which code represents pelvimetry with placental localization?

If there is no and/or diuretic) CHC-79 86970 Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility Commonwealth of Massachusetts 78615 Transcatheter Procedures 99334 Domicillary or rest home visit for the evaluation and management of an established 76948 Ultrasonic guidance for aspiration of ova, imaging supervision and interpretation 86664 Epstein-Barr (EB) virus, nuclear antigen (EBNA) monitoring, per 30-day period of time; tracing only Commonwealth of Massachusetts 70460 with contrast material(s) 603 Laboratory Service Codes and Descriptions (cont.) Date 85557 incubated

89130 Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology - an expanded problem-focused history; 84311 Spectrophotometry, analyte not elsewhere specified 88275 interphase in situ hybridization, analyze 100-300 cells (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 95009), (Eligible providers are nurse midwives employed by 85260 factor X (Stuart-Prower) - a comprehensive history; attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) 83890 Molecular diagnostics; molecular isolation or extraction Page Urea nitrogen (BUN) (84520).) Subchapter Number and Title Code Service Description MassHealth 88189 16 or more markers

Date Counseling and/or coordination of care with other providers or agencies are provided 75966 Transluminal balloon angioplasty, renal or other visceral artery, radiological supervision and the provider must use a modifier. Brewed to perfection. Service Codes and Descriptions translucency measurement, transabdominal or transvaginal approach; single or first gestation 87277 Legionella micdadei

Commonwealth of Massachusetts 87073 quantitative, anaerobic with isolation and presumptive identification of isolates, any source 87380 hepatitis, delta agent monitoring, radiological supervision and interpretation Community Health Center Manual 6-29 Service community health centers.) Community Health Center Manual 76000 Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (e.g., 83045 methemoglobin, qualitative Nurse Practitioner 83519 Immunoassay, analyte, quantitative; by radiopharmaceutical technique (e.g., RIA) 75889 Hepatic venography, wedged or free, with hemodynamic evaluation, radiological supervision and Provider Manual Series 70486 Computed tomography, maxillofacial area; without contrast material

70553 without contrast material, followed by contrast material(s) and further sequences Subchapter Number and Title 83894 separation by gel electrophoresis (e.g., agarose, polyacrylamide) physicians employed by community health centers.) 85337 Thrombomodulin MassHealth Service Codes and Descriptions 86677 Helicobacter pylori 86406 titer, each antibody 82390 Ceruloplasmin 82693 Ethylene glycol Boston, MA 02111 MassHealth Appendix E. Utilization Management Program . E-1 Service Codes and Descriptions 83840 Methadone Commonwealth of Massachusetts Transmittal Letter 88362 Nerve-teasing preparations A 74241 with or without delayed films, with KUB by community health centers)

83835 Metanephrines step methods for the detection of antibodies to infectious agents. 78660 Radiopharmaceutical dacryocystography CHC-79 84135 Pregnanediol Date Hyperthermia is used only as an adjunct to radiation therapy or chemotherapy. miniaturized printout; includes recording, microprocessor-based analysis with report, Code Service Description Code Service Description 80418 Combined rapid anterior pituitary evaluation panel (This panel must include the following: 82943 Glucagon 6. Musculoskeletal System 603 Laboratory Service Codes and Descriptions (cont.) 94774 Pediatric home apnea monitoring event recording including respiratory rate, pattern and heart rate 99381 Initial comprehensive preventive medicine evaluation and management of an individual including Community Health Center Manual CHC-79 Subchapter Number and Title MassHealth Web Site Providers should refer to www.cms.hhs.gov for service 6. 78593 Pulmonary ventilation imaging, gaseous, with rebreathing and washout with or without single

6-2 72010 Radiologic examination, spine, entire, survey study, anteroposterior and lateral

