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 LAB-32 December 2007 TO: Independent Clinical Laboratories Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Independent Clinical Laboratory Manual (2008 HCPCS) This letter transmits revisions to the service codes in the Independent Clinical Laboratory Manual. The Centers for Medicare & Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2008. The revised Subchapter 6 is effective for dates of service on or after January 1, 2008. For dates of service on or after January 1, 2008, you must use the new codes in order to obtain reimbursement. If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The 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 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.) Independent Clinical Laboratory Manual Pages vi and 6-1 through 6-36 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Independent Clinical Laboratory Manual Page vi — transmitted by Transmittal Letter LAB-28 Pages 6-1 through 6-28 — transmitted by Transmittal Letter LAB-29 Pages 6-29 through 6-36 — transmitted by Transmittal Letter LAB-31 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Independent Clinical Laboratory Manual Transmittal Letter LAB-32 Date 01/01/08 6. Service Codes and Descriptions Laboratory Service Codes and Descriptions 6-1 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-1 Appendix W. EPSDT Services: Medical Protocol and Periodicity Schedule W-1 Appendix X. Family Assistance Copayments and Deductibles X-1 Appendix Y. REVS Codes/Messages Y-1 Appendix Z. Appendix Z: EPSDT/PPHSD Screening Services Codes Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-1 Date 01/01/08 PATHOLOGY AND LABORATORY ORGAN OR DISEASE-ORIENTED PANELS These panels were developed for coding purposes only and should not be interpreted as clinical parameters. The tests listed with each panel identify the defined components of that panel. These panel components are not intended to limit the performance of other tests. If one performs tests in addition to those specifically indicated for a particular panel, those tests should be reported separately in addition to the panel code. Service Code Service Description 80047 Basic metabolic panel (Calcium ionized) (This panel must include the following: Calcium, ionized (82330), Carbon dioxide (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Potassium (84132), Sodium (84295), and Urea nitrogen (BUN) (84520).) 80048 Basic metabolic panel (Calcium total) (This panel must include the following: Calcium (82310), Carbon dioxide (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Potassium (84132), Sodium (84295), and Urea nitrogen (BUN) (84520).) 80050 General health panel (This panel must include the following: Comprehensive metabolic panel (80053), Blood count, complete (CBC), automated and automated differential (85025 or 85027 and 85004) or Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009), and Thyroid stimulating hormone (TSH) (84443).) 80051 Electrolyte panel (This panel must include the following: Carbon dioxide (82374), Chloride (82435), Potassium (84132), and Sodium (84295).) 80053 Comprehensive metabolic panel (This panel must include the following: Albumin (82040), Bilirubin, total (82247), Calcium (82310), Carbon dioxide (bicarbonate) (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Phosphatase, alkaline (84075), Potassium (84132), Protein, total (84155), Sodium (84295), Transferase, alanine amino (ALT) (SGPT) (84460), Transferase, aspartate amino (AST) (SGOT) (84450), and Urea nitrogen (BUN) (84520).) 80055 Obstetric panel (This panel must include the following: Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004) or Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009), Hepatitis B surface antigen (HBsAg) (87340), Antibody, rubella (86762), Syphilis test, qualitative (e.g., VDRL, RPR, ART) (86592), Antibody screen, RBC, each serum technique (86850), Blood typing, ABO (86900), and Blood typing, Rh (D) (86901).) 80061 Lipid panel (This panel must include the following: Cholesterol, serum, total (82465), Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718), and Triglycerides (84478).) 80069 Renal function panel (This panel must include the following: Albumin (82040), Calcium (82310), Carbon dioxide (bicarbonate) (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Phosphorus inorganic (phosphate) (84100), Potassium (84132), Sodium (84295), and Urea nitrogen (BUN) (84520).) Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-2 Date 01/01/08 80074 Acute hepatitis panel (This panel must include the following: Hepatitis A antibody (HAAb), IgM antibody (86709), Hepatitis B core antibody (HBcAb), IgM antibody (86705), Hepatitis B surface antigen (HBsAg) (87340), and Hepatitis C antibody (86803).) 80076 Hepatic function panel (This panel must include the following: Albumin (82040), Bilirubin, total (82247), Bilirubin, direct (82248), Phosphatase, alkaline (84075), Protein, total (84155), Transferase, alanine amino (ALT) (SGPT) (84460), and Transferase, aspartate amino (AST) (SGOT) (84450).) DRUG TESTING The following list contains examples of drugs or classes of drugs that are commonly assayed by qualitative screen, followed by confirmation with a second method. Alcohols Amphetamines Barbiturates Benzodiazepines Cocaine and metabolites Methadones Methaqualones Opiates Phencyclidines Phenothiazines Propoxyphenes Tetrahydrocannabinoids Tricyclic antidepressants Confirmed drugs may also be quantitated. Use 80100 for each multiple drug class chromatographic procedure. Use 80102 for each procedure necessary for confirmation. For chromatography, each combination of stationary and mobile phase is to be counted as one procedure. For example, if detection of three drugs by chromatography requires one stationary phase with three mobile phases, use 80100 three times. However, if multiple drugs can be detected using a single analysis (e.g., one stationary phase with one mobile phase), use 80100 only once. For quantitation of drugs screened, use appropriate code in Chemistry section (82000-84999) or Therapeutic Drug Assay section (80150-80299). Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-3 Date 01/01/08 80100 Drug screen, qualitative; multiple drug classes chromatographic method, each procedure 80101 single drug class method (e.g., immunoassay, enzyme assay), each drug class 80102 Drug confirmation, each procedure 80103 Tissue preparation for drug analysis THERAPEUTIC DRUG ASSAYS The material for examination may be from any source. Examination is quantitative. For nonquantitative testing, see drug testing (80100-80103). 80150 Amikacin 80152 Amitriptyline 80154 Benzodiazepines 80156 Carbamazepine; total 80157 free 80158 Cyclosporine 80160 Desipramine 80162 Digoxin 80164 Dipropylacetic acid (valproic acid) 80166 Doxepin 80168 Ethosuximide 80170 Gentamicin 80172 Gold 80173 Haloperidol 80174 Imipramine 80176 Lidocaine 80178 Lithium 80182 Nortriptyline 80184 Phenobarbital 80185 Phenytoin; total 80186 free 80188 Primidone 80190 Procainamide 80192 with metabolites (e.g., n-acetyl procainamide) 80194 Quinidine 80195 Sirolimus 80196 Salicylate 80197 Tacrolimus 80198 Theophylline 80200 Tobramycin 80201 Topiramate 80202 Vancomycin 80299 Quantitation of drug, not elsewhere specified Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-4 Date 01/01/08 EVOCATIVE/SUPPRESSION TESTING 80400 ACTH stimulation panel; for adrenal insufficiency (This panel must include the following: Cortisol (82533 x 2).) 80402 for 21 hydroxylase deficiency (This panel must include the following: Cortisol (82533 x 2) and 17 hydroxyprogesterone (83498 x 2).) 80406 for 3 beta-hydroxydehydrogenase deficiency (This panel must include the following: Cortisol (82533 x 2) and 17 hydroxypregnenolone (84143 x 2).) 80408 Aldosterone suppression evaluation panel (e.g., saline infusion) (This panel must include the following: Aldosterone (82088 x 2) and Renin (84244 x 2).) 80410 Calcitonin stimulation panel (e.g., calcium, pentagastrin) (This panel must include the following: Calcitonin (82308 x 3).) 80412 Corticotropic releasing hormone (CRH) stimulation panel (This panel must include the following: Cortisol (82533 x 6) and Adrenocorticotropic hormone (ACTH) (82024 x 6).) 80414 Chorionic gonadotropin stimulation panel; testosterone response (This panel must include the following: Testosterone (84403 x 2 on three pooled blood samples).) 80415 estradiol response (This panel must include the following: Estradiol (82670 x 2 on three pooled blood samples).) 80416 Renal vein renin stimulation panel (e.g., captopril) (This panel must include the following: Renin (84244 x 6).) 