reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 423.000 establishes
				the requirements for the provision and payment of freestanding ambulatory
				surgery center services under the MassHealth Program. The MassHealth agency
				pays for freestanding ambulatory surgery center services that are medically
				necessary and appropriately provided in the most cost-effective setting; that
				is, the total cost of the service (for example, the rate of payment for the
				corresponding payment group including directly related ancillaries, plus the
				cost of prosthetic devices or implants) does not exceed the cost to the
				MassHealth agency of providing that same service in any other medically
				appropriate setting, as determined by the MassHealth agency or its agent. The
				quality of the services delivered to MassHealth members must meet
				professionally recognized standards of care.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR 423.000 have the
				meanings given in 130 CMR 423.402, unless the context clearly requires a
				different meaning. The reimbursability of services defined in
				130 CMR 423.000 is not
				determined by these definitions, but by application of regulations elsewhere in
				130 CMR 423.000 and
				450.000:
Administrative and Billing Regulations
.
Freestanding Ambulatory Surgery Center
-- a facility, geographically independent of any other health-care facility,
				that operates autonomously and functions exclusively for the purpose of
				providing outpatient same-day surgical, diagnostic, and medical services
				requiring a dedicated operating room and a postoperative recovery room. These
				surgical, diagnostic, and medical services provide diagnosis or treatment
				through operative procedures requiring general, local, or regional anesthesia
				to patients who do not require hospitalization or overnight services upon
				completion of the procedure, but who require constant medical supervision for a
				limited amount of time following the conclusion of the procedure. A
				freestanding ambulatory surgery center does not include individual or
				group-practice offices of private physicians, dentists, or podiatrists.These
				centers are referred to as surgical centers in 130 CMR 423.000.
Individual Consideration
-- a
				designation given to a claim that will receive individual consideration (I.C.)
				to determine payment where a fee could not be established.
Institutionalized Individual
- an
				individual who is
(1) involuntarily confined or detained, under a civil or
				criminal statute, in a correctional or rehabilitative facility, including a
				psychiatric hospital or other facility for the care and treatment of mental
				illness; or
(2) confined under a voluntary commitment, in a psychiatric
				hospital or other facility for the care and treatment of mental illness.
Mentally Incompetent Individual
- an
				individual who has been declared mentally incompetent by a federal, state, or
				local court of competent jurisdiction for any purpose, unless the individual
				has been declared competent for purposes which include the ability to consent
				to sterilization.
Operative Report
-- a report that
				states the operation performed, the name of the recipient, the date of the
				operation, the preoperative diagnosis, the postoperative diagnosis, the names
				of the surgeon and his or her assistants, and the technical procedures
				performed.
Sterilization
- any medical procedure,
				treatment, or operation for the purpose of rendering an individual permanently
				incapable of reproducing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
MassHealth Members and Recipients of Emergency Aid to the Elderly,
			 Disabled and Children Program
.
(1)
MassHealth
			 Members
. The MassHealth agency pays for freestanding ambulatory
			 surgical center services only when provided to eligible MassHealth members,
			 subject to the restrictions and limitations described in the MassHealth
			 regulations.
			 130 CMR 450.105:
Coverage Types
, specifically states, for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of Emergency Aid to the Elderly, Disabled and Children
			 Program
. For information on covered services for recipients of the
			 Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for the services described in
				130 CMR 423.000 will be
				made only to in-state and out-of-state surgical centers participating in
				MassHealth on the date of service. The MassHealth agency has established the
				provider eligibility requirements listed below for in-state and out-of-state
				providers. Providers must meet all of these requirements to participate in
				MassHealth as a surgical center.
(A)
Procedures for Hospitalization
. An in-state or
			 out-of-state surgical center must have established procedures to ensure the
			 transfer of a member to a hospital if an emergency occurs that requires
			 treatment beyond the capabilities of the surgical center. Either the surgical
			 center must have a written transfer agreement with a hospital, or all the
			 dentists, physicians, and podiatrists with surgical privileges at the surgical
			 center must have admitting privileges at the hospital. The hospital must be a
			 MassHealth-participating provider, and must be licensed to operate as a
			 hospital in accordance with
			 105 CMR
			 130.000:
Hospital Licensure
or with
			 its own state's licensing agency.
(B)
In-state
			 Providers
. To participate in MassHealth, an in-state surgical
			 center must:
(1) obtain a MassHealth provider
			 number from the MassHealth agency;
(2) operate under a clinic license issued by
			 the Massachusetts Department of Public Health, in accordance with
			 105 CMR
			 140.000:
Licensure of
			 Clinics
;
(3) participate
			 in the Medicare program as an ambulatory surgery center;
(4) be accredited by a national accrediting
			 body for ambulatory surgery centers; and
(5) have a minimum of two dedicated operating
			 rooms.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.405 - Payment

