Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 347.00 - Rates for Freestanding Ambulatory Surgery Center Services › Section 347.02 - Definitions

Current through Register 1525, July 5, 2024
The terms used in
				101 CMR
				347.00 have the meanings set forth in
				101
				CMR 347.02, unless the context requires
				otherwise. The five-digit codes included in
				101 CMR
				347.00 utilize the Healthcare Common Procedural Coding
				System (HCPCS) for Level I and Level II coding.
Level 1 CPT-4 codes are obtained from the American Medical
				Association's
CPT 2023 Professional Edition
, unless otherwise
				specified. Level II codes are obtained from the 2023 HCPCS maintained jointly
				by the Centers for Medicare and 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 two-digit modifiers
				for reporting medical services and procedures performed by physicians and other
				healthcare professionals, as well as associated non-physician services.
				101 CMR
				347.00 includes only HCPCS numeric and alpha-numeric
				identifying codes and modifiers for reporting medical services and procedures
				that were selected by EOHHS. Any use of CPT outside the fee schedule should
				refer to the American Medical Association's
CPT 2023 Professional
				Edition
. For code descriptions,
see
the FASC service
				code spreadsheet at:
www.mass.gov/regulations/101-CMR-34700-rates-for-freestanding-ambulatory-surgery-center-services
.
Center
. The Center for Health
				Information and Analysis established under M.G.L. c. 12C.
Eligible Provider
. A licensed FASC
				that meets the conditions of participation adopted by a governmental unit, and
				to the extent specified by such governemental unit.
Facility Component
. Rate of payment
				for an FASC's facility costs. The facility component does not include payment
				for a physician's, dentist's, or podiatrist's services in performing a surgical
				procedure.
Freestanding Ambulatory Surgery Center
				(FASC)
. A distinct entity that operates exclusively for the
				purpose of providing surgical services that do not require the availability of
				hospital facilities, is licensed by the Massachusetts Department of Public
				Health (or, if out-of-state, the applicable licensing authority of that state),
				and meets the conditions for payment by the governmental unit for facility
				services.
Governmental Unit
. The Commonwealth of
				Massachusetts or any of its departments, agencies, boards, commissions, or
				political subdivisions.
Individual Consideration (I.C.)
.
				Freestanding ambulatory surgery center services that are authorized but not
				listed in
				101 CMR
				347.00, FASC services performed in unusual
				circumstances, and services whose fees are designated by the letters "I.C." are
				individually considered items. The governmental unit or purchaser analyzes the
				eligible provider's operative report, which must contain a diagnosis, a
				pertinent medical history, a description of the services rendered, and the
				length of time spent with the patient. In making the determination of whether
				the service is appropriately classified as an individually considered item, and
				in determining appropriate payment for services designated as I.C., the
				governmental unit considers standards and criteria including the following,
				subject to any documentation requirements of the governmental unit:
(a) policies, procedures, and practices of
			 other third-party purchasers of care, both governmental and private;
(b) the severity and complexity of the
			 patient's disorder or disability;
(c) prevailing provider ethics and accepted
			 practice; and
(d) time, degree of
			 skill, and cost including equipment cost required to perform the procedure(s).
Modifiers
. Listed services may be
				modified under certain circumstances. When applicable, the modifying
				circumstances must be identified by the addition of the appropriate two-digit
				number or letters to the service code.
Publicly Aided Individual
. 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 service
				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.