80417 Peripheral vein renin stimulation panel (e.g., captopril) (This panel must include the following: Renin (84244 x 2).) 80418 Combined rapid anterior pituitary evaluation panel (This panel must include the following: Adrenocorticotropic hormone (ACTH) (82024 x 4), Luteinizing hormone (LH) (83002 x 4), Follicle stimulating hormone (FSH) (83001 x 4), Prolactin (84146 x 4), Human growth hormone (HGH) (83003 x 4), Cortisol (82533 x 4), and Thyroid stimulating hormone (TSH) (84443 x 4).) 80420 Dexamethasone suppression panel, 48 hour (This panel must include the following: Free cortisol, urine (82530 x 2), Cortisol (82533 x 2), and Volume measurement for timed collection (81050 x 2).) (For single dose dexamethasone, use 82533.) 80422 Glucagon tolerance panel; for insulinoma (This panel must include the following: Glucose (82947 x 3) and Insulin (83525 x 3).) 80424 for pheochromocytoma (This panel must include the following: Catecholamines, fractionated (82384 x 2).) 80426 Gonadatropin releasing hormone stimulation panel (This panel must include the following: Follicle stimulating hormone (FSH) (83001 x 4) and Luteinizing hormone (LH) (83002 x 4).) 80428 Growth hormone stimulation panel (e.g., arginine infusion, l-dopa administration). (This panel must include the following: Human growth hormone (HGH) (83003 x 4).) 80430 Growth hormone suppression panel (glucose administration) (This panel must include the following: Glucose (82947 x 3) and Human growth hormone (HGH) (83003 x 4).) 80432 Insulin-induced C-peptide suppression panel (This panel must include the following: Insulin (83525), C-peptide (84681 x 5), and Glucose (82947 x 5).) 80434 Insulin tolerance panel; for ACTH insufficiency (This panel must include the following: Cortisol (82533 x 5) and Glucose (82947 x 5).) 80435 for growth hormone deficiency (This panel must include the following: Glucose (82947 x 5) and Human growth hormone (HGH) (83003 x 5).) Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-5 Date 01/01/08 80436 Metyrapone panel (This panel must include the following: Cortisol (82533 x 2) and 11 deoxycortisol (82634 x 2).) 80438 Thyrotropin releasing hormone (TRH) stimulation panel; one hour (This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 3).) 80439 two hours (This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 4).) 80440 for hyperprolactinemia (This panel must include the following: Prolactin (84146 x 3).) URINALYSIS 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy 81001 automated, with microscopy 81002 non-automated, without microscopy 81003 automated, without microscopy 81005 Urinalysis; qualitative or semiquantitative, except immunoassays 81007 bacteriuria screen, except by culture or dipstick (specify type) 81015 microscopic only 81020 two or three glass test 81025 Urine pregnancy test, by visual color comparison methods 81050 Volume measurement for timed collection, each 81099 Unlisted urinalysis procedure (I.C.) CHEMISTRY The material for examination may be from any source. Examination is quantitative unless specified. Clinical information derived from the results of laboratory data that is mathematically calculated (e.g., free thyroxine index (T7)) is considered part of the test procedure and therefore is not a separately reportable service. 82000 Acetaldehyde, blood 82003 Acetaminophen 82009 Acetone or other ketone bodies, serum; qualitative 82010 quantitative 82013 Acetylcholinesterase 82016 Acylcarnitines; qualitative, each specimen 82017 quantitative, each specimen 82024 Adrenocorticotropic hormone (ACTH) 82030 Adenosine; 5-monophosphate, cyclic (cyclic AMP) 82040 Albumin; serum 82042 urine or other source, quantitative, each specimen 82043 urine, microalbumin, quantitative Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-1 Date 01/01/08 82044 urine, microalbumin, semiquantitative (e.g., reagent strip assay) 82045 Albumin, Ischemia modified 82055 Alcohol (ethanol); any specimen except breath 82085 Aldolase 82088 Aldosterone 82101 Alkaloids, urine, quantitative 82103 Alpha-1-antitrypsin; total 82104 phenotype 82105 Alpha-fetoprotein; serum 82106 amniotic fluid 82107 Alpha-fetoprotein (AFP); AFP-L3 fraction isoform and total AFP (including ratio) 82108 Aluminum 82120 Amines, vaginal fluid, qualitative 82127 Amino acids; single, qualitative, each specimen 82128 multiple, qualitative, each specimen 82131 single, quantitative, each specimen 82135 Aminolevulinic acid, delta (ALA) 82136 Amino acids, two to five amino acids, quantitative, each specimen 82139 Amino acids, six or more amino acids, quantitative, each specimen 82140 Ammonia 82143 Amniotic fluid scan (spectrophotometric) 82145 Amphetamine or methamphetamine 82150 Amylase 82154 Androstanediol glucuronide 82157 Androstenedione 82160 Androsterone 82163 Angiotensin II 82164 Angiotensin I - converting enzyme (ACE) 82172 Apolipoprotein, each 82175 Arsenic 82180 Ascorbic acid (vitamin C), blood 82190 Atomic absorption spectroscopy, each analyte 82205 Barbiturates, not elsewhere specified 82232 Beta-2 microglobulin 82239 Bile acids; total 82240 cholylglycine 82247 Bilirubin; total 82248 direct 82252 feces, qualitative 82261 Biotinidase, each specimen 82270 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided three cards or single triple card for consecutive collection) 82271 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; other sources 82272 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, one to three simultaneous determinations, performed for other than colorectal neoplasm screening Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-7 Date 01/01/08 82274 Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, one to three simultaneous determinations 82286 Bradykinin 82300 Cadmium 82306 Calcifediol (25-OH vitamin D-3) 82307 Calciferol (vitamin D) 82308 Calcitonin 82310 Calcium; total 82330 ionized 82331 after calcium infusion test 82340 urine quantitative, timed specimen 82355 Calculus; qualitative analysis 82360 quantitative analysis, chemical 82365 infrared spectroscopy 82370 X-ray diffraction 82373 Carbohydrate deficient transferrin 82374 Carbon dioxide (bicarbonate) 82375 Carbon monoxide (carboxyhemoglobin); quantitative 82376 qualitative 82378 Carcinoembryonic antigen (CEA) 82379 Carnitine (total and free), quantitative, each specimen 82380 Carotene 82382 Catecholamines; total urine 82383 blood 82384 fractionated 82387 Cathepsin-D 82390 Ceruloplasmin 82397 Chemiluminescent assay 82415 Chloramphenicol 82435 Chloride; blood 82436 urine 82438 other source 82441 Chlorinated hydrocarbons, screen 82465 Cholesterol, serum or whole blood, total 82480 Cholinesterase; serum 82482 RBC 82485 Chondroitin B sulfate, quantitative 82486 Chromatography, qualitative; column (e.g., gas liquid or HPLC), analyte not elsewhere specified 82487 paper, one-dimensional, analyte not elsewhere specified 82488 paper, two-dimensional, analyte not elsewhere specified 82489 thin layer, analyte not elsewhere specified 82491 Chromatography, quantitative, column (e.g., gas liquid or HPLC); single analyte not elsewhere specified, single stationary and mobile phase 82492 multiple analytes, single stationary and mobile phase 82495 Chromium Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-8 Date 01/01/08 82507 Citrate 82520 Cocaine or metabolite 82523 Collagen cross links, any method 82525 Copper 82528 Corticosterone 82530 Cortisol; free 82533 total 82540 Creatine 82541 Column chromatography/mass spectrometry (e.g., GC/MS, or HPLC/MS), analyte not elsewhere specified; qualitative, single stationary and mobile phase 82542 quantitative, single stationary and mobile phase 82543 stable isotope dilution, single analyte, quantitative, single stationary and mobile phase 82544 stable isotope dilution, multiple analytes, quantitative, single stationary and mobile phase 82550 Creatine kinase (CK), (CPK); total 82552 isoenzymes 82553 MB fraction only 82554 isoforms 82565 Creatinine; blood 82570 other source 82575 clearance 82585 Cryofibrinogen 82595 Cryoglobulin, qualitative or semi-quantitative (e.g., cryocrit) 82600 Cyanide 82607 Cyanocobalamin (vitamin B-12) 82608 unsaturated binding capacity 82610 Cystatin C 82615 Cystine and homocystine, urine, qualitative 82626 Dehydroepiandrosterone (DHEA) 82627 Dehydroepiandrosterone-sulfate (DHEA-S) 82633 Desoxycorticosterone, 11- 82634 Deoxycortisol, 11- 82638 Dibucaine number 82646 Dihydrocodeinone 82649 Dihydromorphinone 82651 Dihydrotestosterone (DHT) 82652 Dihydroxyvitamin D, 1,25- 82654 Dimethadione 82656 Elastase, pancreatic (EL-1), fecal, qualitative or semi-quantitative 82657 Enzyme activity in blood cells, cultured cells, or tissue, not elsewhere