 0001T 0034T 0055T 15786 19316 32850 0005T 0035T 0056T 15787 19324 33930 0006T 0036T 0057T 15788 19325 33940 0007T 0037T 0058T 15789 19355 36415 0008T 0038T 0059T 15792 19370 36416 0009T 0039T 0060T 15793 19371 36468 0010T 0040T 0061T 15810 19396 36469 0012T 0041T 10040 15811 20930 36540 0013T 0042T 11920 15819 20936 37765 0014T 0043T 11921 15824 21120 37766 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series ACUTE OUTPATIENT HOSPITAL MANUAL SUBCHAPTER NUMBER AND TITLE 6 SERVICE CODES PAGE 6-2 TRANSMITTAL LETTER AOH-6 DATE 09/01/04 41870 77399 89256 90700 92352 96151 41872 78267 89257 90701 92353 96152 43752 78268 89258 90702 92354 96153 43842 78351 89259 90708 92355 96154 43843 80500 89260 90710 92358 96155 44132 80502 89261 90712 92371 96567 44133 82075 89264 90715 92390 96902 44135 82962 89268 90718 92391 97005 44136 84061 89272 90720 92392 97006 47133 84830 89280 90721 92393 97537 48160 86079 89281 90723 92395 97545 58750 86585 89290 90744 92396 97546 58752 86890 89291 90748 92531 97601 58760 86891 89300 90816 92532 97602 58970 86910 89310 90817 92533 97755 58974 86911 89320 90818 92534 97780 58976 86927 89321 90819 92548 97781 59070 86930 89325 90821 92559 97802 59072 86931 89329 90822 92560 97803 59412 86932 89330 90823 92561 97804 59897 86945 89335 90824 92562 98940 62287 86950 89342 90826 92564 98941 63043 86965 89343 90827 93660 98942 63044 86985 89344 90828 93760 98943 65760 87903 89346 90829 93762 99000 65765 87904 89352 90845 93770 99001 65767 88000 89353 90865 93784 99002 65771 88005 89354 90875 93786 99024 65780 88007 89356 90876 93788 99026 65781 88012 90281 90880 93790 99027 65782 88014 90283 90885 94015 99050 69090 88016 90287 90889 95052 99056 71552 88020 90379 90901 95120 99058 72159 88025 90384 90911 95125 99071 72198 88027 90386 90939 95130 99075 73225 88028 90389 90940 95131 99078 76082 88029 90396 90989 95132 99080 76083 88036 90586 90993 95133 99082 76085 88037 90633 90997 95134 99090 76093 88040 90634 90999 95824 99091 76094 88045 90636 91132 95965 99100 76140 88099 90645 91133 95966 99116 76150 88125 90646 92314 95967 99135 76350 89250 90647 92315 96000 99140 76390 89251 90648 92316 96001 99141 76400 89252 90665 92317 96002 99142 76496 89253 90669 92325 96003 99172 76497 89254 90680 92330 96004 76498 89255 90698 92335 96150 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX F: REVENUE CODES AND HCPCS COMBINATION GUIDE PAGE F-1 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-6 DATE 09/01/04 MassHealth Revenue Codes and HCPCS Combination Guide The following crosswalk should be used as a guide for acute outpatient hospitals (AOHs), hospital-licensed health centers, and provider-based satellites, when billing MassHealth-covered services. For most revenue codes, ranges of HCPCS are listed. Hospitals should check Subchapter 6 in the Acute Outpatient Hospital Manual to determine if a specific code within a range is covered by MassHealth, since not all codes in the ranges are payable by MassHealth. Revenue Code Description HCPCS Required? Allowable HCPCS 025X Pharmacy 0250 General no N/A 0251 Generic drugs no N/A 0252 Non-generic drugs no N/A 0253 Take-home drugs no N/A 0254 Drugs incident to other diagnostic services no N/A 0255 Drugs incident to radiology no N/A 0257 Nonprescription drugs no N/A 0258 IV solutions no N/A 026X IV Therapy 0260 General no Q0081 027X Medical/Surgical Supplies and Devices – General 0270 General no N/A 0271 Non-sterile supply no N/A 0272 Sterile supply no N/A 0273 Take-home supplies no N/A 0274 Prosthetic/orthotic devices no N/A 0275 Pacemaker no N/A 0276 Intraocular lens no N/A 0278 Other implants no N/A 028X Oncology 0280 General yes within 99201 – 99290 range 029X DME 0290 General no N/A 0291 Rental no N/A 0292 Purchase of new DME no N/A 0293 Purchase of used DME no N/A 030X Laboratory 0300 General yes within 80048 – 89356 range 0301 Chemistry yes within 80048 – 89356 range 0302 Immunology yes within 80048 – 89356 range 0304 Non-routine dialysis yes within 80048 – 89356 range 0305 Hematology yes within 80048 – 89356 range 0306 Bacteriology and microbiology yes within 80048 – 89356 range 0307 Urology yes within 80048 – 89356 range 0309 Other yes within 80048 – 89356 range 031X Laboratory Pathological – General 0310 Laboratory pathological – general yes within 80048 – 89356 range 0311 Cytology yes within 80048 – 89356 range 0312 Histology yes within 80048 – 89356 range 0314 