101 CMR, § 313.03

Current through Register 1536, December 6, 2024

Section 313.03 - General Rate Provisions

(1)Rate Determination. Rates of payment for eligible providers of abortion and sterilization services are the lowest of

(a) the eligible provider's usual fee to the general public;

(b) the eligible provider's actual charge submitted; and

(c) the allowable fees set forth in 101 CMR 313.03(5).

(2)Abortion Services. The rates for an induced abortion, physician and clinic services include preoperative evaluation and counseling, laboratory services, surgery, anesthesia, and postoperative care due to complications. The post-abortion visit rate constitutes full compensation for routine follow-up care for abortion patients who return for such care.

(3)Sterilization Services. The rates of payment for sterilization services represent full compensation for these services, which include preoperative evaluation and counseling, laboratory services, surgery, anesthesia, and postoperative care.

(4)Modifiers.

(a)Modifier -51 Pertains to Multiple Procedures. This modifier must be used to report multiple procedures performed at the same session. The service code for the major procedure or service must be reported without a modifier. The secondary, additional or lesser procedure(s) must be identified by adding the modifier -51 to the end of the service code for the secondary procedure(s). The addition of the modifier '51' to the second and subsequent procedure codes allows 50% of the allowable fee contained in 101 CMR 313.03(5) to be paid to the eligible provider.

(b)Modifier - TF - Intermediate Level of Care. Use with procedure codes 59840, 59841, or S2260, if applicable, in accordance with the fee schedules set forth in 101 CMR 313.03(5).

(c) Modifier - TG - Complex/High Tech Level of Care. Use with procedure codes 59840, 59841, or S2260, if applicable, in accordance with the fee schedules set forth in 101 CMR 313.03(5).

(d)Modifiers for Provider Preventable Conditions. Below are modifiers for reporting "provider preventable conditions" that are National Coverage Determinations, in accordance with 42 CFR 447.26.

Modifier Name	Description
PA	Surgical or other invasive procedure on wrong body part
PB	Surgical or other invasive procedure on wrong patient
PC	Wrong surgery or other invasive procedure on patient

(5)Maximum Allowable Rates.

Code	Modifer	Allowable Fee	Description
55250	$543.36	Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s)
58600	$842.99	Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral approach
58670	$786.16	Laparoscopy, surgical, with fulguration of oviducts (with or without transection)
58671	$828.23	Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip or Falope ring)
59820	$438.36	Treatment of missed abortion, completed surgically first trimester (includes physician's charges and clinic services)
59840	$400.37	Induced abortion, by dilation and curettage (includes physician's charges and clinic services with either I.V. sedation or general anesthesia)
59840	-TF	$544.31	Induced abortion, by dilation and curettage (includes physician's charges and clinic services with either I.V. sedation or general anesthesia)
59840	-TG	$767.71	Induced abortion, by dilation and curettage (includes physician's charges and clinic services with either I.V. sedation or general anesthesia)
59841	$622.21	Induced abortion, by dilation and evacuation (includes physician's charges and clinic services)
59841	-TF	$1,177.38	Induced abortion, by dilation and evacuation (includes physician's charges and clinic services)
59841	-TG	$1,257.02	Induced abortion, by dilation and evacuation (includes physician's charges and clinic services)
J2790	I.C.	Injection, Rho D immune globulin, human, full dose, 300 mcg (1500 IU) (when required only, reimbursed at the actual wholesale cost of the serum. A copy of the purchase invoice must be submitted with the claim form)
S0199	$490.44	Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion) except drugs
S0190	I.C.	Mifepristone, oral, 200mg
S0191	I.C.	Misoprostol, oral, 200mcg
S2260	$758.86	Induced abortion, 17 to 24 weeks (includes physician's charges and clinic services)
S2260	-TF	$1,032.05	Induced abortion, 17 to 24 weeks (includes physician's charges and clinic services)
S2260	-TG	$1,457.01	Induced abortion, 17 to 24 weeks (includes physician's charges and clinic services)

(6)Services and Payments Covered under Other Regulations. The rates of payment for other abortion and sterilization services not listed in 101 CMR 313.03(5) that are authorized by the purchasing governmental unit, will be based on the applicable EOHHS regulation, such as 101 CMR 312.00: Rates for Family Planning Services; 101 CMR 316.00: Rates for Surgery and Anesthesia Services; 101 CMR 317.00: Rates for Medicine Services; and 101 CMR 318.00: Rates for Radiology Services.

The rates of payment for the following procedures are based upon 101 CMR 312.00: Rates for Family Planning Services.

Code	Description
99211	Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. (Post abortion check-up visit) (routine follow-up care only)
99213	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. (Post abortion check-up visit) (routine follow-up care only)
99215	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter. (Post abortion check-up visit) (routine follow-up care only)

The rates of payment for the following procedures are based upon 101 CMR 316.00: Rates for Surgery and Anesthesia Services.

Code	Description
58120	Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical)
58565	Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants
59200	Insertion of cervical dilator (e.g., luminaria, prostaglandin) (separate procedure)
59812	Treatment of incomplete abortion, any trimester
59821	Treatment of missed abortion, completed surgically; 2^nd trimester
59870	Uterine evacuation and curettage for hydatidiform mole

The rates of payment for the following procedures are based upon 101 CMR 317.00: Rates for Medicine Services.

Code	Description
90385	Rho (D) immune globulin (RhIg), human, mini-dose for intramuscular use

The rates of payment for the following procedures are based upon 101 CMR 318.00: Rates for Radiol Services.

Code	Description
76805	Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester (> or = 14 weeks 0 days), transabdominal approach; single or first gestation
76815	Ultrasound, pregnant uterus, real time with image documentation, limited (e.g., fetal heart beat, placental location, fetal position and/or qualitative amniotic fluid volume), one or more fetuses