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-8 February 2010 TO: Independent Diagnostic Testing Facilities Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Independent Diagnostic Testing Facility Manual (2010 HCPCS) This letter transmits revisions to the service codes in the Independent Diagnostic Testing Facility Manual. The Centers for Medicare & Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2010. The revised Subchapter 6 is effective for dates of service on or after January 1, 2010. We will accept either the new or the old codes for dates of service through December 31, 2009. For dates of service on or after January 1, 2010, 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/sprDivision 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 Diagnostic Testing Facility Manual Pages vi, vii, and 6-1 through 6-34 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Independent Diagnostic Testing Facility Manual Pages vi, 6-5, 6-6, 6-9 through 6-12, and 6-15 through 6-24 — transmitted by Transmittal Letter IDTF-6 Page vii — transmitted by Transmittal Letter IDTF-1 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-7 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 6. Service Codes and Descriptions Introduction ................................................................................................................................. 6-1 Portable X Ray: Radiology Service Codes and Descriptions ....................................................... 6-1 Freestanding Magnetic Resonance Imaging (FMRI): Radiology Service Codes and Descriptions..................................................................................................................... 6-5 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions 6-8 Mammography Vans: Radiology Service Codes and Descriptions ............................................. 6-33 Sleep Centers: Radiology Service Codes and Descriptions ......................................................... 6-33 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 Subchapter Number and Title Preface Page vii Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 The regulations and instructions governing provider participation in MassHealth are published in the Provider Manual Series. MassHealth publishes a separate manual for each provider type. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, administrative and billing instructions, and general information. MassHealth regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. MassHealth regulations are assigned Title 130 of the Code. The regulations governing provider participation in MassHealth are assigned Chapters 400 through 499 within Title 130. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For independent diagnostic testing facility services, those matters are covered in 130 CMR Chapter 431.000, reproduced as Subchapter 4 in the Independent Diagnostic Testing Facility Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for making changes by hand ("pen-and-ink" revisions), and by substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead MassHealth’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with MassHealth and its members. 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-8 Date 01/01/10 601 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-8 Date 01/01/10 602 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-8 Date 01/01/10 602 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-8 Date 01/01/10 602 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 6-5 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 603 Freestanding Magnetic Resonance Imaging (FMRI): Radiology Service Codes and Descriptions Service Code Service Description 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 Head and Neck 70336 Magnetic resonance (e.g., proton) imaging, temporomandibular joint(s) (PA) 70540 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s) 70542 with contrast material(s) 70543 without contrast material(s), followed by contrast material(s) and further sequences 70544 Magnetic resonance angiography, head; without contrast material(s) 70545 with contrast material(s) 70546 without contrast material(s), followed by contrast material(s) and further sequences 70547 Magnetic resonance angiography, neck; without contrast material(s) 70548 with contrast material(s) 70549 without contrast material(s), followed by contrast material(s) and further sequences 70551 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material 70552 with contrast material(s) (professional component only) 70553 without contrast material, followed by contrast material(s) and further sequences 70557 Magnetic resonance (e.g., proton) imaging, brain (including brain stem and skull base), during open intracranial procedure (e.g., to assess for residual tumor or residual vascular malformation); without contrast material 70558 with contrast material(s) 70559 without contrast material(s), followed by contrast material(s) and further sequences Chest 71550 Magnetic resonance (e.g., proton) imaging, chest (e.g., for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) 71551 with contrast material(s) 71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) Spine and Pelvis 72141 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; without contrast material 72142 with contrast material(s) 72146 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; without contrast material Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-6 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 603 Freestanding Magnetic Resonance Imaging (FMRI): Radiology Service