Code of Massachusetts Regulations, Title 114.3 CMR 40.00, Section 40.05 - Policies for Individual Service Types | Code of Massachusetts Regulations

(1) Acupuncture.

(a) Eligible Providers. An Eligible Provider is any person licensed by the Board of Registration in Acupuncture under M.G.L. c. 112, §§ 148 through 162, to practice acupuncture.

(b) Acupuncture Services. Acupuncture is the insertion of needles through the skin at certain points on the body in an attempt to relieve pain or improve bodily function. Services include examinations, Evaluation and Management services (E/M), acupuncture treatments and supportive services. The acupuncture treatment codes include a patient assessment. Additional E/M services may be reported separately using the modifier '-25', if the patient's condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure.

(c) Fees. Payment rates for acupuncture services are set forth in 114.3 CMR 40.06(1).

(d) Modalities and Supportive Procedures. A charge may be assessed for modalities only in conjunction with an acupuncture treatment performed during the course of the same visit.

(e) Nutritional Supplements. The payment rate for nutritional supplements is the invoice cost, plus a handling fee of $3.00.

(2) Anesthesia Services.

(a) Eligible Providers. An Eligible Provider is:

1. a licensed medical doctor or licensed osteopath, other than an intern or resident, authorized by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112; or

2. a certified registered nurse anesthetist (CRNA) licensed and subject to the rules and requirements in accordance with the provisions of M.G.L. c. 112 and 244 CMR 4.00 to practice as a CRNA. The CRNA is limited to those procedures within the scope of CRNA services and subject to the rules of physician relationship for reimbursement defined by the Commonwealth's Nurse Practice Act, M.G.L. c. 112, §§ 74 through 81. The CRNA is an employee of the eligible physician provider and not salaried by the health care facility. Availability by telephone is not direct supervision; however, the physician need not be in the room where the services are being performed.

(b) Anesthesia Services. Services include, but are not limited to, general, regional, supplementation to local anesthesia, or other supportive services for optimal anesthesia care to the patient. These services include anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services, (eg, ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry). These services do not include preoperative and postoperative services or pain management services that may be billable separately. Unusual forms of monitoring beyond the basic anesthesia service (eg, intra-arterial, central venous, and Swan-Ganz catheters) are not included and are reimbursed separately based on the appropriate medical or surgical fee schedule.

(c) Fees. The payment rates for anesthesia services are set forth in 114.3 CMR 40.05(2)(g) for use with base units set forth in 114.3 CMR 40.06(2). Fees for supplies and materials provided by the physician (eg, sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately using code 99070.

(d) Payments for Qualified CRNAs. Payment rates are established using the appropriate 2 digit modifier listed in 114.3 CMR 40.07: Appendix A to denote services rendered by a non-physician provider. Payments to employers billing for eligible CRNA services as specified in 114.3 CMR 40.05(2)(a)2. are:

1. 50% of the fees specified in 114.3 CMR 40.05(2)(c) for CRNA services with medical direction of 2, 3 or 4 concurrent procedures by a physician, or

2. 100% of the allowable fee specified in 114.3 CMR 40.05(2)(c) for CRNA services with medical direction of one CRNA or without direction by a physician.

(e) Time Reporting. Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating suite (or its equivalent area) and ends when the anesthesiologist is no longer in personal attendance, i.e., when the patient is placed in postoperative supervision.

(f) Qualifying Circumstances. If anesthesia services are provided under particularly difficult circumstances, based on factors such as extraordinary condition of the patient, notable operative conditions, and/or unusual risk factors, CPT codes 99100 to 99140 may be listed as additional procedure codes as follows:

Qualifying Circumstances in CP	Description	Unit Value
99100	Anesthesia for a patient of extreme age, under one year old and 70 years of age or older	1
99116	Anesthesia complicated by utilization of total body hypothermia	5
99135	Anesthesia complicated by utilization of controlled hypotension	5
99140	Anesthesia complicated by emergency conditions (an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part.)	2

(g) Determining Payment for Anesthesia Services. Providers must use anesthesia codes and report time in minutes to ensure proper payment. Payments are determined by adding base units, time units and modifying units (if any) and multiplying this sum by a rate per unit. Each time unit equals 15 minutes. Partial time units should be reported rounded to one decimal place.

