101 CMR, § 318.02

Current through Register 1536, December 6, 2024

Section 318.02 - General Definitions

Meaning of Terms: The five-digit procedure codes and two-digit modifiers included in 101 CMR 318.00, and their corresponding descriptions, utilize the Healthcare Common Procedure Code System (HCPCS) for Level I and Level II coding. Level I CPT-4 codes are obtained from the Physicians' 2023 Current Procedural Terminology (CPT), copyright 2022 by the American Medical Association (AMA), unless otherwise specified. Level II codes are obtained from the 2020 HCPCS, maintained jointly by the Centers for Medicare and Medicaid Services (CMS), the Blue Cross and Blue Shield Association, and the Health Insurance Association of America. HCPCS is a listing of descriptive terms and identifying codes and modifiers for reporting medical services and procedures performed by physicians and other health care professionals, as well as associated nonphysician services. No fee schedules, basic unit value, relative value guides, conversion factors, or scales are included in any part of the Physicians' Current Procedure Terminology. For code descriptions, see the radiology services code spreadsheet at www.mass.gov/regulations/101-CMR-31800-radiology.

In addition, terms used in 101 CMR 318.00 have the meanings set forth in 101 CMR 318.02.

Eligible Provider. The established rates apply in accordance with 101 CMR 318.01 to the following types of providers who meet conditions of participation of the governmental unit purchasing such services, and to the extent specified by such governmental unit. Eligible providers must provide such services in accordance with accepted professional standards and in accordance with state licensing requirements and certification by national credentialing bodies as required by law.

(a) A licensed physician (other than an intern, resident, fellow, or house officer), licensed podiatrist, licensed dentist, licensed chiropractor, and licensed optometrist.

(b) A provider of therapeutic and diagnostic radiology services. Such radiology services may be rendered by eligible providers such as, but not limited to, independent diagnostic testing facilities (IDTFs). These eligible providers must be independent of a hospital or a physician's office.

(c) A provider of radiation oncology services. Radiation oncology services may be rendered by eligible providers such as, but not limited to, independent radiation oncology centers. These eligible providers must be independent of a hospital or a physician's office.

(d) A clinic licensed by the Massachusetts Department of Public Health in accordance with 105 CMR 140.000: Licensure of Clinics to provide radiology services.

(e) A freestanding birth center facility that is not operating under a hospital's license, and is licensed as a birth center by the Massachusetts Department of Public Health pursuant to 105 CMR 140.000: Licensure of Clinics.

(f) An advanced practice registered nurse who is authorized by the Board of Registration in Nursing to practice as a certified nurse practitioner, certified nurse midwife, clinical nurse specialist, psychiatric clinical nurse specialist, or a certified registered nurse anesthetist (CRNA).

(g) A licensed physician assistant who is authorized by the Board of Registration for Physician Assistants to practice as a physician assistant.

EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A.

Governmental Unit. The Commonwealth, any department, agency, board, or commission of the Commonwealth and any political subdivision of the Commonwealth.

Individual Consideration (I.C.). Radiology services that are authorized but not listed in 101 CMR 318.00, radiology services performed in unusual circumstances, and services designated "I.C." are individually considered items. The governmental unit or purchaser analyzes the eligible provider's report of services rendered and charges submitted under the appropriate unlisted services or procedures category. The governmental unit or purchaser determines appropriate payment for procedures designated I.C. in accordance with the following standards and criteria:

(a) the amount of time required to perform the service;

(b) the degree of skill required to perform the service;

(c) the severity or complexity of the patient's disease, disorder, or disability;

(d) any applicable relative value studies;

(e) any complications or other circumstances that may be deemed relevant;

(f) the policies, procedures, and practices of other third-party insurers;

(g) the payment rate for prescribed drugs as set forth in 101 CMR 331.00: Prescribed Drugs; and

(h) a copy of the current invoice from the supplier.

Modifiers. Listed services and procedures may be modified under certain circumstances. When applicable, the modifying circumstances should be identified by the addition of the appropriate two-digit number.

Publicly Aided Individual (or Publicly Aided Patient). A person who receives health care and services for which a governmental unit is in whole or in part liable under a statutory program of public assistance.

Radiology Services. Radiology services including diagnostic ultrasound, radiation oncology, and nuclear medicine provided for the assessment and/or treatment of a medical condition, injury, or illness.

Separate Procedure. Some of the listed procedures are commonly carried out as an integral part of a total service, and as such do not warrant a separate identification. When, however, such a procedure is performed independently of, and is not immediately related to, other services, it may be listed as a separate procedure in the procedure description. Thus, when a procedure that is ordinarily a component of a larger procedure is performed alone for a specific purpose, it may be considered to be a separate procedure.

Supervision and Interpretation Only. When a procedure is performed by two eligible physicians, the radiologic portion of the procedure is designated as "radiological supervision and interpretation". When an eligible physician performs both the procedure and the imaging supervision and interpretation, a combination of procedure codes outside the 70000 series and imaging supervision and interpretation codes are to be used. The radiological supervision and interpretation codes are not applicable to the Radiology Oncology subsection.

Unlisted Procedure or Service. A service or procedure that may be provided that is covered, but not listed in 101 CMR 318.04. When reporting such a service, the appropriate "Unlisted Procedure" code may be used to indicate the service.