Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter IDTF-10 March 2012 TO: Independent Diagnostic Testing Facilities Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: IDTF Manual (2012 HCPCS) This letter transmits revisions to the service codes in the Independent Diagnostic Testing Facility (IDTF) Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) codes for 2012. The revised Subchapter 6 is effective for dates of service on or after January 1, 2012. In addition, this revised Subchapter 6 no longer includes service descriptions for covered codes. MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) or the Health Care Procedure Code Set (HCPCS) Level II code book for the service code and service descriptions when billing for services provided to MassHealth members. Division of Health Care Finance and Policy regulations establish the fee schedule for covered services in the Independent Diagnostic Testing Facility Manual. You may download the regulations at no cost at www.mass.gov/dhcfp or purchase a paper copy from either the Massachusetts State Bookstore or 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 for IDTF services are 114.3 CMR 17.00: Medicine Services and 114.3 CMR 18.00: Radiology 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 Transmittal Letter IDTF-10 March 2012 Page 2 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 Diagnostic Testing Facility Manual Pages vi and 6-1 through 6-6 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Independent Diagnostic Testing Facility Manual Pages vi and 6-1 through 6-34 — transmitted by Transmittal Letter IDTF-9 Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Diagnostic Testing Facility Manual Subchapter Number and Title Table of Contents Transmittal Letter IDTF-10 Page vi Date 01/01/12 6. Service Codes and Descriptions Introduction 6-1 Portable X Ray: Radiology Service Codes 6-1 Freestanding Magnetic Resonance Imaging (FMRI): Radiology Service Codes 6-2 Diagnostic Imaging Centers: Radiology Service Codes 6-2 Mammography Vans: Radiology Service Codes 6-5 Sleep Centers: Radiology Service Codes 6-5 Appendix A. Directory A-1 Appendix B. Enrollment Centers B-1 Appendix C. Third-Party-Liability Codes C-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 Independent Diagnostic Testing Facility Manual Subchapter Number and Title 6. Service Codes Transmittal Letter IDTF-10 Page 6-1 Date 01/01/12 601 Introduction 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 431.000 and 450.000. MassHealth providers must refer to the American Medical Association’s Current Procedural Terminology (CPT) or the Health Care Procedure Code Set (HCPCS) Level II code book for the service code and service descriptions when billing for services provided to MassHealth members. An independent diagnostic testing facility (IDTF) may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Independent Diagnostic Testing Facility Manual. “IC” indicates that the claim requires individual consideration. See 130 CMR 431.406 for more information. “PA” indicates that the service requires prior authorization. See 130 CMR 450.303 for more information. 602 Portable X Ray: Radiology Service Codes Service Code 70030 70100 70110 70120 70130 70134 70140 70150 70160 70190 70200 70210 70220 70240 70250 70260 70300 70310 70320 70328 70330 70332 70350 70355 70360 70370 70371 70373 70380 70390 71010 71015 71020 71021 71022 71023 71030 71034 71035 71040 71060 71100 71101 71110 71111 71120 71130 72010 72020 72040 72050 72052 72069 72070 72072 72074 72080 72090 72100 72110 72114 72120 72170 72190 72200 72202 72220 72240 72255 72265 72270 72275 72285 72295 73000 73010 73020 73030 73040 73050 73060 73070 73080 73085 73090 73092 73100 73110 73115 73120 73130 73140 73500 73510 73520 73525 73530 73540 73550 73560 73562 73564 73565 73580 73590 73592 73600 73610 73615 73620 73630 73650 73660 74000 74010 74020 74022 74210 74220 74230 74235 74240 74241 74245 74246 74247 74249 74250 74251 74260 74270 74280 74290 74291 74300 74301 74305 74320 Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Diagnostic Testing Facility Manual Subchapter Number and Title 6. Service Codes Transmittal Letter IDTF-10 Page 6-2 Date 01/01/12 603 Freestanding Magnetic Resonance Imaging (FMRI): Radiology Service Codes 70336 (PA) 70540 70542 70543 70544 70545 70546 70547 70548 70549 70551 70552 70553 70557 70558 70559 71550 71551 71555 72141 72142 72146 72147 72148 72149 72156 72157 72158 72195 72196 72197 73218 73219 73220 73221 73222 73223 73718 73719 73720 73721 73722 73723 73725 74181 74182 74183 74185 74301 74305 74320 75557 75559 75561 75563 75565 77021 77022 77058 (PA) 77059 (PA) A4641 A9500 (IC) A9502 (IC) A9503 (IC) A9505 (IC) A9512 (IC) A9537 (IC) 604 Diagnostic Imaging Centers: Radiology Service Codes Service Code 59025 70030 70100 70110 70120 70130 70134 70140 70150 70160 70190 70200 70210 70220 70240 70250 70260 70300 70310 70320 70328 70330 70332 70336 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 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Diagnostic Testing Facility Manual Subchapter Number and Title 6. Service Codes Transmittal Letter IDTF-10 Page 6-3 Date 01/01/12 604 Diagnostic Imaging Centers: Radiology Service Codes (cont.) 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 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Diagnostic Testing Facility Manual Subchapter Number and Title 6. Service Codes Transmittal Letter IDTF-10 Page 6-4 Date 01/01/12 604 Diagnostic Imaging Centers: Radiology Service Codes (cont.) 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 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 78710 78725 78730 78740 78761 78799 (IC) 78800 78801 78802 78803 78804 78805 78806 78807 78808 78811 78812 78813 78814 78815 78816 78999 (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 93786 93788 93790 93797 93798 93799 (IC) Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Diagnostic Testing Facility Manual Subchapter Number and Title 6. Service Codes Transmittal Letter IDTF-10 Page 6-5 Date 01/01/12 604 Diagnostic Imaging Centers: Radiology Service Codes (cont.) 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 A4641 IC) A9500 (IC) A9502 (IC) A9503 (IC) A9505 (IC) A9512 (IC) A9537 (IC) G0202 G0204 G0206 605 Mammography Vans: Radiology Service Codes Service Code 76645 77051 77052 77053 77054 77055 77056 77057 G0202 G0204 G0206 606 Sleep Centers: Radiology Service Codes Service Code 95800 95801 95805 95806 95807 95808 95810 95811 This publication contains codes that are copyrighted by the American Medical Association. Commonwealth of Massachusetts MassHealth Provider Manual Series Independent Diagnostic Testing Facility Manual Subchapter Number and Title 6. Service Codes Transmittal Letter IDTF-10 Page 6-6 Date 01/01/12 This page is reserved.