97172 97537 97545 97546 97755 98940 98941 98942 98943 98960 98961 98962 98966 98967 98968 98969 99000 99001 99002 99024 99026 99027 99053 99056 99058 99060 99071 99075 99078 99080 99082 99090 99091 99100 99116 99135 99140 99151 99152 99153 99155 99156 99157 99172 99174 99177 99190 99191 99192 99241 99242 99243 99244 99245 99251 99252 99253 99254 99255 99288 99315 99316 99339 99340 99354 99355 99356 99357 99358 99359 99360 99366 99367 99368 99374 99375 99377 99378 99379 99380 99401 99402 99403 99404 99406 99408 99409 99411 99412 99429 99441 99442 99443 99444 99446 99447 99448 99449 99450 99455 99456 99485 99486 99487 99489 99490 99495 99496 99497 99498 99500 99501 99502 99503 99504 99505 99506 99507 99509 99510 99511 99512 99601 99602 99605 99606 99607
Service Code Req. or Limit 01999 IC 11920 PA 11921 PA 11950 CD (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 11951 CD (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 11952 CD (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 11954 CD (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 11970 PA (for gender services only) 11971 PA (for gender services only) 15820 PA 15821 PA 15822 PA 15823 PA 15830 PA 15832 PA 15833 PA 15834 PA 15835 PA 15836 PA 15837 PA 15838 PA 15839 PA 15876 CD; IC (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 15877 CD; IC (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) Service Code Req. or Limit 15878 CD; IC (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 15879 CD; IC (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) 15999 IC 17380 PA (covered in preparation for gender affirming surgery only) 17999 PA; IC 19300 PA 19303 PA (for gender services only) 19304 PA (for gender services only) 19316 PA 19318 PA 19324 PA 19325 PA 19328 PA 19340 PA 19350 PA 19499 IC 20999 IC 21088 IC 21089 IC 21137 PA 21138 PA 21139 PA 21146 PA 21147 PA 21150 PA 21151 PA 21154 PA 21155 PA 21159 PA 21160 PA 21172 PA 21175 PA 21188 PA dysphoria- related dysphoria- related related related
Service Code Req. or Limit 21193 PA 21194 PA 21195 PA 21196 PA 21198 PA 21199 PA 21206 PA 21208 PA 21209 PA 21210 PA 21215 PA 21230 PA 21235 PA 21240 PA 21242 PA 21243 PA 21244 PA 21247 PA 21255 PA 21256 PA 21299 PA; IC 21499 IC 21742 IC 21743 IC 21899 IC 22857 PA 22862 PA 22865 PA 22899 IC 22999 IC 23929 IC 24940 IC 24999 IC 25999 IC 26989 IC 27299 IC 27445 PA1 27446 PA1 27447 PA1 27486 PA1 27487 PA1 27488 PA1 27599 IC 27899 IC 28890 PA Service Code Req. or Limit 28899 IC 29799 IC 29800 PA 29804 PA 29870 PA1 29873 PA1 29874 PA1 29875 PA1 29876 PA1 29877 PA1 29879 PA1 29880 PA1 29881 PA1 29882 PA1 29883 PA1 29884 PA1 29885 PA1 29886 PA1 29887 PA1 29888 PA1 29889 PA1 29999 IC 30400 PA 30410 PA 30420 PA 30430 PA 30435 PA 30450 PA 30999 IC 31299 IC 31599 IC 31899 IC 32851 PA 32852 PA 32853 PA 32854 PA 32999 IC 33935 PA 33945 PA 33981 IC 33982 IC 33983 IC 33999 IC 34841 IC 34842 IC
Service Code Req. or Limit 34843 IC 34844 IC 34845 IC 34846 IC 34847 IC 34848 IC 36299 IC 36470 PA 36471 PA 37195 IC 37216 IC 37501 IC 37799 IC 38129 IC 38230 PA 38240 PA 38241 PA 38242 PA 38589 IC 38999 IC 39499 IC 39599 IC 40799 IC 40840 PA 40842 PA 40843 PA 40844 PA 40845 PA 40899 IC 41599 IC 41820 PA; IC 41821 IC 41850 IC 41899 IC 42280 PA 42281 PA 42299 IC 42699 IC 42999 IC 43289 IC 43496 IC 43499 IC 43644 PA 43645 PA 43647 PA; IC Service Code Req. or Limit 43648 IC 43659 IC 43770 PA 43771 PA 43772 PA 43773 PA 43774 PA 43775 PA 43846 PA 43847 PA 43848 PA 43881 PA; IC 43882 IC 43886 PA 43887 PA 43888 PA 43999 IC 44135 PA; IC 44136 PA; IC 44137 PA; IC 44238 IC 44799 IC 44899 IC 44979 IC 45399 IC 45499 IC 45999 IC 46999 IC 47135 PA 47379 IC 47399 IC 47579 IC 47999 IC 48554 PA 48999 IC 49329 IC 49659 IC 49906 IC 49999 IC 50549 IC 50949 IC 51925 HI-1 51999 IC 53430 PA (for gender services only)
