Commonwealth of Massachusetts Executive Office of Health and Human Services



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P9604




604 Payable Visit and Vaccine Service Codes

This section lists visit and vaccine service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).


When claiming payment for visits or vaccines, a CHC must bill according to the following service codes. A visit during which a member sees more than one professional for the same medical problem or general purpose must be claimed as only one visit. (See 130 CMR 405.421 for other requirements.)

  1. The following visit and associated service codes have special requirements or limitations.

Service

Code Modifier Special Requirement or Limitation
99188 Covered for children younger than age 21. The CHC may bill for a medical visit in addition to the fluoride varnish application only if fluoride varnish was not the sole service, treatment, or procedure provided during the visit.

D9450 Use only for dental enhancement fee. This code may only be billed once per date of service for each member receiving dental services on that date. The dental enhancement fee may not be billed for a fluoride varnish application separately or in addition to a medical visit.

J3490 Use for injectable and infusible drugs and devices supplied in the clinic. Do not use for medications and injectables related to family planning services. (IC)

T1015 Use for individual medical visit.

T1015 HQ Use for group clinic visit.

90899 Use for individual mental health visit. (IC)

99050 Use for urgent care Monday through Friday from 5:00 P.M. to 6:59 A.M., and Saturday 7:00 A.M. to Monday 6:59 A.M. This code may be billed in addition to the individual medical visit.

99402 Use for HIV counseling visits.



  1. This section lists evaluation and management visit service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).





99218

99219


99220

99221


99222

99223


99224

99225


99226

99231


99232

99233


99238

99239


99304

99305


99306

99307


99308

99309


99310

99324


99325

99326


99327

99334


99335

99336


99337

99341


99342

99343


99345 (IC)

99347


99348

99349


99350 (IC)

99460


99462

The following vaccine administration service codes are payable in addition to the evaluation and management visit service codes in this Section 604(B), provided that the vaccine administration is a medically necessary, separately identifiable service. Under these circumstances, the CHC may append modifier 25 to the evaluation and management visit service code. See MassHealth All Provider Bulletin 236 for additional information.


90460

90461


90471

90472


90473

90474
(C) The following vaccine service codes have special requirements or limitations.


Service

Code Special Requirement or Limitation

90630 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90632 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90636 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90649 Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90650 Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90651 Covered for members aged 19 to 26; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90654 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90655 Only for privately purchased vaccine; vaccine must not otherwise be available free of charge through the Massachusetts Immunization Program.

90656 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90657 Only for privately purchased vaccine; vaccine must not otherwise be available free of charge through the Massachusetts Immunization Program.

90658 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

Service

Code Special Requirement or Limitation

90660 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90661 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90662 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90664 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90666 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90667 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90668 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90670 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90672 Covered for members aged 19 to 49; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90673 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90686 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90688 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90707 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90713 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90714 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90715 Covered for adults > 19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90716 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90732 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90733 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.

90734 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age. (IC)

90736 (IC); PA is required for members < age 50.

90746 Covered for adults >19; available free of charge through the Massachusetts Immunization Program for children under 19 years of age.


605 Payable Obstetrics Service Codes
This section lists obstetrics service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).

See 130 CMR 405.422 through 405.426 for other requirements.



  1. Fee-for-Service Deliveries

59409

59410


59414

59514


59515

59525 (HI-1 form required)

59612
59614

59620


59622

  1. Global Deliveries

59400

59510


59610

59618

606 Payable Surgery Service Codes

This section lists surgery service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).




44955

49255


49320

54057


54150

54160


55250 (CS-18 or CS-21 required) (SP)

55450 (CS-18 or CS-21 required) (SP)

56420

56440


57240

57250


57260

57520


57522

57700


58120

58140


58146

58150 (HI-1 form required; PA for Gender Dysphoria- Related Services Only)

58180 (HI-1 form required; PA for Gender Dysphoria- Related Services Only)

58353


58541 (HI-1 form required; PA for Gender Dysphoria- Related Services Only)

58542 (HI-1 form required; PA for Gender Dysphoria- Related Services Only)

58543 (HI-1 form required; PA for Gender Dysphoria- Related Services Only)

58544 (HI-1 form required; PA for Gender Dysphoria- Related Services Only)

58555

58558


58560

58561


58600 (CS-18 or CS-21 required)

58605 (CS-18 or CS-21 required) (SP)

58611 (CS-18 or CS-21 required)

58615 (CS-18 or CS-21 required)

58660

58661 (CS-18* or CS-21* required; PA for Gender Dysphoria-Related Services Only)



58670 (CS-18 or CS-21 required)

58671 (CS-18 or CS-21 required)

58700

58720 (CS-18* or CS-21* required; PA for Gender Dysphoria-Related Services Only)



58940

59000


59012

59015


59025

59870




607 Payable Nurse-Midwife Service Codes

This section lists nurse-midwife service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).


See 130 CMR 405.427 for requirements. When billing for delivery services performed by a nurse midwife, the provider must use a modifier.
Service

Code Modifier Special Requirement or Limitation

T1015 TH Use for a medical visit with a nurse midwife for a prenatal or postpartum service.



