Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 316.00 - Rates for surgery and anesthesia services › Section 316.05 - Maximum Allowable Fees - Surgical Services

Current through Register 1525, July 5, 2024
(1)
Surgical and Obstetrical Services
. Except as provided
			 elsewhere in this
			 101
			 CMR 316.05(1), the allowable
			 fees for surgical and obstetrical services are the fees listed in
			 101
			 CMR 316.05(4)(b), subject to
			 101
			 CMR 316.03 and appropriate modifiers, as
			 applicable. (Anesthesia procedure codes (00100-01999) and corresponding base
			 anesthesia units for purposes of
			 101
			 CMR 316.04 are listed in
			 101
			 CMR 316.05(4)(a)). Certain
			 codes in
			 101
			 CMR 316.05(4)(b)  are
			 identified with an asterisk (*). The allowable fees for these codes are as set
			 forth in
			 101
			 CMR 316.05(4)(b), except
			 when any of those codes are billed as part of a facial feminization surgery to
			 treat gender dysphoria, in which case the allowable fees are those set forth in
			 101
			 CMR 316.05(4)(c).
			 (Anesthesia procedure codes (00100-01999) and corresponding base anesthesia
			 units for purposes of
			 101
			 CMR 316.04 are listed in
			 101
			 CMR 316.05(4)(a)).
(2) Unless otherwise specified, guidelines,
			 notes, and definitions provided in the 2023 CPT Coding Handbook are applicable
			 to the use of the procedure codes and modifiers listed below, as well as their
			 corresponding descriptions. For code descriptions,
see
the
			 anesthesia and surgery service code spreadsheets at:
www.mass.gov/regulations/101-CMR-31600-surgery-and-anesthesia-services
.
(3)
Modifiers
.
(a)
26: Professional
			 Component
. The component of a service or procedure representing
			 the physician's or other qualified health care professional's work interpreting
			 or performing the service or procedure. (When the physician or other qualified
			 health care professional component is reported separately, the addition of
			 modifier 26 to the procedure code will allow payment of the professional
			 component allowable fee (PC Fee) contained in
			 101
			 CMR 316.05(4)(b), adjusted
			 by 101 CMR 316.03 as
			 applicable.)
(b)
50:
			 Bilateral Procedure
. Payment for bilateral procedures performed at
			 the same operative session must be identified by the appropriate service code
			 and modifier 50. Only one claim line is billed for both procedures. (The
			 addition of modifier 50 to the bilateral code will allow payment of 150% of the
			 allowable fee contained in
			 101
			 CMR 316.05(4)(b), adjusted
			 by 101 CMR 316.03 as applicable,
			 to the eligible provider for performance of both bilateral
			 procedures.)
(c)
51:
			 Multiple Procedures
. This modifier must be used to report multiple
			 procedures performed at the same session. The service code for the major
			 procedure or service must be reported without a modifier. The secondary,
			 additional, or lesser procedure(s) must be identified by adding modifier 51 to
			 the end of the service code for the secondary procedure(s). (The addition of
			 modifier 51 to the second and subsequent procedure codes allows payment of 50%
			 of the allowable fee contained in
			 101
			 CMR 316.05(4)(b), adjusted
			 by 101 CMR 316.03 as applicable,
			 to the eligible provider.)
Note
: This modifier should not be used
				with designated "add-on" codes or with codes in which the narrative begins with
				"each additional."
(d)
52: Reduced Services
. Under certain circumstances, a
			 service or procedure is partially reduced or eliminated at the physician's or
			 other qualified health care professional's election. Under these circumstances,
			 the service provided can be identified by its usual procedure number and
			 addition of modifier 52, signifying that the service is reduced. This provides
			 a means of reporting reduced services without disturbing the identification of
			 the basic service.
(e)
54: Surgical Care Only
. When one eligible physician or
			 other qualified health care professional performs a surgical procedure and
			 another provides preoperative and/or postoperative management, surgical
			 services may be identified by adding modifier 54 to the appropriate procedure
			 code. (This allows payment of 85% of the allowable fee contained in
			 101
			 CMR 316.05(4)(b), adjusted
			 by 101 CMR 316.03 as applicable,
			 to the physician or other qualified health care professional performing the
			 surgery.)
(f)
55:
			 Postoperative Management Only
. When one eligible physician or
			 other qualified health care professional performs the postoperative management
			 and another performed the surgical procedure, the postoperative component may
			 be identified by adding modifier 55 to the appropriate procedure code. (This
			 allows payment of 15% of the allowable fee contained in
			 101
			 CMR 316.05(4)(b), adjusted
			 by 101 CMR 316.03 as applicable,
			 to the physician or other qualified health care professional.)
(g)
58: Staged or Related
			 Procedure or Service by the Same Physician or Other Qualified Health Care
			 Professional during the Postoperative Period
. It may be necessary
			 to indicate the performance of a procedure or service during the postoperative
			 period was:
1. planned or anticipated
			 (staged);
2. more extensive than
			 original procedure; or
3. for
			 therapy following a surgical procedure. This circumstance may be reported by
			 adding modifier 58 to the staged or related procedure.