Service Code Req. or Limit 77061 IC 77062 IC 77299 IC 77387 IC 77399 IC 77499 IC 77799 IC 78099 IC 78199 IC 78299 IC 78399 IC 78499 IC 78599 IC 78699 IC 78799 IC 78999 IC 79999 IC 81099 IC 81162 PA 81211 PA 81212 PA 81215 PA 81217 PA 81228 PA; IC 81229 PA; IC 81420 PA; IC 81479 IC 81507 PA; IC 81519 PA; IC 84999 IC 88199 IC 85999 IC 86849 IC 86999 IC 87999 PA; IC 88299 IC 88399 IC 89240 IC 90281 IC 90283 IC 90284 IC 90287 IC 90288 IC 90296 IC Service Code Req. or Limit 90378 PA; IC 90384 IC 90385 IC 90386 IC 90389 IC 90393 PA; IC 90396 IC 90399 IC 90476 IC 90477 IC 90581 IC 90620 IC 90621 IC 90625 IC 90630 Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90632 Covered for adults ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90633 IC; Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90636 Covered for members ≥ 19; available free of charge through the Massachusetts Immunization Program for children younger than 19 years of age 90651 IC; Covered for female members aged 19 to 26 years; available free of charge through the Massachusetts Immunization Program for children younger than 19
Service Code Req. or Limit 98929 PA for OMT >20 99050 Urgent care only 99051 Urgent care only 99070 IC; excluding family planning supplies, such as trays used in used in the collection of Code Req. or Limit specimens 99188 Once per three-month period 99195 For hematologic disorders only 99199 IC 99499 IC 99600 IC 604 Payable HCPCS Level II Service Codes This section lists Level II HCPCS codes that are payable under MassHealth. For more detailed descriptions when billing for these codes provided to MassHealth members, refer to the Centers for Medicare & Medicaid Services website at . Service Req. or Code Limit A4261 IC A4266 A4267 A4268 A4269 A4641 IC A4648 IC A9500 IC A9502 IC A9503 IC A9505 IC A9512 IC A9537 IC A9575 A9576 A9577 A9578 A9579 A9581 A9585 A9606 PA G0027 G0105 G0108 G0109 G0121 Service Req. or Code Limit G0270 G0271 G0279 G0297 G0455 IC G0480 G0481 G0482 G0483 J0129 PA J0131 IC J0135 PA; IC J0153 J0171 J0178 J0202 PA J0215 PA; IC J0221 PA J0256 J0257 J0285 J0287 J0289 J0290 J0295 J0348 Service Req. or Code Limit J0364 IC J0400 IC J0401 J0456 J0461 J0470 J0475 J0476 J0485 PA J0490 PA J0558 J0561 J0565 PA; IC J0570 PA J0571 PA; IC J0572 IC J0573 IC J0574 IC J0575 IC J0585 PA J0586 PA J0587 PA J0588 PA J0592 J0594 J0596 PA
Service Req. or Code Limit J9302 PA J9303 J9305 J9306 PA J9307 J9308 PA J9310 PA J9315 PA J9320 J9325 PA J9328 J9330 J9340 IC J9351 J9352 J9354 PA J9355 J9357 J9360 J9370 J9371 PA J9390 J9395 PA J9400 PA J9999 IC Q0138 Q0139 Q0162 Service Req. or Code Limit Q2009 IC Q2017 IC Q2028 IC; CD (covered with diagnosis of lipodystrophy associated with or secondary to HIV only) Q2035 Q2036 IC Q2037 Q2038 IC Q2043 PA Q2049 IC Q2050 Q4074 Q4081 Q4101 Q4102 Q4103 IC Q4104 IC Q4106 Q4107 Q4108 IC Q4110 IC Q4121 Q4131 Q4132 Q4107 Service Req. or Code Limit Q4133 Q4161 IC Q4162 IC Q4163 IC Q4164 IC Q4165 IC Q5101 Q9950 Q9980 PA; IC S0020 IC S0021 IC S0023 IC S0077 IC S0190 IC S0191 IC S0199 S0302 S2260 (CPA-2); IC S3005 S4989 IC S4993 T1023 V2600 PA; IC V2610 PA; IC V2615 PA; IC V2799 PA; IC