Commonwealth of Massachusetts 
Executive Office of Health and Human Services 
Office of Medicaid 

www.mass.gov/masshealth 


MassHealth 
Transmittal Letter IDTF-12 
March 2013 

TO: Independent Diagnostic Testing Facilities Participating in MassHealth 
FROM: Julian J. Harris, M.D., Medicaid Director 

RE: Independent Diagnostic Testing Facility Manual (2013 HCPCS) 

This letter transmits revisions to the service codes in the Independent 
Diagnostic Testing Facility Manual. The Centers for Medicare & Medicaid Services 
(CMS) has revised the Healthcare Common Procedure Coding System (HCPCS) codes 
for 2013. 

The revised Subchapter 6 is effective for dates of service on or after January 
1, 2013. For dates of service on or after January 1, 2013, you must use the new 
codes. 

MassHealth providers must refer to the American Medical Association’s Current 
Procedural Terminology (CPT) or the Health Care Procedure Code Set (HCPCS) Level 
II code book for the service descriptions of the codes listed in Subchapter 6 
when billing for services provided to MassHealth members. 

If you wish to obtain a fee schedule, you may download the regulations at no 
cost at www.mass.gov/eohhs/gov/laws-regs/hhs/regs.html. The regulation titles 
for IDTF services are 

114.3 CMR 17.00: Medicine Services and 114.3 CMR 18.00: Radiology Services. 

MassHealth Website 

This transmittal letter and attached pages are available on the MassHealth 
website at www.mass.gov/masshealth. 




MassHealth 
Transmittal Letter IDTF-12 
March 2013 
Page 2 

Questions 

If you have any questions about this transmittal letter, please contact 
MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to 
providersupport@mahealth.net, or fax your inquiry to 617-988-8974. 

NEW MATERIAL 
(The pages listed here contain new or revised language.) 
Independent Diagnostic Testing Facility Manual 
Pages vi and 6-1 through 6-6 
OBSOLETE MATERIAL 
(The pages listed here are no longer in effect.) 
Independent Diagnostic Testing Facility Manual 
Pages 6-1 through 6-4 — transmitted by Transmittal Letter IDTF-10 
Pages vi and 6-5 and 6-6 — transmitted by Transmittal Letter IDTF-11 




Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
Independent Diagnostic Testing 
Facility Manual 
Subchapter Number and Title 
Table of Contents 
Page 
vi 
Transmittal Letter 
IDTF-12 
Date 
01/01/13 

6. Service Codes and Descriptions 

 Introduction 
................................................................................
................................................. 6-1 
Portable X Ray: Radiology Service Codes 
................................................................................
. 6-1 
Freestanding Magnetic Resonance Imaging (FMRI): Radiology Service Codes 
......................... 6-2 
Diagnostic Imaging Centers: Radiology Service Codes …………………………………………. 6-2 
Mobile Mammography Van: Radiology Service Codes 
............................................................. 6-5 
Sleep Centers: Radiology Service Codes 
................................................................................
.... 6-5 
Modifiers 
................................................................................
................................................. 6-5 


Appendix A. Directory 
................................................................................
..................................... A-1 
Appendix B. Enrollment Centers 
................................................................................
...................... B-1 
Appendix C. Third-Party-Liability Codes 
................................................................................
........ C-1 
Appendix U. DPH-Designated Serious Reportable Events That Are Not Provider 
Preventable Conditions 
................................................................................
............... U-1 
Appendix V. MassHealth Billing Instructions for Provider Preventable Conditions 
....................... V-1 
Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity 
Schedules............... W-1 
Appendix X. Family Assistance Copayments and Deductibles 
........................................................ X-1 
Appendix Y. EVS Codes/Messages 
................................................................................
................. Y-1 
Appendix Z. EPSDT/PPHSD Screening Services 
Codes.................................................................. Z-1 





Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
Independent Diagnostic Testing Facility 
Manual 
Subchapter Number and Title 
6. Service Codes 
Page 
6-1 
Transmittal Letter 
IDTF-12 
Date 
01/01/13 

601 Introduction 

MassHealth pays for the services represented by the codes listed in Subchapter 6 
in effect at the time of service, subject to all conditions and limitations in 
MassHealth regulations at 130 CMR 431.000 and 450.000. MassHealth providers must 
refer to the American Medical Association’s Current Procedural Terminology (CPT) 
or the Health Care Procedure Code Set (HCPCS) Level II code book for the service 
code and service descriptions when billing for services provided to MassHealth 
members. 

An independent diagnostic testing facility (IDTF) may request prior 
authorization for any medically necessary service reimbursable under the federal 
Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 
U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger 
than 21 years of age, even if it is not designated as covered or payable in 
Subchapter 6 of the Independent Diagnostic Testing Facility Manual. 
“IC” indicates that the claim requires individual consideration. See 130 CMR 
431.406 for more information. 
“PA” indicates that the service requires prior authorization. See 130 CMR 
450.303 for more information. 

