Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid www.mass.gov/masshealth MassHealth Transmittal Letter AOH-26 December 2011 TO: Acute Outpatient Hospitals Participating in MassHealth FROM: Julian J. Harris, M.D., Medicaid Director RE: Acute Outpatient Hospital Manual (2011 HCPCS Updates) This letter transmits revisions to the laboratory service codes in the Acute Outpatient Hospital Manual. The Centers for Medicare & Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) codes for 2011. The revised Subchapter 6 is effective for dates of service on or after December 1, 2011. For dates of service on or after December 1, 2011, you must use the new codes in order to obtain reimbursement. Drug Screen Service Codes Effective December 1, 2011, MassHealth will no longer pay for drug screen Service Codes 80100 (Drug screen, qualitative; multiple drug classes chromatographic method, each procedure) and 80101 (Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class). Drug screen services should now be reported using Service Code G0431 (Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter) or G0434 (Drug screen, other than chromatographic; any number of drug classes, by CLIA waived test or moderate complexity test, per patient encounter). G0431 and G0434 are bundled codes that pay a single fee for the drug screen services being provided at the patient encounter regardless of the number of drug classes being tested. Providers should not routinely bill for the quantification of drug classes (e.g., chemistry section 82000-84999 or therapeutic drug assay section 80150- 80299) being tested as part of the drug screen service. Providers should bill only for the quantification of drug classes being tested as part of a drug screen service or a confirmatory drug test if there is a positive screen for one or more drug classes being tested. Standing Order Requests Providers are reminded that MassHealth issued revised regulations about standing order requests made to independent clinical laboratories via Transmittal Letter LAB-35, issued in March 2010. These amendments pertain to standing order requests, information required for written requests for laboratory services, record keeping requirements, conditions relating to authorized prescribers, and EPSDT services. As part of these changes, MassHealth established that standing order requests made by authorized prescribers to a MassHealth independent clinical lab to perform most services must not exceed 180 days and for substance abuse testing must not exceed 30 days. Please review all the updated regulations transmitted via Transmittal Letter LAB-35. MassHealth Transmittal Letter AOH-26 December 2011 Page 2 Fee Schedule If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy regulations at no cost at www.mass.gov/dhcfp. You may also purchase a paper copy of Division of Health Care Finance and Policy regulations from either the Massachusetts State Bookstore or from the Division of Health Care Finance and Policy (see addresses and telephone numbers below). You must contact them first to find out the price of the paper copy of the publication. The regulation title for laboratory services is 114.3 CMR 20.00: Clinical Laboratory Services. Massachusetts State Bookstore State House, Room 116 Boston, MA 02133 Telephone: 617-727-2834 www.mass.gov/sec/spr Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100 www.mass.gov/dhcfp MassHealth Web Site This transmittal letter and attached pages are available on the MassHealth Web site at www.mass.gov/masshealth. Questions If you have any questions about 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.) Acute Outpatient Hospital Manual Pages vi and 6-1 through 6-12 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Acute Outpatient Hospital Manual Pages vi and 6-1 through 6-14 — transmitted by Transmittal Letter AOH-25 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title Table of Contents Page vi Transmittal Letter AOH-26 Date 12/01/11 6. Service Codes Introduction.................................................................... ............................................................. 