Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter CHC-94 April 2012 TO: Community Health Centers Participating in MassHealth FROM: Dr. Julian Harris, M.D., Medicaid Director RE: Community Health Center Manual (2012 HCPCS and Vaccine Codes) This letter transmits revisions to Subchapter 6 of the Community Health Center Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) for 2012. MassHealth has updated Subchapter 6 to reflect these changes and at the same time, has removed service code descriptions. In addition, MassHealth has added certain influenza vaccine service codes to Subchapter 6. The revised Subchapter 6 is effective for dates of service on or after January 1, 2012, with the exception of the vaccine codes specified below, which are effective for dates of service on or after September 1, 2011. Community health centers (CHCs) should use the American Medical Association Current Procedural Terminology (CPT) 2012 code book or the Healthcare Procedure Coding System (HCPCS) Level II code book to get service descriptions for the codes listed in Subchapter 6 of the Community Health Center Manual. 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 the Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The specific regulation titles are, 114.3 CMR 18.00: Radiology, 114.3 CMR 20.00: Clinical Laboratory Services, 114.3 CMR 4.00: Rates for Community Health Centers, and 114.3 CMR 17.00: Medicine. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp MassHealth Transmittal Letter CHC-94 April 2012 Page 2 Vaccines Provided in Community Health Centers Effective for dates of service on or after September 1, 2011, MassHealth has added the following vaccine service codes for influenza to Subchapter 6 of the Community Health Center Manual: 90656, 90658, 90660, 90661, and 90662 – for adults 19 years and older. These vaccines are available free of charge through the Massachusetts Immunization Program for children under 19 years of age. Vaccines supplied by the Massachusetts Department of Public Health (DPH) free of charge are not payable by MassHealth. MassHealth separately pays CHCs for vaccines not supplied by DPH free of charge, only if the vaccine is listed in Section 604 (Visit Service Codes and Descriptions) of Subchapter 6 of the Community Health Center Manual. The cost of the administration of the vaccine is included in the CHC visit rate and is not separately payable. For additional information and individual consideration (I.C.) requirements, see Section 604 of Subchapter 6 of the Community Health Center Manual, and MassHealth regulations at 130 CMR 450.271. Information about the availability of DPH-supplied vaccines can be found on the following DPH Web sites. www.mass.gov/dph www.mass.gov/eohhs/provider/guidelines-resources/clinical-treatment/diseases- conditions/immunization/ MassHealth Web Site 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 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.) Community Health Center Manual Pages vi and 6-1 through 6-16 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Community Health Center Manual Pages vi and 6-1 through 6-76 — transmitted by Transmittal Letter CHC-91 Commonwealth of Massachusetts MassHealth Provider Manual Series Community Health Center Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter CHC-94 Page vi Date 01/01/12 6. Service Codes and Descriptions Introduction and Explanation of Abbreviations 6-1 Payable Radiology Service Codes 6-1 Payable Laboratory Service Codes 6-4 Payable Visit Service Codes 6-9 Payable Obstetrics Service Codes 6-11 Payable Surgery Service Codes 6-11 Payable Nurse-Midwife Service Codes 6-12 Payable Audiology Service Codes 6-12 Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment Service Codes 6-12 Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Test Service Codes 6-13 Payable Tobacco Cessation Service Codes 6-13 Payable Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes 6-14 Payable Behavioral Health Screening Tool Service Codes 6-14 Modifiers 6-15 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix D. Supplemental Instructions for TPL Exceptions D-1 Appendix E. Utilization Management Program E-1 Appendix F. Admission Guidelines F-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 and Descriptions Page 6-1 Community Health Center Manual Transmittal Letter CHC-94 Date 01/01/12 601 Introduction and Explanation of Abbreviations MassHealth pays for the services represented by the codes listed in Subchapter 6 in effect at