PAYMENT EQUALS : (TIME UNITS + BASE UNITS + MODIFYING UNITS) TIMES $39.00 (Rate per UNIT)

(h) Special Coding Situations.

1. Multiple Procedures. When multiple surgical procedures are performed during a single anesthetic administration, providers must report only the anesthesia procedure with the highest unit value. The provider must report time as the combined total for all procedures performed.

2. Anesthesia Modifiers. Physical status and common CPT modifiers used in conjunction with anesthesia codes are set forth in 114.3 CMR 40.07(1): Appendix A.

3. Postoperative Pain Management. Postoperative pain management is payable as an additional procedure.

(3) Chiropractic Services.

(a) Eligible Providers. An Eligible Provider is an individual licensed by the Board of Registration of Chiropractors in accordance with the provisions of M.G.L. c. 112.

(b) Chiropractic Services. Chiropractic Services include examinations, Evaluation and Management services (E/M), Chiropractic Manipulative Treatment (CMT), therapeutic (supportive) procedures and modalities. The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional E/M services may be reported separately using the modifier '-25' if the patient's condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure. When an extraspinal manipulation (code 98943) is performed in conjunction with CMT codes 98940 through 98942, the Multiple Procedure modifier -51 must be added to code 98943 indicating payment at 50% of the allowable fee set forth in 114.3 CMR 40.06.

(c) Fees. Payment rates for chiropractic services are set forth in 114.3 CMR 40.06(3).

(d) Modalities and Supportive Procedures. A charge may be assessed for modalities (97012-97039) only in conjunction with a chiropractic treatment performed over the course of treatment of the patient. Service provisions pertaining to physical medicine are set forth in 114.3 CMR 40.05(13) and rates of payment for supportive procedures are listed in 114.3 CMR 40.06(12). No charge will be allowed for application of hot and cold packs (CPT code 97010).

(e) Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS). Payment rates for durable medical equipment, prosthetic/orthotics and supplies are set forth in 114.3 CMR 40.06(6) and subject to the provisions and guidelines set forth in 114.3 CMR 40.05(6).

(f) Nutritional Supplements. The payment rate for nutritional supplements is the invoice cost, plus a handling fee of $3.00.

(g) Radiology. Payment rates for radiological services are set forth in 114.3 CMR 40.06(7) subject to the provisions and guidelines set forth in 114.3 CMR 40.05(12).

(4) Clinical Laboratory Services.

(a) Eligible Providers. An Eligible Provider is an independent licensed clinical diagnostic laboratory, a diagnostic laboratory in a physician's office or a hospital laboratory. Payment for clinical laboratory tests subject to 114.3 CMR 40.06(4) applies to the person or entity that performs or supervises the performance of the tests.

(b) Clinical Laboratory Services. Clinical Laboratory Services include microbiological, chemical, hematological, biophysical, cytological, immunohematological, or pathological examinations performed in a laboratory on materials derived from the human body to provide information for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition.

(c) Fees. Payment rates for clinical laboratory services are set forth in 114.3 CMR 40.06(4). Payment Rates for physician laboratory services, i.e., anatomic and surgical pathology are set forth in 114.3 CMR 40.06(8).

(d) Items Over and Above Usual Service. If the physician's administration of supplies and drugs includes items over and above the usual service rendered (eg, sterile trays, drugs, supplies and materials), the provider may list these separately using code 99070. To report physician attendance and monitoring during the test, providers must use the appropriate evaluation and management code, including the prolonged physician care codes if appropriate. Prolonged physician care codes are not separately reported when evocative/ suppression testing involves prolonged descriptors where reference is made to a particular analyte (eg, Cortisol (82533 x 2) where the "x 2" refers to the number of times the test for that particular analyte is performed).

(e) Pricing of Automated Tests. The payment for automated tests is based on the total number of actual tests whether billed individually or as part of a panel. For example, if three automated tests are performed on one blood draw from a patient, the total fee allowed for these tests will be $9.29, the pricing equivalent for three tests.

(5) Dental Services .

(a) Eligible Providers. An Eligible Provider is:

1. a dentist registered by the Board of Registration in Dentistry in accordance with the provisions of M.G.L. c. 112; or

2. an authorized governmental, nonprofit or charitably incorporated dental clinic not involved with teaching dental students; or

3. an authorized dental clinic that wholly or partially derives support from Title V Funds under the Social Security Act; or

4. a teaching dental clinic operated by dental education institutions.