Codes and Descriptions (cont.) Service Code Service Description 72147 with contrast material(s) 72148 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without contrast material 72149 with contrast material(s) 72156 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical 72157 thoracic 72158 lumbar 72195 Magnetic resonance (e.g., proton) imaging, pelvis; without contrast materials 72196 with contrast material(s) 72197 without contrast material(s), followed by contrast material(s) and further sequences Upper Extremities 73218 Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; without contrast material(s) 73219 with contrast material(s) 73220 without contrast material(s), followed by contrast material(s) and further sequences 73221 Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; without contrast material(s) 73222 with contrast material(s) 73223 without contrast material(s), followed by contrast material(s) and further sequences Lower Extremities 73718 Magnetic resonance (e.g.) proton imaging, lower extremity other than joint; without contrast material(s) 73719 with contrast material(s) 73720 Magnetic resonance (e.g., proton) imaging, lower extremity, other than joint; 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) 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) 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-8 Date 01/01/10 603 Freestanding Magnetic Resonance Imaging (FMRI): Radiology Service Codes and Descriptions (cont.) Service Code Service Description Heart 75557 Cardiac magnetic resonance imaging for morphology and function without contract material 75559 with stress imaging 75561 Cardiac magnetic resonance imaging for morphology and function without contract material; followed by contrast material(s) and further sequences 75563 followed by contrast material(s) and further sequences; with stress imaging 75565 Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure) 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-8 Date 01/01/10 604 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 6-9 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 70480 Computed tomography, orbit, sella, or posterior fossa or outer, middle, or inner ear; without contrast material 70481 with contrast material(s) 70482 without contrast material, followed by contrast material(s) and further sections 70486 Computed tomography, maxillofacial area; without contrast material 70487 with contrast material(s) 70488 without contrast material, followed by contrast material(s) and further sections 70490 Computed tomography, soft tissue neck; without contrast material 70491 with contrast material(s) 70492 without contrast material followed by contrast material(s) and further sections 70540 Magnetic resonance (e.g., proton) imaging, orbit, face, and/or neck; without contrast material(s) 70542 with contrast materials 70543 without contrast material(s), followed by contrast material(s) and further sequences 70544 Magnetic resonance angiography, head; without contrast material(s) 70545 with contrast material(s) 70546 without contrast material(s), followed by contrast material(s) and further sequences 70547 Magnetic resonance angiography, neck; without contrast material(s) 70548 with contrast material(s) 70549 without contrast material(s), followed by contrast material(s) and further sequences 70551 Magnetic resonance (e.g., proton) imaging, brain (including brain stem); without contrast material 70552 with contrast material(s) (professional component only) 70553 without contrast material, followed by contrast material(s) and further sequences 70554 Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration 70555 requiring physician or psychologist administration of entire neurofunctional testing Chest 71010 Radiologic examination, chest; single view, frontal 71015 stereo, frontal 71020 Radiologic examination, chest, two views, frontal and lateral 71021 with apical lordotic procedure 71022 with oblique projections 71023 with fluoroscopy 71030 Radiologic examination, chest, complete, minimum of four 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; two views 71101 including posteroanterior chest, minimum of three views 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 71110 Radiologic examination, ribs, bilateral; three views 71111 including posteroanterior chest, minimum of four views 71120 Radiologic examination; sternum, minimum of two views 71130 sternoclavicular joint or joints, minimum of three views 71550 Magnetic resonance (e.g. proton) imaging, chest (e.g. for evaluation of hilar and mediastinal lymphadenopathy); without contrast material(s) 71551 with contrast material(s) 71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) 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; two or three views 72050 minimum of four views 72052 complete, including oblique and flexion and/or extension studies 72069 Radiological examination, spine, thoracolumbar, standing (scoliosis) 72070 Radiologic examination, spine; thoracic, two views 72072 thoracic, three views 72074 thoracic, minimum of four views 72080 thoracolumbar, two views 72090 scoliosis study, including supine and erect studies 72100 Radiologic examination, spine, lumbosacral; two or three views 72110 minimum of four views 72114 complete, including bending views 72120 Radiologic examination, spine, lumbosacral, bending views only, minimum of four views 72125 Computed tomography, cervical spine; without contrast material 72126 with contrast material 72127 without contrast material, followed by contrast material(s) and further sections 72128 Computed tomography, thoracic spine; without