6-1 Nonpayable CPT Codes ................................................................................ .............................. 6-1 Payable Level II HCPCS Codes........................................................................... ........................ 6-11 Modifiers ................................................................................ .................................................... 6-12 Appendix A. Directory ................................................................................ ....................................... A-1 Appendix B. Enrollment Centers......................................................................... ............................... B-1 Appendix C. Third-Party-Liability Codes ................................................................................ .......... C-1 Appendix D. Utilization Management Program......................................................................... ........ D-1 Appendix E. Admission Guidelines ................................................................................ ................... E-1 Appendix F. Revenue Codes ................................................................................ .............................. F-1 Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity Schedules.............. W-1 Appendix X. Family Assistance Copayments and Deductibles ......................................................... X-1 Appendix Y. EVS Codes/Messages ................................................................................ ................... Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes................................................................... Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-1 Acute Outpatient Hospital Manual Transmittal Letter AOH-26 Date 12/01/11 601 Introduction MassHealth providers must refer to the official list of HCPCS codes and descriptions posted on the Centers for Medicare & Medicaid Services Web site at www.cms.gov/medicare/hcpcs when billing for services provided to MassHealth members. For a list of billable revenue codes, please refer to Appendix F of the Acute Outpatient Hospital Manual. CPT Codes MassHealth pays for services billed using all medicine, radiology, laboratory, surgery, and anesthesia CPT codes in effect at the time of service, except for those codes listed in Section 602 of this subchapter, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. Level II HCPCS Codes MassHealth pays for services billed using only those Level II HCPCS codes listed in Section 603 of this subchapter that are in effect at the time of service, subject to all conditions and limitations described in MassHealth regulations at 130 CMR 410.000 and 450.000, and in the most current Acute Hospital Request for Application. EPSDT An acute outpatient hospital provider may request prior authorization (PA) for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Acute Outpatient Hospital Manual. 602 Nonpayable CPT Codes MassHealth does not ordinarily pay for services billed under the following codes and code ranges. 