(b) Dental Services . Dental services include, but are not limited to, diagnostic, consultative and evaluative oral examinations, X-rays, preventive, restorative, endodontic, periodontic, prosthodontic, surgical, exodontic and orthodontic procedures and appliances.

(c) Fees. Payment rates for dental services are set forth in 114.3 CMR 40.06(5).

(d) Surgery. Payment rates for surgical dental services are set forth in 114.3 CMR 40.06(8) and subject to the provisions and guidelines set forth in 114.3 CMR 40.05(14).

(e) Codes and Descriptions. All codes and descriptions are copyrighted by the American Dental Association's Current Dental Terminology, (CDT-4).

(6) Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS).

(a) Eligible Providers. An Eligible Provider is:

1. any person, partnership, corporation, or other entity authorized by the Commonwealth of Massachusetts to engage in the business of furnishing Durable Medical Equipment (DME), Medical and surgical supplies, Customized equipment, Oxygen or respiratory therapy equipment, Mobility systems, Intravenous and enteral therapy equipment, and/or related supplies and services;

2. a provider authorized under 114.3 CMR 40.05 to provide equipment or supplies relative to his or her specialty in an office setting;

3. an eligible prosthesis provider certified by the American Board for Certification in Prosthetics and Orthotics (P&O) with experience and knowledge of upper and lower extremity prostheses, cosmetic restoration and devices for traumatic or congenital deformities, their design, fabrication and fitting; or

4. any person, partnership, corporation or other entity authorized by the Commonwealth of Massachusetts to engage in the business of furnishing orthotic devices. At the discretion of the purchasing agency, a provider of certain orthotic devices may be a certified orthotist who has experience in and knowledge of upper and lower extremity bracing, torso, and spinal bracing, devices for congenital deformities, their design, fabrication and fitting.

(b) Exclusions. 114.3 CMR 40.00 does not govern the payment rates for the following services:

1. Respiratory therapy services rendered by a qualified respiratory therapist;

2. Oxygen provided to a nursing home that is reimbursed under the per diem rate for such nursing home;

3. Services for inpatients at a facility licensed as an acute or chronic hospital.

(c) General Provisions.

1. Coverage. 114.3 CMR 40.05 governs the payment rates for the following situations:

a. the purchase or rental of durable medical equipment;

b. the purchase or rental of medical/surgical supplies;

c. the purchase or rental of prescribed oxygen delivery systems and respiratory therapy equipment and related supplies;

d. the purchase or rental of seating, positioning, mobility systems and related accessories;

e. the purchase or rental of intravenous and enteral supplies, equipment and services; and

f. the repair of the listed types of equipment in 114.3 CMR 40.05(6)(c)1.a. through e.

2. Pre-authorization. Insurers and other payers under 114.3 CMR 40.00 may require pre-authorization, recertification and/or other requirements documenting medical necessity for equipment and related supplies and services under 114.3 CMR 40.05(6). In most cases, the physician's prescription for the equipment and other medical information available are sufficient to establish that the equipment is necessary and suitable in the treatment of the illness or injury. Providers should determine if there are documentation and coverage requirements associated with a prescription for durable medical supplies prior to dispensing.

(d) Fees. Payment rates for DMEPOS, are set forth in 114.3 CMR 40.06(6).

(e) Payment Methodology. DME fee schedules are calculated for the following DME payment classes:

1. Inexpensive and Other Routinely Purchased Items (IN). These items have a purchase price of $150 or less, or are generally purchased 75% of the time or more, or are accessories used in conjunction with certain nebulizers, aspirators, and ventilators. These items can be purchased new or used and can be rented; however, total payments cannot exceed the purchase new fee for the item.

2. Frequently Serviced Items (FS). These items require frequent and substantial servicing. These items can be rented as long as they are medically necessary.

3. Oxygen and Oxygen Equipment. Payment for oxygen and oxygen equipment is made on a monthly basis. One bundled monthly payment amount is made for all covered stationary equipment, stationary and portable contents, and all accessories used in conjunction with the oxygen equipment. A monthly payment is made for oxygen contents only. An additional monthly payment may be made for portable oxygen.