contrast material 72129 with contrast material 72130 without contrast material, followed by contrast material(s) and further sections 72131 Computed tomography, lumbar spine; without contrast material 72132 with contrast material 72133 without contrast material, followed by contrast material(s) and further sections 72141 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, cervical; without contrast material 72142 with contrast material(s) 72146 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, thoracic; without contrast material 72147 with contrast material(s) 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 72148 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without contrast material 72149 with contrast material(s) 72156 Magnetic resonance (e.g., proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical 72157 thoracic 72158 lumbar 72170 Radiologic examination, pelvis; one or two views 72190 complete, minimum of three views 72192 Computed tomography, pelvis; without contrast material 72193 with contrast material(s) 72194 without contrast material, followed by contrast material(s) and further sections 72195 Magnetic resonance (e.g., proton) imaging, pelvis; without contrast materials 72196 with contrast material(s) 72197 without contrast material(s), followed by contrast material(s) and further sequences 72200 Radiologic examination, sacroiliac joints; less than three views 72202 three or more views 72220 Radiologic examination, sacrum and coccyx, minimum of two views 72240 Myelography, cervical, radiological supervision and interpretation 72255 Myelography, thoracic, radiological supervision and interpretation 72265 Myelography, lumbosacral, radiological supervision and interpretation 72270 Myelography, two 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 Discography, cervical or thoracic, radiological supervision and interpretation 72291 Radiological supervision and interpretation, percutaneous vertebroplasty, vertebral augmentation, or sacral augmentation (sacroplasty), including cavity creation, per vertebral body or sacrum; under fluoroscopic guidance 72292 under CT guidance 72295 Discography, 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 two 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 two views 73070 Radiologic examination, elbow; two views 73080 complete, minimum of three views 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 73085 Radiologic examination, elbow, arthrography, radiological supervision and interpretation 73090 Radiologic examination; forearm, two views 73092 upper extremity, infant, minimum of two views 73100 Radiologic examination, wrist; two views 73110 complete, minimum of three views 73115 Radiologic examination, wrist, arthrography, radiological supervision and interpretation 73120 Radiologic examination, hand; two views 73130 minimum of three views 73140 Radiologic examination, finger(s), minimum of two views 73200 Computed tomography, upper extremity; without contrast material 73201 with contrast material(s) 73202 without contrast material, followed by contrast material(s) and further sections 73218 Magnetic resonance (e.g., proton) imaging, upper extremity, other than joint; without contrast materials 73219 with contrast material(s) 73220 without contrast material(s), followed by contrast material(s) and further sequences 73221 Magnetic resonance (e.g., proton) imaging, any joint of upper extremity; without contrast material(s) 73222 with contrast material(s) 73223 without contrast material(s), followed by contrast material(s) and further sequences Lower Extremities 73500 Radiologic examination, hip, unilateral; one view 73510 complete, minimum of two views 73520 Radiologic examination, hips, bilateral, minimum of two 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 two views 73542 Radiological examination, sacroliac joint arthrography, radiological supervision and interpretation 73550 Radiologic examination, femur, two views 73560 Radiologic examination, knee; one or two views 73562 three views 73564 complete, four or more views 73565 both knees, standing, anteroposterior 73580 Radiologic examination, knee, arthrography, radiological supervision and interpretation 73590 Radiologic examination; tibia and fibula, two views 73592 lower extremity, infant, minimum of two views 73600 Radiologic examination, ankle; two views 73610 complete, minimum of three views 73615 Radiologic examination, ankle, arthrography, radiological supervision and interpretation 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-8 Date 01/01/10 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 73620 Radiologic examination, foot; two views 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. 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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 74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material (PA) 74262 with contrast material(s) including non-contrast images, if performed (PA) 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 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 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 74475 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation 74480 Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous, radiological supervision and interpretation 74485 Dilation of nephrostomy, ureters, or urethra, radiological supervision and interpretation Gynecological and Obstetrical 74710 Pelvimetry, with or without placental localization 74740 Hysterosalpingography, radiological supervision and interpretation 74742 Transcervical catheterization of fallopian tube, radiological supervision