specified; nonradioactive substrate, each specimen 82658 radioactive substrate, each specimen 82664 Electrophoretic technique, not elsewhere specified 82666 Epiandrosterone 82668 Erythropoietin 82670 Estradiol Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-9 Date 01/01/08 82671 Estrogens; fractionated 82672 total 82677 Estriol 82679 Estrone 82690 Ethchlorvynol 82693 Ethylene glycol 82696 Etiocholanolone 82705 Fat or lipids, feces; qualitative 82710 quantitative 82715 Fat differential, feces, quantitative 82725 Fatty acids, nonesterified 82726 Very long chain fatty acids 82728 Ferritin 82731 Fetal fibronectin, cervicovaginal secretions, semi-quantitative 82735 Fluoride 82742 Flurazepam 82746 Folic acid; serum 82747 RBC 82757 Fructose, semen 82759 Galactokinase, RBC 82760 Galactose 82775 Galactose-1-phosphate uridyl transferase; quantitative 82776 screen 82784 Gammaglobulin; IgA, IgD, IgG, IgM, each 82785 IgE 82787 immunoglobulin subclasses (IgG1, 2, 3, or 4), each 82800 Gases, blood, pH only 82803 Gases, blood, any combination of pH, pCO2, pO2, CO2, HCO3 (including calculated O2 saturation) 82805 with O2 saturation, by direct measurement, except pulse oximetry 82810 Gases, blood, O2 saturation only, by direct measurement, except pulse oximetry 82820 Hemoglobin-oxygen affinity (pO2 for 50% hemoglobin saturation with oxygen) 82926 Gastric acid, free and total, each specimen 82928 Gastric acid, free or total; each specimen 82938 Gastrin after secretin stimulation 82941 Gastrin 82943 Glucagon 82945 Glucose, body fluid, other than blood 82946 Glucagon tolerance test 82947 Glucose; quantitative, blood (except reagent strip) 82948 blood, reagent strip 82950 post-glucose dose (includes glucose) 82951 tolerance test (GTT), three specimens (includes glucose) 82952 tolerance test, each additional beyond three specimens 82953 tolbutamide tolerance test Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-10 Date 01/01/08 82955 Glucose-6-phosphate dehydrogenase (G6PD); quantitative 82960 screen 82963 Glucosidase, beta 82965 Glutamate dehydrogenase 82975 Glutamine (glutamic acid amide) 82977 Glutamyltransferase, gamma (GGT) 82978 Glutathione 82979 Glutathione reductase, RBC 82980 Glutethimide 82985 Glycated protein 83001 Gonadotropin; follicle-stimulating hormone (FSH) 83002 luteinizing hormone (LH) 83003 Growth hormone, human (HGH) (somatotropin) 83008 Guanosine monophosphate (GMP), cyclic 83009 Helicobacter pylori, blood test analysis for urease activity, non-reactive isotope (e.g., C-13) 83010 Haptoglobin; quantitative 83012 phenotypes 83013 Helicobacter pylori; breath test analysis for urease acitivity, non-radioactive isotope (e.g., C-13) 83014 drug administration 83015 Heavy metal (e.g., arsenic, barium, beryllium, bismuth, antimony, mercury); screen 83018 quantitative, each 83020 Hemoglobin fractionation and quantitation; electrophoresis (e.g., A2, S, C, and/or F) 83021 chromatography (e.g., A2, S, C, and/or F) 83026 Hemoglobin; by copper sulfate method, non-automated 83030 F (fetal), chemical 83033 F (fetal), qualitative 83036 glycosylated (A1C) 83037 glycosylated (A1C) by device cleared by FDA for home use 83045 methemoglobin, qualitative 83050 methemoglobin, quantitative 83051 plasma 83055 sulfhemoglobin, qualitative 83060 sulfhemoglobin, quantitative 83065 thermolabile 83068 unstable, screen 83069 urine 83070 Hemosiderin; qualitative 83071 quantitative 83080 b-Hexosaminidase, each assay 83088 Histamine 83090 Homocystine 83150 Homovanillic acid (HVA) 83491 Hydroxycorticosteroids, 17- (17-OHCS) 83497 Hydroxyindolacetic acid, 5- (HIAA) 83498 Hydroxyprogesterone, 17-d Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-11 Date 01/01/08 83499 Hydroxyprogesterone, 20- 83500 Hydroxyproline; free 83505 total 83516 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, qualitative or semiquantitative; multiple step method 83518 single step method (e.g., reagent strip) 83519 Immunoassay, analyte, quantitative; by radiopharmaceutical technique (e.g., RIA) 83520 not otherwise specified 83525 Insulin; total 83527 free 83528 Intrinsic factor 83540 Iron 83550 Iron-binding capacity 83570 Isocitric dehydrogenase (IDH) 83582 Ketogenic steroids, fractionation 83586 Ketosteroids, 17- (17-KS); total 83593 fractionation 83605 Lactate (lactic acid) 83615 Lactate dehydrogenase (LD), (LDH); 83625 isoenzymes, separation and quantitation 83630 Lactoferrin, fecal; qualitative 83631 quantitative 83632 Lactogen, human placental (HPL) human chorionic somatomammotropin 83633 Lactose, urine; qualitative 83634 quantitative 83655 Lead 83661 Fetal lung maturity assessment; lecithin sphingomyelin (L/S) ratio 83662 foam stability test 83663 fluorescence polarization 83664 lamellar body density 83670 Leucine aminopeptidase (LAP) 83690 Lipase 83695 Lipoprotein (a) 83698 Lipoprotein-associated phospholipase A2 83700 Lipoprotein, blood; electrophoretic separation and quantitation 83701 high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (e.g.,electrophoresis, ultracentrifugation) 83704 quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (e.g., by nuclear magnetic resonance spectroscopy) 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) 83719 direct measurement, VLDL cholesterol 83721 direct measurement, LDL cholesterol 83727 Luteinizing-releasing factor (LRH) 83735 Magnesium 83775 Malate dehydrogenase Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-12 Date 01/01/08 83785 Manganese 83788 Mass spectrometry and tandem mass spectrometry (MS, MS/MS), analyte not elsewhere specified; qualitative, each specimen 83789 quantitative, each specimen 83805 Meprobamate 83825 Mercury, quantitative 83835 Metanephrines 83840 Methadone 83857 Methemalbumin 83858 Methsuximide 83864 Mucopolysaccharides, acid; quantitative 83866 screen 83872 Mucin, synovial fluid (Ropes test) 83873 Myelin basic protein, cerebrospinal fluid 83874 Myoglobin 83880 Natriuretic peptide 83883 Nephelometry, each analyte not elsewhere specified 83885 Nickel 83887 Nicotine Molecular Diagnostics The series of codes 83890-83912 is intended for use with molecular diagnostic techniques for analysis of nucleic acids. These services are coded by procedure rather than analyte. Code separately for each procedure used in an analysis. For example, a procedure requiring isolation of DNA, restriction endonuclease digestion, electrophoresis, and nucleic acid probe amplification would be coded 83890, 83892, 83894, and 83898. 83890 Molecular diagnostics; molecular isolation or extraction 83891 isolation or extraction of highly purified nucleic acid 83892 enzymatic digestion 83893 dot/slot blot production 83894 separation by gel electrophoresis (e.g., agarose, polyacrylamide) 83896 nucleic acid probe, each 83897 nucleic acid transfer (e.g., Southern, Northern) 83898 amplification, target, each nucleic acid sequence 83900 amplification, target, multiplex, first two nucleic acid sequences 83901 amplification, target, multiplex, each additional nucleic acid sequence beyond two (List separately in addition to code for primary procedure.) 83902 reverse transcription 83903 mutation scanning, by physical properties (e.g., single strand conformational polymorphisms (SSCP), heteroduplex, denaturing gradient gel electrophoresis (DGGE), RNA’ase A), single segment, each 83904 mutation identification by sequencing, single segment, each segment 83905 mutation identification by allele specific transcription, single segment, each segment Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-13 Date 01/01/08 83906 mutation identification by allele specific translation, single segment, each segment 83907 lysis of cells prior to nucleic acid extraction (e.g., stool specimens, paraffin embedded tissue) 83908 amplification, signal, each nucleic acid sequence 83909 separation and identification by high resolution technique (e.g., capillary electrophoresis) 83912 interpretation and report 83913 RNA stabilization 83914 mutation identification by enzymatic ligation or primer extension, single segment, each segment (e.g., oligonucleotide ligation assay (OLA), single base chain extension (SBCE) or allele-specific primer extensioni (ASPE)) 83915 Nucleotidase 5’- 83916 Oligoclonal immune (oligoclonal bands) 83918 Organic acids; total, quantitative, each specimen 83919 qualitative, each specimen 83921 Organic acid, single, quantitative 83925 Opiates (e.g., morphine, meperidine) 83930 Osmolality; blood 83935 urine 83937 Osteocalcin (bone g1a protein) 83945 Oxalate 83950 Oncoprotein, HER-2/neu 83970 Parathormone (parathyroid hormone) 83986 pH, body fluid, except blood 83992 Phencyclidine (PCP) 83993 Calprotectin, fecal 84022 Phenothiazine 84030 Phenylalanine (PKU), blood 84035 Phenylketones, qualitative 84060 Phosphatase, acid; total 84066 prostatic 84075 Phosphatase, alkaline 84078 heat stable (total not included) 84080 isoenzymes 84081 Phosphatidylglycerol 84085 Phosphogluconate, 6-, dehydrogenase, RBC 84087 Phosphohexose isomerase 84100 Phosphorus inorganic (phosphate); 84105 urine 84106 Porphobilinogen, urine; qualitative 84110 quantitative 84119 Porphyrins, urine; qualitative 84120 quantitation and fractionation 84126 Porphyrins, feces; quantitative 84127 qualitative 84132 Potassium; serum 84133 urine 84134 Prealbumin Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-14 Date 01/01/08 84135 Pregnanediol 84138 Pregnanetriol 84140 Pregnenolone 84143 17-hydroxypregnenolone 84144 Progesterone 84146 Prolactin 84150 Prostaglandin, each 84152 Prostate specific antigen (PSA); complexed (direct measurement) 84153 total 84154 free 84155 Protein, total, except by refractometry; serum 84156 urine 84157 other source (e.g., synovial fluid, cerebrospinal fluid) 84160 Protein, total, by refractometry, any source 84163 Pregnancy associated plasma protein A (PAPP-A) 84165 Protein; electrophoretic fractionation and quantitation, serum 84166 Protein; electrophoretic fractionation and quantitation, other fluids with concentration (e.g, urine, CSF) 84181 Western Blot, with interpretation and report, blood or other body fluid 84182 Western Blot, with interpretation and report, blood or other body fluid, immunological probe for band identification, each 84202 Protoporphyrin, RBC; quantitative 84203 screen 84206 Proinsulin 84207 Pyridoxal phosphate (vitamin B-6) 84210 Pyruvate 84220 Pyruvate kinase 84228 Quinine 84233 Receptor assay; estrogen 84234 progesterone 84235 endocrine, other than estrogen or progesterone (specify hormone) 84238 non-endocrine (specify receptor) 84244 Renin 84252 Riboflavin (vitamin B-2) 84255 Selenium 84260 Serotonin 84270 Sex hormone binding globulin (SHBG) 84275 Sialic acid 84285 Silica 84295 Sodium; serum 84300 urine 84302 other source 84305 Somatomedin 84307 Somatostatin 84311 Spectrophotometry, analyte not elsewhere specified 84315 Specific gravity (except urine) Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-15 Date 01/01/08 84375 Sugars, chromatographic, TLC or paper chromatography 84376 Sugars (mono-, di, and oligosaccharides); single qualitative, each specimen 84377 multiple qualitative, each specimen 84378 single quantitative, each specimen 84379 multiple quantitative, each specimen 84392 Sulfate, urine 84402 Testosterone; free 84403 total 84425 Thiamine (vitamin B-1) 84430 Thiocyanate 84432 Thyroglobulin 84436 Thyroxine; total 84437 requiring elution (e.g., neonatal) 84439 free 84442 Thyroxine binding globulin (TBG) 84443 Thyroid-stimulating hormone (TSH) 84445 Thyroid-stimulating immune globulins (TSI) 84446 Tocopherol alpha (vitamin E) 84449 Transcortin (cortisol binding globulin) 84450 Transferase; aspartate amino (AST) (SGOT) 84460 alanine amino (ALT) (SGPT) 84466 Transferrin 84478 Triglycerides 84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) 84480 Triiodothyronine T3; total (TT-3) 84481 free 84482 reverse 84484 Troponin, quantitative 84485 Trypsin; duodenal fluid 84488 feces, qualitative 84490 feces, quantitative, 24-hour collection 84510 Tyrosine 84512 Troponin, qualitative 84520 Urea nitrogen; quantitative 84525 semiquantitative (e.g., reagent strip test) 84540 Urea nitrogen, urine 84545 Urea nitrogen, clearance 84550 Uric acid; blood 84560 other source 84577 Urobilinogen, feces, quantitative 84578 Urobilinogen, urine; qualitative 84580 quantitative, timed specimen 84583 semiquantitative 84585 Vanillylmandelic acid (VMA), urine Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-16 Date 01/01/08 84586 Vasoactive intestinal peptide (VIP) 84588 Vasopressin (antidiuretic hormone, ADH) 84590 Vitamin A 84591 Vitamin, not otherwise specified 84597 Vitamin K 84600 Volatiles (e.g., acetic anhydride, carbon tetrachloride, dichloroethane, dichloromethane, diethylether, isopropyl alcohol, methanol) 84620 Xylose absorption test, blood and/or urine 84630 Zinc 84681 C-peptide 84702 Gonadotropin, chorionic (hCG); quantitative 84703 qualitative 84704 free beta chain 84999 Unlisted chemistry procedure (I.C.) HEMATOLOGY AND COAGULATION 85002 Bleeding time 85004 Blood count; automated differential WBC count 85007 blood smear, microscopic examination with manual differential WBC count 85008 blood smear, microscopic examination without manual differential WBC count 85009 manual differential WBC count, buffy coat 85013 spun microhematocrit 85014 hematocrit (Hct) 85018 hemoglobin (Hgb) 85025 complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count 85027 complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) 85032 manual cell count (erythrocyte, leukocyte, or platelet) each 85041 red blood cell (RBC), automated 85044 reticulocyte, manual 85045 reticulocyte, automated 85046 reticulocytes, automated, including one or more cellular parameters (e.g., reticulocyte hemoglobin content (CHR), immature reticulocyte fraction (IRF), reticulocyte volume (MRV), RNA content), direct measurement 85048 leukocyte (WBC), automated 85049 platelet, automated 85055 Reticulated platelet assay 85060 Blood smear, peripheral, interpretation by physician with written report 85097 Bone marrow, smear interpretation 85130 Chromogenic substrate assay 85170 Clot retraction 85175 Clot lysis time, whole blood dilution 85210 Clotting; factor II, prothrombin, specific 85220 factor V (AcG or proaccelerin), labile factor Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-17 Date 01/01/08 85230 factor VII (proconvertin, stable factor) 85240 factor VIII (AHG), one stage 85244 factor VIII related antigen 85245 factor VIII, VW factor, ristocetin cofactor 85246 factor VIII, VW factor antigen 85247 factor VIII, von Willebrand factor, multimetric analysis 85250 factor IX (PTC or Christmas) 85260 factor X (Stuart-Prower) 85270 factor XI (PTA) 85280 factor XII (Hageman) 85290 factor XIII (fibrin stabilizing) 85291 factor XIII (fibrin stabilizing), screen solubility 85292 prekallikrein assay (Fletcher factor assay) 85293 high molecular weight kininogen assay (Fitzgerald factor assay) 85300 Clotting inhibitors or anticoagulants; antithrombin III, activity 85301 antithrombin III, antigen assay 85302 protein C, antigen 85303 protein C, activity 85305 protein S, total 85306 protein S, free 85307 Activated Protein C (APC) resistance assay 85335 Factor inhibitor test 85337 Thrombomodulin 85345 Coagulation time; Lee and White 85347 activated 85348 other methods 85360 Euglobulin lysis 85362 Fibrin(ogen) degradation (split) products (FDP)(FSP); agglutination slide; semiquantitative 85366 paracoagulation 85370 quantitative 85378 Fibrin degradation products, D-dimer; qualitative or semiquantitative 85379 quantitative 85380 ultrasensitive (e.g., for evaluation for venous thromboembolism), qualitative or semiquantitative 85384 Fibrinogen; activity 85385 antigen 85390 Fibrinolysins or coagulopathy screen, interpretation and report 85396 Coagulation/fibrinolysis assay, whole blood (e.g., viscoelastic clot assessment), including use of any pharmacologic additive(s), as indicated, including interpretation and written report, per day 85400 Fibrinolytic factors and inhibitors; plasmin 85410 alpha-2 antiplasmin 85415 plasminogen activator 85420 plasminogen, except antigenic assay 85421 plasminogen, antigenic assay Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-18 Date 01/01/08 85441 Heinz bodies; direct 85445 induced, acetyl phenylhydrazine 85460 Hemoglobin or RBCs, fetal, for fetomaternal hemorrhage; differential lysis (Kleihauer-Betke) 85461 rosette 85475 Hemolysin, acid 85520 Heparin assay 85525 Heparin neutralization 85530 Heparin-protamine tolerance test 85536 Iron stain, peripheral blood 85540 Leukocyte alkaline phosphatase with count 85547 Mechanical fragility, RBC 85549 Muramidase 85555 Osmotic fragility, RBC; unincubated 85557 incubated 85576 Platelet; aggregation (in vitro), each agent 85597 Platelet neutralization 85610 Prothrombin time 85611 substitution, plasma fractions, each 85612 Russell viper venom time (includes venom); undiluted 85613 diluted 85635 Reptilase test 85651 Sedimentation rate, erythrocyte; non-automated 85652 automated 85660 Sickling of RBC, reduction 85670 Thrombin time; plasma 85675 titer 85705 Thromboplastin inhibition; tissue 85730 Thromboplastin time, partial (PTT); plasma or whole blood 85732 substitution, plasma fractions, each 85810 Viscosity 85999 Unlisted hematology and coagulation procedure (I.C.) IMMUNOLOGY 86000 Agglutinins, febrile (e.g., Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain spotted fever, scrub typhus), each antigen 86001 Allergen specific IgG; quantitative or semiquantitative, each allergen 86003 Allergen specific IgE; quantitative or semiquantitative, each allergen 86005 qualitative, multiallergen screen (dipstick, paddle, or disk) 86021 Antibody identification; leukocyte antibodies 86022 platelet antibodies 86023 platelet-associated immunoglobulin assay Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-19 Date 01/01/08 86038 Antinuclear antibodies (ANA) 86039 titer 86060 Antistreptolysin 0; titer 86063 screen 86140 C-reactive protein 86141 high sensitivity (hsCRP) 86146 Beta 2 Glycoprotein I antibody, each 86147 Cardiolipin (phospholipid) antibody, each Ig class 86148 Anti-phosphatidylserine (phospholipid) antibody 86155 Chemotaxis assay, specify method 86156 Cold agglutinin; screen 86157 titer 86160 Complement; antigen, each component 86161 functional activity, each component 86162 total hemolytic (CH50) 86171 Complement fixation tests, each antigen 86185 Counterimmunoelectrophoresis, each antigen 86200 Cyclic citrullinated peptide (CCP), antibody 86215 Deoxyribonuclease, antibody 86225 Deoxyribonucleic acid (DNA), antibody; native or double stranded 86226 single stranded 86235 Extractable nuclear antigen, antibody to, any method (e.g., nRNP, SS-A, SS-B, Sm, RNP, Sc170, J01), each antibody 86243 Fc receptor 86255 Fluorescent noninfectious agent antibody; screen, each antibody 86256 titer, each antibody 86277 Growth hormone, human (HGH), antibody 86280 Hemagglutination inhibition test (HAI) 86294 Immunoassay for tumor antigen, qualitative or semiquantitative (e.g., bladder tumor antigen) 86300 Immunoassay for tumor antigen, quantitative; CA 15-3 (27.29) 86301 CA 19-9 86304 CA 125 86308 Heterophile antibodies; screening 86309 titer 86310 titers after absorption with beef cells and guinea pig kidney 86316 Immunoassay for tumor antigen; other antigen, quantitative (e.g., CA 50, 72-4, 549), each 86317 Immunoassay for infectious agent antibody, quantitative, not otherwise specified 86318 Immunoassay for infectious agent antibody, qualitative or semiquantitative, single step method (e.g., reagent strip) 86320 Immunoelectrophoresis; serum 86325 other fluids (e.g., urine, cerobrospinal fluid) with concentration 86327 crossed (two-dimensional assay) Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-20 Date 01/01/08 86329 Immunodiffusion; not elsewhere specified 86331 gel diffusion, qualitative (Ouchterlony), each antigen or antibody 86332 Immune complex assay 86334 Immunofixation electrophoresis, serum 86335 Immunofixation electrophoresis; other fluids with concentration (e.g, urine, CSF) 86336 Inhibin A 86337 Insulin antibodies 86340 Intrinsic factor antibodies 86341 Islet cell antibody 86343 Leukocyte histamine release test (LHR) 86344 Leukocyte phagocytosis 86353 Lymphocyte transformation, mitogen (phytomitogen) or antigen-induced blastogenesis 86355 B cells, total count 86356 Mononuclear cell antigen, quantitative (e.g., flow cytometry), not otherwise specified, each antigen 86357 Natural killer (NK) cells, total count 86359 T cells; total count 86360 absolute CD4 and CD8 count, including ratio 86361 absolute CD4 count 86367 Stem cells (i.e., CD34), total count 86376 Microsomal antibodies (e.g., thyroid or liver-kidney), each 86378 Migration inhibitory factor test (MIF) 86382 Neutralization test, viral 86384 Nitroblue tetrazolium dye test (NTD) 86403 Particle agglutination; screen, each antibody 86406 titer, each antibody 86430 Rheumatoid factor; qualitative 86431 quantitative 86480 Tuberculosis test, cell mediated immunity measurement of gamma interferon antigen response 86485 Skin test; candida 86486 unlisted antigen, each 86490 coccidioidomycosis 86510 histoplasmosis 86590 Streptokinase, antibody 86592 Syphilis test; qualitative (e.g., VDRL, RPR, ART) 86593 quantitative Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-21 Date 01/01/08 The following codes (86602-86804) are qualitative or semiquantitative immunoassays performed by multiple step methods for the detection of antibodies to infectious agents. For immunoassays by single step method (e.g., reagent strips), use code 86318. Procedures for the identification of antibodies should be coded as precisely as possible. For example, an antibody to a virus could be coded with increasing specificity for virus, family, genus, species, or type. In some cases, further precision may be added to codes by specifying the class of immunoglobulin being detected. When multiple tests are done to detect antibodies to organisms classified more precisely than the specificity allowed by available codes, it is appropriate to code each as a separate service. For example, a test for antibody to an enterovirus is coded as 86658. Coxsackie viruses are enteroviruses, but there are no codes for the individual species of enterovirus. If assays are performed for antibodies to coxsackie A and B species, each assay should be separately coded. Similarly, if multiple assays are performed for antibodies of different immunoglobulin classes, each assay should be coded separately. 86602 Antibody; actinomyces 86603 adenovirus 86606 Aspergillus 86609 bacterium, not elsewhere specified 86611 Bartonella 86612 Blastomyces 86615 Bordetella 86617 Borrelia burgdorferi (Lyme disease) confirmatory test (e.g., Western blot or immunoblot) 86618 Borrelia burgdorferi (Lyme disease) 86619 Borrelia (relapsing fever) 86622 Brucella 86625 Campylobacter 86628 Candida 86631 Chlamydia 86632 Chlamydia, IgM 86635 Coccidioides 86638 Coxiella Brunetii (Q fever) 86641 Cryptococcus 86644 cytomegalovirus (CMV) 86645 cytomegalovirus (CMV), IgM 86648 Diphtheria 86651 encephalitis, California (La Crosse) 86652 encephalitis, Eastern equine 86653 encephalitis, St. Louis 86654 encephalitis, Western equine 86658 enterovirus (e.g., coxsackie, echo, polio) 86663 Epstein-Barr (EB) virus, early antigen (EA) 86664 Epstein-Barr (EB) virus, nuclear antigen (EBNA) 86665 Epstein-Barr (EB) virus, viral capsid (VCA) 86666 Ehrlichia 86668 Francisella tularensis 86671 fungus, not elsewhere specified Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-22 Date 01/01/08 86674 Giardia lamblia 86677 Helicobacter pylori 86682 helminth, not elsewhere specified 86684 Haemophilus influenza 86687 HTLV-I 86688 HTLV-II 86689 HTLV or HIV antibody, confirmatory test (e.g., Western blot) 86692 hepatitis, delta agent 86694 herpes simplex, non-specific type test 86695 herpes simplex, type 1 86696 herpes simplex, type 2 86698 histoplasma 86701 HIV-1 86702 HIV-2 86703 HIV-1 and HIV-2, single assay 86704 Hepatitis B core antibody (HBcAb); total 86705 IgM antibody 86706 Hepatitis B surface antibody (HBsAb) 86707 Hepatitis Be antibody (HBeAb) 86708 Hepatitis A antibody (HAAb); total 86709 IgM antibody 86710 Antibody; influenza virus 86713 Legionella 86717 Leishmania 86720 Leptospira 86723 Listeria monocytogenes 86727 lymphocytic choriomeningitis 86729 lymphogranuloma venereum 86732 mucormycosis 86735 mumps 86738 mycoplasma 86741 Neisseria meningitidis 86744 Nocardia 86747 parvovirus 86750 Plasmodium (malaria) 86753 protozoa, not elsewhere specified 86756 respiratory syncytial virus 86757 Rickettsia 86759 rotavirus 86762 rubella 86765 rubeola 86768 Salmonella 86771 Shigella 86774 tetanus 86777 Toxoplasma Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-23 Date 01/01/08 86778 Toxoplasma, IgM 86781 Treponema pallidum, confirmatory test (e.g., FTA-abs) 86784 trichinella 86787 varicella-zoster 86788 West Nile virus, IGM 86789 West Nile virus 86790 virus, not elsewhere specified 86793 Yersinia 86800 Thyroglobulin antibody 86803 Hepatitis C antibody 86804 confirmatory test (e.g., immunoblot) Tissue Typing 86805 Lymphocytotoxicity assay, visual crossmatch; with titration 86806 without titration 86807 Serum screening for cytotoxic percent reactive antibody (PRA); standard method 86808 quick method 86812 HLA typing; A, B, or C (e.g., A10, B7, B27), single antigen 86813 A, B, or C, multiple antigens 86816 DR/DQ, single antigen 86817 DR/DQ, multiple antigens 86821 lymphocyte culture, mixed (MLC) 86822 lymphocyte culture, primed (PLC) 86849 Unlisted immunology procedure (I.C.) TRANSFUSION MEDICINE 86850 Antibody screen, RBC, each serum technique 86860 Antibody elution (RBC), each elution 86870 Antibody identification, RBC antibodies, each panel for each serum technique 86880 Antihuman globulin test (Coombs test); direct, each antiserum 86885 indirect, qualitative, each reagent red cell 86886 indirect, each antibody titer 86900 Blood typing; ABO 86901 Rh (D) 86903 antigen screening for compatible blood unit using reagent serum, per unit screened 