4. Other Covered Items. Supplies necessary for the effective use of the DME.

5. Capped Rental Items (CR). Items that do not fall under any other DME payment category, generally expensive items that are routinely rented. Items designated as "capped rental" in the code description are rented for a maximum period of 15 months or until the rental fees paid equal the purchase price, at which point the provider stops billing. The provider may bill for repairs as needed to maintain proper working condition of the equipment for the patient's use after the 15th month. The methodology for payment of items on a capped rental basis is as follows:

a. for the first three months of rental, 10% of the new purchase fee;

b. for months four through 15, 75% of the monthly fee for months one through three;

c. if provided equipment is used for less than one month, the payment will be prorated. The payment is determined by dividing the monthly rental fee by the number of days in the applicable month, and multiplying the daily rate by the number of rental days. For purchase of capped rental items, the purchase price may not exceed the sum of the capped rental methodology applied for ten months.

6. Unlisted Items. Items that are not listed but may be prescribed as medically necessary for the treatment of illness or injury or to improve patient function are payable using the Medicare fee for the locality in which the item is prescribed. If no Medicare fee is available then the item shall be paid under the reimbursement policies for individually considered (I.C.) items in accordance with 114.3 CMR 40.05(6). In this case a code not listed in 114.3 CMR 40.06(6) should be assigned an unlisted service or procedure code such as A9900 (Miscellaneous DME supply, accessory, and/or service component of another HCPCS code) or E1399 (Durable Medical Equipment, miscellaneous.) Customized items that are deemed medically necessary are payable at individual consideration (I.C.).

(f) Individual Consideration (I.C.). The payment for individually considered items is the lower of:

1. The Eligible Provider's usual and customary charge to the general public; or

2. The adjusted acquisition cost to the Eligible Provider plus a markup not to exceed:

a. 30% for inexpensive and routinely purchased items; or

b. 40% for frequently serviced items, customized equipment, prosthetics and orthotics; or

c. as priced in 114.3 CMR 40.06(6)

(g) Labor Rate for Repair Services.

1. Payments for labor costs for repair code E1340 to an Eligible Provider for items that require additional service, intensive time or procedures, or that require repair, may be billed at the rate of $21.00 per 15 minutes.

2. Payments for labor costs for orthotic repair code L4205 and prosthetic repair code L7520 to an Eligible Provider for items that require additional service, intensive time or procedures, or that require repair, may be billed at the rate of $21.00 per 15 minutes.

(7) Freestanding Diagnostic Facilities.

(a) Eligible Provider. An Eligible Provider is a licensed freestanding diagnostic imaging facility or hospital.

(b) Fees. Payment rates for freestanding diagnostic facilities and imaging technical components are set forth in 114.3 CMR 40.06(7).

(c) General Rate Guidelines.

1. The TC payment for CAT and MRI procedures that specify "with contrast" include payment for contrast media.

2. The TC rate for nuclear medicine does not include the radionuclide used in connection with the procedure. These substances are separately billed under codes A4641 and A4642 for diagnostic procedures and are paid on an I.C. basis depending on the substance used.

(8) Freestanding Ambulatory Surgical Centers.

(a) Eligible Provider. An Eligible Provider is a DPH licensed freestanding ambulatory surgical center (FASC) or hospital outpatient surgical center.

(b) FASC Services. FASC Services are procedures that CMS recognizes as safe to perform in an ambulatory setting without requiring hospital facilities as of January 1, 2008.

(c) Fees. Payment rates are based upon Medicare rates for Massachusetts effective January 1, 2008. The fees are listed in 114.3 CMR 40.06(8). For procedures that are deemed safe to perform in the ambulatory setting subsequent to January 1, 2008, the Medicare fee for Massachusetts should be used for services provided under 114.3 CMR 40.00.

(d) Global Surgical Procedures Facility Coverage. The fee covers services and the normal range of care required before and after surgery that are included in the Medicare fee.

(e) Services not included in the global facility rate. Services required in conjunction with the surgical procedure that are not included in the Medicare fee should be reimbursed at their respective CPT/HCPCS rates.

(f) Implanted DME, implanted prosthetic devices, replacement parts (External or Internal), accessories and supplies for the implanted DME. Payment for items not included in the Medicare ASC fee but listed in 114.3 CMR 40.06(6) includes the associated fees. Otherwise payment for the items is the invoice cost as specified in 114.3 CMR 40.02. No separate payment shall be made for implanted devices that are included in the Medicare ASC fee. Fees do not include medically appropriate observation stays in hospitals which are established under 114.1 CMR 41.00.

