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 316.02 - General Definitions

Current through Register 1525, July 5, 2024
Meaning of Terms
. The five-digit
				procedure codes and two-digit modifiers included in 101 CMR 316.00, and their
				corresponding descriptions, utilize the Healthcare Common Procedure Code System
				(HCPCS) for Level I and Level II coding. Level I CPT-4 codes are obtained from
				the Physicians' 2023
Current Procedural Terminology
(CPT),
				copyright 2022 by the American Medical Association (AMA), unless otherwise
				specified. Level II codes are obtained from the 2023 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
				health care professionals, as well as associated nonphysician services. No fee
				schedules, basic unit value, relative value guides, conversion factors, or
				scales are included in any part of the Physicians'
Current Procedure
				Terminology
. For code descriptions,
see
the
				anesthesia and surgery service code spreadsheets on the EOHHS rates website at:
www.mass.gov/regulations/101-CMR-31600-surgery-and-anesthesia-services
.
In addition, terms used in 101 CMR 316.00 have the meanings set
				forth in
				101
				CMR 316.02.
Accountable Care Organization (ACO)
.
				An entity that enters into a population-based payment model contract with EOHHS
				as an accountable care organization, wherein the entity is held financially
				accountable for the cost and quality of care for an attributed or enrolled
				member population. ACOs include Accountable Care Partnership Plans, Primary
				Care ACOs, and MCO-administered ACOs.
Eligible Provider
. The rates
				established in 101 CMR 316.00 apply in accordance with
				101
				CMR 316.01 to the following types of
				providers who meet conditions of participation of the governmental unit
				purchasing such services, and to the extent specified by such governmental
				unit. Eligible providers must provide such services in accordance with
				generally accepted professional standards and in accordance with state
				licensing requirements and certification by national credentialing bodies as
				required by law.
(a) A licensed
			 physician (other than an intern, resident, fellow, or house officer), licensed
			 podiatrist, and licensed dentist.
(b) A provider of radiation oncology
			 services. Radiation oncology services may be rendered by eligible providers
			 such as, but not limited to, independent radiation oncology centers. These
			 eligible providers must be physically and financially independent of a hospital
			 or a physician's office.
(c) A
			 clinic licensed by the Massachusetts Department of Public Health in accordance
			 with 105 CMR 140.000:
Licensure of Clinics
to provide surgical
			 diagnostic services.
(d) A
			 freestanding birth center facility that is not operating under a hospital's
			 license, and is licensed as a birth center by the Massachusetts Department of
			 Public Health pursuant to 105 CMR 142.000:
Operation and Maintenance of
			 Birth Centers
.
(e) An
			 advanced practice registered nurse who is authorized by the Board of
			 Registration in Nursing to practice as a certified nurse practitioner,
			 certified nurse midwife, clinical nurse specialist, psychiatric clinical nurse
			 specialist, or a certified registered nurse anesthetist (CRNA).
(f) A licensed physician assistant who is
			 authorized by the Board of Registration for Physician Assistants to practice as
			 a physician assistant.
EOHHS
. The Executive Office of Health
				and Human Services established under M.G.L. c. 6A.
Facility Setting Fee
. Payments for
				services provided by an individual eligible provider in a hospital (including,
				without limitation, a hospital inpatient department, outpatient department,
				emergency department, and hospital licensed health center), or skilled nursing
				facility or freestanding ambulatory surgical center (ASC), will be made
				according to a facility setting fee when an applicable facility setting fee has
				been established for that procedure.
Global Delivery
. Includes direct
				provision and supervision of case management, maternal education (including,
				but not limited to, nutrition, pregnancy and childbirth, and reproductive
				health), and obstetrical risk assessment and monitoring, in addition to pelvic
				or Cesarean-section delivery, all routine prenatal visits, and one postpartum
				visit.
Governmental Unit
. The Commonwealth,
				any department, agency, board, or commission of the Commonwealth and any
				political subdivision of the Commonwealth.
Individual Consideration (I.C.)
.
				Surgical procedures that are authorized but not listed in 101 CMR 316.00,
				surgical procedures performed in unusual circumstances, and services designated
				I.C. are individually considered items. The governmental unit or purchaser
				analyzes the eligible provider's report of services rendered and charges
				submitted under the appropriate unlisted services or procedures category. The
				governmental unit or purchaser determines appropriate payment for procedures
				designated I.C. in accordance with the following standards and criteria:
(a) the amount of time required to perform
			 the service;
(b) the degree of
			 skill required to perform the service;
(c) the severity or complexity of the
			 patient's disease, disorder, or disability;
(d) any applicable relative-value
			 studies;
(e) any complications or
			 other circumstances that may be deemed relevant;
(f) the policies, procedures and practices of
			 other third party insurers;
(g) the
			 payment rate for prescribed drugs as set forth in 101 CMR 331.00:
Prescribed Drugs
; and
(h) a copy of the current invoice from the
			 supplier.
Modifiers
. Listed services may be
				modified under certain circumstances. When applicable, the modifying
				circumstances should be identified by the addition of the appropriate two-digit
				number or letters to the procedure code.
Primary Care Clinician (PCC) Plan
. A
				managed care option administered by the MassHealth agency through which
				enrolled members receive primary care and certain other medical services.
Publicly Aided Individual (or Publicly Aided Patient)
.
				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.
Separate Procedure
. Some of the listed
				procedures are commonly carried out as an integral part of a total service, and
				as such do not warrant a separate identification. When, however, such a
				procedure is performed independently of, and is not immediately related to,
				other services, it may be listed as a separate procedure in the procedure
				description. Thus, when a procedure that is ordinarily a component of a larger
				procedure is performed alone for a specific purpose, it may be considered to be
				a separate procedure.
Surgical Team Fee
. Reimbursement for
				highly complex surgical procedures requiring the expertise of several
				physicians (usually of different specialties) and other highly skilled,
				specially-trained personnel. More than one surgeon may be performing parts of
				the procedure simultaneously. 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 members of the surgical team.
Unlisted Procedure or Service
. A
				service or procedure that may be provided that is not listed in
				101
				CMR 316.05. When reporting such a service,
				the appropriate "Unlisted Procedure" code may be used to indicate the
				service.