Current through Register 1525, July 5, 2024
Payment for a surgical procedure performed at a surgical center
				consists of two components: the facility component and the professional
				component.
(A)
Facility
			 Component
. The facility component is an all-inclusive fee that
			 pays the surgical center for rent, equipment, utilities, supplies, salaries and
			 benefits for administrative and technical staff, and other overhead expenses.
(1) This fee includes payment for
(a) surgical center facilities and
			 equipment;
(b) nursing services,
			 technician services, and other related services;
(c) drugs, biologicals, surgical dressings,
			 supplies, splints, casts, appliances, and equipment directly related to the
			 provision of the surgical procedures;
(d) administrative, recordkeeping, and
			 housekeeping items and services;
(e) materials for anesthesia;
(f) blood;
(g) urinalysis and blood hemoglobin and
			 hematocrit; and
(h) diagnostic or
			 therapeutic services related to the provision of the surgical
			 procedure.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.406 - Prior Authorization

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency requires the surgeon to obtain prior authorization for services that are
			 designated "P.A." listed in Subchapter 6 of the
Freestanding Ambulatory
			 Surgery Center Manual
. No payment will be made for such services
			 unless prior authorization has been obtained from the MassHealth agency before
			 the delivery of service. The MassHealth agency will not grant retroactive
			 prior-authorization requests.
(B)
			 Prior authorization determines only the medical necessity of the authorized
			 service and does not establish or waive any other prerequisites for payment
			 such as, but not limited to, member eligibility or resort to health insurance
			 payment.
(C) MassHealth regulations
			 about prior-authorization requirements may be found in the individual program
			 regulations for dentists, podiatrists, and physicians at
			 130 CMR
			 420.000:
Dental Services
, 424.000:
Podiatrist Services
, and 433.000:
Physician
			 Services
, respectively.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.407 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary surgery
				center services for EPSDT-eligible members in accordance with
				130
				CMR 450.140:
Early and Periodic
				Screening, Diagnosis and Treatment (EPSDT) Services: Introduction
through 450.149:
EPSDT: Recordkeeping Requirements
, without
				regard to service limitations described in
				130 CMR 423.000, and with
				prior authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.414 - Payable Surgical Procedures

Current through Register 1525, July 5, 2024
The MassHealth agency pays surgical centers for those services
				listed in Subchapter 6 of the
Freestanding Ambulatory Surgery Center
				Manual
(
see
130 CMR 423.401 for
				further requirements). All prosthetic devices, except intraocular lenses,
				whether implanted, inserted, or otherwise related to procedures on the current
				list of payable surgical procedures, are paid separately from the surgical
				center facility component. 130 CMR 423.414 notwithstanding, providers must
				comply with the requirements specified in
				130 CMR 423.401,
				which state that payment is provided only for services that are medically
				necessary and furnished in the least costly medically appropriate
				setting.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.415 - Service Limitations

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency does not pay for experimental, unproven, cosmetic, or otherwise
			 medically unnecessary procedures or treatments performed at the
			 center.
(B) The MassHealth agency
			 does not pay a surgical center for the treatment of male or female infertility
			 (including, but not limited to, laboratory tests, drugs, and procedures
			 associated with such treatment); however, the MassHealth agency will pay a
			 surgical center for diagnosis of male or female infertility.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.416 - Sterilization Services: Introduction

Current through Register 1525, July 5, 2024
(A)
Covered Services
. The MassHealth agency pays for
			 sterilization services provided to a member only if all of the following
			 conditions are met.
(1) The member has
			 voluntarily given informed consent for the sterilization procedure in the
			 manner and at the time described in
			 130 CMR
			 423.417, and such consent is documented in
			 the manner described in
			 130 CMR
			 423.418.
(2) The member is 18 of age or older at the
			 time consent is obtained.
(3) The
			 member is not a mentally incompetent individual or an institutionalized
			 individual.
(4) The sterilization
			 is performed by a licensed physician.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.417 - Sterilization Services: Informed Consent

