Code of Massachusetts Regulations
101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES
Title 101 CMR 312.00 - Rates for Family Planning Services
Section 312.03 - General Rate Provisions
Current through Register 1531, September 27, 2024
(1) Reimbursement as Full Payment. Each eligible provider must, as a condition 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 the services rendered. Any third-party payments or sliding fees received on behalf of a publicly aided individual reduces, by that amount, the purchasing governmental unit's payment for services rendered to the publicly aided individual.
(2) Rates. Subject to the conditions listed herein, rates of payment for authorized family planning services for which 101 CMR 312.00 applies are the lowest of:
(3) Modifiers.
Modifier Name |
Description |
PA |
Surgical or other invasive procedure on wrong body part |
PB |
Surgical or other invasive procedure on wrong patient |
PC |
Wrong surgery or other invasive procedure on patient |
(4) Schedule of Allowable Fees.
Code |
Allowable Fee |
Description |
90651 |
I.C. |
Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use. |
New Patient |
||
99202 |
$93.03 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) |
99203 |
$141.34 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) |
99204 |
$205.54 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) |
99205 |
$259.24 |
Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) |
Established Patient |
||
99211 |
$36.90 |
Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) |
99212 |
$66.55 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) |
99213 |
$101.92 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) |
99214 |
$147.47 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) |
99215 |
$197.30 |
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) |
Preventive Medicine Services |
||
99384 |
$108.01 |
Initial comprehensive preventive medicine evaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) |
99385 |
$108.01 |
Initial comprehensive preventive medicine evaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years |
99386 |
$121.00 |
Initial comprehensive preventive medicine evaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years |
99394 |
$93.73 |
Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) |
99395 |
$94.20 |
Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years |
99396 |
$100.28 |
Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years |
99402 |
$69.57 |
Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individual (separate procedure); approximately 30 minutes. |
Allowable Medical and Related Supplies |
||
S4993 |
$11.08 |
Contraceptives pills for birth control |
All Other Medical and Related Supplies |
||
S4989 |
I.C. |
Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies. |
A4261 |
I.C. |
Cervical cap for contraceptive use |
A4266 |
$9.55 |
Diaphragm for contraceptive use (includes applicator and contraceptive cream or jelly) |
A4267 |
$0.19 |
Contraceptive supply, condom, male, each |
A4268 |
$2.09 |
Contraceptive supply, condom, female, each |
A4269 |
$4.01 |
Contraceptive supply, spermicide (e.g., foam, gel), each (per tube or package) (includes contraceptive sponges) |
J1050 |
I.C. |
Injection, medroxyprogesterone acetate, 1 mg |
J7296 |
I.C. |
Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg |
J7297 |
I.C. |
Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg |
J7298 |
I.C. |
Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg |
J3490- FP |
I.C. |
Unclassified Drugs (service provided as part of a Medicaid family planning program) (may be used by other governmental purchasers of family planning services) |
J7300 |
I.C. |
Intrauterine copper contraceptive |
J7301 |
I.C. |
Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg |
J7303 |
I.C. |
Contraceptive supply, hormone containing vaginal ring, each |
J7304 |
I.C. |
Contraceptive supply, hormone containing patch, each |
J7307 |
I.C. |
Etonogestrel (contraceptive) implant system, including implant and supplies |
Medical and Surgical Procedures |
||
11976 |
$154.65 |
Removal, implantable contraceptive capsules. |
11981 |
$255.74 |
Insertion, non-biodegradable drug delivery implant |
(5) Other Family Planning Services. The rates of payment for other family planning services not listed in 101 CMR 312.03(4) that are authorized by the purchasing governmental unit, will be based on the applicable EOHHS regulations such as 101 CMR 313.00: Rates for Freestanding Clinics Providing Abortion and Sterilization Services; 101 CMR 316.00: Rates for Surgery and Anesthesia Services; 101 CMR 317.00: Rates for Medicine Services; 101 CMR 318.00: Rates for Radiology Services; and 101 CMR 320.00: Rates for Clinical Laboratory Services.