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 IDTF-7 January 2009 TO: Independent Diagnostic Testing Facilities Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Independent Diagnostic Testing Facility Manual (2009 HCPCS Changes) This letter transmits revisions to the service codes and descriptions in Subchapter 6 of the Independent Diagnostic Testing Facility Manual. The Centers for Medicare & Medicaid Services (CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) for 2009. These changes are included in the attached Subchapter 6 and are effective for dates of service on or after January 1, 2009. After this date, you must use the new codes in order to obtain payment. 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 titles for IDTF services are 114.3 CMR 18.00: Radiology 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 If you have any questions about the information in this transmittal letter please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Independent Diagnostic Testing Facility Manual Pages 6-1 through 6-4, 6-7, 6-8, 6-13, 6-14, and 6-25 through 6-32 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Independent Diagnostic Testing Facility Manual Pages 6-1 through 6-4, 6-7, 6-8, 6-13, 6-14, and 6-25 through 6-32 — transmitted by Transmittal Letter IDTF-6 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-1 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 601 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. 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 and Descriptions Service Code Service Description Diagnostic Radiology (Diagnostic Imaging) Head and Neck 70030 Radiologic examination, eye, for detection of foreign body 70100 Radiologic examination, mandible; partial, less than 4 views 70110 complete, minimum of 4 views 70120 Radiologic examination, mastoids; less than 3 views per side 70130 complete, minimum of 3 views per side 70134 Radiologic examination, internal auditory meati, complete 70140 Radiologic examination, facial bones; less than 3 views 70150 complete, minimum of 3 views 70160 Radiologic examination, nasal bones, complete, minimum of 3 views 70190 Radiologic examination; optic foramina 70200 orbits, complete, minimum of 4 views 70210 Radiologic examination, sinuses, paranasal, less than 3 views 70220 Radiologic examination, sinuses, paranasal, complete, minimum of 3 views 70240 Radiologic examination, sella turcica 70250 Radiologic examination, skull; less than 4 views 70260 complete, minimum of 4 views 70300 Radiologic examination, teeth; single view 70310 partial examination, less than full mouth 70320 complete, full mouth 70328 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral 70330 bilateral 70332 Temporomandibular joint arthrography, radiological supervision and interpretation 70350 Cephalogram, orthodontic 70355 Orthopantogram 70360 Radiologic examination; neck, soft tissue 70370 pharynx or larynx, including fluoroscopy and/or magnification technique 70371 Complex dynamic pharyngeal and speech evaluation by cine or video recording 70373 Laryngography, contrast, radiological supervision and interpretation 70380 Radiologic examination, salivary gland for calculus 70390 Sialography, radiological supervision and interpretation Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 602 Portable X Ray: Radiology Service Codes and Descriptions (cont.) Service Code Service Description Chest 71010 Radiologic examination, chest; single view, frontal 71015 stereo, frontal 71020 Radiologic examination, chest, 2 views, frontal and lateral 71021 with apical lordotic procedure 71022 with oblique projections 71023 with fluoroscopy 71030 Radiologic examination, chest, complete, minimum of 4 views 71034 with fluoroscopy 71035 Radiologic examination, chest, special views (e.g., lateral decubitus, Bucky studies) 71040 Bronchography, unilateral, radiological supervision and interpretation 71060 Bronchography, bilateral, radiological supervision and interpretation 71100 Radiologic examination, ribs, unilateral; 2 views 71101 including posteroanterior chest, minimum of 3 views 71110 Radiologic examination, ribs, bilateral; 3 views 71111 including posteroanterior chest, minimum of 4 views 71120 Radiologic examination; sternum, minimum of 2 views 71130 sternoclavicular joint or joints, minimum of 3 views Spine and Pelvis 72010 Radiologic examination, spine, entire, survey study, anteroposterior and lateral 72020 Radiologic examination, spine, single view, specify level 72040 Radiologic examination, spine, cervical; 2 or 3 views 72050 minimum of 4 views 72052 complete, including oblique and flexion and/or extension studies 72069 Radiologic examination, spine, thoracolumbar, standing (scoliosis) 72070 