Current through Register 1525, July 5, 2024
A member's consent for sterilization will be considered
				informed and voluntary only if such consent is obtained in accordance with the
				requirements specified in 130 CMR 423.417(A) and (B), and such consent is
				documented as specified in
				130 CMR
				423.418.
(A)
Informed Consent
			 Requirements
.
(1) The person who
			 obtains consent (a physician, nurse, or counselor, for example) must orally
			 provide all of the following information and advice to the member requesting
			 sterilization:
(a) advice that the recipient
			 is free to withhold or withdraw consent for the procedure at any time before
			 the sterilization without affecting the right to future care or treatment and
			 without loss of any federal- or state-funded program benefits to which the
			 member otherwise might be entitled;
(b) a description of available alternative
			 methods of family planning and birth control;
(c) advice that the sterilization procedure
			 is considered irreversible;
(d) a
			 thorough explanation of the specific sterilization procedure to be
			 performed;
(e) a full description
			 of the discomforts and risks that may accompany or follow the procedure,
			 including an explanation of the type and possible effects of any anesthetic to
			 be used;
(f) a full description of
			 the benefits or advantages that may be expected as a result of the
			 sterilization; and
(g) advice that
			 the sterilization will not be performed for at least 30 days, except under the
			 circumstances specified in 130 CMR 423.417(B)(1).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.418 - Sterilization Services: Consent Form Requirements

Current through Register 1525, July 5, 2024
Informed consent for sterilization must be documented by the
				completion of the MassHealth agency's Consent for Sterilization form in
				accordance with the following requirements. (Instructions for obtaining the
				Consent for Sterilization forms are located in Subchapter 5 of the
Freestanding Ambulatory Surgery Center Manual
.)
(A)
Required Consent
			 Form
.
(1) One of the following
			 Consent for Sterilization forms must be used:
(a) CS-18 - for members 18 through 20 years
			 of age; or
(b) CS-21 - for members
			 21 years of age or older.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers › Section 423.419 - Abortion Services

Current through Register 1525, July 5, 2024
(A) Abortions may be
			 performed in a surgical center in accordance with M.G.L. c. 112, § 12I
			 through 12N, inserted by St. 1974, c. 706, and with license rules and
			 regulations of the Massachusetts Department of Public Health.
(B) A surgeon must certify that the abortion
			 is medically necessary by completion of the Certification for Payable Abortion
			 (CPA-2) form. The surgeon must comply with
			 130 CMR
			 433.000:
Physician
			 Services
.
(C) All surgical
			 centers must attach a completed CPA-2 form to each claim form submitted to the
			 MassHealth agency for a payable abortion. (Instructions for obtaining the CPA-2
			 form can be found in Subchapter 5 of the
Freestanding Ambulatory
			 Surgery Center Manual
.) The surgical center must attach a copy of the
			 completed CPA-2 form with each claim made to the MassHealth agency for a
			 payable abortion. Service codes requiring a CPA-2 form are indicated in
			 Subchapter 6 of the
Freestanding Ambulatory Surgery Center
			 Manual
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.401 - Introduction