and interpretation 74775 Perineogram (e.g., vaginogram, for sex determination or extent of anomalies) Heart 75557 Cardiac magnetic resonance imaging for morphology and function without contract material 75559 with stress imaging 75561 Cardiac magnetic resonance imaging for morphology and function without contrast material, followed by contrast material(s) and further sequences 75563 with stress imaging 75565 Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to primary procedure) 75572 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed) 75573 Computed tomography, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evaluation of venous structures, if performed) 75574 Computed tomography angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed) 75600 Aortography, thoracic, without serialography, radiological supervision and interpretation 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description Vascular Procedures Aorta and Arteries 75605 Aortography, thoracic, by serialography, radiological supervision and interpretation 75625 Aortography, abdominal, by serialography, radiological supervision and interpretation 75630 Aortography, abdominal plus bilateral iliofemoral lower extremity, catheter, by serialography, radiological supervision and interpretation 75650 Angiography, cervicocerebral, catheter, including vessel origin, radiological supervision and interpretation 75658 Angiography, brachial, retrograde, radiological supervision and interpretation 75660 Angiography, external carotid, unilateral, selective, radiological supervision and interpretation 75662 Angiography, external carotid, bilateral, selective, radiological supervision and interpretation 75665 Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation 75671 Angiography, carotid, cerebral, bilateral, radiological supervision and interpretation 75676 Angiography, carotid, cervical, unilateral, radiological supervision and interpretation 75680 Angiography, carotid, cervical, bilateral, radiological supervision and interpretation 75685 Angiography, vertebral, cervical, and/or intracranial, radiological supervision and interpretation 75705 Angiography, spinal, selective, radiological supervision and interpretation 75710 Angiography, extremity, unilateral, radiological supervision and interpretation 75716 Angiography, extremity, bilateral, radiological supervision and interpretation 75722 Angiography, renal, unilateral, selective (including flush aortogram), radiological supervision and interpretation 75724 Angiography, renal, bilateral, selective (including flush aortogram), radiological supervision and interpretation 75726 Angiography, visceral, selective or supraselective (with or without flush aortogram), radiological supervision and interpretation 75731 Angiography, adrenal, unilateral, selective, radiological supervision and interpretation 75733 Angiography, adrenal, bilateral, selective, radiological supervision and interpretation 75736 Angiography, pelvic, selective or supraselective, radiological supervision and interpretation 75741 Angiography, pulmonary, unilateral, selective, radiological supervision and interpretation 75743 Angiography, pulmonary, bilateral, selective, radiological supervision and interpretation 75746 Angiography, pulmonary, by nonselective catheter or venous injection, radiological supervision and interpretation 75756 Angiography, internal mammary, radiological supervision and interpretation 75774 Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation (List separately in addition to code for primary procedure.) 75791 Angiography, arteriovenous shunt (e.g., dialysis patient fistula/graft), complete evaluation of dialysis access, including fluoroscopy, image documentation and report (includes injections of contrast and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow inclusing the inferior or superior vena cava), radiological supervision and interpretation 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description Vein and Lymphatics 75801 Lymphangiography, extremity only, unilateral, radiological supervision and interpretation 75803 Lymphangiography, extremity only, bilateral, radiological supervision and interpretation 75805 Lymphangiography, pelvic/abdominal, unilateral, radiological supervision and interpretation 75807 Lymphangiography, pelvic/abdominal, bilateral, radiological supervision and interpretation 75809 Shuntogram for investigation of previously placed indwelling nonvascular shunt (e.g., LeVeen shunt, ventriculoperitoneal shunt, indwelling infusion pump), radiological supervision and interpretation 75810 Splenoportography, radiological supervision and interpretation 75820 Venography, extremity, unilateral, radiological supervision and interpretation 75822 Venography, extremity, bilateral, radiological supervision and interpretation 75825 Venography, caval, inferior, with serialography, radiological supervision and interpretation 75827 Venography, caval, superior, with serialography, radiological supervision and interpretation 75831 Venography, renal, unilateral, selective, radiological supervision and interpretation 75833 Venography, renal, bilateral, selective, radiological supervision and interpretation 75840 Venography, adrenal, unilateral, selective, radiological supervision and interpretation 75842 Venography, adrenal, bilateral, selective, radiological supervision and interpretation 75860 Venography, venous sinus (e.g., petrosal and inferior saggital) or jugular, catheter, radiological supervision and interpretation 75870 Venography, superior sagittal sinus, radiological supervision and interpretation 75872 