Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 423.000 - Freestanding Ambulatory Surgical Centers
Section 423.405 - Payment

Universal Citation: 130 MA Code of Regs 130.423

Current through Register 1537, December 20, 2024

Payment for a surgical procedure performed at a surgical center consists of two components: the facility component and the professional component.

(A) Facility Component. The facility component is an all-inclusive fee that pays the surgical center for rent, equipment, utilities, supplies, salaries and benefits for administrative and technical staff, and other overhead expenses.

(1) This fee includes payment for
(a) surgical center facilities and equipment;

(b) nursing services, technician services, and other related services;

(c) drugs, biologicals, surgical dressings, supplies, splints, casts, appliances, and equipment directly related to the provision of the surgical procedures;

(d) administrative, recordkeeping, and housekeeping items and services;

(e) materials for anesthesia;

(f) blood;

(g) urinalysis and blood hemoglobin and hematocrit; and

(h) diagnostic or therapeutic services related to the provision of the surgical procedure.

(2) Payment for both in-state and out-of-state surgical center services is made in accordance with the rate or rates of payment established for surgical centers by the Massachusetts Executive Office of Health and Human Services (EOHHS) at 114. 3 CMR 47.00: Freestanding Ambulatory Surgical Facilities. Surgical procedures are classified into payment groups. All procedures within a payment group are assigned the same rate.
(a) Multiple Procedures. If more than one payable surgical procedure requiring an unrelated operative incision is provided in a single operative session, the full maximum fee is 100% for the operative procedure in the highest payment group and a percentage of the payment-group rate, as determined by EOHHS, for each additional payable procedure.

(b) Bilateral Procedures. If a payable surgical procedure provided in a single operative session is performed bilaterally, the full maximum fee is 150% of the payment-group rate for the operative procedure.

(c) Cancelled Procedures. The MassHealth agency does not pay for a surgical procedure that has been cancelled or postponed, for any reason, before the procedure is initiated.

(d) Terminated Procedures.
(i) The MassHealth agency determines payment on an individual-consideration (I.C.) basis for procedures that have been terminated after the procedure has been initiated. Appropriate payment for an I.C. service is determined by the MassHealth agency based on the operative report of services furnished. Payment of prosthetic devices for a terminated procedure depends on the preparation of the device. The preparation of the prosthetic device must require distinct preliminary measures (for example, immersion in an antibiotic solution) and does not include the action of opening a sterile implant onto the surgical field or instrument table.

(ii) The facility must use the service code in Subchapter 6 of the Freestanding Ambulatory Surgery Center Manual designated for terminated procedures. An operative report, including the operative summary, nursing notes, and anesthesia record, must accompany the claim. If a report is not submitted, no payment will be made. If, after review of the operative summary, nursing notes, and anesthesia record, the MassHealth agency determines that there should be payment for the prosthetic device, then this payment is included in the payment for the terminated procedure.

(B) Professional Component. Payment for professional services furnished by a dentist, podiatrist, or physician in a surgical center will be made in accordance with 130 CMR 420.000: Dental, 424.000: Podiatrist, and 433.000: Physician, respectively. All professional services must be furnished by a provider participating in MassHealth.

Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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