Radiologic examination, spine; thoracic, 2 views 72072 thoracic, 3 views 72074 thoracic, minimum of 4 views 72080 thoracolumbar, 2 views 72090 scoliosis study, including supine and erect studies 72100 Radiologic examination, spine, lumbosacral; 2 or 3 views 72110 minimum of 4 views 72114 complete, including bending views 72120 Radiologic examination, spine, lumbosacral, bending views only, minimum of 4 views 72170 Radiologic examination, pelvis; one or 2 views 72190 complete, minimum of 3 views 72200 Radiologic examination, sacroiliac joints; less than 3 views 72202 3 or more views 72220 Radiologic examination, sacrum and coccyx, minimum of 2 views 72240 Myelography, cervical, radiological supervision and interpretation Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-3 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 602 Portable X Ray: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 72255 Myelography, thoracic, radiological supervision and interpretation 72265 Myelography, lumbosacral, radiological supervision and interpretation 72270 Myelography, 2 or more regions (e.g., lumbar/thoracic, cervical/thoracic, lumbar/cervical, lumbar/thoracic/cervical), radiological supervision and interpretation 72275 Epidurography, radiological supervision and interpretation 72285 Diskography, cervical or thoracic, radiological supervision and interpretation 72295 Diskography, lumbar, radiological supervision and interpretation Upper Extremities 73000 Radiologic examination; clavicle, complete 73010 scapula, complete 73020 Radiologic examination, shoulder; one view 73030 complete, minimum of 2 views 73040 Radiologic examination, shoulder, arthrography, radiological supervision and interpretation 73050 Radiologic examination; acromioclavicular joints, bilateral, with or without weighted distraction 73060 humerus, minimum of 2 views 73070 Radiologic examination, elbow; 2 views 73080 complete, minimum of 3 views 73085 Radiologic examination, elbow, arthrography, radiological supervision and interpretation 73090 Radiologic examination; forearm, 2 views 73092 upper extremity, infant, minimum of 2 views 73100 Radiologic examination, wrist; 2 views 73110 complete, minimum of 3 views 73115 Radiologic examination, wrist, arthrography, radiological supervision and interpretation 73120 Radiologic examination, hand; 2 views 73130 minimum of 3 views 73140 Radiologic examination, finger(s), minimum of 2 views Lower Extremities 73500 Radiologic examination, hip, unilateral; one view 73510 complete, minimum of 2 views 73520 Radiologic examination, hips, bilateral, minimum of 2 views of each hip, including anteroposterior view of pelvis 73525 Radiologic examination, hip, arthrography, radiological supervision and interpretation 73530 Radiologic examination, hip, during operative procedure 73540 Radiologic examination, pelvis and hips, infant or child, minimum of 2 views 73542 Radiological examination, sacroliac joint arthrography, radiological supervision and interpretation 73550 Radiologic examination, femur, 2 views 73560 Radiologic examination, knee; one or 2 views 73562 3 views 73564 complete, 4 or more views Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-4 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 602 Portable X Ray: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 73565 both knees, standing, anteroposterior 73580 Radiologic examination, knee, arthrography, radiological supervision and interpretation 73590 Radiologic examination; tibia and fibula, 2 views 73592 lower extremity, infant, minimum of 2 views 73600 Radiologic examination, ankle; 2 views 73610 complete, minimum of 3 views 73615 Radiologic examination, ankle, arthrography, radiological supervision and interpretation 73620 Radiologic examination, foot; 2 views 73630 complete, minimum of 3 views 73650 Radiologic examination; calcaneus, minimum of 2 views 73660 toe(s), minimum of 2 views Abdomen 74000 Radiologic examination, abdomen; single anteroposterior view 74010 anteroposterior and additional oblique and cone views 74020 complete, including decubitus and/or erect views 74022 complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest Gastrointestinal Tract 74210 Radiologic examination; pharynx and/or cervical esophagus 74220 esophagus 74230 Swallowing function, with cineradiography/videoradiography 74235 Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision and interpretation 74240 Radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB 74241 with or without delayed films, with KUB 74245 with small intestine, includes multiple serial films 74246 Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed films, without KUB 74247 with or without delayed films, with KUB 74249 with small