Venography, epidural, radiological supervision and interpretation 75880 Venography, orbital, radiological supervision and interpretation 75885 Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation 75887 Percutaneous transhepatic portography without hemodynamic evaluation, radiological supervision and interpretation 75889 Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and interpretation 75891 Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and interpretation 75893 Venous sampling through catheter, with or without angiography (e.g., for parathyroid hormone, renin), radiological supervision and interpretation 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 75870 Venography, superior sagittal sinus, radiological supervision and interpretation 75872 Venography, epidural, radiological supervision and interpretation 75880 Venography, orbital, radiological supervision and interpretation 75885 Percutaneous transhepatic portography with hemodynamic evaluation, radiological supervision and interpretation 75887 Percutaneous transhepatic portography without hemodynamic evaluation, radiological supervision and interpretation 75889 Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and interpretation 75891 Hepatic venography, wedged or free, without hemodynamic evaluation, radiological supervision and interpretation 75893 Venous sampling through catheter, with or without angiography (e.g., for parathyroid hormone, renin), radiological supervision and interpretation Transcatheter Procedures 75898 Angiography through existing catheter for follow-up study for transcatheter therapy, embolization or infusion 75900 Exchange of a previously placed intravascular catheter during thrombolytic therapy with contrast monitoring, radiological supervision and interpretation 75901 Mechanical removal of pericatheter obstructive material (e.g., fibrin sheath) from central venous device via separate venous access, radiologic supervision and interpretation 75902 Mechanical removal of intraluminal (intracathether) obstructive material from central venous device through device lumen, radiologic supervision and interpretation 75945 Intravascular ultrasound (non-coronary vessel), radiological supervision and interpretation; initial vessel 75946 each additional non-coronary vessel (List separately in addition to code for primary procedure.) Other Procedures 76000 Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (e.g., cardiac fluoroscopy) 76001 Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician (e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy) 76010 Radiologic examination from nose to rectum for foreign body, single view, child 76080 Radiologic examination, abscess, fistula or sinus tract study, radiological supervision and interpretation 76098 Radiological examination, surgical specimen 76100 Radiologic examination, single plane body section (e.g., tomography), other than with urography 76101 Radiologic examination, complex motion (i.e., hypercycloidal) body section (e.g., mastoid polytomography), other than with urography; unilateral 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 76102 bilateral 76120 Cineradiography/videoradiography, except where specifically included 76125 Cineradiography/videoradiography to complement routine examination (List separately in addition to code for primary procedure.) 76376 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation 76377 requiring image postprocessing on an independent station 76380 Computed tomography, limited or localized follow-up study 76499 Unlisted diagnostic radiographic procedure (IC) Diagnostic Ultrasound Head and Neck 76506 Echoencephalography, real time with image documentation (gray scale) (for determination of ventricular size, delineation of cerebral contents, and detection of fluid masses or other intracranial abnormalities), including A-mode encephalography as secondary component where indicated 76510 Ophthalmic ultrasound, diagnostic; B-scan and quantitative A-scan performed during the same patient encounter 76511 quantitative A-scan only 76512 B-scan (with or without superimposed non-quantitative A-scan) 76513 anterior segment ultrasound, immersion (water bath) B-scan or high resolution biomicroscopy 76514 corneal pachymetry, unilateral or bilateral (determination of corneal thickness) 76516 Ophthalmic biometry by ultrasound echography, A-scan 76519 with intraocular lens power calculation 76529 Ophthalmic ultrasonic foreign body localization 76536 Ultrasound, soft tissues of head and neck (e.g., thyroid, parathyroid, parotid), real time with image documentation Chest 76604 Ultrasound, chest (includes mediastinum), real time with image documentation 76645 Ultrasound, breast(s) (unilateral or bilateral), real time with image documentation 76700 Ultrasound, abdominal real time with image documentation; complete 76705 limited (e.g., single organ, quadrant, follow-up) 76770 Ultrasound, retroperitoneal (e.g., renal, aorta, nodes), real time with image documentation; complete 76775 limited 76776 Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description Spinal Canal 76800 Ultrasound, spinal canal and contents Pelvis 76801 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester (<14 weeks 0 days), transabdominal approach; single or first gestation 76802 each additional gestation (List separately in addition to code for primary procedure.) 76805 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation 76810 each additional gestation (List separately in addition to code for primary procedure.) 76811 Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation 76812 each additional gestation (List separately in addition to code for primary procedure.) 