the time of service, subject to all conditions and limitations in MassHealth regulations at 130 CMR 405.000 and 450.000. A community health center may request prior authorization (PA) for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age even if it is not designated as covered or payable in Subchapter 6 of the Community Health Center Manual. For complete descriptions of the service codes listed in Subchapter 6, MassHealth providers must refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). The following abbreviations are used in Subchapter 6. (A) PA indicates that service-specific prior authorization is required (see 130 CMR 450.303). (B) IC indicates that the claim will receive individual consideration to determine payment. A descriptive report must accompany the claim (see 130 CMR 450.271). (C) SP indicates that the procedure is commonly performed as part of a total service and does not usually warrant a separate fee. The procedure must be performed separately to receive the separate fee. 602 Payable Radiology Service Codes This section lists radiology service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). 70030 70100 70110 70120 70130 70134 70140 70150 70160 70190 70200 70210 70220 70240 70250 70260 70300 70310 70320 70328 70330 70332 70336 (PA) 70350 70355 70360 70370 70371 70373 70380 70390 70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491 70492 70540 70542 70543 70544 70545 70546 70547 70548 70549 70551 70552 70553 70554 70555 70557 70558 70559 71010 71015 71020 71021 71022 71023 71030 71034 71035 71040 71060 71100 71101 71110 71111 71120 71130 71550 71551 71555 72010 72020 72040 72050 72052 72069 72070 72072 72074 72080 72090 72100 72110 72114 72120 72125 72126 72127 72128 72129 72130 72131 72132 72133 72141 72142 72146 72147 72148 72149 72156 72157 72158 72170 72190 72192 72193 72194 72195 72196 72197 72200 72202 72220 72240 72255 72265 72270 72275 72285 72291 72292 72295 73000 73010 73020 73030 73040 73050 73060 73070 73080 73085 73090 73092 73100 73110 73115 73120 73130 73140 73200 73201 73202 73218 73219 73220 73221 73222 73223 73500 73510 73520 73525 73530 73540 73550 73560 73562 73564 73565 73580 73590 73592 73600 73610 73615 73620 73630 73650 73660 73700 73701 73702 73718 73719 73720 73721 73722 73723 73725 74000 74010 74020 74022 74150 74160 74170 74174 74176 74177 74178 74181 74182 74183 74185 74190 74210 74220 74230 74235 74240 74241 74245 74246 74247 74249 74250 74251 74260 74261 (PA) 74262 (PA) 74270 74280 74283 74290 74291 74300 74301 74305 74320 74327 74330 74340 74355 74400 74410 74415 74420 74425 74430 74440 74445 74450 74455 74470 74475 74480 74485 74710 74740 74742 74775 75557 75559 75561 75563 75565 75572 75573 75574 75600 75605 75625 75630 75650 75658 75660 75662 75665 75671 75676 75680 75685 75705 75710 75716 75726 75731 75733 75736 75741 75743 75746 75756 75774 75791 75801 75803 75805 75807 75809 75810 75820 75822 75825 75827 75831 75833 75840 75842 75860 75870 75872 75880 75885 75887 75889 75891 75893 75898 75900 75901 75902 75945 75946 76000 76001 76010 76080 76098 76100 76101 76102 76120 76125 76376 76377 76380 76499 (IC) 76506 76510 76511 76512 76513 76514 76516 76519 76529 76536 76604 76645 76700 76705 76770 76775 76776 76800 76801 76802 76805 76810 76811 76812 76813 76814 76815 76816 76817 76818 76820 76821 76825 76826 76827 76828 76830 76831 76856 76857 76870 76872 76873 76881 76882 76885 76886 76937 76942 76945 76946 76948 76950 76965 76970 76977 76999 (IC) 77001 77002 77003 77011 77012 77013 77014 77021 77022 77051 77052 77053 77054 77055 77056 77057 77058 (PA) 77059 (PA) 77071 77072 77073 77074 77075 77076 77077 77078 77080 77081 77082 78000 78001 78003 78006 78007 78010 78011 78015 78016 78018 78020 78070 78075 78099 (IC) 78102 78103 78104 78110 78111 78120 78121 78122 78130 78135 78140 78185 78190 78191 78195 78199 (IC) 78201 78202 78205 78206 78215 78216 78226 78227 78230 78231 78232 78258 78261 78262 78264 78270 78271 78272 78278 78282 (IC) 78290 78291 78299 (IC) 78300 78305 78306 78315 78320 78350 78399 (IC) 78414 (IC) 78428 78445 78451 78452 78453 78454 78456 78457 78458 78459 78466 78468 78469 78472 78473 78481 78483 78491 78492 78494 78496 78499 (IC) 78579 78580 78582 78597 78598 78599 (IC) 78600 78601 78605 78607 78608 78609 78610 78630 78635 78645 78647 78650 78660 78699 (IC) 78700 78701 78707 78708 78709 78710 78725 78730 78740 78761 78799 (IC) 78800 78801 78802 78803 78804 78805 78806 78807 78808 78811 78812 78813 78814 78815 78816 78999 (IC) G0202 G0204 G0206 603 Payable Laboratory Service Codes This section lists laboratory service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). 