59400

59409


59410

59414


59610

59612


59614


608 Payable Audiology Service Codes

This section lists audiology service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).

See 130 CMR 405.461 through 405.463 for other requirements.

92551


92552

92553


92567

609 Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment Service Codes

This section lists Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Health Assessment service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).
See 130 CMR 450.140 through 450.149 for other requirements.


99381

99382


99383

99384


99385

99391


99392

99393


99394

99395

610 Payable Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Test Service Codes

This section lists Early and Periodic Screening, Diagnosis and Treatment (EPSDT): Audiometric Hearing and Vision Test service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).


92551

92552


92587

99173
611 Payable Tobacco Cessation Service Codes

This section lists tobacco cessation service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).
Service

Code Modifier Special Requirement or Limitation

99407 at least 30 minutes; eligible providers are physicians employed by community health centers.

99407 HN at least 30 minutes; eligible providers are physician assistants employed by community health centers.

99407 HQ for an individual in a group setting, 60-90 minutes; eligible providers are physicians employed by community health centers.

99407 SA at least 30 minutes; eligible providers are nurse practitioners employed by community health centers.

99407 SB at least 30 minutes; eligible providers are nurse midwives employed by community health centers.

99407 TD at least 30 minutes; eligible providers are registered nurses employed by community health centers.

99407 TF intake assessment for an individual, at least 45 minutes; eligible providers are physicians employed by community health centers.

99407 U1 at least 30 minutes; eligible providers are tobacco cessation counselors employed by community health centers.

99407 U2 intake assessment for an individual, at least 45 minutes; eligible providers are nurse practitioner, nurse midwife, physician assistant, registered nurse, and tobacco cessation counselor.

99407 U3 for an individual in a group setting, 60-90 minutes; eligible providers are nurse practitioners, nurse midwives, physician assistants, registered nurses, and tobacco cessation counselors.
612 Payable Medical Nutrition Therapy and Diabetes Self-Management Training Service Codes

This section lists medical nutrition therapy and diabetes self-management training service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book and to the HCPCS Level II code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).


G0108

G0109


G0270

G0271


97802

97803


97804

613 Payable Behavioral Health Screening Tool Service Codes

This section lists behavioral health screening tool service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).
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 Modifier Special Requirement or Limitation

96110 U1 Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; with no behavioral health need identified* (Eligible providers are physicians employed by community health centers.)

96110 U2 Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; and behavioral health need identified* (Eligible providers are physicians employed by community health centers.)

96110 U3 Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; with no behavioral health need identified* (Eligible providers are nurse midwives employed by community health centers.)

96110 U4 Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; and behavioral health need identified* (Eligible providers are nurse midwives employed by community health centers.)

96110 U5 Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; with no behavioral health need identified* (Eligible providers are nurse practitioners employed by community health centers.)



613 Payable Behavioral Health Screening Tool Service Codes (cont.)

Service

Code Modifier Special Requirement or Limitation

96110 U6 Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; and behavioral health need identified* (Eligible providers are nurse practitioners employed by community health centers.)

96110 U7 Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; with no behavioral health need identified* (Eligible providers are physician assistants employed by community health centers.)

96110 U8 Covered for members birth to 21 for the administration and scoring of a standardized behavioral health screening tool from the approved menu of tools found in Appendix W of your MassHealth provider manual; and behavioral health need identified* (Eligible providers are physician assistants employed by community health centers.)



* “Behavioral health need identified” means the provider administering the screening tool, in his or her professional judgment, identifies a child with a potential behavioral health services need.

614 Payable Acupuncture Service Codes

This section lists acupuncture service codes that are payable under MassHealth. For complete descriptions of the service codes listed, refer to the American Medical Association’s latest Current Procedural Terminology (CPT) code book (or the Centers for Medicare & Medicaid Services website at www.cms.gov).

97810


97811

97813


97814

615 Modifiers

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

Modifier Description

24 Unrelated evaluation and management service by the same physician during postoperative period.

25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service

26 Professional Component

50 Bilateral procedure

51 Multiple procedures

54 Surgical care only

615 Modifiers (cont.)



Modifier Description

57 Decision for Surgery

58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period.

59 Distinct procedural service.

62 Two surgeons

66 Surgical team

78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period.

79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period.

80 Assistant surgeon

82 Assistant surgeon (when qualified resident surgeon not available)

91 Repeat clinical diagnostic laboratory test.

99 Multiple modifiers


LT Left side (used to identify procedures performed on the left side of the body).

RT Right side (used to identify procedures performed on the right side of the body).

TC Technical Component

XE Separate Encounter: a service that is distinct because it occurred during a separate encounter

XP Separate Practitioner: a service that is distinct because it was performed by a different

practitioner

XS Separate Structure: a service that is distinct because it was performed on a separate

organ/structure

XU Unusual Non-Overlapping Service: the use of a service that is distinct because it does not

overlap usual components of the main service


The following modifiers are for Provider Preventable Conditions that are National Coverage Determinations

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. Certain terms used in the service descriptions for HCPCS codes are defined in the Current Procedural Terminology (CPT) code book.

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