83009 Helicobacter pylori, blood test analysis for urease activity, non-reactive isotope (eg, C-12) 82248 direct Page Subchapter Number and Title thin layer preparation that are examined using any system of reporting (Bethesda or non-Bethesda). Provider Manual Series Service Codes and Descriptions 86709 IgM antibody 80188 Primidone - a detailed examination; 93701 Bioimpedance, thoracic, electrical Provider Manual Series 77056 bilateral MassHealth 604 Visit Service Codes and Descriptions (cont.) 602 Radiology Service Codes and Descriptions (cont.) 72275 Epidurography, radiological supervision and interpretation 601 Introduction and Explanation of Abbreviations health need identified* (eligible providers are nurse practitioners employed by

86922 antiglobulin technique (I.C.) (The pages listed here are no longer in effect.) 76940 Ultrasonic guidance for, and monitoring of, visceral tissue ablation

82541 Column chromatography/mass spectrometry (e.g., GC/MS, or HPLC/MS), analyte not elsewhere 76857 limited or follow-up (e.g., for follicles) www.mass.gov/sec/spr www.mass.gov/dhcfp 70482 without contrast material, followed by contrast material(s) and further sections Provider Manual Series Transmittal Letter 01/01/08 specified, single stationary and mobile phase 86384 Nitroblue tetrazolium dye test (NTD) Page 87070 any other source except urine, blood, or stool, aerobic, with isolation and presumptive 72158 lumbar 86378 Migration inhibitory factor test (MIF)

84132 Potassium; serum 82633 Desoxycorticosterone, 11- 94014 Patient-initiated spirometric recording per 30-day period of time; includes reinforced education, 94620) 85347 activated

Code Modifier Service Description

78647 tomographic (SPECT) 77032 Mammographic guidance for needle placement, breast (e.g., for wire localization or for injection), Sterilization Form (CS-18 or CS-21) required) 84143 17-hydroxypregnenolone stain, each virus diethylether, isopropyl alcohol, methanol) the 2007 deleted code in accordance with DHCFP regulations. MassHealth 99407-TD Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes Appendix Z. EPSDT/PPHSD Screening Services Codes.. Z-1

You may also purchase a paper copy of the 6-47 87482 Candida species, quantification

86702 HIV-2

59510 Routine obstetric care including antepartum care, cesarean delivery, and postpartum care Page 83704 Quantitation of lipoprotein particle numbers and lipoprotein particle subclasses (eg, by nuclear 87205 Smear, primary source with interpretation; Gram or Giemsa stain for bacteria, fungi, or cell types Page use a standardized behavioral-health screening tool when performing the behavioral-health screening 84260 Serotonin Service 99407 SB 87206 fluorescent and/or acid-fast stain for bacteria, fungi, parasites, viruses, or cell types

603 Laboratory Service Codes and Descriptions (cont.) Community Health Center Manual Page Service Codes and Descriptions 6. CHC-79 followed by contrast material(s) and further sequences; cervical 82379 Carnitine (total and free), quantitative, each specimen This publication contains codes that are copyrighted by the American Medical Association. 81099 Unlisted urinalysis procedure (I.C.) MassHealth bilateral (Consent for Sterilization Form (CS-18 or CS-21) required) spend 15 minutes with the patient and/or family or caregiver. Tests Service Codes and Descriptions (The pages listed here contain new or revised language.) 99326 Domicillary or rest home visit for the evaluation and management of a new patient, by community health centers) 01/01/08 telangiectasia, Fanconi anemia, fragile X) to 93880 and 93882) 84275 Sialic acid 83909 separation and identification by high resolution technique (eg, capillary electrophoresis) Barbiturates Individual tobacco Subchapter Number and Title Physician Assistant qualitative or semiquantitative; multiple step method 83037 Glycosylated (AIC) by device cleared by FDA for home use 78483 multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study 82106 amniotic fluid 93010 interpretation and report only 85291 factor XIII (fibrin stabilizing), screen solubility 6. (84443 x 4).) interpretation Transmittal Letter 85301 antithrombin III, antigen assay Community Health Center Manual 83992 Phencyclidine (PCP) 89235 Water load test CHEMISTRY Commonwealth of Massachusetts 71555 Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s) * Behavioral health need identified includes needs in the areas of behavioral health, social-emotional well-being, or mental 70332 Temporomandibular joint arthrography, radiological supervision and interpretation consistent with the nature of the problem(s) and the patients and/or familys needs. Community Health Center Manual MassHealth 88267 Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 karyotype, with Code Service Description 72131 Computed tomography, lumbar spine; without contrast material Follicle stimulating hormone (FSH) (83001 x 4), Prolactin (84146 x 4), Human growth hormone Executive Office of Health and Human Services