80047 80048 80050 80051 80053 80055 80061 80069 80074 80076 80102 80103 80150 80152 80154 80156 80157 80158 80160 80162 80164 80166 80168 80170 80172 80173 80174 80176 80178 80182 80184 80185 80186 80188 80190 80192 80194 80195 80196 80197 80198 80200 80201 80202 80299 80400 80402 80406 80408 80410 80412 80414 80415 80416 80417 80418 80420 80422 80424 80426 80428 80430 80432 80434 80435 80436 80438 80439 80440 81000 81001 81002 81003 81005 81007 81015 81020 81025 81050 81099 (IC) 82000 82003 82009 82010 82013 82016 82017 82024 82030 82040 82042 82043 82044 82045 82055 82085 82088 82101 82103 82104 82105 82106 82107 82108 82120 82127 82128 82131 82135 82136 82139 82140 82143 82145 82150 82154 82157 82160 82163 82164 82172 82175 82180 82190 82205 82232 82239 82240 82247 82248 82252 82261 82270 82271 82272 82274 82286 82300 82306 82308 82310 82330 82331 82340 82355 82360 82365 82370 82373 82374 82375 82376 82378 82379 82380 82382 82383 82384 82387 82390 82397 82415 82435 82436 82438 82441 82465 82480 82482 82485 82486 82487 82488 82489 82491 82492 82495 82507 82520 82523 82525 82528 82530 82533 82540 82541 82542 82543 82544 82550 82552 82553 82554 82565 82570 82575 82585 82595 82600 82607 82608 82610 82615 82626 82627 82633 82634 82638 82646 82649 82651 82652 82654 82656 82657 82658 82664 82666 82668 82670 82671 82672 82677 82679 82690 82693 82696 82705 82710 82715 82725 82726 82728 82731 82735 82742 82746 82747 82757 82759 82760 82775 82776 82784 82785 82787 82800 82803 82805 82810 82820 82930 82938 82941 82943 82945 82946 82947 82948 82950 82951 82952 82953 82955 82960 82963 82965 82975 82977 82978 82979 82980 82985 83001 83002 83003 83008 83009 83010 83012 83013 83014 83015 83018 83020 83021 83026 83030 83033 83036 83037 83045 83050 83051 83055 83060 83065 83068 83069 83070 83071 83080 83088 83090 83150 83491 83497 83498 83499 83500 83505 83516 83518 83519 83520 83525 83527 83528 83540 83550 83570 83582 83586 83593 83605 83615 83625 83630 83631 83632 83633 83634 83655 83661 83662 83663 83664 83670 83690 83695 83698 83700 83701 83704 83718 83719 83721 83727 83735 83775 83785 83788 83789 83805 83825 83835 83840 83857 83858 83861 83864 83866 83872 83873 83874 83876 83880 83883 83885 83887 83890 83891 83892 83893 83894 83896 83897 83898 83900 83901 83902 83903 83904 83905 83906 83907 83908 83909 83912 83913 83914 83915 83916 83918 83919 83921 83925 83930 83935 83937 83945 83950 83951 83970 83986 83992 83993 84022 84030 84035 84060 84066 84075 84078 84080 84081 84085 84087 84100 84105 84106 84110 84112 84119 84120 84126 84127 84132 84133 84134 84135 84138 84140 84143 84144 84146 84150 84152 84153 84154 84155 84156 84157 84160 84163 84165 84166 84181 84182 84202 84203 84206 84207 84210 84220 84228 84233 84234 84235 84238 84244 84252 84255 84260 84270 84275 84285 84295 84300 84302 84305 84307 84311 84315 84375 84376 84377 84378 84379 84392 84402 84403 84425 84430 84432 84436 84437 84439 84442 84443 84445 84446 84449 84450 84460 84466 84478 84479 84480 84481 84482 84484 84485 84488 84490 84510 84512 84520 84525 84540 84545 84550 84560 84577 84578 84580 84583 84585 84586 84588 84590 84591 84597 84600 84620 84630 84681 84702 84703 84704 84999 (IC) 85002 85004 85007 85008 85009 85013 85014 85018 85025 85027 85032 85041 85044 85045 85046 85048 85049 85055 85060 85097 85130 85170 85175 85210 85220 85230 85240 85244 85245 85246 85247 85250 85260 85270 85280 85290 85291 85292 85293 85300 85301 85302 85303 85305 85306 85307 85335 85337 85345 85347 85348 85360 85362 85366 85370 85378 85379 85380 85384 85385 85390 85396 85397 85400 85410 85415 85420 85421 85441 85445 85460 85461 85475 85520 85525 85530 85536 85540 85547 85549 85555 85557 85576 85597 85598 85610 85611 85612 85613 85635 85651 85652 85660 85670 85675 85705 85730 85732 85810 85999 (IC) 86000 86001 86003 86005 86021 86022 86023 86038 86039 86060 86063 86140 86141 86146 86147 86148 86155 86156 86157 86160 86161 86162 86171 86185 86200 86215 86225 86226 86235 86243 86255 86256 86277 86280 86294 86300 86301 86304 86308 86309 86310 86316 86317 86318 86320 86325 86327 86329 86331 86332 86334 86335 86336 86337 86340 86341 86343 86344 86352 86353 86355 86356 86357 86359 86360 86361 86367 86376 86378 86382 86384 86386 86403 86406 86430 86431 86480 86481 86485 86486 86490 86510 86590 86592 86593 86602 86603 86606 86609 86611 86612 86615 86617 86618 86619 86622 86625 86628 86631 86632 