Current through Register 1531, September 27, 2024
(1)
Scope and Purpose.
(a) 101 CMR 316.00 governs the payment rates
used by all governmental units for surgery and anesthesia services provided to
publicly aided patients. Rates for services provided to individuals covered by
the Workers' Compensation Act, M.G.L. c. 152, are not set forth in 101 CMR
316.00, but are at 114.3 CMR 40.00: Rates for Services under M.G.L. c.
152, Worker's Compensation Act.
(b) The following laboratory services have a
professional and technical component: 83020, 84165, 84166, 84181, 84182, 85390,
85576, 86255, 86256, 86320, 86325, 86327, 86334, 86335, 87164, 87207, 88371,
88372 and 89060. Payment rates for the professional component are contained
herein. Payment rates for the technical component for these codes are contained
in 101 CMR 320.00: Rates for Clinical Laboratory
Services.
(2)
Applicable Dates of Service. Rates contained in 101
CMR 316.00 apply for dates of service on or after May 1, 2024, except as
otherwise noted.
(3)
Coverage.
(a) Payment
rates in 101 CMR 316.00 are used to pay for surgical and anesthesia services
rendered to patients in a private medical office, freestanding ambulatory
surgical center, licensed clinic, hospital or other inpatient or outpatient
facility or department, or other appropriate setting by an individual eligible
provider, when an eligible provider bills for the medical services rendered and
no other payment method applies.
(b) The rates of payment under 101 CMR 316.00
are full compensation for patient care rendered to publicly aided patients as
well as for any related administrative or supervisory duties in connection with
patient care. The rates of payment also reimburse all overhead expenses
associated with the service provided, without regard to where the care is
rendered.
(4)
Disclaimer of Authorization of Services. 101 CMR
316.00 is not authorization for or approval of the procedures for which rates
are determined pursuant to 101 CMR 316.00. Governmental units that purchase
care are responsible for the definition, authorization, coverage policies, and
approval of care and services provided to publicly aided patients.
(5)
Coding Updates and
Corrections. EOHHS may publish procedure code updates and
corrections in the form of an administrative bulletin. Updates may reference
coding systems including, but not limited to, the American Medical
Association's Current Procedural Terminology (CPT).
(a) The publication of such updates and
corrections will list
1. codes for which the
code numbers change, with the corresponding cross references between the new
codes and the codes being replaced. Rates for such updated codes are set at the
rate of the code that is being replaced;
2. deleted codes for which there are no
corresponding new codes; and
3.
codes for entirely new services that require pricing. EOHHS will list these
codes and apply individual consideration (I.C.) reimbursement for these codes
until appropriate rates can be developed.
(b) For entirely new codes that require new
pricing and have Medicare assigned relative value units (RVUs) (or, for
applicable services, Medicare rates), EOHHS may list these codes and price them
according to the rate methodology used in setting physician rates. When
Medicare RVU s (or, for applicable services, Medicare rates) are not available,
EOHHS may apply individual consideration in reimbursing for these new codes
until appropriate rates can be developed.
(6)
Administrative
Bulletins. EOHHS may issue Administrative Bulletins to add,
delete, or otherwise update codes or modifiers, and to clarify its policy on
and understanding of substantive provisions of 101 CMR 316.00. EOHHS may also
issue Administrative Bulletins to clarify to which duly licensed or certified
health care professionals or students the rate methods in 101 CMR 316.00
apply.
