114.3 CMR 40.02
(1) Meaning of Terms. Terms used in 114.3 CMR 40.00 will have the meanings set forth in 114.3 CMR 40.02:
Adjusted Acquisition Cost. The price paid to a supplier by an Eligible Provider for durable medical equipment, medical/surgical supplies, customized equipment, oxygen and respiratory therapy equipment. The adjusted acquisition cost shall not exceed the manufacturer's current catalogue price.
Administrative Costs. A provider's costs for administration, including but not limited to facility costs overhead and other costs of doing business, are included in the rates set forth in this fee schedule, unless stated otherwise.
At Invoice Cost (AI). The price paid by the provider net of any manufacturer discounts received. Documentation of AI cost must be supplied to purchaser for payment upon request however submission of the request to the provider must be made within ten days of the initial billing date, will not affect the payment timeframe dictated by DIA regulations and will be limited to items where the provider's cost exceeds $500.00. The provider is responsible for maintaining documentation of the cost for any items costing less than $500.00 for a minimum of three years from the date of the original bill to the carrier.
Centers for Medicare and Medicaid Services (CMS). A division of the U.S. Department of Health and Human Services (HHS) that oversees and publishes rules and guidelines of the Medicare and Medicaid programs.
Consultation. A service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services.
The written or verbal request for a consultation may be made by a physician or other appropriate source and must be documented in the patient's medical record. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated by written report to the requesting physician or other appropriate source.
A consultation initiated by a patient and/or family, and not requested by a physician, is not reported using the consultation codes but may be reported using the appropriate office visit codes.
Any procedure that can be identified with a specific CPT code performed on or subsequent to the date of the initial consultation should be reported separately. If, subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patient's condition(s), the appropriate Evaluation and Management services code for the service should be reported.
CPT Codes. 114.3 CMR 40.00 uses Codes from the Physicians' Current Procedural Terminology (CPT)© system developed and maintained by the American Medical Association. All CPT codes are copyrighted by the American Medical Association. All procedures and codes set forth under 114.3 CMR 40.00 conform to CPT 2008 codes and descriptors and the principles for their use, as set forth in the Physicians' Current Procedural Terminology, 2008, and any later updates. These CPT publications contain the complete and most current listings of CPT descriptive terms and numeric identifying codes and modifiers for reporting medical services and procedures.
Department of Industrial Accidents (DIA). A department of the Commonwealth of Massachusetts Executive Office of Labor and Workforce Development that oversees the Workers' Compensation system pursuant to M.G.L. c. 152 and other applicable laws and waivers.
Department of Public Health (DPH). A department of the Commonwealth of Massachusetts established under M.G.L. c.17, § 1 that oversees and licenses healthcare facility standards and operations and administers public health programs for all Massachusetts residents.
Description. An explanation of the medical procedure or item assigned to the code. This may include certain stipulations relevant to Massachusetts under M.G.L. c. 152.
Division. The Division of Health Care Finance and Policy established under M.G.L. c. 118G.
Durable Medical Equipment (DME). Prosthetic devices, implantable devices, replacement parts (external or internal), accessories and supplies for the DME and other devices identified as DMEPOS by CMS. Implantable devices not listed with a fee in 114.3 CMR 40.06(6) and not included as a portion of the ambulatory surgery fee will be paid at invoice (A.I.) cost net of any manufacturer discounts received by the provider plus a mark up of 20% not to exceed $200.00.
Eligible Provider. A provider as defined in 114.3 CMR 40.05, that also meets such conditions of participation as have been or may be adopted by a Governmental Unit or purchaser under M.G.L. c. 152. Out-of-state providers must meet the comparable conditions of licensure and participation required by the state in which they practice.
Established Patient. A person who has received professional services from the physician or another physician of the same specialty in the same group practice within the past three years. Under 114.3 CMR 40.00, Established Patient will be applied to a single work related injury or episode of illness.
Fee. The payment value for the medical procedure or item set forth in 114.3 CMR 40.06 and identified by a Code. Fees may be listed as Professional Component Fee (PC Fee), Technical Component Fee (TC Fee) and Global Fee (GL Fee) when a professional, technical or global fee applies. Single payment rates are listed as "Fees". See definitions of (GL), (PC) and (TC).
Global Fee (GL). The Global Fee is the sum of the PC Fee and TC Fee. See definitions of (PC) and (TC) below.
Governmental Unit. The Commonwealth, any division, department, agency, board or commission of the Commonwealth, and any political subdivision of the Commonwealth.
HCPCS National Codes. Level II coding system of alpha-numeric codes published by the Centers for Medicare and Medicaid Services (CMS) to supplement CPT codes for medical services and supplies. All D codes are copyrighted by the American Dental Association. Services and items set forth under 114.3 CMR 40.00 utilize HCPCS 2008 codes and descriptors.