86635 86638 86641 86644 86645 86648 86651 86652 86653 86654 86658 86663 86664 86665 86666 86668 86671 86674 86677 86682 86684 86687 86688 86689 86692 86694 86695 86696 86698 86701 86702 86703 86704 86705 86706 86707 86708 86709 86710 86713 86717 86720 86723 86727 86729 86732 86735 86738 86741 86744 86747 86750 86753 86756 86757 86759 86762 86765 86768 86771 86774 86777 86778 86780 86784 86787 86788 86789 86790 86793 86800 86803 86804 86805 86806 86807 86808 86812 86813 86816 86817 86821 86822 86825 86826 86849 (IC) 86850 86860 86870 86880 86885 86886 86900 86901 86902 86904 86905 86906 86920 86921 86922 86923 86940 86941 86970 86971 86972 86975 86976 86977 86978 86999 (IC) 87001 87003 87015 87040 87045 87046 87070 87071 87073 87075 87076 87077 87081 87084 87086 87088 87101 87102 87103 87106 87107 87109 87110 87116 87118 87140 87143 87147 87149 87152 87158 87164 87166 87168 87169 87172 87176 87177 87181 87184 87185 87186 87187 87188 87190 87197 87205 87206 87207 87209 87210 87220 87230 87250 87252 87253 87254 87255 87260 87265 87267 87269 87270 87271 87272 87273 87274 87275 87276 87277 87278 87279 87280 87281 87283 87285 87290 87299 87300 87301 87305 87320 87324 87327 87328 87329 87332 87335 87336 87337 87338 87339 87340 87341 87350 87380 87385 87389 87390 87391 87400 87420 87425 87427 87430 87449 87450 87451 87470 87471 87472 87475 87476 87477 87480 87481 87482 87485 87486 87487 87490 87491 87492 87495 87496 87497 87498 87500 87501 87502 87503 87510 87511 87512 87515 87516 87517 87520 87521 87522 87525 87526 87527 87528 87529 87530 87531 87532 87533 87534 87535 87536 87537 87538 87539 87540 87541 87542 87550 87551 87552 87555 87556 87557 87560 87561 87562 87580 87581 87582 87590 87591 87592 87620 87621 87622 87640 87641 87650 87651 87652 87653 87660 87797 87798 87799 87800 87801 87802 87803 87804 87807 87808 87809 87810 87850 87880 87899 87902 87905 87906 87999 (PA)(IC) 88104 88106 88108 88112 88120 88121 88130 88140 88141 88142 88143 88147 88148 88150 88152 88153 88154 88155 88160 88161 88162 88164 88165 88166 86167 88172 88173 88174 88175 88177 88182 88184 88185 88187 88188 88189 88199 (IC) 88230 88233 88235 88237 88239 88240 88241 88245 88248 88249 88261 88262 88263 88264 88267 88269 88271 88272 88273 88274 88275 88280 88283 88285 88289 88291 88299 (IC) 88300 88302 88304 88305 88307 88309 88311 88312 88313 88314 88319 88342 88346 88347 88348 88349 88355 88356 88358 88360 88361 88362 88363 88365 88367 88368 88371 88372 88380 (IC) 88381 88384 88385 88386 88387 88388 88399 (IC) 88720 88740 88741 89049 89050 89051 89055 89060 89125 89160 89190 89220 (IC) 89230 (IC) 89240 (IC) 93000 93005 93010 93015 93016 93017 93018 93024 93025 93040 93041 93042 93224 93225 93226 93227 93228 (IC) 93229 (IC) 93230 93268 93270 93271 93272 93278 93303 93304 93306 93307 93308 93312 93313 93314 93315 93316 93317 93318 93320 93321 93325 93350 93351 93352 93724 93740 93745 (IC) 93784 93788 93790 93797 93798 93799 (IC) 93880 93882 93886 93888 93890 93893 93922 93923 93924 93925 93926 93930 93931 93965 93970 93971 93975 93976 93978 93979 93980 93981 93990 93998 (IC) 95950 95951 95953 95956 G0431 G0434 604 Payable Visit Service Codes This section lists visit service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). When claiming payment for visits, a CHC must bill according to the following service codes. A visit during which a member sees more than one professional for the same medical problem or general purpose must be claimed as only one visit. (See 130 CMR 405.421 for other requirements.) (A) The following visit service codes have special requirements or limitations. Service Code Modifier Special Requirement or Limitation D1206 Covered for children under age 21. The CHC may bill for a medical visit in addition to the fluoride varnish application only if fluoride varnish was not the sole service, treatment, or procedure provided during the visit. D9450 Use only for dental enhancement fee. This code may only be billed once per date of service for each member receiving dental services on that date. The dental enhancement fee may not be billed for a fluoride varnish application separately or in addition to a medical visit. J3490 Use for injectable and infusible drugs and devices supplied in the clinic. Do not use for medications and injectables related to family planning services. (IC) T1015 Use for individual medical visit. T1015 HQ Use for group clinic visit. 