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 40.02 - General Definitions

Current through Register 1525, July 5, 2024
(1)
Meaning of Terms
. Terms used in
				114.3 CMR 40.00 will have the meanings set forth in 114.3 CMR 40.02:
Adjusted Acquisition Cost
. The price
				paid to a supplier by an Eligible Provider for durable medical equipment,
				medical/surgical supplies, customized equipment, oxygen and respiratory therapy
				equipment. The adjusted acquisition cost shall not exceed the manufacturer's
				current catalogue price.
Administrative Costs
. A provider's
				costs for administration, including but not limited to facility costs overhead
				and other costs of doing business, are included in the rates set forth in this
				fee schedule, unless stated otherwise.
At Invoice Cost (AI)
. The price paid
				by the provider net of any manufacturer discounts received. Documentation of AI
				cost must be supplied to purchaser for payment upon request however submission
				of the request to the provider must be made within ten days of the initial
				billing date, will not affect the payment timeframe dictated by DIA regulations
				and will be limited to items where the provider's cost exceeds $500.00. The
				provider is responsible for maintaining documentation of the cost for any items
				costing less than $500.00 for a minimum of three years from the date of the
				original bill to the carrier.
Centers for Medicare and Medicaid Services
				(CMS)
. A division of the U.S. Department of Health and Human
				Services (HHS) that oversees and publishes rules and guidelines of the Medicare
				and Medicaid programs.
Consultation
. A service provided by a
				physician whose opinion or advice regarding evaluation and/or management of a
				specific problem is requested by another physician or other appropriate source.
				A physician consultant may initiate diagnostic and/or therapeutic
				services.
The written or verbal request for a consultation may be made by
				a physician or other appropriate source and must be documented in the patient's
				medical record. The consultant's opinion and any services that were ordered or
				performed must also be documented in the patient's medical record and
				communicated by written report to the requesting physician or other appropriate
				source.
A consultation initiated by a patient and/or family, and not
				requested by a physician, is not reported using the consultation codes but may
				be reported using the appropriate office visit codes.
Any procedure that can be identified with a specific CPT code
				performed on or subsequent to the date of the initial consultation should be
				reported separately. If, subsequent to the completion of a consultation, the
				consultant assumes responsibility for management of a portion or all of the
				patient's condition(s), the appropriate Evaluation and Management services code
				for the service should be reported.
CPT Codes
. 114.3 CMR 40.00 uses Codes
				from the Physicians' Current Procedural Terminology (CPT)© system developed and
				maintained by the American Medical Association. All CPT codes are copyrighted
				by the American Medical Association. All procedures and codes set forth under
				114.3 CMR 40.00 conform to CPT 2008 codes and descriptors and the principles
				for their use, as set forth in the Physicians' Current Procedural Terminology,
				2008, and any later updates. These CPT publications contain the complete and
				most current listings of CPT descriptive terms and numeric identifying codes
				and modifiers for reporting medical services and procedures.
Department of Industrial Accidents
				(DIA)
. A department of the Commonwealth of Massachusetts Executive
				Office of Labor and Workforce Development that oversees the Workers'
				Compensation system pursuant to M.G.L. c. 152 and other applicable laws and
				waivers.
Department of Public Health (DPH)
. A
				department of the Commonwealth of Massachusetts established under M.G.L. c.17,
				§ 1 that oversees and licenses healthcare facility standards and operations and
				administers public health programs for all Massachusetts residents.
Description
. An explanation of the
				medical procedure or item assigned to the code. This may include certain
				stipulations relevant to Massachusetts under M.G.L. c. 152.
Division
. The Division of Health Care
				Finance and Policy established under M.G.L. c. 118G.
Durable Medical Equipment (DME)
.
				Prosthetic devices, implantable devices, replacement parts (external or
				internal), accessories and supplies for the DME and other devices identified as
				DMEPOS by CMS. Implantable devices not listed with a fee in 114.3 CMR 40.06(6)
				and not included as a portion of the ambulatory surgery fee will be paid at
				invoice (A.I.) cost net of any manufacturer discounts received by the provider
				plus a mark up of 20% not to exceed $200.00.
Eligible Provider
. A provider as
				defined in 114.3 CMR 40.05, that also meets such conditions of participation as
				have been or may be adopted by a Governmental Unit or purchaser under M.G.L. c.
				152. Out-of-state providers must meet the comparable conditions of licensure
				and participation required by the state in which they practice.
Established Patient
. A person who has
				received professional services from the physician or another physician of the
				same specialty in the same group practice within the past three years. Under
				114.3 CMR 40.00, Established Patient will be applied to a single work related
				injury or episode of illness.
Fee
. The payment value for the medical
				procedure or item set forth in 114.3 CMR 40.06 and identified by a Code. Fees
				may be listed as Professional Component Fee (PC Fee), Technical Component Fee
				(TC Fee) and Global Fee (GL Fee) when a professional, technical or global fee
				applies. Single payment rates are listed as "Fees".
See
definitions of (GL), (PC) and (TC).
Global Fee (GL)
. The Global Fee is the
				sum of the PC Fee and TC Fee. See definitions of (PC) and (TC) below.
Governmental Unit
. The Commonwealth,
				any division, department, agency, board or commission of the Commonwealth, and
				any political subdivision of the Commonwealth.
HCPCS National Codes
. Level II coding
				system of alpha-numeric codes published by the Centers for Medicare and
				Medicaid Services (CMS) to supplement CPT codes for medical services and
				supplies. All D codes are copyrighted by the American Dental Association.
				Services and items set forth under 114.3 CMR 40.00 utilize HCPCS 2008 codes and
				descriptors.
