Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 433.000 - Physician Services › Section 433.401 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR
				433.000 have the meanings given in
				130
				CMR 433.401 unless the context clearly
				requires a different meaning. The reimbursability of services defined in
				130 CMR
				433.000 is not determined by these definitions, but by
				application of regulations elsewhere in
				130 CMR
				433.000 and in
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
Acupuncture
- the insertion of metal
				needles through the skin at certain points on the body, with or without the use
				of herbs, with or without the application of an electric current, and with or
				without the application of heat to the needles, skin, or both.
Child and Adolescent Needs and Strengths
				(CANS)
- a tool that provides a standardized way to organize
				information gathered during behavioral-health clinical assessments. A
				Massachusetts version of the tool has been developed and is intended to be used
				as a treatment decision support tool for behavioral-health providers serving
				MassHealth members younger than 21 years old.
Consultant
- a licensed physician
				whose practice is limited to a specialty and whose written advice or opinion is
				requested by another physician or agency in the evaluation or treatment of a
				member's illness or disability.
Consultation
- a visit made at the
				request of another physician.
Controlled Substance
- a drug listed
				in Schedule II, III, IV, V, or VI of the Massachusetts Controlled Substances
				Act (M.G.L. c. 94C).
Cosmetic Surgery
- a surgical
				procedure that is performed for the exclusive purpose of altering appearance
				and is unrelated to disease or physical defect, or traumatic injury.
Couple Therapy
- therapeutic services
				provided to a couple for whom the disruption of their marriage, family, or
				relationship is the primary reason for seeking treatment.
Diagnostic Radiology Service
- a
				radiology service intended to identify an injury or illness.
Domiciliary
- for use in the member's
				place of residence, including a long-term-care facility.
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 Medical Condition
- a
				medical condition, whether physical or mental, manifesting itself by symptoms
				of sufficient severity, including severe pain, that the absence of prompt
				medical attention could reasonably be expected by a prudent layperson who
				possesses an average knowledge of health and medicine, to result in placing the
				health of the member or another person in serious jeopardy, serious impairment
				to body function, or serious dysfunction of any body organ or part, or, with
				respect to a pregnant individual, as further defined in § 1867(e)(1)(B) of
				the Social Security Act, 42
				U.S.C. §
									1395dd(e)(1)(B).
Emergency Services
- medical services
				that are furnished by a provider that is qualified to furnish such services,
				and are needed to evaluate or stabilize an emergency medical condition.
Family Planning
- any medically
				approved means, including diagnosis, treatment, and related counseling, that
				helps individuals of childbearing age, including sexually active minors, to
				determine the number and spacing of their children.
Family Therapy
- a session for
				simultaneous treatment of two or more members of a family.
Group Therapy
- application of
				psychotherapeutic or counseling techniques to a group of persons, most of whom
				are not related by blood, marriage, or legal guardianship.
High-risk Newborn Care
- care of a
				full-term newborn with a critical medical condition or of a premature newborn
				requiring intensive care.
Home or Nursing Facility Visit
- a
				visit by a physician to a member at a residence, nursing facility, extended
				care facility, or convalescent or rest home.
Hospital-licensed Health Center (HLHC)
- a facility that
(1) operates under a
			 hospital's license but is not physically attached to the hospital;
(2) is subject to the fiscal, administrative,
			 and clinical management of the hospital;
(3) provides services to patients solely on
			 an outpatient basis;
(4)
			 demonstrates CMS provider-based status in accordance with
			 42
			 CFR 413.65;
(5) meets all regulatory requirements for
			 participation in MassHealth as a hospital-licensed health center; and
(6) is enrolled with the MassHealth agency as
			 a hospital-licensed health center.
Hospital Visit
- a bedside visit by a
				physician to a hospitalized member, except for routine preoperative and
				postoperative care.
Hysterectomy
- a medical procedure or
				operation for the purpose of removing the uterus.
Independent Diagnostic Testing Facility
				(IDTF)
- a Medicare-certified diagnostic imaging center,
				freestanding MRI center, portable x-ray, sleep center, or mammography van in a
				fixed location or mobile entity independent of a hospital or physician's
				office, that performs diagnostic tests and meets the requirements of
				130 CMR 431.000:
Independent Diagnostic Testing Services
.
Individual Psychotherapy
- private
				therapeutic services provided to a member to lessen or resolve emotional
				problems, conflicts, and disturbances.
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.
Intensive Care Services
- the services
				of a physician other than the attending physician, provided for a continuous
				period of hours (rather than days), required for the treatment of an unusual
				aspect or complication of an illness, injury, or pregnancy.
Interchangeable Drug Product
- a
				product containing a drug in the same amounts of the same active ingredients in
				the same dosage form as another product with the same generic or chemical name
				that has been determined to be therapeutically equivalent (that is, "A-rated")
				by the Food and Drug Administration for Drug Evaluation and Research (FDA
				CDER), or by the Massachusetts Drug Formulary Commission.
Maintenance Program
- repetitive
				services, required to maintain or prevent the worsening of function, that do
				not require the judgment and skill of a licensed physician or licensed
				therapist for safety and effectiveness.
MassHealth Drug List
- a list of
				commonly prescribed drugs and therapeutic class tables published by the
				MassHealth agency. The MassHealth Drug List specifies the drugs that are
				payable under MassHealth. The list also specifies which drugs require prior
				authorization. Except for drugs and drug therapies described in
				130 CMR
				433.443(B), any drug that
				does not appear on the MassHealth Drug List requires prior authorization, as
				otherwise set forth in
				130 CMR
				433.000.