0001F 0052T 0101T 0142T 0051T 0005F 0053T 0102T 0143T 0052T 0012F 0071T 0103T 0155T 0053T 0014F 0072T 0104T 0156T 0071T 0015F 0073T 0105T 0157T 0072T 4002F 0075T 0106T 0158T 0073T 4006F 0076T 0107T 0159T 0075T 4009F 0078T 0108T 0160T 0076T 4011F 0079T 0109T 0161T 0078T 0016T 0080T 0110T 0163T 0079T 0017T 0081T 0111T 0016T 0080T 0019T 0085T 0123T 0017T 0081T 0030T 0092T 0124T 0019T 0085T 0042T 0095T 0126T 0030T 0092T 0048T 0098T 0130T 0042T 0095T 0050T 0099T 0140T 0048T 0098T 0051T 0100T 0141T 0050T 0099T Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-2 Transmittal Letter AOH-26 Date 12/01/11 602 Nonpayable CPT Codes (cont.) 0100T 0187T 15829 21123 21616 0101T 0188T 15847 21125 21620 0102T 0189T 15876 21127 21627 0103T 0190T 15877 21141 21630 0104T 0191T 15878 21142 21632 0105T 0192T 15879 21143 21705 0106T 0193T 16036 21145 21740 0107T 0195T 17340 21146 21750 0108T 0196T 17360 21147 21810 0109T 0197T 17380 21151 21825 0110T 0198T 19271 21154 22010 0111T 0199T 19272 21155 22015 0123T 0200T 19305 21159 22110 0124T 0201T 19306 21160 22112 0126T 0202T 19316 21172 22114 0130T 0203T 19324 21179 22116 0140T 0204T 19325 21180 22206 0141T 0205T 19355 21182 22207 0142T 0206T 19361 21183 22208 0143T 0207T 19364 21184 22210 0155T 00100 19367 21188 22212 0156T through 19368 21193 22214 0157T 01999 19369 21194 22216 0158T 10040 19396 21196 22220 0159T 11004 20660 21245 22224 0160T 11005 20661 21246 22226 0161T 11006 20664 21247 22318 0163T 11008 20802 21248 22319 0164T 11922 20805 21249 22325 0165T 11950 20808 21255 22326 0166T 11951 20816 21256 22328 0167T 11952 20824 21268 22526 0168T 11954 20827 21343 22527 0169T 15756 20838 21344 22532 0171T 15757 20930 21346 22533 0172T 15758 20931 21347 22534 0173T 15781 20936 21348 22548 0174T 15782 20937 21366 22554 0175T 15783 20938 21386 22556 0176T 15786 20955 21387 22558 0177T 15787 20956 21395 22585 0178T 15788 20957 21422 22590 0179T 15789 20962 21423 22595 0180T 15792 20969 21431 22600 0181T 15793 20970 21432 22610 0182T 15819 20985 21433 22630 0183T 15824 21045 21435 22632 0184T 15825 21120 21436 22800 0185T 15826 21121 21510 22802 0186T 15828 21122 21615 22804 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-3 Transmittal Letter AOH-26 Date 12/01/11 602 Nonpayable CPT Codes (cont.) 22808 26992 27236 27557 31800 22810 27005 27240 27558 31805 22812 27025 27244 27580 32035 22818 27030 27245 27590 32036 22819 27036 27248 27591 32095 22830 27054 27253 27592 32100 22840 27070 27254 27596 32110 22841 27071 27258 27598 32120 22842 27075 27259 27645 32124 22843 27076 27268 27646 32140 22844 27077 27269 27702 32141 22845 27078 27280 27703 32150 22846 27079 27282 27712 32151 22847 27090 27284 27715 32160 22848 27091 27286 27724 32200 22849 27120 27290 27725 32225 22850 27122 27295 27727 32310 22852 27125 27303 27880 32320 22855 27130 27365 27881 32402 22856 27132 27445 27882 32440 22857 27134 27447 27886 32442 22861 27137 27448 27888 32445 22862 27138 27450 28800 32480 22864 27140 27454 28805 32482 22865 27146 27455 31225 32484 23200 27147 27457 31230 32486 23210 27151 27465 31290 32488 23220 27156 27466 31291 32491 23332 27158 27468 31360 32500 23472 27161 27470 31365 32501 23900 27165 27472 31367 32503 23920 27170 27477 31368 32504 24900 27175 27479 31370 32540 24920 27176 27485 31375 32650 24930 27177 27486 31380 32651 24931 27178 27487 31382 32652 24940 27179 27488 31390 32653 25900 27181 27495 31395 32654 25905 27185 27506 31584 32655 25909 27187 27507 31587 32656 25915 27215 27511 31725 32657 25920 27217 27513 31760 32658 25924 27218 27514 31766 32659 25927 27222 27519 31770 32660 26551 27226 27535 31775 32661 26553 27227 27536 31780 32662 26554 27228 27540 31781 32663 26556 27232 27556 31786 32664 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-4 Transmittal Letter AOH-26 Date 12/01/11 602 Nonpayable CPT Codes (cont.) 32665 33320 33511 33720 33875 