602 Portable X Ray: Radiology Service Codes 

Service code Service code Service code Service code Service code 

70030 71015 72190 73510 74245 
70100 71020 72200 73520 74246 
70110 71021 72202 73525 74247 
70120 71022 72220 73530 74249 
70130 71023 72240 73540 74250 
70134 71030 72255 73550 74251 
70140 71034 72265 73560 74260 
70150 71035 72270 73562 74270 
70160 71100 72275 73564 74280 
70190 71101 72285 73565 74290 
70200 71110 72295 73580 74291 
70210 71111 73000 73590 74300 
70220 71120 73010 73592 74301 
70240 71130 73020 73600 74305 
70250 72010 73030 73610 74320 
70260 72020 73040 73615 
70300 72040 73050 73620 
70310 72050 73060 73630 
70320 72052 73070 73650 
70328 72069 73080 73660 
70330 72070 73085 74000 
70332 72072 73090 74010 
70355 72074 73092 74020 
70360 72080 73100 74022 
70370 72090 73110 74210 
70371 72100 73115 74220 
70373 72110 73120 74230 
70380 72114 73130 74235 
70390 72120 73140 74240 
71010 72170 73500 74241 




Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
Subchapter Number and Title 
6. Service Codes 
Page 
6-2 
Independent Diagnostic Testing Facility 
Manual 
Transmittal Letter 
IDTF-12 
Date 
01/01/13 

603 Freestanding Magnetic Resonance Imaging (FRMI): Radiology Service Codes 

Service Code Service Code Service Code 

604 Diagnostic Imaging Centers: Radiology Service Codes 

Service Code

70336 (PA) 70558 72195 
70540 70559 72196 
70542 71550 72197 
70543 71551 73218 
70544 71555 73219 
70545 72141 73220 
70546 72142 73221 
70547 72146 73222 
70548 72147 73223 
70549 72148 73718 
70551 72149 73719 
70552 72156 73720 
70553 72157 73721 
70557 72158 73722 

604 Diagnostic Imaging Centers: Radiology Service Codes 

Service Code

59025 
70030 
70100 
70110 
70120 
70130 
70134 
70140 
70150 
70160 
70190 
70200 
70210 
70220 
70240 
70250 
70260 
70300 
70310 
70320 
70328 
70330 
70332 
70336 
70350 
70355 
70360 

Service Code

70370 
70371 
70373 
70380 
70390 
70450 
70460 
70470 
70480 
70481 
70482 
70486 
70487 
70488 
70490 
70491 
70492 
70540 
70542 
70543 
70544 
70545 
70546 
70547 
70548 
70549 
70551 

Service Code 

70552 
70553 
70554 
70555 
71010 
71015 
71020 
71021 
71022 
71023 
71030 
71034 
71035 
71100 
71101 
71110 
71111 
71120 
71130 
71550 
71551 
71555 
72010 
72020 
72040 
72050 
72052 

Service Code

73723 
73725 
74181 
74182 
74183 
74185 
74301 
74305 
74320 
75557 
75559 
75561 
75563 

Service Code

72069 
72070 
72072 
72074 
72080 
72090 
72100 
72110 
72114 
72120 
72125 
72126 
72127 
72128 
72129 
72130 
72131 
72132 
72133 
72141 
72142 
72146 
72147 
72148 
72149 
72156 
72157 

Service Code 

75565 
77021 
77022 
77058 (PA) 
77059 (PA) 
A4641 
A9500 (IC) 
A9502 (IC) 
A9503 (IC) 
A9505 (IC) 
A9512 (IC) 
A9537 (IC) 

Service Code 

72158 
72170 
72190 
72192 
72193 
72194 
72195 
72196 
72197 
72200 
72202 
72220 
72240 
72255 
72265 
72270 
72275 
72285 
72291 
72292 
72295 
73000 
73010 
73020 
73030 
73040 
73050 




Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
Independent Diagnostic Testing Facility 
Manual 
Subchapter Number and Title 
6. Service Codes 
Page 
6-3 
Transmittal Letter 
IDTF-12 
Date 
01/01/13 

604 Diagnostic Imaging Centers: Radiology Service Codes (cont.) 

Service Code Service Code Service Code Service Code Service Code 

73060 73719 74330 75791 76512 
73070 73720 74340 75801 76513 
73080 73721 74355 75803 76514 
73085 73722 74400 75805 76516 
73090 73723 74410 75807 76519 
73092 73725 74415 75809 76529 
73100 74000 74420 75810 76536 
73110 74010 74425 75820 76604 
73115 74020 74430 75822 76645 
73120 74022 74440 75825 76700 
73130 74150 74445 75827 76705 
73140 74160 74450 75831 76770 
73200 74170 74455 75833 76775 
73201 74174 74470 75840 76776 
73202 74176 74475 75842 76800 
73218 74177 74480 75860 76801 
73219 74178 74485 75870 76802 
73220 74181 74710 75872 76805 
73221 74182 74740 75880 76810 
73222 74183 74742 75885 76811 
73223 74185 74775 75887 76812 
73500 74190 75557 75889 76813 
73510 74210 75559 75891 76814 
73520 74220 75561 75893 76815 
73525 74230 75563 75898 76816 
73530 74235 75565 75901 76817 
73540 74240 75572 75902 76818 
73550 74245 75573 75945 76820 
73560 74246 75574 75946 76821 
73562 74247 75600 76000 76825 
73564 74249 75605 76001 76826 
73565 74250 75625 76010 76827 
73580 74251 75630 76080 76828 
73590 74260 75658 76098 76830 
73592 74261 (PA) 75705 76100 76831 
73600 74262 (PA) 75710 76101 76856 
73610 74270 75716 76102 76857 
73615 74280 75726 76120 76870 
73620 74283 75731 76125 76872 
73630 74290 75733 76376 76873 
73650 74291 75736 76377 76881 
73660 74300 75741 76380 76882 
73700 74301 75743 76499 (IC) 76885 
73701 74305 75746 76506 76886 
73702 74320 75756 76510 76937 
73718 74327 75774 76511 76942 




Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
Independent Diagnostic Testing Facility 
Manual 
Subchapter Number and Title 
6. Service Codes 
Page 
6-4 
Transmittal Letter 
IDTF-12 
Date 
01/01/13 

604 Diagnostic Imaging Centers: Radiology Service Codes (cont.) 

Service Code Service Code Service Code Service Code Service Code 

76945 78072 78320 78700 93270 
76946 78075 78350 78701 93271 
76948 78099 (IC) 78399 (IC) 78707 93272 
76950 78102 78414 (IC) 78708 93278 
76965 78103 78428 78709 93303 
76970 78104 78445 78710 93304 
76977 78110 78451 78710 78725 93306 
76999 (IC) 78111 78452 78730 93307 
77001 78120 78453 78740 93308 
77002 78121 78454 78761 93312 
77003 78122 78456 78799 (IC) 93313 
77011 78130 78457 78800 93314 
77012 78135 78458 78801 93315 
77013 78140 78459 78802 93316 
77014 78185 78466 78803 93317 
77021 78190 78468 78804 93318 
77022 78191 78469 78805 93320 
77051 78195 78472 78806 93321 
77052 78199 78473 78807 93325 
77053 78201 78481 78808 93350 
77054 78202 78483 78811 93351 
77055 78205 78491 78812 93352 
77056 78206 78492 78813 93724 
77057 78215 78494 78814 93740 
77058 (PA) 78216 78496 78815 93745 (IC) 
77059 (PA) 78226 78499 (IC) 78816 93784 
77071 78227 78579 78999 (IC) 93786 
77072 78230 78580 93000 93788 
77073 78231 78582 93005 93790 
77074 78232 78597 93010 93797 
77075 78258 78598 93015 93798 
77076 78261 78599 (IC) 93016 93799 (IC) 
77077 78262 78600 93017 93880 
77078 78264 78601 93018 93882 
77080 78270 78605 93024 93886 
77081 78271 78607 93025 93888 
77082 78272 78608 93040 93890 
78012 78278 78609 93041 93893 
78013 78282 (IC) 78610 93042 93922 
78014 78290 78630 93224 93923 
78015 78291 78635 93225 93924 
78016 78299 (IC) 78645 93226 93925 
78018 78300 78647 93227 93926 
78020 78305 78650 93228 (IC) 93930 
78070 78306 78660 93229 (IC) 93931 
78071 78315 78699 (IC) 93268 93965 




Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
Subchapter Number and Title 
6. Service Codes 
Page 
6-5 
Independent Diagnostic Testing Facility 
Manual 
Transmittal Letter 
IDTF-12 
Date 
01/01/13 

604 Diagnostic Imaging Centers: Radiology Service Codes (cont.) 

Service Code Service Code Service Code Service Code Service Code 

93970 93979 95950 A9500 (IC) A9537 (IC) 
93971 93980 95951 A9502 (IC) G0202 
93975 93981 95953 A9503 (IC) G0204 
93976 93990 95956 A9505 (IC) G0206 
93978 93998 (IC) A4641 IC) A9512 (IC) 

605 Mobile Mammography Van: Radiology Service Codes 

Service Code Service Code Service Code Service Code Service Code 

76645 
77051 
77052 
77053 
77054 
77055 
77056 
77057 
G0202 
G0204 
G0206 

606 Sleep Centers: Radiology Service Codes 

Service Code Service Code Service Code Service Code 

95782 95800 95805 95807 95810 
95783 95801 95806 95808 95811 


607 Modifiers 

The following service code modifiers are allowed for billing under MassHealth. 


Modifier Modifier Description 
26 Professional Component 
TC Technical Component 

The following modifiers are for Provider Preventable Conditions (PPCs) that are 
National Coverage Determinations. 

Modifier Modifier Description 
PA Surgical or other invasive procedure on wrong body part 
PB Surgical or other invasive procedure on wrong patient 
PC Wrong surgery or other invasive procedure on patient 

For more information on the use of these modifiers, see Appendix V of your 
provider manual. 

This publication contains codes that are copyrighted by the American Medical 
Association. 




Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series 
Subchapter Number and Title 
6. Service Codes 
Page 
6-6 
Independent Diagnostic Testing Facility 
Manual 
Transmittal Letter 
IDTF-12 
Date 
01/01/13 

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