(g) Modifiers. See 114.3 CMR 40.07(1): Appendix A for a list of Level 1 CPT modifiers.

(9) Homemaker Services.

(a) Eligible Provider. An Eligible Provider is an individual, partnership or corporation that employs homemakers.

(b) Homemaker Services. Homemaker Services are services that comply with the Homemaker Standards issued by the Executive Office of Elder Affairs to assist a client with IADL.

(c) Fees. The payment rate for homemaker services is set forth in 114.3 CMR 40.06(9).

(10) Medicine.

(a) Eligible Providers. Eligible Providers include:

1. a physician or osteopath other than an intern, resident, or house officer licensed by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112. A licensed Physician Assistant (PA) authorized by the Board of Registration for Physician Assistants in accordance with the provisions of M.G.L. c. 112, may not bill separately for services rendered.

2. a licensed, registered podiatrist other than an intern, resident, or house officer authorized by the Board of Registration in Medicine or the Board of Registration in Podiatry in accordance with the provisions of M.G.L. c. 112, whose eligibility is limited to those procedures within the scope of his/her licensure.

3. a licensed registered nurse authorized by the Board of Registration in Nursing in accordance with the provisions of M.G.L. c. 112 to practice as a Nurse Practitioner (NP), limited to those procedures within the scope of NP services and subject to the rules of physician relationship for reimbursement defined by the Commonwealth's Nurse Practice Act, M.G.L. c. 112, §§ 74 through 81.

(b) Fees. Payment rates for medicine services are set forth in 114.3 CMR 40.06(10).

(c) Payments for Qualified NPs and PAs. Payment to employers billing for eligible NPs and PAs as specified in 114.3 CMR 40.05(10)(a)3. is 85% of the fees set forth in 114.3 CMR 40.06. Providers must use the appropriate 2-digit modifier listed in 114.3 CMR 40.07: Appendix A to denote services rendered by a non-physician provider.

(d) Allowable Fees - Medical Services.

1. Office Visits. The office visit fees apply only when the Eligible Provider customarily bills for services rendered.

2. Drugs, Medications, Supplies and Laboratory Specimen Collections. Supplies and materials used in preparation for or as part of a procedure (eg, bandages, laboratory kits, syringes or disposable gloves) are not reimbursed separately, but included in the office visit rate. In addition, no supplemental charge will be submitted nor payment allowed for routine specimen collection in a physician's office and preparation for clinical laboratory analysis (and activities related thereto), eg, venipuncture, urine, fecal and sputum sample collection, culturing, swabbing and scraping for removal of tissues.

3. Payments for Other Services. Where applicable, payment for drugs, medicines, supplies, and related materials dispensed to patients are governed by provisions of other Division regulations applicable to the service provided, and may not exceed the physician's usual and customary fee. If there is no appropriate code for the supplies or materials provided by the physician over and above those usually included with the office visit, the service should be billed under code (99070).

4. Medication and Injections. Medication and injectables not available free of charge from the Department of Public Health may be billed under the appropriate J Code at A.I. cost net of any manufacturer discounts received by the provider. See 114.3 CMR 40.07(4): Appendix D for a list of J codes. If the code is not available, use an unlisted procedures category (such as code 90749 for immunizations or code 99070 under miscellaneous services).

Immunization injections are usually given in conjunction with a medical service. When an immunization is the only service performed, a minimal service (such as codes 90471, 90472 or 96400) may be listed in addition to the injection; an office visit should not be separately billed. Immunization procedures include the supply of materials.

5. Physical Medicine . Service provisions pertaining to physical and restorative medicine are set forth in 114.3 CMR 40.05(13) and codes and fees for physical medicine procedures are listed in 114.3 CMR 40.06(12).

(11) Psychology.

(a) Eligible Providers. An Eligible Provider is:

1. a psychologist licensed by the Massachusetts Board of Registration of Psychologists in accordance with the provisions of M.G.L. c. 112; or

2. a social worker (LICSW) licensed by the Massachusetts Board of Registration of Social Work in accordance with the provisions of M.G.L. c. 112.

Psychiatric Services provided by a licensed physician are set in accordance with 114.3 CMR 40.05(10).

