Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 433.000 - Physician Services
Section 433.451 - Surgery Services: Introduction
Universal Citation: 130 MA Code of Regs 130.433
Current through Register 1531, September 27, 2024
(A) Provider Eligibility. The MassHealth agency pays a physician for surgery only if the physician is scrubbed and present in the operating room during the major portion of the operation. (See 130 CMR 433.421(B)(2) for the single exception to this requirement.)
(B) Nonpayable Services. The MassHealth agency does not pay for
(1) any experimental, unproven, cosmetic, or
otherwise medically unnecessary procedure or treatment;
(2) the treatment of male or female
infertility (including, but not limited to, laboratory tests, drugs, and
procedures associated with such treatment); however, MassHealth does pay for
the diagnosis of male or female infertility;
(3) reconstructive surgery, unless the
MassHealth agency determines, pursuant to a request for prior authorization,
the service is medically necessary to correct, repair, or ameliorate the
physical effects of disease or physical defect, or traumatic injury;
(4) services billed under codes listed in
Subchapter 6 of the Physician Manual as not payable;
(5) services otherwise identified in the
MassHealth regulations at 130 CMR 433.000 or 450.000 as not payable;
and
(6) services billed with
otherwise covered service codes when such codes are used to bill for nonpayable
circumstances as described in
130 CMR
433.404.
(C) Definitions. The following terms have the meanings given for purposes of 130 CMR 433.451 and 433.452, unless otherwise indicated.
(1)
Complications Following Surgery - all additional
medical or surgical services required of the surgeon during the postoperative
period of the surgery because of complications that do not require additional
trips to the operating room.
(2)
Evaluation and Management (E/M) Services - visits and
consultations furnished by physicians in various settings and of various
complexities as defined in the Evaluation and Management section of the
American Medical Association's Current Procedural Terminology (CPT)
code book.
(3)
Intraoperative Services - intraoperative services that
are normally a usual and necessary part of a surgical procedure.
(4)
Major Surgery -
a surgery for which the Centers for Medicare & Medicaid Services (CMS)
determines the preoperative period is one day and the postoperative period is
90 days.
(5)
Minor
Surgery - a surgery for which CMS determines the preoperative
period is zero days and the postoperative period is zero or ten days.
(6)
Postoperative
Period -
(a) The postoperative
period for major surgery is 90 days.
(b) The postoperative period for minor
surgery and endoscopies is zero or ten days.
(7)
Postoperative
Visits - follow-up visits during the postoperative period of the
surgery that are related to recovery from the surgery.
(8)
Postsurgical Pain
Management - postsurgical pain management by the surgeon,
including supplies.
(9)
Preoperative Period -
(a) The preoperative period for major surgery
is one day.
(b) The preoperative
period for minor surgery is zero days.
(10)
Preoperative
Visits - preoperative visits after the decision is made to
operate, beginning with the day before the day of surgery for major procedures
and the day of surgery for minor procedures.
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