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 that include the ability to consent to
				sterilization.
Midlevel Practitioner
-a certified
				nurse practitioner, certified nurse midwife, certified registered nurse
				anesthetist, clinical nurse specialist, psychiatric clinical nurse specialist,
				and physician assistant. In general, subject to compliance with state and
				federal law, the requirements and limitations in
				130 CMR
				433.000 that apply to a physician, such as service and
				payment limitations, recordkeeping and reporting requirements, and
				prior-authorization and other conditions of coverage, also apply to midlevel
				practitioners.
Multiple-source Drug
- a drug marketed
				or sold by two or more manufacturers or labelers, or a drug marketed or sold by
				the same manufacturer or labeler under two or more different names.
Non-drug Product List
- a section of
				the MassHealth Drug List comprised of those products not classified as drugs
				(
i.e
., blood testing supplies) that are payable by the
				MassHealth agency through the Pharmacy Program. Payment for these items is in
				accordance with rates published in 114. 3 CMR 22.00:
Durable Medical
				Equipment, Oxygen, and Respiratory Therapy Equipment
and
				101
				CMR 317.00:
Medicine
. The MassHealth
				Non-drug Product List also specifies which of the included products require
				prior authorization.
Over-the-counter Drug
- any drug for
				which no prescription is required by federal or state law. These drugs are
				sometimes referred to as nonlegend drugs. The MassHealth agency requires a
				prescription for both prescription drugs and over-the-counter drugs
				(
see
130 CMR
				433.441(A)).
Not Otherwise Classified
- a term used
				for service codes that should be used when no other service code is appropriate
				for the service provided.
Occupational Therapy
- therapy
				services, including diagnostic evaluation and therapeutic intervention,
				designed to improve, develop, correct, rehabilitate, or prevent the worsening
				of functions that affect the activities of daily living that have been lost,
				impaired, or reduced as a result of acute or chronic medical conditions,
				congenital anomalies, or injuries. Occupational therapy programs are designed
				to improve quality of life by recovering competence and preventing further
				injury or disability, and to improve the individual's ability to perform tasks
				required for independent functioning, so that the individual can engage in
				activities of daily living.
Oxygen
- gaseous or liquid
				medical-grade oxygen that conforms to United States Pharmacopoeia
				Standards.
Pharmacy Online Processing System
				(POPS)
- the online, real-time computer network that adjudicates
				pharmacy claims, incorporating prospective drug utilization review, prior
				authorization, and member eligibility verification.
Physical Therapy
- therapy services,
				including diagnostic evaluation and therapeutic intervention, designed to
				improve, develop, correct, rehabilitate, or prevent the worsening of physical
				functions that have been lost, impaired, or reduced as a result of acute or
				chronic medical conditions, congenital anomalies, or injuries. Physical therapy
				emphasizes a form of rehabilitation focused on treatment of dysfunctions
				involving neuromuscular, musculoskeletal, cardiovascular/pulmonary, or
				integumentary systems through the use of therapeutic interventions to optimize
				functioning levels.
Prescription Drug
- any drug for which
				a prescription is required by applicable federal or state law or regulation,
				other than MassHealth regulations. These drugs are sometimes referred to as
				legend drugs.
Reconstructive Surgery
- a surgical
				procedure performed to correct, repair, or ameliorate the physical effects of
				disease or physical defect (for example, correction of cleft palate), or
				traumatic injury.
Referral
- the transfer of the total
				or specific care of a member from one physician to another. For the purposes of
				130 CMR
				433.000, a referral is not a
				consultation.
Respiratory Therapy Equipment
- a
				product that
(1) is fabricated
			 primarily and customarily for use in the domiciliary treatment of pulmonary
			 insufficiencies for its therapeutic and remedial effect;
(2) is of proven quality and dependability;
			 and
(3) conforms to all applicable
			 federal and state product standards.
Speech/Language Therapy
- therapy
				services, including diagnostic evaluation and therapeutic intervention, that
				are designed to improve, develop, correct, rehabilitate, or prevent the
				worsening of speech/language communication and swallowing disorders that have
				been lost, impaired, or reduced as a result of acute or chronic medical
				conditions, congenital anomalies, or injuries. Speech and language disorders
				are those that affect articulation of speech, sounds, fluency, voice,
				swallowing (regardless of presence of a communication disability), and those
				that impair comprehension, spoken, written, or other symbol systems used for
				communication.
Sterilization
- any medical procedure,
				treatment, or operation for the purpose of rendering an individual permanently
				incapable of reproducing.
Therapeutic Radiology Service
- a
				radiology service used to treat an injury or illness.
Therapy Visit
- a personal contact
				provided as an office visit or outpatient visit for the purpose of providing a
				covered physical or occupational therapy service by a physician or licensed
				physical or occupational therapist employed by the physician. Additionally,
				speech therapy services provided by a physician as an office or outpatient
				visit is considered a therapy visit.
Unit-dose Distribution System
- a
				means of packaging or distributing drugs, or both, devised by the manufacturer,
				packager, wholesaler, or retail pharmacist. A unit-dose contains an exact
				dosage of medication and may also indicate the total daily dosage or the times
				when the medication should be taken.