90632 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90649 Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90650 Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90656 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 604 Payable Visit Service Codes (cont.) Service Code Modifier Special Requirement or Limitation 90658 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90660 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90661 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC) 90662 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC) 90707 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90713 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90715 Covered for adults > 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90716 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90732 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90736 (IC); PA is required for members < age 60. 90746 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. 90899 Use for individual mental health visit. (IC) 99050 Use for urgent care Monday through Friday from 5:00 P.M. to 6:59 A.M., and Saturday 7:00 A.M. to Monday 6:59 A.M. This code may be billed in addition to the individual medical visit. 99402 Use for HIV counseling visits. (B) This section lists visit service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). 99218 99219 99220 99221 99222 99223 99224 99225 99226 99231 99232 99233 99304 99305 99306 99307 99308 99309 99310 99324 99325 99326 99327 99334 99335 99336 99337 99341 99342 99343 99345 (IC) 99347 99348 99349 99350 (IC) 99460 99462 605 Payable Obstetrics Service Codes This section lists obstetrics service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). See 130 CMR 405.422 through 405.426 for other requirements. (A) Fee-for-Service Deliveries 59409 59410 59414 59514 59515 59525 (HI-1 form required) 59612 59614 59620 59622 (B) Global Deliveries 59400 59510 59610 59618 606 Payable Surgery Service Codes This section lists surgery service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). 44955 49255 49320 54057 54150 54160 55250 (CS-18/CS-21 required) (SP) 55450 (CS-18/CS-21 required) (SP) 56420 56440 57240 57250 57260 57520 57522 57700 58120 58140 58146 58150 (HI-1 form required) 58180 (HI-1 form required) 58353 58541 (HI-1 form required) 58543 (HI-1 form required) 58544 (HI-1 form required) 58555 58558 58560 58561 58600 (CS-18 or CS-21 required) 58605 (CS-18 or CS-21 required) (SP) 58611 (CS-18 or CS-21 required) 58615 (CS-18 or CS-21 required) 58660 58661 (CS-18 or CS-21 required) 58670 (CS-18 or CS-21 required) 58671 (CS-18 or CS-21 required) 58700 58720 58940 59000 59012 59015 59025 59870 607 Payable Nurse-Midwife Service Codes This section lists nurse-midwife service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). See 130 CMR 405.427 for requirements. When billing for delivery services performed by a nurse midwife, the provider must use a modifier. Service Code Modifier Special Requirement or Limitation T1015 TH Use for a medical visit with a nurse midwife for a prenatal or postpartum service. 59400 59409 59410 59414 59610 59612 59614 608 Payable Audiology Service Codes This section lists audiology service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). See 130 CMR 405.461 through 405.463 for other requirements. 92551 92552 92553 92567 609 Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment Service Codes This section lists Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). See 130 CMR 450.140 through 450.149 for other requirements. 99381 99382 99383 99384 99385 99391 99392 99393 99394 99395 610 Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Test Service Codes This section lists Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Test service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). 92551 92552 92587 99173 611 Payable Tobacco Cessation Service Codes This section lists tobacco cessation service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). Service Code Modifier Special Requirement or Limitation 99407 at least 30 minutes; eligible providers are physicians employed by community health centers. 99407 HN at least 30 minutes; eligible providers are physician assistants employed by community health centers. 99407 HQ for an individual in a group setting, 60-90 minutes; eligible providers are physicians employed by community health centers. 99407 SA at least 30 minutes; eligible providers are nurse practitioners employed by community health centers. 99407 SB at least 30 minutes; eligible providers are nurse midwives employed by community health centers. 