General Definitions

The terms used in 101 CMR 315.00 shall have the meanings ascribed in 101 CMR 315.02 and in the CPT Coding Handbook. The descriptions and five-digit procedure codes included in 101 CMR 315.00 are obtained from the American Medical Association’s Current Procedural Terminology (CPT), copyright 2024, or the 2024 Healthcare Common Procedure Coding System Level II (HCPCS) unless otherwise specified. Both sources provide a listing of descriptive terms and alpha-numeric identifying codes and modifiers for reporting medical services and procedures performed by health care providers. Consultation. A type of service provided by a physician or ophthalmologist or optometrist whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or ophthalmologist or optometrist or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services. The request for a consultation from the attending physician or ophthalmologist or optometrist or other appropriate source and the need for consultation 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 to the requesting physician or other appropriate source. Any specifically identifiable procedure (i.e., identified with a specific CPT code) performed on or subsequent to the date of the initial consultation should be reported separately. If a consultant subsequently assumes responsibility for management of a portion or all of the patient's condition(s), the consultation codes should not be used. Eligible Provider (Provider). Ophthalmologists, optometrists, and dispensing opticians who are registered by an appropriate board of registration in accordance with the provision of M.G.L. c. 112; are not under contractual arrangement with a hospital or affiliated teaching institution for professional services; and who also meet such conditions of participation as may be required by a governmental unit purchasing vision care services and ophthalmic materials or by purchasers under M.G.L. c. 152. EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A. Established Patient. A patient who has received professional services from the physician or ophthalmologist or optometrist within the past three years. Governmental Unit. The Commonwealth, any department, agency, board, or commission of the Commonwealth, and any political subdivision of the Commonwealth. Individual Consideration (IC). For service codes for which no rate is listed, the purchaser determines the payment amount on an individual consideration basis upon receipt of a bill that describes the services rendered. The purchaser shall determine the appropriate payment in accordance with the following criteria: (a) time required to perform the procedure; (b) degree of skill required for the procedure rendered; (c) severity and complexity of the patient's disorder or disability; (d) cost of goods supplied in rendering the service, including catalogue prices of major supplies; and (e) policies, procedures, and practices of other third-party purchasers of care, governmental and private. Low Vision. Any pathological, traumatic, or congenital condition of the eye or brain that results in reduced visual acuity or reduction of visual field, and that is not amenable to medical, surgical, or ordinary optical correction. Low-vision Aids. Items including, but not limited to, microscopic and telescopic lenses to correct low vision. Low-vision Evaluation. A series of evaluative vision tests to measure the degree of low vision and the corrective lenses or aids required. Modifiers. Listed services may be modified under certain circumstances. When applicable, the modifying circumstances should be identified by the addition of the appropriate two-digit number or letters placed after the usual procedure number from which it is separated by a hyphen. New Patient. A patient who has not received any professional services from the physician or ophthalmologist or optometrist within the past three years. Ocular Prosthetic Services. The dispensing and adjustment of false eyes. Publicly Aided Individual. A person for whose medical and other services a governmental unit is in whole or in part liable under a statutory program. Vision-care Services and Ophthalmic Materials. Professional care of the eye for the purpose of diagnosing and correcting refractive errors and includes the measurement, specification, formulation, construction, and dispensing of eyeglasses and related eye-care appliances.