76813 Ultrasound, pregnant uterus,real time with image documentation, first trimester fetal nuchal translucency measurement, transabdominal or transvaginal approach; single of first gestation 76814 each additional gestation (List separately in addition to code for primary procedure.) 76815 Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses 76816 Ultrasound, pregnant uterus, real time with image documentation, follow-up (e.g., reevaluation of fetal size by measuring standard growth parameters and amniotic fluid volume, reevaluation of organ system(s) suspected or confirmed to be abnormal on a previous scan), transabdominal approach, per fetus 76817 Ultrasound, pregnant uterus, real time with image documentation, transvaginal 76818 Fetal biophysical profile; with non-stress testing 76820 Doppler velocimetry, fetal; umbilical artery 76821 middle cerebral artery 76825 Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M-mode recording; 76826 follow-up or repeat study 76827 Doppler echocardiography, fetal, cardiovascular system, pulsed wave and/or continuous wave with spectral display; complete 76828 follow-up or repeat study 76830 Ultrasound, transvaginal 76831 Saline infusion sonohysterography (SIS), including color flow Doppler, when performed 76856 Ultrasound, pelvic (nonobstetric), real time with image documentation; complete 76857 limited or follow-up (e.g., for follicles) 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description Genitalia 76870 Ultrasound, scrotum and contents 76872 transrectal; 76873 prostate volume study for brachytherapy treatment planning (separate procedure) Extremities 76880 Ultrasound, extremity, non-vascular, real time with image documentation 76885 Ultrasound, infant hips, real time with imaging documentation; dynamic (requiring physician manipulation) 76886 limited, static (not requiring physician manipulation) Ultrasonic Guidance Procedures 76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure.) 76942 Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation 76945 Ultrasonic guidance for chorionic villus sampling, imaging supervision and interpretation 76946 Ultrasonic guidance for amniocentesis, imaging supervision and interpretation 76948 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation 76950 Ultrasonic guidance for placement of radiation therapy fields 76965 Ultrasonic guidance for interstitial radioelement application Other Procedures 76970 Ultrasound study follow-up (specify) 76977 Ultrasound bone density measurement and interpretation, peripheral site(s), any method 76999 Unlisted ultrasound procedure (e.g., diagnostic, interventional) (IC) Radiologic Guidance Fluroscopic Guidance 77001 Fluoroscopic guidance for central venous access device placement, replacement (catheter only or complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any necessary contrast injections through access site or catheter with related venography radiologic supervision and interpretation, and radiographic documentation of final catheter position) (List separately in addition to code for primary procedure.) 77002 Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 77003 Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid, or sacroiliac joint), including neurolytic agent destruction Computed Tomography Guidance 77011 Computed tomography guidance for sterotactic localization 77012 Computed tomography guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), radiologic supervision and interpretation 77013 Computed tomography guidance for, and monitoring of, parenchymal tissue ablation 77014 Computed tomography guidance for placement of radiation therapy fields 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 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 (two-view film study of each breast) 77058 Magnetic resonance imaging, breast, without and/or with contrast material(s); unilateral (P.A.) 77059 bilateral (P.A.) Bone/Joint Studies 77071 Manual application of stress performed by physician for joint radiography, including contralateral joint if indicated 77072 Bone age studies 77073 Bone length studies (orthoroentgenogram, scanogram) 77074 Radiologic examination, osseous survey; limited (e.g., for metastases) 77075 complete (axial and appendicular skeleton) 77076 Radiologic examination, osseous survey, infant 604 Diagnostic Imaging Centers: Radiology Service Codes and Descriptions (cont.) Service Code Service Description 77077 Joint survey, single view, two or more joints (specify) 77078 Computed tomography, bone mineral density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine) 77079 appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 77080 Dual-energy x-ray absorptiometry (DXA), bone density study, one or more sites; axial skeleton (e.g., hips, pelvis, spine) 77081 appendicular skeleton (peripheral) (e.g., radius, wrist, heel) 77082 vertebral fracture assessment 77083 Radiographic absorptiometry (e.g., photodensitometry, radiogrammetry), one or more sites Nuclear Medicine Endocrine System 78000 Thyroid uptake; single determination 78001 multiple determinations 78003 stimulation, suppression or discharge (not including initial uptake studies) 78006 Thyroid imaging, with uptake; single determination 78007 multiple determinations 78010 Thyroid imaging; only 78011 with vascular flow 78015 Thyroid carcinoma metastases imaging; limited area (e.g., neck and chest only) 78016 with additional studies (e.g., urinary recovery) 78018 whole body 78020 Thyroid carcinoma metastases uptake (List separately in addition to code for primary procedure.) 