intestine follow-through 74250 Radiologic examination, small intestine, includes multiple serial films 74251 via enteroclysis tube 74260 Duodenography, hypotonic 74270 Radiologic examination, colon; contrast (e.g., barium) enema, with or without KUB 74280 air contrast with specific high density barium, with or without glucagon 74290 Cholecystography, oral contrast 74291 additional or repeat examination or multiple day examination Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-7 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 603 Freestanding Magnetic Resonance Imaging (FMRI): Radiology Service Codes and Descriptions (cont.) Service Code Service Description 75559 with stress imaging 75560 with flow/velocity quantification and stress 75561 Cardiac magnetic resonance imaging for morphology and function without contract material; followed by contrast material(s) and further sequences 75562 with flow/velocity quantification 75563 followed by contrast material(s) and further sequences; with stress imaging 75564 followed by contrast material(s) and further sequences; with flow/velocity quantification and stress imaging Magnetic Resonance Guidance 77021 Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation 77022 Magnetic resonance guidance for, and monitoring of, parenchymal tissue ablation Breast Mammography 77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral (PA) 77059 bilateral (PA) Supplies for Radiologic Procedures A4641 Radiopharmaceutical, diagnostic not otherwise classified (IC) Administrative, Miscellaneous and Investigational A9500 Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries (IC) A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose (IC) A9503 Technetium Tc-99m medronate, diagnostic, per study, up to 30 millicuries (IC) A9505 Thallium T1-201 thallous chloride, diagnostic, per millicurie (IC) A9512 Technetium Tc-99m pertechnetate, diagnostic, per millicurie (IC) A9537 Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries (IC) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-8 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions Service Code Service Description Maternity Care and Delivery Antepartum Services 59025 Fetal non-stress test Diagnostic Radiology (Diagnostic Imaging) Head and Neck 70030 Radiologic examination, eye, for detection of foreign body 70100 Radiologic examination, mandible; partial, less than 4 views 70110 complete, minimum of 4 views 70120 Radiologic examination, mastoids; less than 3 views per side 70130 complete, minimum of 3 views per side 70134 Radiologic examination, internal auditory meati, complete 70140 Radiologic examination, facial bones; less than 3 views 70150 complete, minimum of 3 views 70160 Radiologic examination, nasal bones, complete, minimum of 3 views 70190 Radiologic examination; optic foramina 70200 orbits, complete, minimum of 4 views 70210 Radiologic examination, sinuses, paranasal, less than 3 views 70220 Radiologic examination, sinuses, paranasal, complete, minimum of 3 views 70240 Radiologic examination, sella turcica 70250 Radiologic examination, skull; less than 4 views 70260 complete, minimum of 4 views 70300 Radiologic examination, teeth; single view 70310 partial examination, less than full mouth 70320 complete, full mouth 70328 Radiologic examination, temporomandibular joint, open and closed mouth; unilateral 70330 bilateral 70332 Temporomandibular joint arthrography, radiological supervision and interpretation 70336 Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s) 70350 Cephalogram, orthodontic 70355 Orthopantogram 70360 Radiologic examination; neck, soft tissue 70370 pharynx or larynx, including fluoroscopy and/or magnification technique 70371 Complex dynamic pharyngeal and speech evaluation by cine or video recording 70373 Laryngography, contrast, radiological supervision and interpretation 70380 Radiologic examination, salivary gland for calculus 70390 Sialography, radiological supervision and interpretation 70450 Computed tomography, head or brain; without contrast material 70460 with contrast material(s) 70470 without contrast material, followed by contrast material(s) and further sections Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-13 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 73630 complete, minimum of 3 views 73650 Radiologic examination; calcaneus, minimum of 2 views 73660 toe(s), minimum of 2 views 73700 Computed tomography, lower extremity; without contrast material 73701 with contrast material(s) 73702 without contrast material, followed by contrast material(s) and further sections 73718 Magnetic resonance (e.g., proton imaging, lower extremity other than joint; without contrast material(s) 73719 with contrast material(s) 