59622 including postpartum care 78807 tomographic (SPECT) 6-27 interpretation 6. 82626 Dehydroepiandrosterone (DHEA) 99220 Initial observation care, per day, for the evaluation and management of a patient,

77470 Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, Date Nurse Midwife

84233 Receptor assay; estrogen Provider Manual Series lesions, including image guidance, entire course not to exceed five fractions 6. 83908 amplification, signal, each nucleic acid sequence only Code Service Description 86652 encephalitis, Eastern equine 75665 Angiography, carotid, cerebral, unilateral, radiological supervision and interpretation 87517 hepatitis B virus, quantification manipulation, any necessary contrast injections through access site or catheter with related 77073 Bone length studies 87102 other source (except blood) per day Service patient, which requires at least two of these three components: 602 Radiology Service Codes and Descriptions (cont.) 76001 Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician (e.g., 73000 Radiologic examination; clavicle, complete placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses MassHealth 85547 Mechanical fragility, RBC (intake assessment for an individual, at least 45 minutes). 6-59 venography radiologic supervision and interpretation, and radiographic documentation of final 75564 with flow/velocity quantification and stress - medical decision making of low complexity 84585 Vanillylmandelic acid (VMA), urine 93227 physician review and interpretation

Subchapter Number and Title 86255 Fluorescent noninfectious agent antibody; screen, each antibody Page Commonwealth of Massachusetts 73130 minimum of three views 78458 bilateral Usually the presenting problem(s) are of moderate severity. catheter position) (List separately in addition to code for primary procedure) 76937 Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, analysis (e.g., one stationary phase with one mobile phase), use 80100 only once. - a detailed or comprehensive history 82951 tolerance test (GTT), three specimens (includes glucose) Service 99407 (no required 84156 urine 82528 Corticosterone Community Health Center Manual Preventive Healthcare Screening and Diagnosis (PPHSD) visit according to Appendix W of your

quantitative processing Transmittal Letter 80432 Insulin-induced C-peptide suppression panel (This panel must include the following: Insulin Service 77082 vertebral fracture assessment Date 86781 Treponema pallidum, confirmatory test (e.g., FTA-abs) 76810 each additional gestation (List separately in addition to code for primary procedure) Transmittal Letter 75860 Venography, venous sinus (e.g., petrosal and inferior saggital) or jugular, catheter, radiological 82487 paper, one-dimensional, analyte not elsewhere specified MassHealth 83915 Nucleotidase 5- 83905 mutation identification by allele specific transcription, single segment, each segment 87255 including identification by non-immunologic method, other than by cytopathic effect (e.g., 80150 Amikacin Service interpretation 6-71 Provider Manual Series 71022 with oblique projections multiantimicrobial, per plate 86329 Immunodiffusion; not elsewhere specified 83008 Guanosine monophosphate (GMP), cyclic 76818 Fetal biophysical profile; with non-stress testing Service complete), or removal (includes fluoroscopic guidance for vascular access and catheter

interpretation 86277 Growth hormone, human (HGH), antibody MassHealth 99387 CHC-79 Code Service Description

to 93975) 86975 Pretreatment of serum for use in RBC antibody identification; incubation with drugs, each Date 76800 Ultrasound, spinal canal and contents 83500 Hydroxyproline; free Subchapter Number and Title pharmacologic), with or without additional quantification technique 87804 influenza

78199 Unlisted hematopoietic, reticuloendothelial and lymphatic procedure, diagnostic nuclear medicine 84085 Phosphogluconate, 6-, dehydrogenase, RBC 99219 Initial observation care, per day, for the evaluation and management of a patient, Community Health Center Manual MassHealth 78608 Brain imaging, positron emission tomography (PET); metabolic evaluation Subchapter Number and Title patient, which requires at least two of these three key components: