Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.3 CMR 40.00 - RATES FOR SERVICES UNDER M.G.L. c. 152, WORKERS' COMPENSATION ACT › Section 40.07 - Appendices

Current through Register 1525, July 5, 2024
APPENDIX
DESCRIPTION
A
CPT and HCPCS Modifiers. Add the appropriate Level 1
							 CPT modifier to the five digit code or identify the modifier by use of a
							 separate code by adding 099 before the 2 digit number e.g. 09950, 09951. This
							 table includes only common modifiers, any valid modifier may be used if it is
							 appropriate to the situation.
B
Add-On Codes - Procedures that are commonly carried
							 out in addition to the primary procedure performed and must never be reported
							 as stand-alone codes. These codes are exempt from the multiple modifier '51' as
							 are all codes that specify that they should be listed in addition to the main
							 procedure.
C
Separate Procedures - Procedures that are stand alone
							 codes. These codes are exempt from the multiple modifier '51'.
D
Drugs Administered Other Than Oral Method - List of
							 drugs and biologicals that can be injected either subcutaneously,
							 intramuscularly, or intravenously reimbursed at invoice cost.
APPENDIX A
- Level I and Level II Common Modifiers
				This appendix lists the modifiers that are most commonly used in treating
				injured workers. The absence of a modifier from this appendix does not preclude
				its use in the appropriate situation.
(a)
Anesthesia
			 Modifiers
.
1. Physical Status
			 Modifiers. Physical status modifying units will be reimbursed if the patient is
			 ranked in one of the following three categories. Physical status is included in
			 CPT to distinguish various levels of complexity of the anesthesia service
			 provided. Example: 00100-P3
Physical Status Modifiers
Description
Modifying Unit Value
P3
A patient with severe systemic
							 disease.
1
P4
A patient with severe systemic disease that is a
							 constant threat to life.
2
P5
A moribund patient who is not expected to survive
							 without the operation.
3
2. CPT
			 and HCPCS Modifiers for Anesthesia Services. Add the appropriate Level 1 CPT
			 modifier or HCPCS Level II modifier to the five digit code or identify the
			 modifier by use of a separate code by adding 099 before the 2 digit number e.g.
			 09950, 09951.
Level 1 CPT Modifier
23 Unusual Anesthesia
Description
Occasionally, a procedure, which usually requires
							 either no anesthesia or local anesthesia, because of unusual circumstances must
							 be done under general anesthesia. This circumstance may be reported by adding
							 the modifier '-23' to the procedure code of the basic service.
47 Anesthesia by Surgeon
Regional or general anesthesia provided by the
							 surgeon may be reported by adding the modifier '-47' to the basic service.
							 (This does not include local anesthesia.) Note: Modifier '-47' or 09947 would
							 not be used as a modifier for the anesthesia procedures.
AA Anesthesia services performed personally by
							 anesthesiologist
This modifier must be used in conjunction with the
							 appropriate service code to denote medical direction of one or two concurrent
							 anesthesia procedures involving residents in a teaching environment. Payment
							 for the physician's medical direction service shall be made at 100% of the
							 allowance for the service performed by the physician alone.
QK Medical Direction of Multiple Anesthesia
							 Procedures
This modifier must be used in conjunction with the
							 appropriate service code to denote medical direction of two, three, or four
							 concurrent anesthesia procedures involving qualified individuals. Payment for
							 the physician's medical direction service shall be made at 50% of the allowance
							 for the service performed by the physician alone.
QX CRNA Service
This modifier must be used to report services of a
							 CRNA: with medical direction by a physician. This medical direction modifier is
							 used when the physician medically directs two, three, or four concurrent
							 procedures involving interns, residents, CRNAs and AAs. This allows 50% of the
							 fee to be paid to the employer.
QY CRNA Service
This modifier must be used to report medical
							 direction of one CRNA by an anesthesiologist. This allows 50% of the fee to be
							 paid to the employer.
QZ CRNA Service
This modifier is used to report CRNA service: without
							 medical direction by a physician. This allows 100% of the fee to be paid to the
							 employer.