Current through Register 1525, July 5, 2024
All podiatrists participating in MassHealth must comply with
				the MassHealth regulations, including but not limited to regulations set forth
				in
				130 CMR
				424.000 and
				450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR
				424.000 have the meanings given in 130 CMR 424.402,
				unless the context clearly requires a different meaning. The reimbursability of
				services defined in
				130 CMR
				424.000 is not determined by these definitions, but by
				application of regulations elsewhere in
				130 CMR
				424.000 and
				450.000:
Administrative and Billing Regulations
.
Corrective Devices
- orthotics,
				splints, inlays, appliances, and braces that support or accommodate part or all
				of the foot and serve to restore or improve functions of the foot.
Custom-molded Shoe
- an individually
				patterned shoe fabricated to meet the specific needs of an individual. A
				custom-molded shoe is not off-the-shelf, stock, or prefabricated. The shoe is
				individually constructed by a molded process over a modified positive model of
				the individual's foot. It is made of leather or other suitable material of
				equal quality, has removable customized inserts that can be replaced if
				necessary according to the individual's condition, and has some form of shoe
				closure.
Drug
- a substance containing one or
				more active ingredients in a specified dosage form and strength. Each dosage
				form and strength is a separate drug.
Emergency
- a sudden or unexpected
				illness or injury or traumatic injury or infection other than athlete's foot or
				chronic mycosis infecting the nail bed that must be treated promptly to prevent
				severe pain to the member.
Flexible Adhesive Casting
- the
				application of adhesive tape to orthopedically support or stabilize the foot,
				or to exert beneficial stress for a structural instability.
Hygienic Foot Care
- the trimming of
				nonpathogenic nails; the cleansing or soaking of the feet; the use of skin
				creams to maintain skin tone of both ambulatory and bedridden patients; or such
				other foot care that can be performed by the member or by the nursing facility
				staff if the member resides in a nursing facility.
Last
- a model that approximates the
				shape and size of the foot and over which a shoe is made. A last is usually
				made of wood, plastic, or plaster.
Moldable Shoes
- off-the shelf,
				ready-made shoes formed from heat-activated materials. The shoes are molded by
				a thermo-forming process that first heats the material, then forms it over an
				individual's foot or a positive model of the individual's foot.
Nonstandard Size (Width or Length)
- a
				shoe size made on a standard last pattern, but which is not part of a
				manufacturer's regular inventory.
Orthopedic Shoes
- shoes that are
				specially constructed to aid in the correction of a deformity of the
				musculoskeletal structure of the foot and to preserve or restore the function
				of the musculoskeletal system of the foot.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. The MassHealth agency covers podiatry services only when
			 provided to eligible MassHealth members, subject to the restrictions and
			 limitations described in MassHealth regulations.
			 130 CMR 450.105:
Coverage Types
specifically states, for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of the Emergency Aid to the Elderly, Disabled and
			 Children Program
. For information on covered services for
			 recipients of the Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for services described in
				130 CMR
				424.000 is made only to providers who are
				participating in MassHealth on the date the service was provided or who are
				otherwise eligible for such payment pursuant to
				130 CMR 450.000:
Administrative and Billing Regulations
and who meet the
				requirements of 130 CMR 424.404(A) and (B).
(A)
In-state
. A
			 podiatrist practicing in Massachusetts must be licensed by the Massachusetts
			 Board of Registration in Podiatry.
(B)
Out-of-state
. An
			 out-of-state podiatrist must be licensed by that state's board of registration
			 for podiatrists. The MassHealth agency pays an out-of-state podiatrist only
			 when services are provided to an eligible Massachusetts member under the
			 following circumstances:
(1) the podiatrist
			 practices outside the Massachusetts border and provides emergency services to a
			 member;
(2) the podiatrist
			 practices in a community of Connecticut, Maine, New Hampshire, New York, Rhode
			 Island, or Vermont that is within 50 miles of the Massachusetts border and
			 provides services to a member who resides in a Massachusetts community near the
			 border of that state; or
(3) the
			 podiatrist provides services to a member who is authorized to reside out of
			 state by the Massachusetts Department of Social Services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.405 - Noncovered Services

Current through Register 1525, July 5, 2024
The MassHealth agency does not pay for the following:
(1) hygienic foot care as a separate
			 procedure, except when the member's medical record documents that the member
			 cannot perform the care or risks harming himself or herself by performing it.
			 The preceding sentence notwithstanding, payment for hygienic foot care
			 performed on a resident of a nursing facility is included in the nursing
			 facility's
per diem
rate and is not reimbursable in any case
			 as a separate procedure;
(2)
			 canceled or missed appointments;
(3) services provided by a podiatrist whose
			 contractual arrangements with a state institution, acute, chronic, or
			 rehabilitation hospital, medical school, or other medical institution involve a
			 salary, compensation in kind, teaching, research, or payment from any other
			 sources, if such payment would result in dual compensation for professional,
			 supervisory, or administrative services related to member care;
(4) telephone consultations;
(5) in-service education;
(6) research or experimental
			 treatment;
(7) cosmetic services or
			 devices;
(8) sneakers or athletic
			 shoes;
(9) an additional charge for
			 nonstandard size (width or length) in custom-molded shoes; or (10) shoes when
			 there is no diagnosis of associated foot deformities.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.406 - Maximum Allowable Fees

Current through Register 1525, July 5, 2024
The Massachusetts Division of Health Care Finance and Policy
				(DHCFP) determines the maximum allowable fees for podiatry services. Payment is
				always subject to the conditions, exclusions, and limitations set forth in
				130 CMR
				424.000,
				442.000, and
				450.000. Payment for a
				service is the lowest of:
(A) the
			 provider's usual and customary fee;
(B) the provider's actual charge;
			 or
(C) the maximum allowable fee
			 listed in the applicable DHCFP fee schedule.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.407 - Individual Consideration

