Current through Register 1518, March 29, 2024
(1)
Scope, Purpose, and Effective Date.
(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, 86153, 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 January
1, 2023, 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), EOHHS may list
these codes and price them according to the rate methodology used in setting
physician rates. When RVUs 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.