Instrumental Activities of Daily Living
				(IADLs)
. Activities related to personal care of a patient such as
				meal preparation and clean-up, household services, laundry, shopping,
				housekeeping, transportation to a medical provider, or assistance with the care
				and maintenance of adaptive devices.
Liquid Oxygen Systems
. Oxygen and
				oxygen equipment as DME includes the system for furnishing it, the vessels that
				store it, the tubing, and administration sets that allow the safe delivery of
				oxygen in the home, and the oxygen contents.
Medical and Surgical Supplies
. Medical
				and treatment products that:
(a) are produced primarily and routinely to fulfill a medical
				or surgical purpose;
(b) are used in the treatment of a specific medical
				condition;
(c) are non-reusable and disposable.
Modifiers
. A two digit (numeric or
				alpha) sequence that alters the description of a delivered service or supply.
				114.3 CMR 40.07(1):
Appendix A
lists a limited number of the
				common modifiers and certain reimbursement provisions associated with their
				use. However, providers, suppliers and carriers may utilize any appropriate
				current CPT Level I and HCPCS Level II National Modifiers as necessary.
Non-standard Prescription Options
. New
				mobility systems including devices that:
(a) provide their user with a substantially greater range of
				motion than are usually required of the standard device; or
(b) require substantially greater service or time than are
				usually provided for the standard device.
Orthotic Device
. A mechanical device
				designed to support or correct any defect of form or function of the human
				body, and generally known as a "brace" or "orthosis" but not including dental
				braces or breast prostheses.
Oxygen Delivery Systems
. A
				comprehensive oxygen service that includes, but is not limited to: the
				gaseous/liquid oxygen, oxygen generating device and related delivery systems
				container or cylinder, manifold systems whenever high volume oxygen is used,
				stand, cart, walker/stroller, supply reservoir, contents indicator, regulator
				with flow gage, humidifcation devices, cannulas, masks, and special oxygen
				administration device, tubing and refill adapter.
Professional Component (PC)
. Certain
				procedures are a combination of a physician, or professional component and a
				technical component. When the modifier "-26" is added to an appropriate code a
				PC allowable amount will be paid.
Prosthesis
. An artificial device used
				to replace a missing body part, such as a limb, tooth, eye, or heart
				valve.
Prosthetic Device
. Any substitute or
				ancillary equipment or component part used in a prosthesis for replacement or
				modification purposes.
Rehabilitation Technology Specialist
				(RTS)
. A professional with expertise in assistive and
				rehabilitation technology, including wheeled mobility, seating and alternative
				positioning, ambulating assistance, environmental control and related
				activities who meets such conditions of participation as may be adopted by a
				Governmental Unit to work directly with consumers in the provision of wheeled
				mobility systems in the service delivery process.
Respiratory Therapy Devices and
				Supplies
. Devices and necessary ancillary equipment prescribed by
				a physician for the care and treatment of pulmonary illnesses that meet such
				standards as may be required by federal or state Governmental Units.
				Respiratory Therapy Devices may include the complete device and related
				delivery system accessories such as, regulator with flow gauge, humidification
				and heating units, filters, cannulas, masks, and special administration device
				tubing and adapters.
Seating, Positioning, Mobility Systems and Related
				Accessories
. Any device including its components, accessories and
				modifications, that has been prescribed, designed and constructed to meet the
				individual custom needs of a patient. This equipment will be provided by an
				eligible DME provider who employs a Rehabilitation Technology Specialist (RTS).
				The equipment must fulfill a medical purpose and be generally not useful in the
				absence of illness or injury, withstand repeated use over an extended period of
				time, be appropriate for home use, and meet professionally recognized standards
				of quality.
Special Report
. A service that is
				rarely provided, unusual, variable, or new may require an explanation to
				determine the medical appropriateness of the service. These services are
				generally reported as "unlisted services or procedures" and designated by
				digits '99' after the first three beginning code numbers. Pertinent information
				should include, but not be limited to, an adequate definition or description of
				the nature, extent, and need for the procedure; and the time, effort and
				equipment necessary to provide the service. Additional items that can be
				included are: complexity of symptoms, final diagnosis, pertinent physical
				findings, diagnostic and therapeutic procedures, concurrent problems, and
				follow-up care.
Technical Component (TC)
: The TC
				component reflects the technical portion of the procedure code. When the
				technical component is provided by a health care provider other than the one
				providing the professional component, the health care provider bills for the
				technical component by adding Modifier "-TC" to the applicable code. The TC
				rate is payment for the facility's cost of rent, equipment, utilities,
				supplies, administrative and technical salaries and benefits, and all other
				overhead expenses.
Transcutaneous Electrical Nerve Stimulator
				(TENS)
. A TENS unit must be distinguished from other electrical
				stimulators that directly stimulate muscles and/or motor nerves,
eg
, neuromuscular stimulators.
Unlisted Procedure or Service
. A
				service or procedure may be provided that is not listed in Regulation 114.3 CMR
				40.06. When reporting such a service, the appropriate "Unlisted Procedure" code
				may be used to indicate the service. A "Special Report" may be required when
				billing codes for unlisted procedures.
Used Equipment
. Any item that has been
				previously purchased or rented, including equipment that was:
(a) used by a patient for a trial period;
(b) used by the supplier as a demonstrator; or
(c) rented by a patient who now wants to buy it.
Usual and Customary Charge
. The lowest
				fee charged to the general public by an Eligible Provider specified by 114.3
				CMR 40.05:
Usual and Customary Charge
, which fee is
				in effect at the time that such service is performed or equipment is sold or
				rented.