Current through Register 1525, July 5, 2024
(A) Some services
			 listed in Subchapter 6 of the
Podiatrist Manual
are designated
			 "I.C.," an abbreviation for individual consideration. Individual-consideration
			 means that a fee could not be established. Payment for an
			 individual-consideration service will be determined by the Division's
			 professional advisors based on the podiatrist's descriptive report of the
			 service furnished.
(B) To receive
			 payment for an individual-consideration service, the podiatrist must submit
			 with the claim a report that contains the diagnosis, a description of the
			 condition of the foot, and the length of time spent with the member.
(C) Determination of the appropriate payment
			 for an individual-consideration service is in accordance with the following
			 criteria:
(1) the amount of time required to
			 perform the service;
(2) the degree
			 of skill required to perform the service;
(3) the severity and complexity of the
			 member's disease, disorder, or disability;
(4) the policies, procedures, and practices
			 of other third-party insurers, both governmental and private;
(5) prevailing professional ethics and
			 accepted customs of the podiatric community; and
(6) such other standards and criteria as may
			 be adopted from time to time by DHCFP or the Division.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.408 - Referral

Current through Register 1525, July 5, 2024
When, during an examination or as a result of laboratory tests,
				a podiatrist discovers a debilitating or systemic disease (such as diabetes
				mellitus or ischemia caused by circulatory deficiency), the podiatrist must
				inform the member that a physician evaluation is necessary and must document
				this referral in the member's medical record.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.409 - Recordkeeping (Medical Records) Requirements

Current through Register 1525, July 5, 2024
Payment for any service listed in
				130 CMR
				424.000 is conditioned upon its full and complete
				documentation in the member's medical record.
(A) The medical record must contain
			 sufficient data to fully document the nature, extent, and necessity of the care
			 furnished to a member for each date of service claimed for payment, as well as
			 any data that will update the member's medical course. The data maintained in
			 the medical record must also be sufficient to justify any further diagnostic
			 procedures, treatments, and recommendations for return visits or
			 referrals.
(B) Although basic data
			 collected during previous visits (for example, identifying data, chief
			 complaint, or history) do not need to be repeated in the member's medical
			 record for subsequent visits, the medical records of each service provided by a
			 podiatrist at any location must include, but not be limited to:
(1) the member's name and date of
			 birth;
(2) the date of each
			 service;
(3) the reason for the
			 visit;
(4) the name and title of
			 the person performing the service;
(5) the member's medical history;
(6) the diagnosis or chief
			 complaint;
(7) a clear indication
			 of all findings, whether positive or negative, on examination;
(8) any medications administered or
			 prescribed, including strength, dosage, route, regimen, and duration of
			 use;
(9) a description of any
			 treatment given;
(10)
			 recommendations for additional treatments or consultations, when
			 applicable;
(11) any medical goods
			 or supplies dispensed or prescribed;
(12) any tests administered and their
			 results;
(13) documentation of a
			 treatment plan if subsequent visits are expected;
(14) documentation, when applicable, that the
			 member was informed of the necessity of a physician evaluation; and
(15) MassHealth Shoe Medical Necessity Form
			 (if applicable).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.410 - Report Requirements

Current through Register 1525, July 5, 2024
(A)
General Report
. A general written report or a
			 discharge summary must accompany the podiatrist's claim for payment when the
			 service is designated "I.C." in Subchapter 6 of the
Podiatrist
			 Manual
or when a service code for an unlisted procedure is used. This
			 report must be sufficiently detailed to enable professional advisors to assess
			 the extent and nature of the services.
(B)
Operative
			 Report
. For surgery procedures designated "I.C." in Subchapter 6
			 of the
Podiatrist Manual
, operative notes must accompany the
			 podiatrist's claim. An operative report must state the operation performed, the
			 name of the member, the date of the operation, the preoperative diagnosis, the
			 postoperative diagnosis, the names of the podiatrist and his or her assistants,
			 and the technical procedures performed.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.411 - Office Visits

