Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 317.00 - Rates for Medicine Services › Section 317.02 - General Definitions

Current through Register 1525, July 5, 2024
Meaning of Terms.
The five-digit
				procedure codes, and two-digit modifier codes included in 101 CMR 317.00, 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 medicine services code spreadsheet at
www.mass.gov/regulations/101-CMR-31700-medicine
.
In addition, terms used in 101 CMR 317.00 have the meanings set
				forth in
				101
				CMR 317.02.
Child and Adolescent Needs and Strengths
				(CANS)
. A tool that provides a standardized way to organize
				information gathered during a psychiatric diagnostic assessment and is a
				treatment and service decision support tool for children and adolescents
				younger than 21 years old.
CMS
. Centers for Medicare &
				Medicaid Services.
Early and Periodic Screening, Diagnostic and
				Treatment (EPSDT)
. A program of health screening and other medical
				services for publicly assisted individuals younger than 21 years old as
				required by federal law.
Eligible Provider
. The rates
				established in 101 CMR 317.00 apply in accordance with
				101
				CMR 317.01 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, licensed dentist, licensed chiropractor, and licensed
			 optometrist.
(b) A provider of
			 diagnostic medical services. Such medical diagnostic services may be rendered
			 by eligible providers such as, but not limited to, independent diagnostic
			 testing facilities (IDTFs). These eligible providers must be physically and
			 financially independent of a hospital or a physician's office.
(c) 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.
(d) A
			 clinic licensed by the Massachusetts Department of Public Health in accordance
			 with 105 CMR 140.000
: Licensure of Clinics
to provide medical
			 diagnostic services.
(e) 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 140.000
: Licensure of
			 Clinics
.
(f) 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).
(g) A licensed physician assistant, who is
			 authorized by the Board of Registration for Physician Assistants to practice as
			 a physician assistant.
(h) A
			 registered nurse providing tobacco cessation services.
(i) A tobacco cessation counselor, who has
			 completed appropriate training in tobacco cessation counseling according to the
			 qualification criteria established by the purchasing governmental
			 unit.
(j) A pharmacist who is
			 registered by the Board of Registration in Pharmacy.
(k) An acupuncturist who is licensed by the
			 Board of Registration in Medicine to practice acupuncture.
Eligible Provider for Administration of
				Vaccines
. A licensed physician, certified nurse practitioner,
				certified nurse midwife, clinical nurse specialist, psychiatric clinical nurse
				specialist, physician assistant, registered pharmacist or other health care
				professional certified in accordance with 105 CMR 700.000:
Implementation of M.G.L. c. 94C
, and any home health agency
				certified as a provider of home health services under the Medicare Health
				Insurance Program for the Aged (Title XVIII) is eligible to administer
				vaccines, if it otherwise meets such conditions of participation and coverage
				set forth by a purchasing governmental unit. Any other providers authorized by
				the Massachusetts Department of Public Health to possess and administer
				vaccines are also eligible if they otherwise meet such conditions of
				participation and coverage set forth by a purchasing governmental unit.
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.
Governmental Unit
. The Commonwealth,
				any department, agency, board or commission of the Commonwealth and any
				political subdivision of the Commonwealth.
Individual Consideration
. Medical
				services that are authorized but not listed in 101 CMR 317.00, medical services
				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.
Physical Medicine
. The physical
				medicine procedure codes apply only when
(a) the physician prescribed the needed
			 therapy; and
(b) the services are
			 provided by the physician or a licensed physical or occupational therapist
			 employed by the physician.
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.
Referral
. The transfer of the total or
				specific care from one eligible provider to another.
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.
Unlisted Procedure or Service
. A
				service or procedure may be provided that is not listed in
				101
				CMR 317.04. When reporting such a service,
				the appropriate "Unlisted Procedure" code may be used to indicate the
				service.