Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 318.00 - Rates for Radiology Services › Section 318.04 - Maximum Allowable Fees - Radiology Services

Current through Register 1525, July 5, 2024
(1)
			 Unless otherwise specified, guidelines, notes, and definitions provided in the
			 2023 CPT Coding Handbook are applicable to the use of the procedure codes and
			 modifiers listed below, as well as their corresponding descriptions. For code
			 descriptions,
see
the radiology services code spreadsheet at
www.mass.gov/regulations/101-CMR-31800-radiology
.
(2)
Modifiers
.
(a)
26: Professional
			 Component
. The component of a service or procedure representing
			 the physician's or other qualified health care professional's work interpreting
			 or performing the service or procedure. (When the physician or other qualified
			 health care professional component is reported separately, the addition of
			 modifier 26 to the procedure code will allow payment of the professional
			 component allowable fee (PC Fee) contained in
			 101
			 CMR 318.04(3), adjusted by
			 101
			 CMR 318.03 as applicable.)
(b)
51: Multiple
			 Procedures
. Most radiology services do not require modifier 51.
			 Modifier 51 applies only to nuclear medicine procedure codes 78306, 78320,
			 78802, 78803, 78806 and 78807 and should be used only when a whole body bone,
			 tumor, or infection study is performed on the same day prior to a SPECT bone,
			 tumor, or infection study, respectively. Under these circumstances, the
			 modifier must be used to report multiple procedures performed at the same
			 session. The service code for the major procedure or service must be reported
			 without a modifier. The secondary, additional, or lesser procedure(s) must be
			 identified by adding modifier 51 to the end of the service code for the
			 secondary procedure(s). (The addition of modifier 51 to the second and
			 subsequent procedure codes allows payment of 50% of the allowable fee contained
			 in 101 CMR
			 318.04(3), adjusted by
			 101
			 CMR 318.03 as applicable, to the eligible
			 provider. Note: This modifier should not be used with designated "add-on" codes
			 or with codes in which the narrative begins with "each additional".)
(c)
52: Reduced
			 Services
. Under certain circumstances, a service or procedure is
			 partially reduced or eliminated at the physician's or other qualified health
			 care professional's election. Under these circumstances, the service provided
			 can be identified by its usual procedure number and addition of modifier 52,
			 signifying that the service is reduced. This provides a means of reporting
			 reduced services without disturbing the identification of the basic service.
(d)
59: Distinct
			 Procedural Service
. To identify a procedure distinct or
			 independent from other services performed on the same day, add modifier 59 to
			 the end of the appropriate service code. Modifier 59 is used to identify
			 services/procedures that are not normally reported together, but are
			 appropriate under certain circumstances, for example, different site or organ
			 system. However, when another already established modifier is appropriate, it
			 should be used rather than modifier 59.
(e)
PA: Surgical or Other
			 Invasive Procedure Performed on the Wrong Body Part
. This modifier
			 is applied to report Provider Preventable Conditions in accordance with
			 42 CFR
			 447.26 and results in nonpayment for
			 services.
(f)
PB:
			 Surgical or Other Invasive Procedure Performed on the Wrong
			 Patient
. This modifier is applied to report Provider Preventable
			 Conditions in accordance with
			 42 CFR
			 447.26 and results in nonpayment for
			 services.
(g)
PC: Wrong
			 Surgical or Other Invasive Procedure Performed on a Patient
. This
			 modifier is applied to report Provider Preventable Conditions in accordance
			 with 42 CFR
			 447.26 and results in nonpayment for
			 services.
(h)
SA: Nurse
			 Practitioner Rendering Service in Collaboration with a Physician
.
			 This modifier is to be applied to service codes billed by a physician that were
			 performed by a certified nurse practitioner employed by the physician (the
			 physician employer must be practicing as an individual and not practicing as a
			 professional corporation or as a member of a group practice). A certified nurse
			 practitioner billing under his/her own individual provider number, or a group
			 practice, should not use this modifier.
(i)
TC: Technical
			 Component
. The component of a service or procedure representing
			 the cost of rent, equipment, utilities, supplies, administrative and technical
			 salaries and benefits, and other overhead expenses of the service or
			 procedures, excluding the physician's or other qualified health care
			 professional's professional component. (When the technical component is
			 reported separately, the addition of modifier TC to the procedure code will
			 allow payment of the technical component allowable fee (TC Fee) contained in
			 101
			 CMR 318.04(3), adjusted by
			 101
			 CMR 318.03 as applicable.)
(j)
XE: Separate
			 Encounter
. A service that is distinct because it occurred during a
			 separate encounter.
(k)
XS: Separate Structure
. A service that is distinct
			 because it was performed on a separate organ/structure.
(l)
XP: Separate
			 Practitioner
. A service that is distinct because it was performed
			 by a different practitioner.
(m)
XU: Unusual Non-overlapping Service
. The use of a
			 service that is distinct because it does not overlap usual components of the
			 main service.