86904 antigen screening for compatible unit using patient serum, per unit screened 86905 RBC antigens, other than ABO or Rh (D), each 86906 Rh phenotyping, complete 86920 Compatibility test each unit; immediate spin technique 86921 incubation technique 86922 antiglobulin technique 86923 electronic Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-24 Date 01/01/08 86940 Hemolysins and agglutinins; auto, screen, each 86941 incubated 86970 Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with chemical agents or drugs, each 86971 incubation with enzymes, each 86972 by density gradient separation 86975 Pretreatment of serum for use in RBC antibody identification; incubation with drugs, each 86976 by dilution 86977 incubation with inhibitors, each 86978 by differential redcell absorption using patient RBCs or RBCs of known phenotype, each absorption 86999 Unlisted transfusion medicine procedure (I.C.) MICROBIOLOGY 87001 Animal inoculation, small animal; with observation 87003 with observation and dissection 87015 Concentration (any type), for infectious agents 87040 Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate) 87045 stool, aerobic, with isolation and preliminary examination (e.g., KIA, LIA), Salmonella and Shigella species 87046 stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate 87070 any other source except urine, blood, or stool, aerobic, with isolation and presumptive identification of isolates 87071 quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood, or stool 87073 quantitative, anaerobic with isolation and presumptive identification of isolates, any source except urine, blood, or stool 87075 any source, except blood, anaerobic with isolation and presumptive identification of isolates 87076 anaerobic isolate, additional methods required for definitive identification, each isolate 87077 aerobic isolate, additional methods required for definitive identification, each isolate 87081 Culture, presumptive, pathogenic organisms, screening only 87084 with colony estimation from density chart 87086 Culture, bacterial; quantitative colony count, urine 87088 with isolation and presumptive identification of each isolate, urine 87101 Culture, fungi (mold or yeast) isolation, with presumptive identification of isolates; skin, hair, or nail 87102 other source (except blood) 87103 blood 87106 Culture, fungi, definitive identification, each organism; yeast (Use in addition to codes 87101, 87102, or 87103 when appropriate.) 87107 mold Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-25 Date 01/01/08 87109 Culture, mycoplasma, any source 87110 Culture, chlamydia, any source 87116 Culture, tubercle or other acid-fast bacilli (e.g., TB, AFB, mycobacteria) any source, with isolation and presumptive identification of isolates 87118 Culture, mycobacterial, definitive identification, each isolate 87140 Culture, typing; immunofluorescent method, each antiserum 87143 gas-liquid chromatography (GLC) or high pressure liquid chromatography (HPLC) method 87147 immunologic method, other than immunofluorescence (e.g., agglutination grouping), per antiserum 87149 identification by nucleic acid probe 87152 identification by pulse field gel typing 87158 other methods 87164 Dark field examination, any source (e.g., penile, vaginal, oral, skin); includes specimen collection 87166 without collection 87168 Macroscopic examination; arthropod 87169 parasite 87172 Pinworm exam (e.g., cellophane tape prep) 87176 Homogenization, tissue, for culture 87177 Ova and parasites, direct smears, concentration and identification 87181 Susceptibility studies, antimicrobial agent; agar dilution method, per agent (e.g., antibiotic gradient strip) 87184 disk method, per plate (12 or fewer agents) 87185 enzyme detection (e.g., beta lactamase), per enzyme 87186 microdilution or agar dilution (minimum inhibitory concentration (MIC) or breakpoint), each multiantimicrobial, per plate 87187 microdilution or agar dilution, minimum lethal concentration (MLC), each plate (List separately in addition to code for primary procedure.) 87188 macrobroth dilution method, each agent 87190 mycobacteria, proportion method, each agent 87197 Serum bactericidal titer (Schlicter test) 87205 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types 87206 fluorescent and/or acid-fast stain for bacteria, fungi, parasites, viruses, or cell types 87207 special stain for inclusion bodies or parasites (e.g., malaria, coccidia, microsporidia, trypanosomes, herpes viruses) 87209 complex special stain (e.g., trichrome, iron hemotoxylin) for ova and parasites 87210 wet mount for infectious agents (e.g., saline, India ink, KOH preps) 87220 Tissue examination by KOH slide of samples from skin, hair, or nails for fungi or ectoparasite ova or mites (e.g., scabies) 87230 Toxin or antitoxin assay, tissue culture (e.g., Clostridium difficile toxin) Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-26 Date 01/01/08 87250 Virus isolation; inoculation of embryonated eggs, or small animal, includes observation and dissection 87252 tissue culture inoculation, observation, and presumptive identification by cytopathic effect 87253 tissue culture, additional studies or definitive identification (e.g., hemabsorption, neutralization, immunofluorescence stain), each isolate 87254 centrifuge enhanced (shell vial) technique, includes identification with immunofluorescence stain, each virus 87255 including identification by non-immunologic method, other than by cytopathic effect (e.g., virus specific enzymatic activity) Infectious agents by antigen detection, immunofluorescence microscopy; or nucleic acid probe techniques should be reported as precisely as possible. The most specific code possible should be reported. If there is no specific agent code, the general methodology code (e.g., 87299, 87449, 87450, 87797, 87798, 87799, 87899) should be used. For identification of antibodies to many of the listed infectious agents, see 86602-86804. 87260 Infectious agent antigen detection by immunofluorescent technique; adenovirus 87265 Bordetella pertussis/parapertussis 87267 Enterovirus, direct fluorescent antibody (DFA) 87269 giardia 87270 Chlamydia trachomatis 87271 Cytomegalovirus, direct fluorescent antibody (DFA) 87272 cryptosporidium 87273 Herpes simplex virus type 2 87274 Herpes simplex virus type 1 87275 influenza B virus 87276 influenza A virus 87277 Legionella micdadei 87278 Legionella pneumophila 87279 Parainfluenza virus, each type 87280 respiratory syncytial virus 87281 Pneumocystis carinii 87283 Rubeola 87285 Treponema pallidum 87290 Varicella zoster virus 87299 not otherwise specified, each organism 87300 Infectious agent antigen detection by immunofluorescent technique, polyvalent for multiple organisms, each polyvalent antiserum 87301 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; adenovirus enteric types 40/41 87305 Aspergillus 87320 Chlamydia trachomatis 87324 Clostridium difficile toxin(s) 87327 Cryptococcus neoformans 87328 cryptosporidium Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-27 Date 01/01/08 87329 giardia 87332 cytomegalovirus 87335 Escherichia coli 0157 87336 Entamoeba histolytica dispar group 87337 Entamoeba histolytica group 87338 Helicobacter pylori, stool 87339 Helicobacter pylori 87340 hepatitis B surface antigen (HBsAg) 87341 hepatitis B surface antigen (HBsAg) neutralization 87350 hepatitis Be antigen (HBeAg) 87380 hepatitis, delta agent 87385 Histoplasma capsulatum 87390 HIV-1 87391 HIV-2 87400 influenza, A or B, each 87420 respiratory syncytial virus 87425 rotavirus 87427 Shiga-like toxin 87430 Streptococcus, group A 87449 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative; multiple step method, not otherwise specified, each organism 87450 single step method, not otherwise specified, each organism 87451 multiple step method, polyvalent for multiple organisms, each polyvalent antiserum 87470 Infectious agent detection by nucleic acid (DNA or RNA); Bartonella henselae and Bartonella quintana, direct probe technique 87471 Bartonella henselae and Bartonella quintana, amplified probe technique 87472 Bartonella henselae and Bartonella quintana, quantification 87475 Borrelia burgdorferi, direct probe technique 87476 Borrelia burgdorferi, amplified probe technique 87477 Borrelia burgdorferi, quantification 87480 Candida species, direct probe technique 87481 Candida species, amplified probe technique 87482 Candida species, quantification 87485 Chlamydia pneumoniae, direct probe technique 87486 Chlamydia pneumoniae, amplified probe technique 87487 Chlamydia pneumoniae, quantification 87490 Chlamydia trachomatis, direct probe technique 87491 Chlamydia