73720 without contrast material(s), followed by contrast material(s) and further sequences 73721 Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast material 73722 with contrast material(s) 73723 without contrast material(s), followed by contrast material(s) and further sequences 73725 Magnetic resonance angiography, lower extremity, with or without contrast material(s) Abdomen 74000 Radiologic examination, abdomen; single anteroposterior view 74010 anteroposterior and additional oblique and cone views 74020 complete, including decubitus and/or erect views 74022 complete acute abdomen series, including supine, erect, and/or decubitus views, single view chest 74150 Computed tomography, abdomen; without contrast material 74160 with contrast material(s) 74170 without contrast material, followed by contrast material(s) and further sections 74181 Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s) 74182 with contrast material(s) 74183 without contrast material(s), followed by with contrast material(s) and further sequences 74185 Magnetic resonance angiography, abdomen, with or without contrast material(s) 74190 Peritoneogram (e.g., after injection of air or contrast), radiological supervision and interpretation Gastrointestinal Tract 74210 Radiologic examination; pharynx and/or cervical esophagus 74220 esophagus 74230 Swallowing function, with cineradiography/videoradiography 74235 Removal of foreign body(s), esophageal, with use of balloon catheter, radiological supervision and interpretation 74240 Radiologic examination, gastrointestinal tract, upper; with or without delayed films, without KUB 74241 with or without delayed films, with KUB 74245 with small intestine, includes multiple serial films Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-14 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 74246 Radiological examination, gastrointestinal tract, upper, air contrast, with specific high density barium, effervescent agent, with or without glucagon; with or without delayed films, without KUB 74247 with or without delayed films, with KUB 74249 with small intestine follow-through 74250 Radiologic examination, small intestine, includes multiple serial films 74251 via enteroclysis tube 74260 Duodenography, hypotonic 74270 Radiologic examination, colon; contrast (e.g., barium) enema, with or without KUB 74280 air contrast with specific high density barium, with or without glucagon 74283 Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (e.g., meconium ileus) 74290 Cholecystography, oral contrast 74291 additional or repeat examination or multiple day examination 74300 Cholangiography and/or pancreatography; intraoperative, radiological supervision and interpretation 74301 additional set intraoperative, radiological supervision and interpretation (List separately in addition to code for primary procedure.) 74305 through existing catheter, radiological supervision and interpretation 74320 Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation 74327 Postoperative biliary duct calculus removal, percutaneous via T-tube tract, basket or snare (e.g., Burhenne technique), radiological supervision and interpretation 74330 Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation 74340 Introduction of long gastrointestinal tube (e.g., Miller-Abbott), including multiple fluoroscopies and films, radiological supervision and interpretation 74355 Percutaneous placement of enteroclysis tube, radiological supervision and interpretation Urinary Tract 74400 Urography (pyelography), intravenous, with or without KUB, with or without tomography 74410 Urography, infusion, drip technique and/or bolus technique 74415 with nephrotomography 74420 Urography, retrograde, with or without KUB 74425 Urography, antegrade (pyelostogram, nephrostogram, loopogram), radiological supervision and interpretation 74430 Cystography, minimum of 3 views, radiological supervision and interpretation 74440 Vasography, vesiculography, or epididymography, radiological supervision and interpretation 74445 Corpora cavernosography, radiological supervision and interpretation 74450 Urethrocystography, retrograde, radiological supervision and interpretation 74455 Urethrocystography, voiding, radiological supervision and interpretation 74470 Radiologic examination, renal cyst study, translumbar, contrast visualization, radiological supervision and interpretation Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-25 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 78494 Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing 78496 Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique (List separately in addition to code for primary procedure.) 