Code of Maine Rules
90 - INDEPENDENT AGENCIES
351 - WORKERS' COMPENSATION BOARD
Chapter 5 - MEDICAL FEES; REIMBURSEMENT LEVELS; REPORTING REQUIREMENTS
Sec2 351-5-1 - GENERAL PROVISIONS
Subsection 351-5-1-03 - DEFINITIONS

1. Acute Care Hospital: A health care facility with a General Acute Care Hospital Primary Taxonomy in the NPI Registry.

2. Ambulatory Payment Classification System (APC): Centers for Medicare & Medicaid Services' list of procedure codes, status indicators, ambulatory payment classifications, and relative weighting factors.

3. Ambulatory Surgical Center (ASC): A health care facility with an Ambulatory Surgical Clinic/Center Primary Taxonomy in the NPI Registry.

4. Bill: A request by a health care provider that is submitted to an employer/insurer for payment of medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids provided for treatment of a work-related injury or disease.

5. Board: The Maine Workers' Compensation Board pursuant to 39­A M.R.S.A. §151.

6. Critical Access Hospital: A health care facility with a Critical Access Hospital Primary Taxonomy in the NPI Registry.

7. Global Days: The number of days of care following a surgical procedure that are included in the procedure's maximum allowable payment but does not include care for complications, exacerbations, recurrence, or other diseases or injuries.

8. Health Care Provider: An individual, group of individuals, or facility licensed, registered, or certified and practicing within the scope of the health care provider's license, registration or certification. This paragraph shall not be construed as enlarging the scope and/or limitations of practice of any health care provider.

9. Health Care Records: includes office notes, surgical/operative notes, progress notes, diagnostic test results and any other information necessary to support the services rendered.

10. Implantable: An object or device that is made to replace and act as a missing biological structure that is surgically implanted, embedded, inserted, or otherwise applied. The term also includes any related equipment necessary to operate, program, and recharge the implantable.

11. Incidental Surgery: A surgery which is performed on the same patient, on the same day, by the same health care provider but is not related to the diagnosis.

12. Inpatient Services: Services rendered to a person who is formally admitted to a hospital and whose length of stay exceeds 23 hours or is expected to have a length of stay exceeding 23 hours, even though it later develops that the patient dies, is discharged, or is transferred to another facility and does not actually stay in the institution for more than 23 hours.

13. Maximum Allowable Payment (MAP): The sum of all fees for medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids established by the Board pursuant to this chapter.

14. Modifier: A code adopted by the Centers for Medicare & Medicaid Services that provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.

15. Outpatient Services: Services provided to a patient who is not admitted for inpatient or residential care (includes observation services).

16. Procedure Code: A code adopted by the Centers for Medicare & Medicaid Services that is divided into two principal subsystems, referred to as level I and level II of the Healthcare Common Procedure Coding System (HCPCS). Level I is comprised of Current Procedural Terminology (CPT®), a numeric coding system maintained by the American Medical Association (AMA). Level II is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT® codes. The CPT® manual is published by and may be purchased from the AMA, PO Box 930876, Atlanta, GA 31193-0876.

17. Resource-Based Relative Value Scale (RBRVS): Centers for Medicare & Medicaid Services' list of procedure codes, modifiers, relative weighting factors, global surgery days, and global surgery package percentages.

18. Severity-Diagnosis Related Group System (MS-DRG): Centers for Medicare & Medicaid Services' list of Medicare severity diagnosis-related groups, relative weighting factors, and geometric mean length of stay days.

19. Specialty Hospital: A health care facility with a Long-Term Care Hospital, Psychiatric Hospital, or Rehabilitation Hospital Primary Taxonomy in the NPI Registry. Specialty Hospital also includes those distinct parts of a health care facility that are certified by the Centers for Medicare & Medicaid Services as a Long-Term Care Hospital, Psychiatric Hospital, or Rehabilitation Hospital.

20. Usual and Customary Charge: The charge on the price list for the medical, surgical and hospital services, nursing, medicines, and mechanical, surgical aids that is maintained by the health care provider.