trachomatis, amplified probe technique 87492 Chlamydia trachomatis, quantification 87495 cytomegalovirus, direct probe technique 87496 cytomegalovirus, amplified probe technique 87497 cytomegalovirus, quantification 87498 enterovirus, amplified probe technique 87500 vancomycin resistance (e.g., enterococcus species van A, van B), amplified probe technique 87510 Gardnerella vaginalis, direct probe technique 87511 Gardnerella vaginalis, amplified probe technique Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-28 Date 01/01/08 87512 Gardnerella vaginalis, quantification 87515 hepatitis B virus, direct probe technique 87516 hepatitis B virus, amplified probe technique 87517 hepatitis B virus, quantification 87520 hepatitis C, direct probe technique 87521 hepatitis C, amplified probe technique 87522 hepatitis C, quantification 87525 hepatitis G, direct probe technique 87526 hepatitis G, amplified probe technique 87527 hepatitis G, quantification 87528 herpes simplex virus, direct probe technique 87529 herpes simplex virus, amplified probe technique 87530 herpes simplex virus, quantification 87531 herpes virus-6, direct probe technique 87532 herpes virus-6, amplified probe technique 87533 herpes virus-6, quantification 87534 HIV-1, direct probe technique 87535 HIV-1, amplified probe technique 87536 HIV-1, quantification 87537 HIV-2, direct probe technique 87538 HIV-2, amplified probe technique 87539 HIV-2, quantification 87540 Legionella pneumophila, direct probe technique 87541 Legionella pneumophila, amplified probe technique 87542 Legionella pneumophila, quantification 87550 Mycobacteria species, direct probe technique 87551 Mycobacteria species, amplified probe technique 87552 Mycobacteria species, quantification 87555 Mycobacteria tuberculosis, direct probe technique 87556 Mycobacteria tuberculosis, amplified probe technique 87557 Mycobacteria tuberculosis, quantification 87560 Mycobacteria avium-intracellulare, direct probe technique 87561 Mycobacteria avium-intracellulare, amplified probe technique 87562 Mycobacteria avium-intracellulare, quantification 87580 Mycoplasma pneumoniae, direct probe technique 87581 Mycoplasma pneumoniae, amplified probe technique 87582 Mycoplasma pneumoniae, quantification 87590 Neisseria gonorrhoeae, direct probe technique 87591 Neisseria gonorrhoeae, amplified probe technique 87592 Neisseria gonorrhoeae, quantification 87620 papillomavirus, human, direct probe technique 87621 papillomavirus, human, amplified probe technique 87622 papillomavirus, human, quantification 87640 Staphylococcus aureus, amplified probe technique 87641 Staphylococcus aureus, methicillin resistant, amplified probe technique 87650 Streptococcus, group A, direct probe technique Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-29 Date 01/01/08 87651 Streptococcus, group A, amplified probe technique 87652 Streptococcus, group A, quantification 87653 Streptococcus, group B, amplified probe technique 87660 Trichomonas vaginalis, direct probe technique 87797 Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism 87798 amplified probe technique, each organism 87799 quantification, each organism 87800 Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique 87801 amplified probe(s) technique 87802 Infectious agent antigen detection by immunoassay with direct optical observation; Streptococcus, group B 87803 Clostridium difficile toxin A 87804 influenza 87807 respiratory syncytial virus 87808 Trichomonas vaginalis 87809 adenovirus 87810 Infectious agent detection by immunoassay with direct optical observation; Chlamydia trachomatis 87850 Neisseria gonorrhoeae 87880 Streptococcus, group A 87899 not otherwise specified 87900 Infectious agent drug susceptibility phenotype prediction using regularly updated genotypic bioinformatics 87901 Infectious agent genotype analysis by nucleic acid (DNA or RNA); HIV 1, reverse transcriptase and protease 87902 Hepatitis C virus 87903 Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug resistance tissue culture analysis, HIV 1; first through 10 drugs tested 87904 each additional drug tested (List separately in addition to code for primary procedure.) (Use 87904 in conjunction with 87903.) 87999 Unlisted microbiology procedure (I.C.) (P.A.) ANATOMIC PATHOLOGY Cytopathology 88104 Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation 88106 simple filter method with interpretation 88107 smears and simple filter preparation with interpretation 88108 Cytopathology, concentration technique, smears and interpretation (e.g., Saccomanno technique) 88112 Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal 88130 Sex chromatin identification; Barr bodies 88140 peripheral blood smear, polymorphonuclear drumsticks Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-30 Date 01/01/08 Codes 88141-88155, 88164-88167 are used to report cervical or vaginal screening by various methods and to report physician interpretation services. Use codes 88150-88154 to report Pap smears that are examined using non-Bethesda reporting. Use codes 88164-88167 to report Pap smears that are examined using the Bethesda System of reporting. Use codes 88142-88143 to report specimens collected in fluid medium with automated thin layer preparation that are examined using any system of reporting (Bethesda or non-Bethesda). Within each of these three code families choose the one code that describes the screening method(s) used. Codes 88141 and 88155 should be reported in addition to the screening code chosen when the additional services are provided. 88141 Cytopathology, cervical or vaginal (any reporting system); requiring interpretation by physician (List separately in addition to code for technical service.) 88142 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation; manual screening under physician supervision 88143 with manual screening and rescreening under physician supervision 88147 Cytopathology smears, cervical or vaginal; screening by automated system under physician supervision 88148 screening by automated system with manual rescreening under physician supervision 88150 Cytopathology, slides, cervical or vaginal; manual screening under physician supervision 88152 with manual screening and computer-assisted rescreening under physician supervision 88153 with manual screening and rescreening under physician supervision 88154 with manual screening and computer-assisted rescreening using cell selection and review under physician supervision 88155 Cytopathology, slides, cervical or vaginal, definitive hormonal evaluation (e.g., maturation index, karyopyknotic index, estrogenic index) (List separately in addition to code(s) for other technical and interpretation services.) 88160 Cytopathology, smears, any other source; screening and interpretation 88161 preparation, screening, and interpretation 88162 extended study involving over five slides and/or multiple stains 88164 Cytopathology, slides, cervical or vaginal (the Bethesda System); manual screening under physician supervision 88165 with manual screening and rescreening under physician supervision 88166 with manual screening and computer-assisted rescreening under physician supervision 86167 with manual screening and computer-assisted rescreening using cell selection and review under physician supervision 88172 Cytopathology, evaluation of fine needle aspirate; immediate cytohistologic study to determine adequacy of specimen(s) 88173 interpretation and report 88174 Cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by automated system, under physician supervision 88175 with screening by automated system and manual rescreening or review, under physician supervision 88182 Flow cytometry; cell cycle or DNA analysis Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-31 Date 01/01/08 88184 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker 88185 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (list separately in addition to code for first marker) (report 88185 in conjunction with 88184) 88187 Flow cytometry, interpretation; 2 to 8 markers 88188 Flow cytometry, interpretation; 9 to 15 markers 88189 Flow cytometry, interpretation; 16 or more markers 88199 Unlisted cytopathology procedure (I.C.) Cytogenetic Studies 88230 Tissue culture for non-neoplastic disorders; lymphocyte 88233 skin or other solid tissue biopsy 88235 amniotic fluid or chorionic villus cells 88237 Tissue culture for neoplastic disorders; bone marrow, blood cells 88239 solid tumor 88240 Cryopreservation, freezing and storage of cells, each cell line 88241 Thawing and expansion of frozen cells, each aliquot 88245 Chromosome analysis for breakage syndromes; baseline Sister Chromatid Exchange (SCE), 20-25 