78499 Unlisted cardiovascular procedure, diagnostic nuclear medicine (IC) Respiratory System 78580 Pulmonary perfusion imaging; particulate 78584 Pulmonary perfusion imaging, particulate, with ventilation; single breath 78585 rebreathing and washout, with or without single breath 78586 Pulmonary ventilation imaging, aerosol; single projection 78587 multiple projections (e.g., anterior, posterior, lateral views) 78588 Pulmonary perfusion imaging, particulate, with ventilation imaging, aerosol, one or multiple projections 78591 Pulmonary ventilation imaging, gaseous, single breath, single projection 78593 Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single breath; single projection 78594 multiple projections (e.g., anterior, posterior, lateral views) 78596 Pulmonary quantitative differential function (ventilation/perfusion) study 78599 Unlisted respiratory procedure, diagnostic nuclear medicine (IC) Nervous System 78600 Brain imaging, less than 4 static views; 78601 with vascular flow 78605 Brain imaging, minimum 4 static views; 78607 tomographic (SPECT) 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation 78609 perfusion evaluation 78610 Brain imaging, vascular flow only 78630 Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography 78635 ventriculography 78645 shunt evaluation 78647 tomographic (SPECT) 78650 Cerebrospinal fluid leakage detection and localization 78660 Radiopharmaceutical dacryocystography 78699 Unlisted nervous system procedure, diagnostic nuclear medicine (IC) Genitourinary System 78700 Kidney imaging morphology; 78701 with vascular flow 78707 with vascular flow and function, single study without pharmacological intervention Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-26 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 78708 with vascular flow and function, single study, with pharmacological intervention (e.g., angiotensin converting enzyme inhibitor and/or diuretic) 78709 with vascular flow and function, multiple studies, with and without pharmacological intervention (e.g., angiotensin converting enzyme inhibitor and/or diuretic) 78710 Kidney imaging morphology, tomographic (SPECT) 78725 Kidney function study, non-imaging radioisotopic study 78730 Urinary bladder residual study (List separately in addition to code for primary procedure.) 78740 Ureteral reflux study (radiopharmaceutical voiding cystogram) 78761 Testicular imaging with vascular flow 78799 Unlisted genitourinary procedure, diagnostic nuclear medicine (IC) Other Procedures 78800 Radiopharmaceutical localization of tumor or distribution of radiopharmaceutical agent(s); limited area 78801 multiple areas 78802 whole body, single day imaging 78803 tomographic (SPECT) 78804 whole body, requiring 2 or more days imaging 78805 Radiopharmaceutical localization of inflammatory process; limited area 78806 whole body 78807 tomographic (SPECT) 78808 Injection procedure for radiopharmaceutical localization by non-imaging probe study, intravenous (e.g., parathyroid adenoma) 78811 Positron emission tomography (PET) imaging; limited area (e.g. chest, head/neck) 78812 skull base to mid-thigh 78813 whole body 78814 Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; limited area (e.g. chest, head/neck) 78815 skull base to mid-thigh 78816 whole body 78999 Unlisted miscellaneous procedure, diagnostic nuclear medicine (IC) 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 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-27 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 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 93016 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; physician supervision only, without interpretation and report 93017 tracing only, without interpretation and report 93018 interpretation and report only 93024 Ergonovine provocation test 93025 Microvolt T-wave alternans for assessment of ventricular arrhythmias 93040 Rhythm ECG, one to 3 leads; with interpretation and report 93041 tracing only without interpretation and report 93042 interpretation and report only 93224 Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original waveform recording and storage, with visual superimposition scanning; includes recording, scanning analysis with report, physician review and interpretation 93225 recording (includes connection, recording, and disconnection) 93226 scanning analysis with report 93227 physician review and interpretation 93228 Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; physician review and interpretation with report (IC) 93229 technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports (IC) 93230 Wearable electrocardiographic rhythm derived monitoring for 24 hours by continuous original 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 