99407 TD at least 30 minutes; eligible providers are registered nurses employed by community health centers. 99407 TF intake assessment for an individual, at least 45 minutes; eligible providers are physicians employed by community health centers. 99407 U1 at least 30 minutes; eligible providers are tobacco cessation counselors employed by community health centers. 99407 U2 intake assessment for an individual, at least 45 minutes; eligible providers are nurse practitioner, nurse midwife, physician assistant, registered nurse, and tobacco cessation counselor. 99407 U3 for an individual in a group setting, 60-90 minutes; eligible providers are nurse practitioners, nurse midwives, physician assistants, registered nurses, and tobacco cessation counselors. 612 Payable Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes This section lists medical nutrition therapy and diabetes self-management training service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). G0108 G0109 G0270 G0271 97802 97803 97804 613 Payable Behavioral Health Screening Tool Service Codes This section lists behavioral health screening tool service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services Web site at www.cms.gov). The administration and scoring of standardized behavioral-health screening tools selected from the approved menu of tools found in Appendix W of your MassHealth provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. Service Code Modifier Special Requirement or Limitation 96110 U1 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; with no behavioral health need identified* (Eligible providers are physicians employed by community health centers.) 96110 U2 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; and behavioral health need identified* (Eligible providers are physicians employed by community health centers.) 96110 U3 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; with no behavioral health need identified* (Eligible providers are nurse midwives employed by community health centers.) 96110 U4 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; and behavioral health need identified* (Eligible providers are nurse midwives employed by community health centers.) 96110 U5 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; with no behavioral health need identified* (Eligible providers are nurse practitioners employed by community health centers.) 613 Payable Behavioral Health Screening Tool Service Codes (cont.) Service Code Modifier Special Requirement or Limitation 96110 U6 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; and behavioral health need identified* (Eligible providers are nurse practitioners employed by community health centers.) 96110 U7 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; with no behavioral health need identified* (Eligible providers are physician assistants employed by community health centers.) 96110 U8 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; and behavioral health need identified* (Eligible providers are physician assistants employed by community health centers.) * “Behavioral health need identified” means the provider administering the screening tool, in his or her professional judgment, identifies a child with a potential behavioral health services need. 614 Modifiers The following service code modifiers are allowed for billing under MassHealth for CHCs in conjunction with surgery services. Modifier Description 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 This publication contains codes that are copyrighted by the American Medical Association. Certain terms used in the service descriptions for HCPCS codes are defined in the Current Procedural Terminology (CPT) code book. This page is reserved. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Community Health Center Manual Transmittal Letter CHC-94 Date 01/01/12 602 Payable Radiology Service Codes (cont.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-4 Community Health Center Manual Transmittal Letter CHC-94 Date 01/01/12 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-9 Community Health Center Manual Transmittal Letter CHC-94 Date 01/01/12 603 Payable Laboratory Service Codes (cont.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-10 Community Health Center Manual Transmittal Letter CHC-94 Date 01/01/12 603 Payable Laboratory Service Codes (cont.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-16 Community Health Center Manual Transmittal Letter CHC-94 Date 01/01/12