cells 88248 baseline breakage, score 50-100 cells, count 20 cells, 2 karyotypes, (e.g., for ataxia telangiectasia, Fanconi anemia, fragile X) 88249 score 100 cells, clastogen stress (e.g., diepoxybutane, mitomycin C, ionizing radiation, UV radiation) 88261 Chromosome analysis; count 5 cells, 1 karyotype, with banding 88262 count 15-20 cells, 2 karyotypes, with banding 88263 count 45 cells for mosaicism, 2 karyotypes, with banding 88264 analyze 20-25 cells 88267 Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with banding 88269 Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, 1 karyotype, with banding 88271 Molecular cytogenetics; DNA probe, each (e.g., FISH) 88272 chromosomal in situ hybridization, analyze 3-5 cells (e.g., for derivatives and markers) 88273 chromosomal in situ hybridization, analyze 10-30 cells (e.g., for microdeletions) 88274 interphase in situ hybridization, analyze 25-99 cells 88275 interphase in situ hybridization, analyze 100-300 cells 88280 Chromosome analysis; additional karyotypes, each study 88283 additional specialized banding technique (e.g., NOR, C-banding) 88285 additional cells counted, each study 88289 additional high resolution study 88291 Cytogenetics and molecular cytogenetics, interpretation and report 88299 Unlisted cytogenetic study (I.C.) Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-32 Date 01/01/08 SURGICAL PATHOLOGY Complete descriptions for codes 88300 through 88309 are listed in the American Medical Association’s Current Procedural Terminology (CPT) code book. 88300 Level I - surgical pathology, gross examination only 88302 Level II - surgical pathology, gross and microscopic examination 88304 Level III - surgical pathology, gross and microscopic examination 88305 Level IV - surgical pathology, gross and microscopic examination 88307 Level V - surgical pathology, gross and microscopic examination 88309 Level VI - surgical pathology, gross and microscopic examination 88311 Decalcification procedure (List separately in addition to code for surgical pathology examination.) 88312 Special stains (List separately in addition to code for primary service); Group I for microorganisms Gridley, acid fast, methenamine silver), each 88313 Group II, all other (e.g., iron, trichrome), except immunocytochemistry and immunoperoxidase stains, each 88314 histochemical staining with frozen section(s) 88318 Determinative histochemistry to identify chemical components (e.g., copper, zinc) 88319 Determinative histochemistry or cytochemistry to identify enzyme constituents, each 88342 Immunohistochemistry (including tissue immunoperoxidase), each antibody 88346 Immunofluorescent study, each antibody; direct method 88347 indirect method 88348 Electron microscopy; diagnostic 88349 scanning 88355 Morphometric analysis; skeletal muscle 88356 nerve 88358 tumor (eg, DNA ploidy) 88360 Morphometric analysis, tumor immunohistochemistry,(e.g., HER-2/NEU, estrogen receptor/progesterone receptor), quantitative or semiquantitative, each antibody, manual 88361 using computer assisted technology 88362 Nerveteasing preparations 88365 In situ hybridization (e.g, FISH), each probe 88367 Morphometric analysis, in situ hybridization, (quantitative or semiquantitative) each probe, using computer assisted technology 88368 manual 88371 Protein analysis of tissue by Western Blot, with interpretation and report 88372 immunological probe for band identification, each 88380 Microdissection (i.e., sample preparation of microscopically identified target); laser capture (I.C.) 88381 manual 88384 Array-based evaluation of multiple molecular probes; 11 through 50 probes 88385 51 through 250 probes 88386 251 through 500 probes 88399 Unlisted surgical pathology procedure (I.C.) Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-33 Date 01/01/08 OTHER PROCEDURES 89049 Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including interpretation and report 89050 Cell count, miscellaneous body fluids (e.g., cerebrospinal fluid, joint fluid), except blood 89051 with differential count 89055 Leukocyte assessment, fecal, qualitative or semiqualitative 89060 Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine) 89100 Duodenal intubation and aspiration; single specimen (e.g., simple bile study or afferent loop culture) plus appropriate test procedure (I.C.) 89105 collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube 89125 Fat stain, feces, urine, or respiratory secretions 89130 Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology 89132 after stimulation 89135 Gastric intubation, aspiration, and fractional collections (e.g., gastric secretory study); one hour 89136 two hours 89140 two hours including gastric stimulation (e.g., histalog, pentagastrin) 89141 three hours, including gastric stimulation 89160 Meat fibers, feces 89190 Nasal smear for eosinophils 89220 Sputum, obtaining specimen, aerosol induced technique (separate procedure) (I.C.) 89225 Starch granules, feces 89230 Sweat collection by iontophoresis (I.C.) 89235 Water load test 89240 Unlisted miscellaneous pathology test (I.C.) MEDICINE CARDIOVASCULAR Cardiography 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report 93005 tracing only, without interpretation and report 93010 interpretation and report only 93012 Telephonic transmission of post-symptom electrocardiogram rhythm strip(s), 24-hour attended monitoring, per 30-day period of time; tracing only 93014 physician review with interpretation and report only 93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-34 Date 01/01/08 93016 physician supervision only, without interpretation and report 93017 tracing only, without interpretation and report 93018 interpretation and report only 93024 Ergonovine provocation test 93040 Rhythm ECG, one to three leads; with interpretation and report 93041 tracing only without interpretation and report 93042 interpretation and report only 93224 Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation 93225 recording (includes hook-up, recording, and disconnection) 93226 scanning analysis with report 93227 physician review and interpretation 93230 Electrocardiographic monitoring for 24 hours by continuous original ECG waveform recording and storage without superimposition scanning utilizing a device capable of producing a full miniaturized printout; includes recording, microprocessor-based analysis with report, physician review and interpretation 93231 recording (includes hook-up, recording, and disconnection) 93232 microprocessor-based analysis with report 93233 physician review and interpretation 93235 Electrocardiographic monitoring for 24 hours by continuous computerized monitoring and non-continuous recording, and real-time data analysis utilizing a device capable of producing intermittent full-sized waveform tracings, possibly patient activated; includes monitoring and real-time data analysis with report, physician review and interpretation 93236 monitoring and real-time data analysis with report 93237 physician review and interpretation 93268 Patient demand single or multiple event recording with presymptom memory loop, 24-hour attended monitoring, per 30-day period of time; includes transmission, physician review and interpretation 93278 Signal-averaged electrocardiography (SAECG), with or without ECG Other Vascular Studies 93724 Electronic analysis of antitachycardia pacemaker system (includes electrocardiographic recording, programming of device, induction and termination of tachycardia via implanted pacemaker, and interpretation of recordings) 93731 Electronic analysis of dual-chamber pacemaker system (includes evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); without reprogramming 93732 with reprogramming 93734 Electronic analysis of single-chamber pacemaker system (includes evaluation of programmable parameters at rest and during activity where applicable, using electrocardiographic recording and interpretation of recordings at rest and during exercise, analysis of event markers and device response); without reprogramming 93735 with reprogramming Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-35 Date 01/01/08 Other Procedures 93799 Unlisted cardiovascular service or procedure (I.C.) SUPPLEMENTARY P9604 Travel allowance one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing-home-bound patients; prorated miles actually traveled S3820 Complete BRCA1 and BRCA2 gene sequence analysis for susceptibility to breast and ovarian cancer 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Clinical Laboratory Manual Subchapter Number and Title 6. Service Codes and Descriptions Transmittal Letter LAB-32 Page 6-36 Date 01/01/08 This page is reserved.