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 Modifier Allowable Fee Description Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral Laparoscopy, surgical; with fulguration of oviducts (with or without transection) Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) Treatment of missed abortion, completed surgically; first trimester (includes physician’s charges and clinic services) Induced abortion, by dilation and curettage (includes physician's charges and clinic services with either I.V. sedation or general anesthesia) Code Modifier Allowable Fee Description -TF Induced abortion, by dilation and curettage (includes physician's charges and clinic services with either I.V. sedation or general anesthesia) -TG Induced abortion, by dilation and curettage (includes physician's charges and clinic services with either I.V. sedation or general anesthesia) Induced abortion, by dilation and evacuation - (includes physician's charges and clinic services) -TF Induced abortion, by dilation and evacuation - (includes physician's charges and clinic services) -TG Induced abortion, by dilation and evacuation - (includes physician's charges and clinic services) J2790 IC 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) IC Mifepristone, oral, 200 mg IC Misoprostol, oral, 200 mcg 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 Induced abortion, 17 to 24 weeks (includes physician's charges and clinic services) -TF Induced abortion, 17 to 24 weeks (includes physician's charges and clinic services) -TG 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 regulations, such as 101 CMR 312.00: Rates for Family Planning Services; 101 CMR 316.00: Rates for Surgery and Anesthesia Services; for 101 CMR 317.00: Rates for Medicine Services; and 101 CMR 318.00: Rates for Radiology Services.