32800 33321 33512 33722 33877 32810 33322 33513 33724 33880 32815 33330 33514 33726 33881 32820 33332 33516 33730 33883 32850 33335 33517 33732 33884 32851 33400 33518 33735 33886 32852 33401 33519 33736 33889 32853 33403 33521 33737 33891 32854 33404 33522 33750 33910 32855 33405 33523 33755 33915 32856 33406 33530 33762 33916 32900 33410 33533 33764 33917 32905 33411 33534 33766 33920 32906 33412 33535 33767 33922 32940 33413 33536 33768 33924 32997 33414 33542 33770 33925 33015 33415 33545 33771 33926 33020 33416 33548 33774 33930 33025 33417 33572 33775 33933 33030 33420 33600 33776 33935 33031 33422 33602 33777 33940 33050 33425 33606 33778 33944 33120 33426 33608 33779 33945 33130 33427 33610 33780 33960 33140 33430 33611 33781 33961 33141 33460 33612 33782 33967 33202 33463 33615 33783 33968 33203 33464 33617 33786 33970 33236 33465 33619 33788 33971 33237 33468 33641 33800 33973 33238 33470 33645 33802 33974 33243 33471 33647 33803 33975 33250 33472 33660 33813 33976 33251 33474 33665 33814 33977 33254 33475 33670 33820 33978 33255 33476 33675 33822 33979 33256 33478 33676 33824 33980 33257 33496 33677 33840 33981 33258 33500 33681 33845 33982 33259 33501 33684 33851 33983 33261 33502 33688 33852 34001 33265 33503 33690 33853 34051 33266 33504 33692 33860 34151 33300 33505 33694 33861 34401 33305 33506 33697 33863 34451 33310 33507 33702 33864 34502 33315 33510 33710 33870 34800 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-5 Transmittal Letter AOH-26 Date 12/01/11 602 Nonpayable CPT Codes (cont.) 34802 35271 35540 35701 38780 34803 35276 35548 35721 39000 34804 35281 35549 35741 39010 34805 35301 35551 35800 39200 34806 35302 35556 35820 39220 34808 35303 35558 35840 39499 34812 35304 35560 35870 39501 34813 35305 35563 35901 39502 34820 35306 35565 35905 39503 34825 35311 35566 35907 39520 34826 35331 35571 36415 39530 34830 35341 35583 36416 39531 34831 35351 35585 36468 39540 34832 35355 35587 36469 39541 34833 35361 35600 36591 39545 34834 35363 35601 36592 39560 34900 35371 35606 36598 39561 35001 35372 35612 36660 39599 35002 35390 35616 36822 41130 35005 35400 35621 36823 41135 35013 35450 35623 37140 41140 35021 35452 35626 37145 41145 35022 35454 35631 37160 41150 35045 35456 35636 37180 41153 35081 35480 35637 37181 41155 35082 35481 35638 37182 41870 35091 35482 35642 37215 41872 35092 35483 35645 37616 42426 35102 35501 35646 37617 42845 35103 35506 35647 37618 42894 35111 35508 35650 37660 42953 35112 35509 35651 37765 42961 35121 35510 35654 37766 42971 35122 35511 35656 37788 43045 35131 35512 35661 38100 43100 35132 35516 35663 38101 43101 35141 35518 35665 38102 43107 35142 35521 35666 38115 43108 35151 35522 35671 38380 43112 35152 35523 35681 38381 43113 35182 35525 35682 38382 43116 35189 35526 35683 38562 43117 35211 35531 35691 38564 43118 35216 35533 35693 38724 43121 35221 35536 35694 38746 43122 35241 35537 35695 38747 43123 35246 35538 35697 38765 43124 35251 35539 35700 38770 43135 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-6 Transmittal Letter AOH-26 Date 12/01/11 602 Nonpayable CPT Codes (cont.) 43300 43770 44140 44721 47010 43305 43771 44141 44800 47015 43310 43772 44143 44820 47100 43312 43773 44144 44850 47120 43313 43774 44145 44899 47122 43314 43775 44146 44900 47125 43320 43800 44147 44950 47130 43324 43810 44150 44955 47133 43325 43820 44151 44960 47135 43326 43825 44155 45110 47136 43330 43832 44156 45111 47140 43331 43840 44157 45112 47141 43340 43842 44158 45113 47142 43341 43843 44160 45114 47143 43350 43845 44187 45116 47144 43351 43846 44188 45119 47145 43352 43847 44202 45120 47146 43360 43848 44203 45121 47147 43361 43850 44204 45123 47300 43400 43855 44205 45126 47350 43401 43860 