(b) Psychological Services. Psychological Services include:

1. diagnostic services, which are evaluative interviews to determine a client's emotional and psychological disability for the purpose of developing a treatment plan;

2. individual therapy, which is a meeting between an Eligible Provider and the client to help to ameliorate problems, conflicts and disturbances;

3. group therapy, which is a treatment session conducted by an Eligible Provider for the application of psychotherapeutic or counseling techniques to a group of people each of whom manifests an emotional problem or disturbance. Groups are usually five people but are limited to a maximum of ten clients.

4. psychological testing, which is performed with the use of standard test instruments to evaluate aspects of a client's functioning, aptitudes and educational ability, cognitive processes, emotional conflicts and type and degree of psychopathology. All fees for psychological tests cover the complete cost of interviewing, testing, scoring, interpreting and writing reports of test outcomes.

(c) Fees. Payment rates for psychological services are set forth in 114.3 CMR 40.06(11).

(12) Radiology.

(a) Eligible Providers. Eligible Providers include:

1. a physician or osteopath other than an intern, resident, or house officer licensed by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112.

2. a podiatrist other than an intern, resident, or house officer licensed by the Board of Registration in Medicine or the Board of Registration in Podiatry in accordance with the provisions of M.G.L. c. 112, whose eligibility is limited to those procedures specified by the purchaser of the services.

3. an oral and/or maxillofacial surgeon licensed by the Board of Registration in Dentistry in accordance with the provisions of M.G.L. c. 112.

4. a chiropractor licensed by the Board of Registration of Chiropractors under and meeting the requirements of M.G.L. c. 112, §§ 89 through 97, whose eligibility is limited to those procedures within the scope and limitations of chiropractic medicine services.

(b) Radiological Services. Services include all diagnostic and therapeutic imaging. Most radiological services are comprised of a professional component and a technical component. The professional component is the physician's interpretation of the procedure, and the technical component is the equipment, supplies and technician's services used to perform the procedure. Fees and requirements for certain technical component services are set forth in the regulatory section entitled Freestanding Diagnostic Services.

(c) Fees. Rates of payment for radiological services are set forth in 114.3 CMR 40.06(7).

(d) Contrast Media. Complete procedures, interventional radiological procedures or diagnostic studies involving injection of contrast media include all usual pre-injection and post-injection services, eg, necessary local anesthesia, placement of needle catheter, injection of contrast media, supervision of the study, and interpretation of the results. Providers must determine whether the use of ionic or non-ionic contrast media is appropriate for the individual patient.

(13) Rehabilitation Clinic Services, Audiological Services, Restorative Services.

(a) Eligible Providers. Eligible Providers include:

1. a physical therapist (PT) currently licensed by the Board of Allied Health Professionals;

2. an occupational therapist (OT) currently licensed by the Board of Allied Health Professionals;

3. a speech therapist (ST) currently licensed by the Board of Speech and Language Pathology and Audiology;

4. an audiologist currently licensed by the Board of Speech and Language Pathology and Audiology;

5. a freestanding clinic licensed by DPH providing rehabilitative services;

6. a hospital outpatient clinic licensed by the Department of Public Health and not subject to provisions of 114.1 CMR 41.00;

7. any speech and hearing center (proprietorship, partnership or corporation) that provides authorized speech or language services by a qualified speech pathologist that does not bill separately from such facility for professional services rendered; or

8. a chiropractor whose eligibility as it pertains to 114.3 CMR 40.05(13) is limited to modalities and therapeutic procedures.

(b) Rehabilitation, Restorative, Speech/Language Pathology and Audiological Services.

1. Rehabilitation services are comprehensive services deemed appropriate to the needs of an injured person, in a program designed to achieve objectives of improved health and welfare with the realization of optimal physical, social and vocational potential.

2. Restorative services are PT, OT, or ST services for the purpose of maximum reduction of physical and/or speech disability and restoration of optimal functional levels.

3. Speech/Language Pathology services include the evaluation and treatment of communicative disorders with regard to the functions of articulation (including aphasia and dysarthria, language, voice and fluency.)

4. Audiological services include testing related to the determination of hearing loss, evaluation of hearing aids, the prescription of hearing aid devices, and aural rehabilitation which includes lip-reading and auditory training. Complete audiological evaluation includes a routine audiological evaluation plus site of Lesion Testing (Impedance Testing and/or Recruitment Testing) as needed or recommended by a physician.

(c) Fees. Payment rates for restorative services are set forth in 114.3 CMR 40.06(12).

