Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 405.000 - Community Health Center Services › Section 405.421 - Visits: Service Limitations

Current through Register 1525, July 5, 2024
The following restrictions and limitations apply to visits as
				defined in
				130 CMR
				405.402.
(A)
Individual Medical
			 Visit
. An individual medical visit, including family planning, may
			 not be for an individual mental health service or for HIV pre- or post-test
			 counseling visits.
(B)
Individual Mental Health Visit
. An individual mental
			 health visit conducted by a person other than a psychiatrist or an advanced
			 practice registered nurse (APRN) with a graduate degree and advanced training
			 in psychiatric care (a psychiatric clinical nurse specialist or a psychiatric
			 mental health nurse practitioner) is not reimbursable. Other mental health
			 services provided by qualified clinicians and properly billed are reimbursable,
			 but not as Individual Mental Health Visits
(C)
Group Clinic
			 Visit
. All instructional group sessions for members must be
			 carried out by a physician, physician assistant, certified nurse practitioner,
			 clinical nurse specialist, or registered nurse. A group visit conducted by
			 other kinds of professionals (for example, social workers, counselors, or
			 nutritionists) is not reimbursable as a group clinic visit. These limitations
			 do not apply to group clinic visits for tobacco cessation.
(D)
HIV Pre- and Post-test
			 Counseling Visits
. The CHC may be reimbursed for a maximum of two
			 HIV pre-test counseling and two HIV post-test counseling visits per member per
			 test. A maximum of four pre-test counseling visits and four post-test
			 counseling visits per calendar year per member are reimbursable.
(E)
Home Visit
. A
			 home visit must be used to deliver episodic care in the member's home when a
			 health practitioner has determined that it is not advisable for the member to
			 visit the CHC. The medical record must document the reasons for a home visit. A
			 house-bound member with chronic medical and nursing care needs must be referred
			 to a Medicare-certified home health agency.
(F)
Treatments or
			 Procedures
. The CHC may bill for a visit, a treatment, or a
			 procedure, but may not bill for more than one of these services provided to the
			 same member on the same date when the services are performed in the same
			 location. This limitation does not apply to tobacco cessation counseling
			 services provided by a physician or other qualified staff member under the
			 supervision of a physician on the same day as a visit. Examples of treatments
			 or procedures are a vasectomy, colposcopy, or an amniocentesis. X-rays,
			 laboratory tests, and certain diagnostic tests may be billed in addition to an
			 office visit.
(G)
Immunization or Injection
.
(1) The CHC may bill for either an office
			 visit or vaccine administration, but may not bill for both an office visit and
			 vaccine administration for the same member on the same date when the office
			 visit and the vaccine administration are performed in the same location. This
			 limitation does not apply to a significant, separately identifiable office
			 visit provided by the same physician on the same day as the vaccine was
			 administered.
(2) The MassHealth
			 agency pays for the cost of the injectable material unless the Massachusetts
			 Department of Public Health distributes the injectable material free of
			 charge.