44210 45130 47360 43405 43865 44211 45135 47361 43410 43880 44212 45136 47362 43415 43881 44227 45395 47380 43420 43882 44300 45397 47381 43425 44005 44310 45400 47400 43460 44010 44314 45402 47420 43496 44015 44316 45540 47425 43500 44020 44320 45550 47460 43501 44021 44322 45562 47480 43502 44025 44345 45563 47550 43520 44050 44346 45800 47570 43605 44055 44602 45805 47600 43610 44110 44603 45820 47605 43611 44111 44604 45825 47610 43620 44120 44605 46705 47612 43621 44121 44615 46710 47620 43622 44125 44620 46712 47700 43631 44126 44625 46715 47701 43632 44127 44626 46716 47711 43633 44128 44640 46730 47712 43634 44130 44650 46735 47715 43635 44132 44660 46740 47720 43640 44133 44661 46742 47721 43641 44135 44680 46744 47740 43644 44136 44700 46746 47741 43645 44137 44715 46748 47760 43752 44139 44720 46751 47765 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-7 Transmittal Letter AOH-26 Date 12/01/11 602 Nonpayable CPT Codes (cont.) 47780 49428 50526 51580 56631 47785 49605 50540 51585 56632 48000 49606 50545 51590 56633 47801 49610 50546 51595 56634 47802 49611 50547 51596 56637 47900 49900 50548 51597 56640 48000 49904 50600 51701 57110 48001 49905 50605 51702 57111 48020 49906 50610 51800 57112 48100 50010 50620 51820 57270 48105 50040 50630 51840 57280 48120 50045 50650 51841 57296 48140 50060 50660 51845 57305 48145 50065 50700 51860 57307 48146 50070 50715 51865 57308 48148 50075 50722 51900 57311 48150 50100 50725 51920 57531 48152 50120 50727 51925 57540 48153 50125 50728 51940 57545 48154 50130 50740 51960 58140 48155 50135 50750 51980 58146 48160 50205 50760 53415 58150 48400 50220 50770 53448 58152 48500 50225 50780 54125 58180 48510 50230 50782 54135 58200 48520 50234 50783 54332 58210 48540 50236 50785 54336 58240 48545 50240 50800 54390 58267 48547 50250 50810 54411 58275 48548 50280 50815 54417 58280 48551 50290 50820 54430 58285 48552 50300 50825 54535 58293 48554 50320 50830 54650 58400 48556 50323 50840 55605 58410 49000 50325 50845 55650 58520 49002 50327 50860 55801 58540 49010 50328 50900 55810 58548 49020 50329 50920 55812 58605 49040 50340 50930 55815 58611 49060 50360 50940 55821 58700 49062 50365 51060 55831 58720 49203 50370 51525 55840 58740 49204 50380 51530 55842 58750 49205 50400 51550 55845 58752 49215 50405 51555 55862 58760 49220 50500 51565 55865 58822 49255 50520 51570 55866 58825 49425 50525 51575 56630 58940 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-8 Transmittal Letter AOH-26 Date 12/01/11 602 Nonpayable CPT Codes (cont.) 58943 61120 61533 61606 62115 58950 61140 61534 61607 62116 58951 61150 61535 61608 62117 58952 61151 61536 61609 62120 58953 61154 61536 61610 62121 58954 61156 61537 61611 62140 58956 61210 61538 61612 62141 58957 61250 61539 61613 62142 58958 61253 61540 61615 62143 58960 61304 61541 61616 62145 58970 61305 61542 61618 62146 58974 61312 61543 61619 62147 58976 61313 61544 61624 62148 59070 61314 61545 61630 62161 59072 61315 61546 61635 62162 59120 61316 61548 61640 62163 59121 61320 61550 61641 62164 59130 61321 61552 61642 62165 59135 61322 61556 61680 62180 59136 61323 61557 61682 62190 59140 61332 61558 61684 62192 59325 61333 61559 61686 62200 59350 61340 61563 61690 62201 59412 61343 61564 61692 62220 59514 61345 61566 61697 62223 59525 61440 61567 61698 62256 59620 61450 61570 61700 62258 59630 61458 61571 61702 62287 59850 61460 61575 61703 63043 59851 61470 61576 61705 63044 59852 61480 61580 61708 63050 59855 61490 61581 61710 63051 59856 61500 61582 61711 63076 59857 61501 61583 61735 63077 59897 61510 61584 61750 63078 60254 61512 61585 61751 63081 60270 61514 61586 61760 63082 60505 61516 61590 61850 63085 60521 61517 61591 61860 63086 60522 61518 61591 