(d) Functional Capacity Assessments. To report a functional capacity assessment (or Key functional assessment), providers must use CPT code 97750 that may be billed up to a maximum of nine units per session.

(e) Work Hardening and Work Conditioning. Work Hardening and Work Conditioning are goal-oriented therapies designed to prepare injured workers for their return to work. Providers must use CPT codes 97545 and 97456 to report these services. 97456 must be used in conjunction with 97545.

(f) Visits. The number of visits and duration of treatment are the subject of DIA treatment guidelines for various injuries. Providers should seek prior approval for treatment regimens that deviate from these guidelines.

(g) Therapeutic Procedures. Pre-approval should be obtained if a provider believes that more than two therapeutic procedures should be performed at a session. The number of units allowed per session is limited only by medical necessity.

(h) Modalities. A charge may be assessed for supportive services (CPT codes 97012 through 97039) only in conjunction with a procedure performed during the course of the same visit. Pre-approval should be obtained if a provider believes that more than three modalities should be performed in a given session. The number of units allowed per session is limited only by medical necessity. When determining the correct units allowed, round partial units to one decimal place. No fee will be paid for the application of hot and cold packs (CPT code 97010).

(i) Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS). Rates of payment for durable medical equipment, prosthetic/orthotics and supplies are listed in 114.3 CMR 40.06(6) and subject to the provisions and guidelines in 114.3 CMR 40.05(6).

(14) Surgery.

(a) Eligible Providers. An Eligible Provider is:

1. a physician or osteopath other than an intern, resident, or house officer licensed by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112. A physician assistant (PA) licensed by the Board of Registration for Physician Assistants in accordance with the provisions of M.G.L. c. 112 may not bill separately for services rendered;

2. a podiatrist other than an intern, resident, or house officer licensed by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112, whose eligibility is limited to those procedures specified by the purchaser of the services;

3. a registered nurse licensed by the Board of Registration in Nursing in accordance with the provisions of M.G.L. c. 112 to practice as a nurse practitioner (NP), limited to those procedures within the scope of NP services and subject to the rules of physician relationship for reimbursement defined by the Commonwealth's Nurse Practice Act, M.G.L. c. 112, §§ 74 through 81; or

4. a dentist licensed by the Board of Registration in Dentistry in accordance with the provisions of M.G.L. c. 112.

(b) Payment for Surgical Procedures Includes:

1. the immediate preoperative care performed on the same day as surgery, completion of hospital records and initiation of the treatment program;

2. local anesthesia, such as infiltration, metacarpal/digital or topical anesthesia,

3. the surgical procedure;

4. supplies and materials usually included in the office visit or procedure;

5. normal, uncomplicated postoperative care performed on the same day as surgery at the facility.

6. up to two normal post operative follow up visits when indicated by an "I" in the fee schedule.

(c) First Assistants. Non-physician providers who act as first assistants during surgical procedures must be identified by adding the modifier -81, Minimum Assistant Surgeon, to the usual procedure number and will be reimbursed at 15% of the fee stipulated in 114.3 CMR 40.06(16)(f). The non-physician must be an employee of the eligible physician provider and not salaried by a facility.

(d) Fees. Rates of payment for surgical services are set forth in 114.3 CMR 40.06(8).

(e) Payments for Qualified NP's and PA's. Payment to employers billing for eligible NPs and PAs as specified in 114.3 CMR 40.06(16)(a)3 is 85% of the fees set forth in 114.3 CMR 40.06. Providers must use the appropriate two-digit modifier listed in 114.3 CMR 40.07: Appendix A to denote services rendered by a non-physician provider.

(f) Modifiers. See 114.3 CMR 40.07(1): Appendix A for a list of Level 1 CPT modifiers.

(g) Add-on Codes. 114.3 CMR 40.07(2): Appendix B lists procedures that are commonly carried out in addition to the primary procedure performed and must never be reported as stand-alone codes. These codes are exempt from the multiple procedure modifier '51'.

Code of Massachusetts Regulations114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICYTitle 114.3 CMR 40.00 - RATES FOR SERVICES UNDER M.G.L. c. 152, WORKERS' COMPENSATION ACTSection 40.05 - Policies for Individual Service Types

Code of Massachusetts Regulations
114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY
Title 114.3 CMR 40.00 - RATES FOR SERVICES UNDER M.G.L. c. 152, WORKERS' COMPENSATION ACT
Section 40.05 - Policies for Individual Service Types