Service Code Req. or Limit Code Req. or Limit specimens 98929 PA for OMT >20 99188 Once per three-month period 99050 Urgent care only 99195 For hematologic disorders 99051 Urgent care only only 99070 IC; excluding family planning 99199 IC supplies, such as trays used in 99499 IC used in the collection of 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 J0364 IC Code Limit G0270 J0400 IC A4261 IC G0271 J0401 A4266 G0279 J0456 G0297 A4267 J0461 G0455 IC A4268 J0470 G0480 A4269 J0475 G0481 A4641 IC J0476 G0482 A4648 IC J0485 PA G0483 A9500 IC J0490 PA J0129 PA A9502 IC J0558 A9503 IC J0131 IC J0561 J0135 PA; IC A9505 IC J0565 PA; IC J0153 A9512 IC J0570 PA J0171 A9537 IC J0571 PA; IC J0178 A9575 J0572 IC J0202 PA A9576 J0573 IC J0215 PA; IC A9577 J0574 IC A9578 J0221 PA J0575 IC J0256 A9579 J0585 PA J0257 A9581 J0586 PA J0285 A9585 J0587 PA J0287 A9606 PA J0588 PA G0027 J0289 J0592 J0290 G0105 J0594 J0295 G0108 J0596 PA J0348 G0109 Service Req. or G0121 Code Limit Service Req. or
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
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