61863 63087 60540 61519 61592 61864 63088 60545 61520 61595 61867 63090 60600 61521 61596 61868 63091 60605 61522 61597 61870 63101 60650 61524 61598 61875 63102 61105 61526 61600 62005 63103 61107 61530 61601 62010 63170 61108 61531 61605 62100 63172 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-9 Transmittal Letter AOH-26 Date 12/01/11 602 Nonpayable CPT Codes (cont.) 63173 63704 80100 88749 90644 63180 63706 80101 89250 90645 63182 63707 80104 89251 90646 63185 63709 80502 89253 90647 63190 63710 82075 89254 90648 63191 63740 82962 89255 90654 63194 63752 83987 89257 90665 63195 64752 84431 89258 90669 63196 64755 86079 89259 90670 63197 64760 86305 89260 90696 63198 64809 86352 89261 90698 63199 64818 86780 89264 90700 63200 64866 86825 89268 90701 63250 64868 86826 89272 90702 63251 65273 86890 89280 90708 63252 65760 86891 89281 90710 63265 65765 86910 89290 90712 63266 65767 86911 89291 90718 63267 65771 86927 89300 90720 63268 65780 86930 89310 90721 63270 65781 86931 89320 90723 63271 65782 86932 89321 90743 63272 69090 86960 89322 90744 63273 69155 86985 89325 90748 63275 69535 87150 89329 90816 63276 69554 87153 89330 90817 63277 69950 87903 89331 90818 63278 71552 87904 89335 90819 63280 72159 88000 89342 90821 63281 72198 88005 89343 90822 63282 73225 88007 89344 90823 63283 74263 88012 89346 90824 63285 75571 88014 89352 90826 63286 75900 88016 89353 90827 63287 75952 88020 89354 90828 63290 75953 88025 89356 90829 63295 75954 88027 90281 90845 63300 75956 88028 90283 90865 63301 75957 88029 90284 90875 63302 75958 88036 90287 90876 63303 75959 88037 90379 90880 63304 76140 88040 90384 90885 63305 76496 88045 90386 90889 63306 76497 88099 90389 90901 63307 76498 88125 90396 90911 63308 78267 88333 90586 90940 63700 78268 88334 90633 90989 63702 78351 88738 90634 90993 Commonwealth of Massachusetts MassHealth Provider Manual Series Acute Outpatient Hospital Manual Subchapter Number and Title 6. Service Codes Page 6-10 Transmittal Letter AOH-26 Date 12/01/11 602 Nonpayable CPT Codes (cont.) 90997 95052 98960 99467 99377 90999 95120 98961 99471 99378 91132 95125 98962 99472 99379 91133 95130 98966 99468 99380 92314 95131 98967 99469 99401 92315 95132 98968 99478 99402 92316 95133 98969 99479 99403 92317 95134 99000 99480 99404 92325 95824 99001 99304 99406 92352 95965 99002 99305 99408 92353 95966 99024 99306 99409 92354 95967 99026 99307 99411 92355 95992 99027 99308 99412 92358 96000 99050 99309 99420 92371 96001 99051 99310 99429 92531 96002 99053 99315 99441 92532 96003 99056 99316 99442 92533 96004 99058 99318 99443 92534 96150 99060 99324 99444 92540 96151 99071 99325 99450 92548 96152 99075 99326 99455 92550 96153 99078 99327 99456 92559 96154 99080 99328 99477 92560 96155 99082 99334 99499 92561 96376 99090 99335 99500 92562 96567 99091 99336 99501 92564 96902 99100 99337 99502 92570 96904 99116 99339 99503 92630 97005 99135 99340 99504 92633 97006 99140 99341 99505 92970 97537 99143 99342 99506 92971 97545 99144 99343 99507 92975 97546 99148 99344 99509 92992 97597 99149 99345 99510 92993 97598 99150 99347 99511 93660 97602 99172 99348 99512 93770 97605 99190 99349 99600 93786 97606 99191 99350 99601 94005 97755 99192 99354 99602 94011 97810 99199 99355 99605 94012 97811 99251 99356 99606 94013 97813 99252 99357 99607 94015 97814 99253 99358 A4641 94774 98940 99254 99359 A9500 94775 98941 99255 99360 A9502 94776 98942 99288 99374 A9503 94777 98943 99466 99375 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-11 Acute Outpatient Hospital Manual Transmittal Letter AOH-26 Date 12/01/11 603 Payable Level II HCPCS Codes The following Level II HCPCS codes represent services that are covered by MassHealth when provided by