Current through Register 1525, July 5, 2024
The MassHealth agency pays for four types of office visits:
				initial, limited, extended, and follow-up. The fees vary depending on the type
				of visit.
(A) The MassHealth agency
			 pays for one initial visit (the member's first visit to a podiatrist) per
			 member. This visit must include an initial comprehensive history, results of
			 laboratory tests or other findings, whether positive or negative, and
			 identification of both podiatric and general medical problems through vascular,
			 orthopedic, neurological, dermatological, and musculoskeletal examination. The
			 fee for an initial visit includes necessary treatment for relief of
			 symptoms.
(B) The MassHealth agency
			 pays for one limited visit per member within a 30-day period. A limited visit
			 must include an interval history and examination and treatment of the foot,
			 which may include removal of excrescences; palliative and prophylactic onychial
			 care; treatment of hypertrophied toenails; and electroburring when the record
			 documents that the member has a localized illness, injury, or symptoms
			 involving the foot, including diabetes or peripheral vascular
			 disease.
(C) The MassHealth agency
			 pays for one extended visit per member within a 30-day period. An extended
			 visit must include the application of flexible adhesive casting, minor
			 modification to shoes, or electric modality physiotherapy. An extended visit
			 may also include the removal of excrescences, palliative and prophylactic
			 onychial care, treatment of hypertrophied or ingrown nails (or both), and other
			 comparable procedures.
(D) The
			 MassHealth agency pays for one follow-up visit per member per week. A follow-up
			 visit is a return visit for a specific diagnosis (such as warts or an ulcer) in
			 which a brief procedure, such as a dressing change, debridement, or removal of
			 sutures, is performed.
(E) Payment
			 for the removal of an ulcerated keratosis is included in the fees for any type
			 of visit and must not be billed for separately.
(F) The MassHealth agency pays for either an
			 office visit or a treatment or surgical procedure for the same member on the
			 same date of service but not both.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.412 - Out-of-office Visits

Current through Register 1525, July 5, 2024
The MassHealth agency pays for podiatric care provided in a
				hospital, a member's home, or a long-term-care facility only when the following
				conditions are met.
(A) Podiatric care
			 provided in any of the above settings is designed to treat a diagnosed
			 condition, to minimize bed confinement, and to increase the member's
			 activity.
(B) The podiatrist
			 performs and documents a complete evaluation and all necessary treatment for
			 relief of the member's symptoms or for the diagnosed condition.
(C) If further treatment is required, the
			 podiatrist formulates a treatment plan and includes it in the member's medical
			 record. This plan must justify any further diagnostic procedures, additional
			 treatment, return visits, or referrals and must include the following
			 information:
(1) a diagnosis of the member's
			 podiatric condition;
(2) results of
			 X rays and other diagnostic tests, if performed; and
(3) a description of treatment provided and
			 recommendations for additional treatment.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.413 - Surgery Services: Introduction

Current through Register 1525, July 5, 2024
Surgical procedures must be performed in a podiatrist's office,
				in a hospital, or in a freestanding ambulatory surgical center.
(A)
Provider
			 Eligibility
. The MassHealth agency pays a podiatrist for surgery
			 only if the podiatrist is scrubbed and present in the operating room during the
			 major portion of the operation.
(B)
Nonpayable Services
. The MassHealth agency does not
			 pay for
(1) any experimental, unproven,
			 cosmetic, or otherwise medically unnecessary procedure or treatment;
(2) reconstructive surgery, unless the
			 MassHealth agency determines, pursuant to a request for prior authorization,
			 the service is medically necessary to correct, repair, or ameliorate the
			 physical effects of disease or physical defect, or traumatic injury;
(3) services billed under codes listed in
			 Subchapter 6 of the Podiatrist Manual as not payable;
(4) services otherwise identified in
			 MassHealth regulations at
			 130 CMR
			 424.000 or
			 450.000: Administrative and
			 Billing Regulations as not payable; and
(5) services billed with otherwise-covered service codes when such
			 codes are used to bill for nonpayable services as described in
			 130 CMR
			 424.405.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.414 - Recordkeeping (Medical Records) Requirements

Current through Register 1525, July 5, 2024
Surgical services and other invasive procedures are treated as
				separate surgeries and paid as multiple surgeries pursuant to 130 CMR
				424.414(C). The MassHealth agency pays for all medicine and surgery CPT codes
				in effect at the time of service, except for those codes listed in Section 602
				of Subchapter 6 of the
Podiatrist Manual
, subject to all
				conditions and limitations described in MassHealth regulations at
				130 CMR
				424.000 and
				450.000.
(A)
Visit and Treatment/Procedure
			 on Same Day in Same Location
. The MassHealth agency pays a
			 podiatrist for either a visit or a treatment/procedure, whichever fee is
			 greater. The MassHealth agency does not pay for both a preoperative evaluation
			 and management visit, and a treatment/procedure provided to a member on the
			 same day when they are performed in the same location. For minor surgeries and
			 endoscopies, the MassHealth agency does not pay separately for an evaluation
			 and management service on the same day as the surgery or endoscopy.
(B)
Payment for Global Surgical
			 Package
. The payment for a surgical procedure includes a standard
			 package of preoperative, intraoperative, and postoperative services. The
			 services are included in the global surgical package regardless of setting,
			 including but not limited to hospitals, ambulatory surgical centers, and
			 podiatrists' offices.
(1) The following
			 services are included in the payment for a global surgery when furnished by the
			 podiatrist who performs the surgery:
(a)
			 preoperative visits;
(b)
			 intraoperative visits;
(c)
			 complications following surgery;
(d) postoperative visits;
(e) postsurgical pain management;
(f) miscellaneous services related to
			 surgery, including but not limited to dressing changes; local incisional care;
			 removal of operative pack, cutaneous sutures and staples, lines, wires, tubes,
			 drains, casts, and splints; insertion, irrigation, and removal of urinary
			 catheters, routine peripheral intravenous lines, nasogastric tubes, and rectal
			 tubes; and changes and removal of tracheostomy tubes; and
(g) visits related to the surgery to a
			 patient in an intensive care or critical care unit, if made by the podiatrist.
			 Intensive or critical care visits unrelated to surgery are not included in the
			 global surgical package.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.415 - Radiology Services

