General Rate Provisions

(1) Reimbursement as Full Payment. Each eligible provider must, as a condition of payment made by the purchasing governmental unit for services rendered, accept the approved program rate as full payment and discharge of all obligations for the services rendered. Any third-party payments or sliding fees received on behalf of a publicly aided individual reduces, by that amount, the purchasing governmental unit's payment for services rendered to the publicly aided individual. (2) Rates. Subject to the conditions listed herein, rates of payment for authorized family planning services for which 101 CMR 312.00 applies 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 schedule of allowable fees listed below in 101 CMR 312.03(4). (3) Modifiers. (a) 24 – Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period. (b) 25 – Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. (c) 59 – Distinct procedural service. (d) LT – Left side (used to identify procedures performed on the left side of the body). (e) RT – Right side (used to identify procedures performed on the right side of the body). (f) 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 -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 (4) Schedule of Allowable Fees. Code Allowable Fee IC Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use New Patient Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) Code Allowable Fee Established Patient Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) 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 total time on the date of the encounter for (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) 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 total time on the date of the encounter for (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) Code Allowable Fee Preventive Medicine Services Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes Allowable Medical and Related Supplies S4993 Contraceptive pills for birth control Code Allowable Fee All Other Medical and Related Supplies S4989 IC Contraceptive intrauterine device (e.g., Progestasert IUD), including implants and supplies IC Cervical cap for contraceptive use Diaphragm for contraceptive use (includes applicator and contraceptive cream or jelly) Contraceptive supply, condom, male, each Contraceptive supply, condom, female, each Contraceptive supply, spermicide (e.g., foam, gel), each (per tube or package) (includes contraceptive sponges) IC Injection, medroxyprogesterone acetate, 1 mg J3490-FP IC Unclassified Drugs (service provided as part of a Medicaid family planning program) (may be used by other governmental purchasers of family planning services) IC Levonorgestrel-releasing intrauterine contraceptive system, (Kyleena), 19.5 mg IC Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg IC Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg IC Intrauterine copper contraceptive IC Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg IC Contraceptive supply, hormone containing vaginal ring, each IC Contraceptive supply, hormone containing patch, each IC Etonogestrel (contraceptive) implant system, including implant and supplies Medical and Surgical Procedures Removal, implantable contraceptive capsules Insertion, drug-delivery implant (ie, bioresorbable, biodegradable, non-biodegradable) (5) Other Family Planning Services. The rates of payment for other family planning services not listed in 101 CMR 312.03(4) that are authorized by the purchasing governmental unit will be based on the applicable EOHHS regulations such as 101 CMR 313.00: Rates for Freestanding Clinics Providing Abortion and Sterilization Services; 101 CMR 316.00: Rates for Surgery and Anesthesia Services; 101 CMR 317.00: Rates for Medicine Services; 101 CMR 318.00: Rates for Radiology Services; and 101 CMR 320.00: Rates for Clinical Laboratory Services.