Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 351 - WORKERS' COMPENSATION BOARD › Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS › Sec2 351-5-1 - GENERAL PROVISIONS › Subsection 351-5-1-03 - DEFINITIONS

Current through 2024-29, July 17, 2024
1.
Acute Care Hospital
: A health
				  care facility with a General Acute Care Hospital Primary Taxonomy in the NPI
				  Registry.
2.
Ambulatory
				  Payment Classification System (APC)
: Centers for Medicare & Medicaid
				  Services' list of procedure codes, status indicators, ambulatory payment
				  classifications, and relative weighting factors.
3.
Ambulatory Surgical Center
				  (ASC)
: A health care facility with an Ambulatory Surgical Clinic/Center
				  Primary Taxonomy in the NPI Registry.
4.
Bill
: A request by a health
				  care provider that is submitted to an employer/insurer for payment of medical,
				  surgical and hospital services, nursing, medicines, and mechanical, surgical
				  aids provided for treatment of a work-related injury or disease.
5.
Board
: The Maine Workers'
				  Compensation Board pursuant to 39­A M.R.S.A. §151.
6.
Critical Access Hospital
: A
				  health care facility with a Critical Access Hospital Primary Taxonomy in the
				  NPI Registry.
7.
Global
				  Days
: The number of days of care following a surgical procedure that are
				  included in the procedure's maximum allowable payment but does not include care
				  for complications, exacerbations, recurrence, or other diseases or
				  injuries.
8.
Health Care
				  Provider
: An individual, group of individuals, or facility licensed,
				  registered, or certified and practicing within the scope of the health care
				  provider's license, registration or certification. This paragraph shall not be
				  construed as enlarging the scope and/or limitations of practice of any health
				  care provider.
9.
Health Care
				  Records
: includes office notes, surgical/operative notes, progress
				  notes, diagnostic test results and any other information necessary to support
				  the services rendered.
10.
Implantable
: An object or device that is made to replace and act
				  as a missing biological structure that is surgically implanted, embedded,
				  inserted, or otherwise applied. The term also includes any related equipment
				  necessary to operate, program, and recharge the implantable.
11.
Incidental Surgery
: A
				  surgery which is performed on the same patient, on the same day, by the same
				  health care provider but is not related to the diagnosis.
12.
Inpatient Services
: Services
				  rendered to a person who is formally admitted to a hospital and whose length of
				  stay exceeds 23 hours or is expected to have a length of stay exceeding 23
				  hours, even though it later develops that the patient dies, is discharged, or
				  is transferred to another facility and does not actually stay in the
				  institution for more than 23 hours.
13.
Maximum Allowable Payment
				  (MAP)
: The sum of all fees for medical, surgical and hospital services,
				  nursing, medicines, and mechanical, surgical aids established by the Board
				  pursuant to this chapter.
14.
Modifier
: A code adopted by the Centers for Medicare &
				  Medicaid Services that provides the means to report or indicate that a service
				  or procedure that has been performed has been altered by some specific
				  circumstance but not changed in its definition or code.
15.
Outpatient Services
:
				  Services provided to a patient who is not admitted for inpatient or residential
				  care (includes observation services).
16.
Procedure Code
: A code
				  adopted by the Centers for Medicare & Medicaid Services that is divided
				  into two principal subsystems, referred to as level I and level II of the
				  Healthcare Common Procedure Coding System (HCPCS). Level I is comprised of
				  Current Procedural Terminology (CPT®), a numeric coding system maintained
				  by the American Medical Association (AMA). Level II is a standardized coding
				  system that is used primarily to identify products, supplies, and services not
				  included in the CPT® codes. The CPT® manual is published by and may be
				  purchased from the AMA, PO Box 930876, Atlanta, GA 31193-0876.
17.
Resource-Based Relative Value Scale
				  (RBRVS)
: Centers for Medicare & Medicaid Services' list of procedure
				  codes, modifiers, relative weighting factors, global surgery days, and global
				  surgery package percentages.
18.
Severity-Diagnosis Related Group System (MS-DRG)
: Centers for
				  Medicare & Medicaid Services' list of Medicare severity diagnosis-related
				  groups, relative weighting factors, and geometric mean length of stay
				  days.
19.
Specialty
				  Hospital
: A health care facility with a Long-Term Care Hospital,
				  Psychiatric Hospital, or Rehabilitation Hospital Primary Taxonomy in the NPI
				  Registry. Specialty Hospital also includes those distinct parts of a health
				  care facility that are certified by the Centers for Medicare & Medicaid
				  Services as a Long-Term Care Hospital, Psychiatric Hospital, or Rehabilitation
				  Hospital.
20.
Usual and
				  Customary Charge
: The charge on the price list for the medical, surgical
				  and hospital services, nursing, medicines, and mechanical, surgical aids that
				  is maintained by the health care provider.