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency pays for radiology services when the services are needed to confirm the
			 diagnosis of a bony or calcific disorder, to detect soft-tissue disorders, or
			 to detect foreign bodies.
(B)
			 Payment for radiology services is not included in the fees for visits and
			 should be claimed separately.
(C)
			 All radiology equipment used in providing these services must be inspected and
			 approved by the Massachusetts Department of Public Health.
(D) The MassHealth agency pays a podiatrist
			 for radiology services only when the service is provided in the podiatrist's
			 office and only when the films are developed and read in the podiatrist's
			 office.
(E) All X rays must be
			 labeled with the member's name, the date of examination, and the nature of the
			 examination in addition to the information required in
			 130 CMR
			 424.409.
(F) The MassHealth agency pays one maximum
			 allowable fee for a routine study of a particular section of an extremity
			 regardless of the number of X-ray views. An additional fee may be claimed only
			 when a comparison study is necessary.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.416 - Clinical Laboratory Services

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency pays the podiatrist only for laboratory tests listed in the
Podiatrist Manual
and only when the tests are administered and
			 analyzed in the podiatrist's office. The MassHealth agency pays a certified
			 independent clinical laboratory or hospital-licensed clinical laboratory if the
			 laboratory tests are performed at the clinical laboratory.
(B) The MassHealth agency pays for clinical
			 laboratory tests that are necessary for the diagnosis or treatment of
			 conditions of the foot only.
(C)
			 Only the following laboratory tests may be administered without prior
			 authorization:
(1) complete blood count or
			 any of the separate components of such an analysis, including red cell count,
			 white cell count, or hemoglobin;
(2) hematocrit;
(3) fungus culture;
(4) sensitivity, culture, and colony
			 count;
(5) fasting blood
			 sugar;
(6) platelet
			 count;
(7) uric acid;
(8) complete urinalysis; and
(9) combination urinary dip stick (pH, blood,
			 ketones, glucose, nitrites).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.417 - Pharmacy Services: Drugs Dispensed in Pharmacies

Current through Register 1525, July 5, 2024
Coverage of drugs and medical supplies dispensed to MassHealth
				members by MassHealth pharmacy providers and related prescription requirements
				for prescribing clinicians, are governed by
				130 CMR
				406.000:
Pharmacy
				Services
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.423 - Drugs Administered in the Office (Physician-administered Drugs)

Current through Register 1525, July 5, 2024
(A)
Payment
.
(1) Drugs and biologicals administered in the
			 office are payable, subject to the exclusions and service limitations at
			 130 CMR
			 424.405,
			 424.407,
			 and
			 130 CMR
			 406.413(B):
Drug
			 Exclusions
and (C):
Service Limitations
.
(2) The MassHealth agency does not pay a
			 podiatrist separately for drugs that are considered routine and integral to the
			 delivery of a podiatrist's professional services in the course of diagnosis or
			 treatment. Such drugs are commonly provided without charge or are included in
			 the podiatrist fee for the service.
(3) The MassHealth agency does not pay
			 separately for any oral drugs administered in the office for which the
			 podiatrist has not requested and received prior authorization from the
			 MassHealth agency, with the exception of oral vaccines and oral
			 radiopharmaceuticals, which do not require prior authorization.
(4) Claims for drugs and biologicals that are
			 listed in Subchapter 6 of the
Podiatrist Manual
must include
			 the name of the drug or biological, strength, dosage, and number of HCPCS units
			 dispensed, NDC code, NDC units and NDC unit of measurement. In addition, for
			 drugs and/or biologicals that are listed as requiring individual consideration
			 in Subchapter 6 of the
Podiatrist Manual
a copy of the invoice
			 showing the actual acquisition cost must be attached to the claim form, Claims
			 without this information are denied.
(5) The MassHealth agency pays only for
			 prescription drugs that are approved by the U.S. Food and Drug Administration
			 and manufactured by companies that have signed rebate agreements with the U.S.
			 Secretary of Health and Human Services pursuant to
			 42 U.S.C.
			 1396r-8. Payment is calculated in accordance
			 with 101 CMR 331.00:
Medicine
.
(6) Payment for drugs may be claimed in
			 addition to an office visit.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.424 - Shoes and Corrective Devices

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency pays for only those shoes listed in Subchapter 6 of the
Podiatrist Manual
.
(B) For shoes, providers must submit with
			 their claim a copy of the applicable completed MassHealth Orthotic and
			 Prosthetic Prescription and Medical Necessity Form.
(C) The MassHealth agency does not pay for
			 casting materials used in the molding of orthotic shoes or corrective devices.
			 The cost of these materials is included in the fee for prescribing and
			 providing the shoe or corrective device.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 424.000 - Podiatrist Services › Section 424.425 - Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Current through Register 1525, July 5, 2024
The MassHealth agency pays for all medically necessary podiatry
				services for EPSDT-eligible members in accordance with 130 CMR 450.140:
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services:
				Introduction
, without regard to service limitations described in
				130 CMR
				424.000, and with prior
				authorization.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 425.000 contains
				regulations governing psychiatric inpatient hospital services under MassHealth.
				All psychiatric inpatient hospitals participating in MassHealth must comply
				with the MassHealth regulations, including, but not limited to,
				130 CMR 425.000 and
				450.000:
Administrative and Billing Regulations.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A)
(1)
MassHealth
			 Members
. MassHealth covers psychiatric inpatient hospital services
			 only when provided to eligible MassHealth members, subject to the restrictions
			 and limitations described in the MassHealth regulations.
			 130 CMR 450.105:
Coverage Types
specifically states, for each MassHealth
			 coverage type, which services are covered and which members are eligible to
			 receive those services.
(2)
Recipients of the Emergency Aid to the Elderly, Disabled and
			 Children Program
. For information on covered services for
			 recipients of the Emergency Aid to the Elderly, Disabled and Children Program,
see
130 CMR
			 450.106:
Emergency Aid to the
			 Elderly, Disabled and Children Program.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.404 - Exclusion of MassHealth Managed Care Members

Current through Register 1525, July 5, 2024
130 CMR 425.000 does not
				apply to members participating in a MassHealth managed care plan. Participation
				in a MassHealth managed care plan is subject to change. Providers are
				responsible to verify member status on a daily basis. For more information,
see
130 CMR 450.117:
Managed Care Participation.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.405 - Provider Eligibility

Current through Register 1525, July 5, 2024
Payment for the services described in
				130 CMR 425.000 will be
				made only to psychiatric inpatient hospitals participating in MassHealth on the
				date of service.
(A)
In
			 State
. To participate in MassHealth, an in-state psychiatric
			 inpatient hospital must
(1) be a
			 state-operated psychiatric inpatient hospital; or
(2) be a private psychiatric inpatient
			 hospital meeting all of the following criteria:
(a) has a signed provider agreement that
			 specifies a payment methodology with the MassHealth agency;
(b) is licensed as a hospital by the
			 Massachusetts Department of Mental Health (DMH);
(c) is accredited by The Joint
			 Commission;
(d) participates in the
			 Medicare program.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 425.000 - Psychiatric Inpatient Hospital Services › Section 425.406 - Admission Criteria for Members Younger than 21 Years Old

Current through Register 1525, July 5, 2024
(A) A screening team must screen a member
			 younger than 21 years old prior to admission to a psychiatric inpatient
			 hospital or prior to conversion to MassHealth, as defined in
			 130 CMR 425.402. The
			 screening team will determine and certify whether the admission is medically
			 necessary.
(B) To demonstrate the
			 necessity of a psychiatric inpatient hospital admission for a member younger
			 than 21 years old, the following conditions must be met:
(1) the member must have mental
			 illness;
(2) the member must meet
			 one or more of the following criteria:
(a) be
			 dangerous to himself or herself;
(b) be dangerous to others; or
(c) be unable to care for himself or herself;
			 and
(3) the
			 moment-to-moment medical observation or clinical management required cannot be
			 provided in a less restrictive setting.