Biopsy yes within 80048 – 89356 range 0319 Other yes within 80048 – 89356 range • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX F: REVENUE CODES AND HCPCS COMBINATION GUIDE PAGE F-2 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-6 DATE 09/01/04 Revenue Code Description HCPCS Required? Allowable HCPCS 032X Radiology – Diagnostic 0320 General yes within 70010 – 79999 range 0321 Angiocardiography yes within 70010 – 79999 range 0322 Arthrography yes within 70010 – 79999 range 0323 Arteriography yes within 70010 – 79999 range 0324 Chest Xray yes within 70010 – 79999 range 0329 Other yes within 70010 – 79999 range 033X Radiology–Therapeutic and/or Chemotherapy Administration 0330 General yes within 70010 – 79999 range 0331 Chemotherapy administration – injected yes within 96400 – 96549 range 0332 Chemotherapy – oral yes within 96400 – 96549 range 0333 Radiation therapy yes within 70010 – 79999 range 0335 Chemotherapy administration – IV yes within 96400 – 96549 range 034X Nuclear Medicine 0340 General yes within 70010 – 79999 range 0341 Diagnostic yes within 70010 – 79999 range 0342 Therapeutic yes within 70010 – 79999 range 0349 Other yes within 70010 – 79999 range 035X Computerized Tomographic (CT) Scans 0350 General yes within 70010 – 79999 range 0351 Head scan yes within 70010 – 79999 range 0352 Body scan yes within 70010 – 79999 range 0359 Other yes within 70010 – 79999 range 036X Operating Room Services 0360 General yes within 10021 – 69990 range, 92018, 92019, and 92502 0361 Minor surgery yes within 10021 – 69990 range, 92018, 92019, and 92502 037X Anesthesia 0370 General no N/A 0371 Anesthesia incident to radiology no N/A 0372 Anesthesia incident to other diagnostic services no N/A 038X Blood 0381 Packed red blood cells no N/A 0383 Plasma no N/A 0384 Platelets no N/A 0385 Leukocytes no N/A 0386 Other components no N/A 0387 Other derivatives no N/A 039X Blood Storage and Processing 0390 General no N/A 0391 Administration yes within 36430 – 36460 range 040X Other Imaging Services 0400 General yes within 70010 – 79999 range 0401 Diagnostic mammography yes within 70010 – 79999 range 0402 Ultrasound yes within 70010 – 79999 range 0403 Screening mammography yes within 70010 – 79999 range 0404 Positron emission tomography (PET) yes within 70010 – 79999 range 041X Respiratory Services 0410 General yes within 94640 – 94668 range 0412 Inhalation services yes within 94640 – 94668 range 0413 Hyperbaric oxygen therapy yes 99183 0419 Other yes within 94640 – 94668 range • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX F: REVENUE CODES AND HCPCS COMBINATION GUIDE PAGE F-3 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-6 DATE 09/01/04 Revenue Code Description HCPCS Required? Allowable HCPCS 042X Physical Therapy 0420 General yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0421 Visit charge yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0423 Group charge yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0424 Evaluation or reevaluation yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 043X Occupational Therapy 0430 General yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0431 Visit charge yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0433 Group rate yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 0434 Evaluation or reevaluation yes within 92506 – 92526, 97001 – 97542, and 97703 – 97799 ranges 044X Speech-Language Pathology 0440 General yes within 92504 – 92526, 92601 – 92700, 97001 – 97542, and 97703 – 97799 ranges 0441 Visit charge yes within 92504 – 92526, 92601 – 92700, 97001 – 97542, and 97709 – 97799 ranges 0443 Group rate yes within 92504 – 92526, 92601 – 92700, 97001 – 97542, and 97709 – 97799 ranges 0444 Evaluation or reevaluation yes within 92504 – 92526, 92605 – 92700, 97001 – 97542, and 97703 – 97799 ranges 045X Emergency Room 0450 General yes within 10021 – 69990, 92202 – 92287, and 99241 – 99499 ranges 0456 Urgent care yes within 10021 – 69990, 92202 – 92287, and 99241 – 99499 ranges 0459 Other ER yes within 10021 – 69990, 92202 – 92287, and 99241 – 99499 ranges 046X Pulmonary Function 0460 General yes within 94010 – 94621 and 94680 – 94799 ranges 0469 Other yes within 94010 – 94621 and 94680 – 94799 ranges 047X Audiology 0470 General yes within 92504 – 92597 and 92601 – 92617 ranges 0471 Diagnostic yes within 92504 – 92597 and 92601 – 92617 ranges 0472 Treatment yes within 