Instrumental Activities of Daily Living (IADLs). Activities related to personal care of a patient such as meal preparation and clean-up, household services, laundry, shopping, housekeeping, transportation to a medical provider, or assistance with the care and maintenance of adaptive devices.
Liquid Oxygen Systems. Oxygen and oxygen equipment as DME includes the system for furnishing it, the vessels that store it, the tubing, and administration sets that allow the safe delivery of oxygen in the home, and the oxygen contents.
Medical and Surgical Supplies. Medical and treatment products that:
(a) are produced primarily and routinely to fulfill a medical or surgical purpose;
(b) are used in the treatment of a specific medical condition;
(c) are non-reusable and disposable.
Modifiers. A two digit (numeric or alpha) sequence that alters the description of a delivered service or supply. 114.3 CMR 40.07(1): Appendix A lists a limited number of the common modifiers and certain reimbursement provisions associated with their use. However, providers, suppliers and carriers may utilize any appropriate current CPT Level I and HCPCS Level II National Modifiers as necessary.
Non-standard Prescription Options. New mobility systems including devices that:
(a) provide their user with a substantially greater range of motion than are usually required of the standard device; or
(b) require substantially greater service or time than are usually provided for the standard device.
Orthotic Device. A mechanical device designed to support or correct any defect of form or function of the human body, and generally known as a "brace" or "orthosis" but not including dental braces or breast prostheses.
Oxygen Delivery Systems. A comprehensive oxygen service that includes, but is not limited to: the gaseous/liquid oxygen, oxygen generating device and related delivery systems container or cylinder, manifold systems whenever high volume oxygen is used, stand, cart, walker/stroller, supply reservoir, contents indicator, regulator with flow gage, humidifcation devices, cannulas, masks, and special oxygen administration device, tubing and refill adapter.
Professional Component (PC). Certain procedures are a combination of a physician, or professional component and a technical component. When the modifier "-26" is added to an appropriate code a PC allowable amount will be paid.
Prosthesis. An artificial device used to replace a missing body part, such as a limb, tooth, eye, or heart valve.
Prosthetic Device. Any substitute or ancillary equipment or component part used in a prosthesis for replacement or modification purposes.
Rehabilitation Technology Specialist (RTS). A professional with expertise in assistive and rehabilitation technology, including wheeled mobility, seating and alternative positioning, ambulating assistance, environmental control and related activities who meets such conditions of participation as may be adopted by a Governmental Unit to work directly with consumers in the provision of wheeled mobility systems in the service delivery process.
Respiratory Therapy Devices and Supplies. Devices and necessary ancillary equipment prescribed by a physician for the care and treatment of pulmonary illnesses that meet such standards as may be required by federal or state Governmental Units. Respiratory Therapy Devices may include the complete device and related delivery system accessories such as, regulator with flow gauge, humidification and heating units, filters, cannulas, masks, and special administration device tubing and adapters.
Seating, Positioning, Mobility Systems and Related Accessories. Any device including its components, accessories and modifications, that has been prescribed, designed and constructed to meet the individual custom needs of a patient. This equipment will be provided by an eligible DME provider who employs a Rehabilitation Technology Specialist (RTS). The equipment must fulfill a medical purpose and be generally not useful in the absence of illness or injury, withstand repeated use over an extended period of time, be appropriate for home use, and meet professionally recognized standards of quality.
Special Report. A service that is rarely provided, unusual, variable, or new may require an explanation to determine the medical appropriateness of the service. These services are generally reported as "unlisted services or procedures" and designated by digits '99' after the first three beginning code numbers. Pertinent information should include, but not be limited to, an adequate definition or description of the nature, extent, and need for the procedure; and the time, effort and equipment necessary to provide the service. Additional items that can be included are: complexity of symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care.
Technical Component (TC): The TC component reflects the technical portion of the procedure code. When the technical component is provided by a health care provider other than the one providing the professional component, the health care provider bills for the technical component by adding Modifier "-TC" to the applicable code. The TC rate is payment for the facility's cost of rent, equipment, utilities, supplies, administrative and technical salaries and benefits, and all other overhead expenses.
Transcutaneous Electrical Nerve Stimulator (TENS). A TENS unit must be distinguished from other electrical stimulators that directly stimulate muscles and/or motor nerves, eg, neuromuscular stimulators.
Unlisted Procedure or Service. A service or procedure may be provided that is not listed in Regulation 114.3 CMR 40.06. When reporting such a service, the appropriate "Unlisted Procedure" code may be used to indicate the service. A "Special Report" may be required when billing codes for unlisted procedures.
Used Equipment. Any item that has been previously purchased or rented, including equipment that was:
(a) used by a patient for a trial period;
(b) used by the supplier as a demonstrator; or
(c) rented by a patient who now wants to buy it.
Usual and Customary Charge. The lowest fee charged to the general public by an Eligible Provider specified by 114.3 CMR 40.05: Usual and Customary Charge , which fee is in effect at the time that such service is performed or equipment is sold or rented.
114.3 CMR 40.02