Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 355.00 - Rates for Freestanding Birth Center Services › Section 355.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				101 CMR
				355.00, unless the content requires otherwise, terms
				have the meanings in
				101
				CMR 355.02. The descriptions and five-digit
				codes included in
				101 CMR
				355.00 utilize the Healthcare Common Procedure Code
				System (HCPCS) for Level I and Level II coding. Level 1 CPT-4 codes are
				obtained from the Physicians' 2022 Current Procedural Terminology® by the
				American Medical Association, unless otherwise specified. Level II codes are
				obtained from 2022 HCPCS maintained jointly by the Centers for Medicare &
				Medicaid Services (CMS), the Blue Cross and Blue Shield Association, and the
				Health Insurance Association of America.
HCPCS is a listing of descriptive terms and identifying codes
				and modifiers for reporting medical services and procedures performed by
				physicians and other healthcare professionals, as well as associated
				non-physician services.
				101 CMR
				355.00 includes only HCPCS numeric and alpha-numeric
				identifying codes and modifiers for reporting medical services and procedures
				that were selected by EOHHS. Any use of CPT outside the fee schedule should
				refer to the Physicians' 2022 Current Procedural Terminology®.
Center
. The Center for Health
				Information and Analysis established under M.G.L. c. 12C.
Certified Nurse-midwife (CNM)
. An
				advanced practice registered nurse (APRN) who has completed a program of study
				and clinical experience for nurse-midwives, and is licensed by the Board of
				Registration in Nursing to practice as a certified nurse-midwife, whose
				eligibility is limited to those procedures specified by the governmental unit
				purchasing such services, and who also meets such conditions of participation
				as may have been or may be adopted from time to time by a governmental
				unit.
Certified Nurse Practitioner (CNP)
. An
				APRN who has completed a program of study and clinical experience for nurse
				practitioners, and is licensed by the Board of Registration in Nursing to
				practice as a certified nurse practitioner, whose eligibility is limited to
				those procedures specified by the governmental unit purchasing such services,
				and who also meets such conditions of participation as may be adopted by a
				governmental unit.
Clinical Staff
. The physician,
				certified nurse-midwife, certified nurse practitioner, registered nurse,
				licensed practical nurse, and other licensed health care practitioners
				appointed by the governing authority to practice within the birthing center and
				governed by rules approved by the governing body.
EOHHS
. The Executive Office of Health
				and Human Services established under M.G.L. c. 6A.
Facility Component
. Rates of payment
				for a freestanding birth center's facility component costs. The facility
				component does not include payment for physician, certified nurse-midwife, or
				certified nurse practitioner services in performing a procedure or service. The
				facility component does include payment for the services of other clinical
				staff,
e.g
., registered nurses and licensed practical nurses.
				The facility component also includes payment for the component of a service or
				procedure representing the cost of rent, equipment, utilities, supplies, drugs
				and biologicals, clinical laboratory services, malpractice insurance,
				administrative and technical salaries and benefits, all related administrative
				or supervisory duties performed in connection with the provision of the service
				or procedure, and all other overhead expenses of the service or
				procedure.
Freestanding
. Existing independently
				or physically separated from another health care facility and administered by
				separate staff with separate records.
Freestanding Birth Center (FBC)
. A
				health facility not operated under a hospital license that is licensed by the
				Department of Public Health (DPH) as a birth center, pursuant to
				105 CMR
				140.000:
Licensure of Clinics
.
Governmental Unit
. The Commonwealth of
				Massachusetts or any of its departments, agencies, boards, commissions, or
				political subdivisions.
Individual Consideration (I.C.)
.
				Freestanding birth center services that are authorized but not listed in
				101 CMR
				355.00, freestanding birth center services performed
				in unusual circumstances, and services whose fees are designated by the letters
				"I.C." are individually considered items. The governmental unit or purchaser
				analyzes the eligible provider's operative report, which must contain a
				diagnosis, a pertinent medical history, a description of the services rendered,
				and the length of time spent with the patient. In making the determination of
				whether the service is appropriately classified as an individually considered
				item, the following criteria are used:
(a) policies, procedures, and practices of
			 other third-party purchasers of care, both governmental and private;
(b) the severity and complexity of the
			 patient's disorder or disability;
(c) prevailing provider ethics and accepted
			 practice; and
(d) time, degree of
			 skill, and cost including equipment cost required to perform the
			 procedure(s).
Modifiers
. Listed services may be
				modified under certain circumstances. When applicable, the modifying
				circumstances must be identified by the addition of the appropriate two-digit
				number or letters.
Publicly Aided Individual
. A person
				who receives health care and services for which a governmental unit is in whole
				or in part liable under a statutory program of public assistance.