78070 Parathyroid imaging 78075 Adrenal imaging, cortex and/or medulla 78099 Unlisted endocrine procedure, diagnostic nuclear medicine (IC) Hematopoietic, Reticuloendothelial and Lymphatic System 78102 Bone marrow imaging; limited area 78103 multiple areas 78104 whole body 78110 Plasma volume, radiopharmaceutical volume-dilution technique (separate procedure); single sampling 78111 multiple samplings 78120 Red cell volume determination (separate procedure); single sampling 78121 multiple samplings 78122 Whole blood volume determination, including separate measurement of plasma volume and red cell volume (radiopharmaceutical volume-dilution technique) 78130 Red cell survival study; 78135 differential organ/tissue kinetics (e.g., splenic and/or hepatic sequestration) 78140 Labeled red cell sequestration, differential organ/tissue (e.g., splenic and/or hepatic) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. 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Service Code Service Description 78185 Spleen imaging only, with or without vascular flow 78190 Kinetics, study of platelet survival, with or without differential organ/tissue localization 78191 Platelet survival study 78195 Lymphatics and lymph nodes imaging 78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine (IC) Gastrointestinal System 78201 Liver imaging; static only 78202 with vascular flow 78205 Liver imaging (SPECT); 78206 with vascular flow 78215 Liver and spleen imaging; static only 78216 with vascular flow 78220 Liver function study with hepatobiliary agents, with serial images 78223 Hepatobiliary ductal system imaging, including gallbladder, with or without pharmacologic intervention, with or without quantitative measurement of gallbladder function 78230 Salivary gland imaging; 78231 with serial images 78232 Salivary gland function study 78258 Esophageal motility 78261 Gastric mucosa imaging 78262 Gastroesophageal reflux study 78264 Gastric emptying study 78270 Vitamin B-12 absorption study (e.g., Schilling test); without intrinsic factor 78271 with intrinsic factor 78272 Vitamin B-12 absorption studies combined, with and without intrinsic factor 78278 Acute gastrointestinal blood loss imaging 78282 Gastrointestinal protein loss (IC) 78290 Intestine imaging (e.g., ectopic gastric mucosa, Meckel's localization, volvulus) 78291 Peritoneal-venous shunt patency test (e.g., for LeVeen, Denver shunt) 78299 Unlisted gastrointestinal procedure, diagnostic nuclear medicine (IC) Musculoskeletal System 78300 Bone and/or joint imaging; limited area 78305 multiple areas 78306 whole body 78315 three phase study 78320 tomographic (SPECT) 78350 Bone density (bone mineral content) study, one or more sites; single photon absorptiometry Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. 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Service Code Service Description 78399 Unlisted musculoskeletal procedure, diagnostic nuclear medicine (IC) Cardiovascular System 78414 Determination of central c-v hemodynamics (non-imaging) (e.g., ejection fraction with probe technique) with or without pharmacologic intervention or exercise, single or multiple determinations (IC) 78428 Cardiac shunt detection 78445 Non-cardiac vascular flow imaging (i.e., angiography, venography) 78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) 78452 multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection 78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic) 78454 multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection 78456 Acute venous thrombosis imaging, peptide 78457 Venous thrombosis imaging, venogram; unilateral 78458 bilateral 78459 Myocardial imaging, positron emission tomography (PET), metabolic evaluation 78466 Myocardial imaging, infarct avid, planar; qualitative or quantitative 78468 with ejection fraction by first pass technique 78469 tomographic SPECT with or without quantification 78472 Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing 78473 multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification 78481 Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification 78483 multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification 78491 Myocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress 78492 multiple studies at rest and/or stress Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. 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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 6-27 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 604 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 6-28 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 604 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 6-29 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 604 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 6-30 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 604 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 6-31 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 604 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 (e.g., 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 6-32 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 604 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 6-33 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 605 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, unattended, simultaneous recording of heart rate, oxygen saturation, respiratory airflow, and respiratory effort (e.g., thoracoabdominal movement) 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-34 Independent Diagnostic Testing Facility Manual Transmittal Letter IDTF-8 Date 01/01/10 This page is reserved.