Code of Massachusetts Regulations
101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES
Title 101 CMR 317.00 - Rates for Medicine Services
Section 317.02 - General Definitions
Meaning of Terms: The five-digit procedure codes, and two-digit modifier codes included in 101 CMR 317.00, and their corresponding descriptions, utilize the Healthcare Common Procedure Code System (HCPCS) for Level I and Level II coding. Level I CPT-4 codes are obtained from the Physicians' 2020 Current Procedural Terminology (CPT), copyright 2019 by the American Medical Association (AMA), unless otherwise specified. Level II codes are obtained from the 2020 HCPCS, maintained jointly by the Centers for Medicare & Medicaid Services (CMS), the Blue Cross and Blue Shield Association, and the Health Insurance Association of America. HCPCS is a listing of descriptive terms and identifying codes and modifiers for reporting medical services and procedures perforrmed by physicians and other health care professionals, as well as associated nonphysician services. No fee schedules, basic unit value, relative value guides, conversion factors, or scales are included in any part of the Physicians' Current Procedure Terminology. For code descriptions, see the medicine services code spreadsheet on the EOHHS rates website at: www.mass.gov/regulations/101-CMR-31700-medicine.
In addition, terms used in 101 CMR 317.00 have the meanings set forth in 101 CMR 317.02.
Child and Adolescent Needs and Strengths (CANS). A tool that provides a standardized way to organize information gathered during a psychiatric diagnostic assessment and is a treatment and service decision support tool for children and adolescents younger than 21 years old.
CMS. Centers for Medicare & Medicaid Services.
Early and Periodic Screening, Diagnostic and Treatment (EPSDT). A program of health screening and other medical services for publicly assisted individuals younger than 21 years old as required by federal law.
Eligible Provider. The rates established in 101 CMR 317.00 apply in accordance with 101 CMR 317.01 to the following types of providers who meet conditions of participation of the governmental unit purchasing such services, and to the extent specified by such governmental unit. Eligible providers must provide such services in accordance with generally accepted professional standards and in accordance with state licensing requirements and certification by national credentialing bodies as required by law.
(a) A licensed physician (other than an intern, resident, fellow, or house officer), licensed podiatrist, licensed dentist, licensed chiropractor, and licensed optometrist.
(b) A provider of diagnostic medical services. Such medical diagnostic services may be rendered by eligible providers such as, but not limited to, independent diagnostic testing facilities (IDTFs). These eligible providers must be physically and financially independent of a hospital or a physician's office.
(c) A provider of radiation oncology services. Radiation oncology services may be rendered by eligible providers such as, but not limited to, independent radiation oncology centers. These eligible providers must be physically and financially independent of a hospital or a physician's office.
(d) A clinic licensed by the Massachusetts Department of Public Health in accordance with 105 CMR 140.000 : Licensure of Clinics to provide medical diagnostic services.
(e) A freestanding birth center facility that is not operating under a hospital's license, and is licensed as a birth center by the Massachusetts Department of Public Health pursuant to 105 CMR 142.000: The Operation and Maintenance of Birth Centers.
(f) An advanced practice registered nurse who is authorized by the Board of Registration in Nursing to practice as a certified nurse practitioner, certified nurse midwife, clinical nurse specialist, psychiatric clinical nurse specialist, or a certified registered nurse anesthetist (CRNA).
(g) A licensed physician assistant, who is authorized by the Board of Registration for Physician Assistants to practice as a physician assistant.
(h) A registered nurse providing tobacco cessation services.
(i) A tobacco cessation counselor, who has completed appropriate training in tobacco cessation counseling according to the qualification criteria established by the purchasing governmental unit.
(j) A pharmacist who is registered by the Board of Registration in Pharmacy.
(k) An acupuncturist who is licensed by the Board of Registration in Medicine to practice acupuncture.
Eligible Provider for Administration of Vaccines. A licensed physician, certified nurse practitioner, certified nurse midwife, clinical nurse specialist, psychiatric clinical nurse specialist, physician assistant, registered pharmacist or other health care professional certified in accordance with 105 CMR 700.000: Implementation of M.G.L. c. 94C, and any home health agency certified as a provider of home health services under the Medicare Health Insurance Program for the Aged (Title XVIII) is eligible to administer vaccines, if it otherwise meets such conditions of participation and coverage set forth by a purchasing governmental unit. Any other providers authorized by the Massachusetts Department of Public Health to possess and administer vaccines are also eligible if they otherwise meet such conditions of participation and coverage set forth by a purchasing governmental unit.
EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A.
Facility Setting Fee. Payments for services provided by an individual eligible provider in a hospital (including, without limitation, a hospital inpatient department, outpatient department, emergency department, and hospital licensed health center), or skilled nursing facility or freestanding ambulatory surgical center (ASC), will be made according to a facility setting fee when an applicable facility setting fee has been established for that procedure.
Governmental Unit. The Commonwealth, any department, agency, board or commission of the Commonwealth and any political subdivision of the Commonwealth.
Individual Consideration. Medical services that are authorized but not listed in 101 CMR 317.00, medical services perforrmed in unusual circumstances, and services designated "I.C." are Individually Considered items. The governmental unit or purchaser analyzes the eligible provider's report of services rendered and charges submitted under the appropriate unlisted services or procedures category. The governmental unit or purchaser determines appropriate payment for procedures designated I.C. in accordance with the following standards and criteria:
(a) the amount of time required to perform the service;
(b) the degree of skill required to perform the service;
(c) the severity or complexity of the patient's disease, disorder, or disability;
(d) any applicable relative-value studies;
(e) any complications or other circumstances that may be deemed relevant;
(f) the policies, procedures, and practices of other third-party insurers;
(g) the payment rate for prescribed drugs as set forth in 101 CMR 331.00: Prescribed Drugs; and
(h) a copy of the current invoice from the supplier.
Modifiers. Listed services may be modified under certain circumstances. When applicable, the modifying circumstances should be identified by the addition of the appropriate two-digit number or letters.
Physical Medicine. The physical medicine procedure codes apply only when
(a) the physician prescribed the needed therapy; and
(b) the services are provided by the physician or a licensed physical or occupational therapist employed by the physician.
Primary Care Clinician (PCC) Plan. A managed care option administered by the MassHealth agency through which enrolled members receive primary care and certain other medical services.
Publicly Aided Individual (or Publicly Aided Patient). A person who receives health care and services for which a governmental unit is in whole or in part liable under a statutory program of public assistance.
Referral. The transfer of the total or specific care from one eligible provider to another.
Separate Procedure. Some of the listed procedures are commonly carried out as an integral part of a total service, and as such do not warrant a separate identification. When, however, such a procedure is perforrmed independently of, and is not immediately related to, other services, it may be listed as a separate procedure in the procedure description. Thus, when a procedure that is ordinarily a component of a larger procedure is perforrmed alone for a specific purpose, it may be considered to be a separate procedure.
Unlisted Procedure or Service. A service or procedure may be provided that is not listed in 101 CMR 317.04. When reporting such a service, the appropriate "Unlisted Procedure" code may be used to indicate the service.
