Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 315.00 - Rates for Vision Care Services and Ophthalmic Materials › Section 315.02 - General Definitions

Current through Register 1525, July 5, 2024
The terms used in
				101 CMR
				315.00 shall have the meanings ascribed in
				101
				CMR 315.02 and in the CPT Coding Handbook.
				The descriptions and five-digit procedure codes included in
				101 CMR
				315.00 are obtained from the American Medical
				Association's
Current Procedural Terminology
(CPT), copyright
				2022, or the 2022 Healthcare Common Procedure Coding System Level II (HCPCS)
				unless otherwise specified. Both sources provide a listing of descriptive terms
				and alpha-numeric identifying codes and modifiers for reporting medical
				services and procedures performed by health-care providers.
Consultation
- a type of service
				provided by a physician or ophthalmologist or optometrist whose opinion or
				advice regarding evaluation and/or management of a specific problem is
				requested by another physician or ophthalmologist or optometrist or other
				appropriate source. A physician consultant may initiate diagnostic and/or
				therapeutic services. The request for a consultation from the attending
				physician or ophthalmologist or optometrist or other appropriate source and the
				need for consultation 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 to the
				requesting physician or other appropriate source. Any specifically identifiable
				procedure
(i.e.,
identified with a specific CPT code)
				performed on or subsequent to the date of the initial consultation should be
				reported separately. If a consultant subsequently assumes responsibility for
				management of a portion or all of the patient's condition(s), the consultation
				codes should not be used.
Eligible Provider (Provider)
-
				ophthalmologists, optometrists, and dispensing opticians who are registered by
				an appropriate board of registration in accordance with the provision of M.G.L.
				c. 112; are not under contractual arrangement with a hospital or affiliated
				teaching institution for professional services; and who also meet such
				conditions of participation as may be required by a governmental unit
				purchasing vision-care services and ophthalmic materials or by purchasers under
				M.G.L. c. 152.
EOHHS
- the Executive Office of Health
				and Human Services established under M.G.L. c. 6A.
Established Patient
- a patient who
				has received professional services from the physician or ophthalmologist or
				optometrist within the past three years.
Governmental Unit
- the Commonwealth,
				any department, agency, board, or commission of the Commonwealth, and any
				political subdivision of the Commonwealth.
Individual Consideration (I.C.)
- for
				service codes for which no rate is listed, the purchaser determines the payment
				amount on an individual consideration basis upon receipt of a bill that
				describes the services rendered. The purchaser shall determine the appropriate
				payment in accordance with the following criteria:
(a) time required to perform the
			 procedure;
(b) degree of skill
			 required for the procedure rendered;
(c) severity and complexity of the patient's
			 disorder or disability;
(d) cost of
			 goods supplied in rendering the service, including catalogue prices of major
			 supplies; and
(e) policies,
			 procedures, and practices of other third-party purchasers of care, governmental
			 and private.
Low Vision
- any pathological,
				traumatic, or congenital condition of the eye or brain that results in reduced
				visual acuity or reduction of visual field, and that is not amenable to
				medical, surgical, or ordinary optical correction.
Low-vision Aids
- includes, but is not
				limited to, microscopic and telescopic lenses to correct low vision.
Low-vision Evaluation
- a series of
				evaluative vision tests to measure the degree of low vision and the corrective
				lenses or aids required.
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 placed after the usual procedure number from which it is
				separated by a hyphen.
New Patient
- a patient who has not
				received any professional services from the physician or ophthalmologist or
				optometrist within the past three years.
Ocular Prosthetic Services
- the
				dispensing and adjustment of false eyes.
Publicly Aided Individual
- a person
				for whose medical and other services a governmental unit is in whole or in part
				liable under a statutory program.
Vision-Care Services and Ophthalmic
				Materials
- professional care of the eye for the purpose of
				diagnosing and correcting refractive errors and includes the measurement,
				specification, formulation, construction, and dispensing of eyeglasses and
				related eye-care appliances.