Note
: for treatment of a problem that requires a
			 return to the operating/procedure room (
e.g
., unanticipated
			 clinical condition),
see
modifier 78.
(h)
59: Distinct Procedural
			 Service
. To identify a procedure distinct or independent from
			 other services performed on the same day add modifier 59 to the end of the
			 appropriate service code. Modifier 59 is used to identify services/procedures
			 that are not normally reported together, but are appropriate under certain
			 circumstances, for example, different site or organ system. However, when
			 another already established modifier is appropriate, it should be used rather
			 than modifier 59.
(i)
62: Two Surgeons
. When two eligible surgeons work
			 together as primary surgeons performing distinct part(s) of a procedure, each
			 surgeon should report their distinct operative work by adding modifier 62 to
			 the procedure code and any associated add-on code(s) for that procedure as long
			 as both surgeons continue to work together as primary surgeons. Each surgeon
			 should report the procedure once using the same procedure code. If additional
			 procedure(s) (including add-on procedure(s) are performed during the same
			 surgical session, separate codes(s) may also be reported with modifier 62
			 added.) (The addition of modifier 62 to the procedure code allows payment of
			 57.5% of the allowable fee contained in
			 101
			 CMR 316.05(4)(b), adjusted
			 by 101 CMR 316.03 as applicable,
			 to each surgeon. No separate payment will be made for assisting surgical
			 services in these cases; it is included in the total surgical fee
			 listed.)
(j)
66:
			 Surgical Team
. This modifier must be used to identify highly
			 complex procedures (requiring the concomitant services of several eligible
			 physicians, often of different specialties, plus other highly skilled,
			 specially trained personnel, and various types of complex equipment) carried
			 out under the "surgical team" concept. The unit fee is payable to the director
			 of the surgical team and includes all assistant surgeon fees; there are no
			 separate payments for assisting surgical services. The director of the surgical
			 team is expected to distribute the unit fee to the eligible members of the
			 surgical team.
(k)
76:
			 Repeat Procedure by Same Physician or Other Qualified Health Care
			 Professional
. The physician or other qualified health care
			 professional may need to indicate that a procedure or service was repeated
			 subsequent to the original procedure or service. This circumstance may be
			 reported by adding modifier 76 to the repeated procedure/service or the
			 separate five-digit modifier code 09976 may be used.
(l)
77: Repeat Procedure by
			 Another Physician or Other Qualified Health Care Professional
. The
			 physician or other qualified health care professional may need to indicate that
			 a basic procedure or service performed by another physician or other qualified
			 health care professional had to be repeated. This situation may be reported by
			 adding modifier 77 to the repeated procedure/service or the separate five-digit
			 modifier code 09977 may be used.
(m)
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
. The physician or other qualified health care
			 professional may need to indicate that another procedure was performed during
			 that postoperative period of the initial procedure. When this subsequent
			 procedure is related to the first, and requires the use of the operating room,
			 it may be reported by adding modifier 78 to the related procedure, or by using
			 the separate five-digit modifier 09978. (For repeat procedures on the same day,
see
modifier 76.)
(n)
79: Unrelated Procedure or
			 Service by the Same Physician or Other Qualified Health Care Professional
			 during the Postoperative Period
. The physician or other qualified
			 health care professional may need to indicate that the performance of a
			 procedure or service during the postoperative period was unrelated to the
			 original procedure. This circumstance may be reported by using modifier 79 or
			 by using the separate five-digit modifier 09979. (For repeat procedures on the
			 same day,
see
modifier 76.)
(o)
80: Assistant
			 Surgeon
. Surgical assistant services may be identified by adding
			 modifier 80 to the usual procedure code. (This allows payment of 15% of the
			 allowable fee contained in
			 101
			 CMR 316.05(4)(b), adjusted
			 by 101 CMR 316.03 as applicable,
			 to the eligible assistant surgeon.)
(p)
82: Assistant Surgeon (when
			 qualified resident surgeon not available)
. Surgical assistant
			 services may be identified by adding modifier 82 to the usual procedure code
			 when a qualified resident surgeon is not available. (This allows payment of 15%
			 of the allowable fee contained in
			 101
			 CMR 316.05(4)(b), adjusted
			 by 101 CMR 316.03 as applicable,
			 to the eligible assistant surgeon.)
(q)
AA: Anesthesia Services
			 Performed Personally by an Anesthesiologist
. This allows payment
			 of 100% of the Total Anesthesia Fee for the anesthesiologist's
			 services.
(r)
AS:
			 Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services
			 for Assistance at Surgery
. This allows payment of 15% of the
			 allowable fee contained in
			 101
			 CMR 316.05(4)(b), adjusted
			 by 101 CMR 316.03 as applicable,
			 for services of the eligible physician assistant, certified nurse practitioner,
			 or clinical nurse specialist assisting in surgery.