connection, recording, and disconnection) 93232 microprocessor-based analysis with report 93233 physician review and interpretation 93235 Wearable electrocardiographic rhythm derived 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 Wearable patient activated electrocardiographic rhythm derived event recording with presymptom memory loop, 24-hour attended monitoring, per 30-day period of time; includes transmission, physician review and interpretation 93270 recording (includes connection, recording, and disconnection) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-28 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 93271 monitoring, receipt of transmissions, and analysis 93272 physician review and interpretation 93278 Signal-averaged electrocardiography (SAECG), with or without ECG Echocardiography 93303 Transthoracic echocardiography for congenital cardiac anomalies; complete 93304 follow-up or limited study 93306 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography 93307 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography 93308 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, follow-up or limited study 93312 Echocardiography, transesophageal, real-time with image documentation (2D) (with or without M- mode recording); including probe placement, image acquisition, interpretation and report 93313 placement of transesophageal probe only 93314 image acquisition, interpretation and report only 93315 Transesophageal echocardiography for congenital cardiac anomalies; including probe placement, image acquisition, interpretation and report 93316 placement of transesophageal probe only 93317 image acquisition, interpretation and report only 93318 Echocardiography, transesophageal (TEE) for monitoring purposes, including probe placement, real time 2-dimensional image acquisition and interpretation leading to ongoing (continuous) assessment of (dynamically changing) cardiac pumping function and to therapeutic measures on an immediate time basis 93320 Doppler echocardiography, pulsed wave and/or continuous wave with spectral display (List separately in addition to codes for echocardiographic imaging); complete 93321 follow-up or limited study (List separately in addition to codes for echocardiographic imaging) 93325 Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography.) 93350 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report 93351 including performance of continuous electrocardiographic monitoring, with physician supervision 93352 Use of echocardiographic contrast agent during stress echocardiography (List separately in addition to code for primary procedure) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-29 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 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) 93740 Temperature gradient studies 93745 Initial set-up and programming by a physician of wearable cardioverter-defibrillator includes initial programming of system, establishing baseline electronic ECG, transmission of data to data repository, patient instruction in wearing system and patient reporting of problems or events (IC) 93784 Ambulatory blood pressure monitoring, utilizing a system such as magnetic tape and/or computer disk, for 24 hours or longer; including recording, scanning analysis, interpretation and report 93786 recording only 93788 scanning analysis with report 93790 physician review with interpretation and report Other Procedures 93797 Physician services for outpatient cardiac rehabilitation; without continuous ECG monitoring (per session) 93798 with continuous ECG monitoring (per session) 93799 Unlisted cardiovascular service or procedure (IC) Non-Invasive Vascular Diagnostic Studies Cerebrovascular Arterial Studies 93875 Non-invasive physiologic studies of extracranial arteries, complete bilateral study (e.g., periorbital flow direction with arterial compression, ocular pneumoplethysmography, Doppler ultrasound spectral analysis) 93880 Duplex scan of extracranial arteries; complete bilateral study 93882 unilateral or limited study 93886 Transcranial Doppler study of the intracranial arteries; complete study 93888 limited study 93890 vasoreactivity study 93892 emboli detection without intravenous microbubble injection 93893 emboli detection with intravenous microbubble injection Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-30 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description Extremity Arterial Studies (Including Digits) 93922 Non-invasive physiologic studies of upper or lower extremity arteries, single level, bilateral (e.g., ankle/brachial indices, Doppler waveform analysis, volume plethysmography, transcutaneous oxygen tension measurement) 93923 