92504 – 92597 and 92601 – 92617 ranges 0479 Other yes within 92504 – 92597 and 92601 – 92617 ranges 048X Cardiology 0480 General yes within 92950 – 92998 and 93270 – 93668 ranges • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX F: REVENUE CODES AND HCPCS COMBINATION GUIDE PAGE F-4 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-6 DATE 09/01/04 Revenue Code Description HCPCS Required? Allowable HCPCS 0481 Cardiac catheterization lab yes within 92950 – 92998 and 93270 – 93668 ranges 0482 Stress test yes within 92950 – 92998, 93015 – 93018 and 93270 – 93668 ranges 0483 Echocardiology yes within 92950 – 92998 and 93270 – 93668 ranges 0489 Other yes within 92950 – 92998 and 93270 – 93668 ranges 049X Ambulatory Surgical Care 0490 General yes within 10021 – 69990 range and 92018, 92019 and 92502 0499 Other yes within 10021 – 69990 range and 92018, 92019, and 92502 051X Clinic 0510 General yes within 10021 – 69990, 92002 – 92499, 95115 – 95250, 99201 – 99215, and 99241 – 99499 ranges 0515 Pediatric clinic yes within 10021 – 69990, 92002 – 92499, 95115 – 95250, 99201 – 99215, and 99381 – 99499 ranges 0519 Other yes within 10021 – 69990, 92002 – 92499, 95115 – 95250, 99201 – 99215 and 99381 – 99499 ranges 053X Osteopathic Services 0530 General yes within 98925 – 98929 range 061X Magnetic Resonance Technology 0610 General yes within 70010 – 79999 range 0611 MRI – brain yes within 70010 – 79999 range 0612 MRI – spinal cord yes within 70010 – 79999 range 062X Medical/Surgical Supplies 0621 Supplies incident to radiology no N/A 0622 Supplies incident to other diagnostic services no N/A 063X Pharmacy 0634 EPO, less than 10,000 units no N/A 0635 EPO, 10,000 or more units no N/A 0636 Drugs requiring detail coding yes within J0120 – J9999, 90281 – 90399, and 90476 – 90749 ranges 070X Cast Room 0700 General yes within 10021 – 69999 range 071X Recovery Room 0710 General no N/A 072X Labor Room/Delivery 0720 General yes within 10021 – 69999 range 0721 Labor yes within 10021 – 69999 range 0722 Delivery yes within 10021 – 69999 range 073X EKG/ECG 0730 General yes within 93000 – 93014 and 93024 – 93278 range 0731 Holter monitor yes within 93000 – 93014 and 93024 – 93278 range 0732 Telemetry yes Within 93000 – 93014 and 93024 – 93278 range 074X EEG 0740 General yes Within 93000 – 96004 range • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX F: REVENUE CODES AND HCPCS COMBINATION GUIDE PAGE F-5 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-6 DATE 09/01/04 Revenue Code Description HCPCS Required? Allowable HCPCS 075X Gastroenterology 0750 General yes Within 91000 – 91299 range 760X Treatment/Observation Room 0761 Treatment room yes within 10021 – 69990, 90202 – 92287, 99201 – 99215, and 99381 – 99499 ranges 0762 Observation room yes 99217 – 99220 range 077X Preventive Services 0771 Vaccine administration yes within 90471 – 90474 range 082X Hemodialysis 0820 General yes within 90918 – 90999 range 0821 Hemodialysis composite/other rate yes within 90918 – 90999 range 083X Peritoneal Dialysis 0830 General yes within 90918 – 90999 range 0831 Peritoneal composite/other rate yes within 90918 – 90999 range 084X CAPD 0840 General yes within 90918 – 90999 range 0841 CAPD composite/other rate yes within 90918 – 90999 range 085X CCPD 0850 General yes within 90918 – 90999 range 0851 CCPD composite/other rate yes within 90918 – 90999 range 090X Behavioral Health Treatments/Services 0900 General yes within 90801 – 90911 range 0901 Electroshock therapy yes within 90801 – 90911 range 091X Behavoral Health Treatments/Service 0914 Individual therapy yes within 96150 – 96155 range 0918 Testing yes within 96100 – 96117 range 092X Other Diagnostic Services 0920 General yes within 92002 – 96004 range and 99170 0921 Peripheral vascular lab yes within 93668 – 93990 range 0922 Electromyelogram yes within 95860 – 96004 range 0924 Allergy testing yes within 95004 – 95078 range 094X Other Therapeutic Services 0940 General yes within 90780 – 90799, 95990 – 95999, 96567 – 96999, and 99173 – 99199 ranges 0943 Cardiac rehabilitation yes 93797, 93798 0944 Drug rehabilitation yes within 90801 – 90862 range 0945 Alcohol Rehabilitation yes within 90801 – 90862 range • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE APPENDIX F: REVENUE CODES AND HCPCS COMBINATION GUIDE PAGE F-6 ACUTE OUTPATIENT HOSPITAL MANUAL TRANSMITTAL LETTER AOH-6 DATE 09/01/04 This page is reserved.