Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 309.00 - Rates for Certain Services for the Personal Care Attendant Program › Section 309.03 - General Rate Provisions

Current through Register 1525, July 5, 2024
(1)
Services or Functions Included in the Rate
. The
			 approved rate includes payment for care and services or functions listed in
			 101
			 CMR 309.03(4)  that are part
			 of the PCA program under
			 130
			 CMR 422.401 through
			 130
			 CMR 422.423 subject only to the terms of the
			 purchase agreement between the eligible provider and the purchasing
			 governmental unit.
(2)
Reimbursement as Full Payment
. Each eligible provider
			 must, as a condition of acceptance of payment made by the purchasing
			 governmental unit for services rendered, accept the approved program rate as
			 full payment and discharge of all obligations for services rendered. Any
			 third-party payments received on behalf of a publicly aided consumer will
			 reduce, by that amount, the amount of the purchasing governmental unit's
			 obligation for services rendered to the consumer.
(3)
Payment
			 Limitation
. Except as provided in
			 101
			 CMR 309.03(2), no purchasing
			 governmental unit may pay less than, or more than, the approved program
			 rate.
(4)
Rates of
			 Payment for PCM Functions Effective July 1, 2023
.
Code
Modifier
Rate
Unit
Description
99456
$265.41
Per Session
Work related or medical disability examination by
							 other than the treating physician that includes:
completion of a medical history commensurate with
							 the patient's condition;
performance of an examination commensurate with the
							 patient's condition;
formulation of a diagnosis, assessment of
							 capabilities and stability, and calculation of impairment;
development of future medical treatment plan; and
							 completion of necessary documentation/certificates and report (initial
							 evaluation of a member to determine the need, and extent of the need, for PCA
							 services) (per evaluation).
99456
TS
$152.54
Per Session
Work related or medical disability examination by
							 other than the treating physician that includes:
completion of a medical history commensurate with the
							 patient's condition;
performance of an examination commensurate with the
							 patient's condition;
formulation of a diagnosis, assessment of
							 capabilities and stability, and calculation of impairment;
development of future medical treatment plan; and
							 completion of necessary documentation/certificates and report (code with
							 modifier for reevaluations).
T1023
$120.92
Per Session
Screening to determine the appropriateness of
							 consideration of an individual for participation in a specified program,
							 project, or treatment protocol, per encounter (per session charge for intake
							 and orientation services provided to a member who does not yet have PA for PCA
							 services) (maximum three sessions).
T2022
$58.99
Per Member per Month
Case management per month. (Current PA for PCA
							 services required for each member.) Use this code to bill administrative (per
							 member per month). Bill code on the first of month. During a transfer, both PCM
							 agencies may bill for the month the transfer took place (one-month
							 limit).
T2022
U1
$0
Per Session
Case management per month. (Current PA for PCA
							 services required for each member.) Use to bill for required quarterly
							 comprehensive (in person) functional skills training (FST) visits during the
							 first year of approved PCA services. (Bill on the date FST was delivered.)
							 (Bill code once in each calendar year quarter only.) Cannot be billed on the
							 same date as T2022 U2, U3, U4, U5, or another unit of T2022 U1 was
							 billed.
T2022
U2
$0
Per Session
Case management per month. (Current PA for PCA
							 services required for each member.) Use to bill for required annual
							 comprehensive (in person) FST (limit one per year). (Bill on date FST was
							 delivered.) Cannot be billed on the same date as T2022 U3, U4, U5, or another
							 unit of T2022 U2 was billed.
T2022
U5
$0
Per Session
Case management per month. (Current PA for PCA
							 services required for each member.) Use to bill for FST (in person) within ten
							 days of identifying a new surrogate. (Bill on date FST was delivered.) Cannot
							 be billed on same date as T2022 U1, U2, U3, U4, or another unit of T2022 U5 was
							 billed. May bill only once during a calendar year, regardless of multiple
							 surrogate changes. This code does not apply to administrative proxy
							 changes.
T2022
U3
$0
Per Session
Case management per month. (Current PA for PCA
							 services required for each member.) Use to bill for issue-focused (in person)
							 FST. (Bill on date FST was delivered.) Cannot be billed on same date as T2022
							 U1, U2, U5, or another unit of T2022 U3 was billed.
T2022
U4
$0
Per Session
Case management per month. (Current PA for PCA
							 services required for each member.) Use to bill for issue-focused (telephone
							 contact with FST delivery) FST. (Bill on date FST was delivered.) Cannot be
							 billed on same date as T2022 U1 U2 or U5 was billed
(5)
PCA Rates
. The rates for PCA services consist of the
			 employer expense component and the PCA wage component.
(a)
Rates
. The rates
			 of payment for PCA services are established in accordance with the provisions
			 of any collective bargaining agreement under M.G.L. c. 150E and as authorized
			 by the MassHealth program regulations at
			 130
			 CMR 422.413:
Payment for PCA
			 Services.
(b)
PCA Wage Component
. Beginning on the effective date of
			 a collective bargaining agreement, the PCA wage component is based on amounts
			 established by the collective bargaining agreement.
(c)
Employer Expense
			 Component
. The employer expense component is the sum of the
			 employer mandated contribution for each statutorily required tax and benefit.
			 Each mandated contribution amount is calculated by multiplying the PCA wage
			 component by the percentage required by statute, regulation, or other official
			 document. EOHHS issues specific rates in an administrative bulletin that lists
			 rates in time increments that conform to the definitions of the procedure codes
			 authorized for payment by the MassHealth agency. The employer expense component
			 for mandated employer expenses is subject to audit and may be adjusted in
			 accordance with provisions of the fiscal intermediary contract with the
			 purchasing agency.