Non-invasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (e.g., segmental blood pressure measurements, segmental Doppler waveform analysis, segmental volume plethysmography, segmental transcutaneous oxygen tension measurements, measurements with postural provocative tests, measurements with reactive hyperemia) 93924 Non-invasive physiologic studies of lower extremity arteries, at rest and following treadmill stress testing, complete bilateral study 93925 Duplex scan of lower extremity arteries or arterial bypass grafts; complete bilateral study 93926 unilateral or limited study 93930 Duplex scan of upper extremity arteries or arterial bypass grafts; complete bilateral study 93931 unilateral or limited study Special EEG Tests 95950 Monitoring for identification and lateralization of cerebral seizure focus, electroencephalographic (eg, 8 channel EEG) recording and interpretation, each 24 hours 95951 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, combined electroencephalographic (EEG) and video recording and interpretation (eg, for presurgical localization), each 24 hours 95953 Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours 95956 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours Extremity Venous Studies (Including Digits) 93965 Non-invasive physiologic studies of extremity veins, complete bilateral study (e.g., Doppler waveform analysis with responses to compression and other maneuvers, phleborheography, impedance plethysmography) 93970 Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study 93971 unilateral or limited study Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-31 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description Visceral and Penile Vascular Studies 93975 Duplex scan of arterial inflow and venous outflow of abdominal, pelvic, scrotal contents and/or retroperitoneal organs; complete study 93976 limited study 93978 Duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts; complete study 93979 unilateral or limited study 93980 Duplex scan of arterial inflow and venous outflow of penile vessels; complete study 93981 follow-up or limited study 93990 Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) Supplies for Radiologic Procedures A4641 Radiopharmaceutical, diagnostic, not otherwise classified (IC) Administrative, Miscellaneous and Investigational A9500 Technetium Tc-99m sestamibi, diagnostic, per study dose, up to 40 millicuries (IC) A9502 Technetium Tc-99m tetrofosmin, diagnostic, per study dose, (IC) A9503 Technetium Tc-99m medronate, diagnostic, per study, up to 30 millicuries (IC) A9505 Thallium T1-201 thallous chloride, diagnostic, per millicurie (IC) A9512 Technetium Tc-99m pertechnetate, diagnostic, per millicurie (IC) A9537 Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries (IC) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-32 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-7 Date 01/01/09 605 Mammography Vans: Radiology Service Codes and Descriptions Service Code Service Description Radiologic Guidance Breast Mammography 77051 Computer-aided detection (computer algorithim analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; diagnostic mammography (List separately in addition to code for primary procedure.) 77052 screening mammography (List separately in addition to code for primary procedure.) 77053 Mammary ductogram or galactogram, single duct, radiological supervision and interpretation 77054 Mammary ductogram or galactogram, multiple ducts, radiological supervision and interpretation 77055 Mammography; unilateral 77056 bilateral 77057 Screening mammography, bilateral (2-view film study of each breast) Diagnostic Ultrasound Chest 76645 Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation 606 Sleep Centers: Radiology Service Codes and Descriptions Service Code Service Description Neurology and Neuromuscular Procedures Sleep Studies 95805 Multiple sleep latency or maintenance of wakefulness testing, recording, analysis and interpretation of physiological measurements of sleep during multiple trials to assess sleepiness 95806 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, unattended by a technologist 95807 Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist 95808 Polysomnography; sleep staging with one to 3 additional parameters of sleep, attended by a technologist 95810 Polysomnography; sleep staging with 4 or more additional parameters of sleep, attended by a technologist 95811 Polysomnography; sleep staging with 4Pa or more additional parameters of sleep, with initiation of continuous positive airway pressure therapy or bilevel ventilation, attended by a technologist 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 Terminal (CPT) code book.