Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 318.00 - Rates for Radiology Services › Section 318.02 - General Definitions

Current through Register 1525, July 5, 2024
Meaning of Terms
: The five-digit
				procedure codes and two-digit modifiers included in 101 CMR 318.00, 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 2020
				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 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 radiology services code spreadsheet at
www.mass.gov/regulations/101-CMR-31800-radiology
.
In addition, terms used in 101 CMR 318.00 have the meanings set
				forth in
				101
				CMR 318.02.
Eligible Provider
. The established
				rates apply in accordance with
				101
				CMR 318.01 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 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 therapeutic and diagnostic
			 radiology services. Such radiology services may be rendered by eligible
			 providers such as, but not limited to, independent diagnostic testing
			 facilities (IDTFs). These eligible providers must be 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 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 radiology 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.
EOHHS
. The Executive Office of Health
				and Human Services established under M.G.L. c. 6A.
Governmental Unit
. The Commonwealth,
				any department, agency, board, or commission of the Commonwealth and any
				political subdivision of the Commonwealth.
Individual Consideration (I.C.)
.
				Radiology services that are authorized but not listed in 101 CMR 318.00,
				radiology 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 and
				procedures may be modified under certain circumstances. When applicable, the
				modifying circumstances should be identified by the addition of the appropriate
				two-digit number.
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.
Radiology Services
. Radiology services
				including diagnostic ultrasound, radiation oncology, and nuclear medicine
				provided for the assessment and/or treatment of a medical condition, injury, or
				illness.
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.
Supervision and Interpretation Only
.
				When a procedure is performed by two eligible physicians, the radiologic
				portion of the procedure is designated as "radiological supervision and
				interpretation". When an eligible physician performs both the procedure and the
				imaging supervision and interpretation, a combination of procedure codes
				outside the 70000 series and imaging supervision and interpretation codes are
				to be used. The radiological supervision and interpretation codes are not
				applicable to the Radiology Oncology subsection.
Unlisted Procedure or Service
. A
				service or procedure that may be provided that is covered, but not listed in
				101
				CMR 318.04. When reporting such a service,
				the appropriate "Unlisted Procedure" code may be used to indicate the
				service.