AOHs, including hospital-licensed health centers (HLHCs) and other satellite clinics. A9505 J0833 J1745 J2793 J7324 A9512 J0834 J1750 J2794 J7325 A9537 J0881 J1786 J2796 J7335 G0105 J0882 J1790 J2820 J7599 G0108 J0885 J1800 J2910 J7608 G0109 J0886 J1826 J2916 J7614 G0121 J0900 J1885 J2920 J7620 G0202 J1020 J1890 J2930 J7626 G0204 J1030 J1950 J2940 J7633 G0206 J1040 J1956 J2941 J7639 G0270 J1055 J1990 J3010 J7644 G0271 J1056 J2060 J3030 J7669 G0431 J1060 J2150 J3095 J7676 G0434 J1070 J2175 J3110 J7682 J0129 J1080 J2248 J3120 J7686 J0135 J1094 J2250 J3130 J7699 J0171 J1100 J2270 J3230 J7799 J0207 J1160 J2271 J3240 J8562 J0215 J1170 J2275 J3243 J9000 J0256 J1200 J2300 J3250 J9001 J0290 J1260 J2310 J3262 J9025 J0295 J1290 J2315 J3301 J9031 J0348 J1300 J2323 J3302 J9035 J0456 J1320 J2355 J3303 J9040 J0461 J1438 J2357 J3357 J9041 J0475 J1440 J2358 J3360 J9045 J0476 J1441 J2405 J3385 J9055 J0558 J1460 J2430 J3396 J9060 J0561 J1559 J2440 J3410 J9130 J0585 J1561 J2469 J3411 J9155 J0586 J1562 J2503 J3430 J9171 J0587 J1566 J2505 J3487 J9178 J0592 J1569 J2510 J3490 J9181 J0597 J1571 J2515 J3590 J9190 J0598 J1580 J2550 J7030 J9201 J0638 J1599 J2560 J7060 J9202 J0640 J1626 J2562 J7070 J9206 J0690 J1630 J2675 J7302 J9212 J0694 J1650 J2680 J7303 J9213 J0696 J1655 J2760 J7304 J9214 J0697 J1670 J2778 J7307 J9215 J0702 J1710 J2785 J7309 J9216 J0718 J1720 J2788 J7312 J9217 J0775 J1740 J2790 J7321 J9218 J0780 J1743 J2792 J7323 J9219 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes Page 6-12 Acute Outpatient Hospital Manual Transmittal Letter AOH-26 Date 12/01/11 603 Payable Level II HCPCS Codes (cont.) J9250 J9307 L8614 Q4100 Q4112 J9260 J9310 L8615 Q4101 Q4113 J9261 J9315 L8616 Q4102 Q4114 J9263 J9340 L8617 Q4103 Q4115 J9264 J9351 L8618 Q4104 S0023 J9265 J9355 L8619 Q4105 S0028 J9266 J9360 L8690 Q4106 S0077 J9293 J9370 L8691 Q4107 S0302 J9300 J9390 Q0081 Q4108 S2083 J9302 J9395 Q0083 Q4110 J9305 J9999 Q0084 Q4111 604 Modifiers Modifiers for Behavioral Health Screening The administration and scoring of standardized behavioral health screening tools selected from the approved menu of tools found in Appendix W of your MassHealth provider manual is covered for members (except MassHealth Limited) from birth to 21 years of age. Service Code 96110 must be accompanied by one of the modifiers listed below to indicate whether a behavioral health need was identified. “Behavioral health need identified” means the provider administering the screening tool, in her or his professional judgment, identified a child with a potential behavioral health services need. U1 Completed behavioral-health screening using a standardized behavioral-health screening tool selected from the approved menu of tools found in Appendix W of your MassHealth provider manual with no behavioral health need identified. U2 Completed behavioral-health screening using a standardized behavioral-health screening tool selected from the approved menu of tools found in Appendix W of your MassHealth provider manual and behavioral-health need identified. Modifiers for Tobacco-Cessation Services The following modifiers are used in combination with Service Code 99407 to report tobacco-cessation counseling. Service Code 99407 (Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes) may also be billed without a modifier to report an individual smoking and tobacco use cessation counseling visit of at least 30 minutes. HQ Group counseling, at least 60-90 minutes TF Intermediate level of care, at least 45 minutes Modifier for Child and Adolescent Needs and Strengths (CANS) HA Service code 90801 must be accompanied by this modifier to indicate that the Child and Adolescent Needs and Strengths is included in the assessment.