(s) E1: Upper left, eyelid.
(t) E2: Lower left, eyelid.
(u) E3: Upper right, eyelid.
(v) E4: Lower right, eyelid.
(w) F1: Left hand, second digit.
(x) F2: Left hand, third digit.
(y) F3: Left hand, fourth digit.
(z) F4: Left hand, fifth digit.
(aa) F5: Right hand, thumb.
(bb) F6: Right hand, second digit.
(cc) F7: Right hand, third digit.
(dd) F8: Right hand, fourth digit.
(ee) F9: Right hand, fifth digit.
(ff) FA: Left hand, thumb.
(gg) LC: Left circumflex coronary
			 artery.
(hh) LD: Left anterior
			 descending coronary artery.
(ii)
			 LT: Left side: Used to identify procedures performed on the left side of the
			 body.
(jj)
PA: Surgical
			 or Other Invasive Procedure Performed on the Wrong Body Part
. This
			 modifier is applied to report Provider Preventable Conditions in accordance
			 with 42 CFR
			 447.26 and results in nonpayment for
			 services.
(kk)
PB:
			 Surgical or Other Invasive Procedure Performed on the Wrong
			 Patient
. This modifier is applied to report Provider Preventable
			 Conditions in accordance with
			 42 CFR
			 447.26 and results in nonpayment for
			 services.
(ll)
PC:
			 Wrong Surgical or Other Invasive Procedure Performed on a Patient
.
			 This modifier is applied to report Provider Preventable Conditions in
			 accordance with 42 CFR
			 447.26 and results in nonpayment for
			 services.
(mm)
QK:
			 Medical Direction by a Physician of Two, Three, or Four Concurrent Anesthesia
			 Procedures
. Used to indicate physician medical direction of
			 multiple CRNAs. This allows payment of 50% of the Total Anesthesia Fee for the
			 physician's services.
(nn)
QY: Medical Direction of One CRNA by a Physician
. Used
			 to indicate physician medical direction of one CRNA. This allows payment of 50%
			 of the Total Anesthesia Fee for the physician's services.
(oo)
QX: CRNA Anesthesia Services
			 with Medical Direction by a Physician
. Used to indicate CRNA
			 anesthesia services with medical direction by a physician. This allows payment
			 of 50% of the Total Anesthesia Fee for the CRNA's services. Not for use if CRNA
			 is employed by the facility in which the anesthesia services were
			 performed.
(pp)
QZ:
			 CRNA Anesthesia Services without Medical Direction by a Physician
.
			 This allows payment of 100% of the Total Anesthesia Fee for the CRNA's
			 services. Not for use if CRNA is employed by the facility in which the
			 anesthesia services were performed.
(qq)
RC: Right Coronary
			 Artery
.
(rr)
RT: Right Side
: Used to identify procedures performed
			 on the right side of the body.
(ss)
SA: Nurse Practitioner Rendering Service in Collaboration with a
			 Physician
. This modifier is to be applied to service codes billed
			 by a physician that were performed by a certified nurse practitioner employed
			 by the physician (the physician employer must be practicing as an individual
			 and not practicing as a professional corporation or as a member of a group
			 practice. A certified nurse practitioner billing under his or her own
			 individual provider number, or a group practice, should not use this
			 modifier.
(tt) T1: Left foot,
			 second digit.
(uu) T2: Left foot,
			 third digit.
(vv) T3: Left foot,
			 fourth digit.
(ww) T4: Left foot,
			 fifth digit.
(xx) T5: Right foot,
			 great toe.
(yy) T6: Right foot,
			 second digit.
(zz) T7: Right foot,
			 third digit.
(aaa) T8: Right foot,
			 fourth digit.
(bbb) T9: Right foot,
			 fifth digit.
(ccc) TA: Left foot,
			 great toe.
(ddd)
TC:
			 Technical Component
. The component of a service or procedure
			 representing the cost of rent, equipment, utilities, supplies, administrative
			 and technical salaries and benefits, and other overhead expenses of the service
			 or procedures, excluding the physician's professional component. (When the
			 technical component is reported separately, the addition of modifier TC to the
			 procedure code will allow payment of the technical component allowable fee (TC
			 Fee) contained in
			 101
			 CMR 316.05(4)(b), adjusted
			 by 101 CMR 316.03 as
			 applicable.)
(eee)
E:
			 Separate Encounter
. A service that is distinct because it occurred
			 during a separate encounter.
(fff)
XS: Separate Structure
. A service that is distinct
			 because it was performed on a separate organ/structure.
(ggg)
XP: Separate
			 Practitioner
. A service that is distinct because it was performed
			 by a different practitioner.
(hhh)
XU: Unusual Non-overlapping Service
. The use of a
			 service that is distinct because it does not overlap usual components of the
			 main service.