General Definitions

Meaning of Terms. The five-digit procedure codes and two-digit modifiers included in 101 CMR 316.00, 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 2023 HCPCS, maintained jointly by the Centers for Medicare & 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 anesthesia and surgery service code spreadsheets at www.mass.gov/regulations/101-CMR-31600-surgery-and-anesthesia-services. In addition, terms used in 101 CMR 316.00 have the meanings set forth in 101 CMR 316.02. Accountable Care Organization (ACO). An entity that enters into a population-based payment model contract with EOHHS as an accountable care organization, wherein the entity is held financially accountable for the cost and quality of care for an attributed or enrolled member population. ACOs include Accountable Care Partnership Plans, Primary Care ACOs, and MCO-administered ACOs. Eligible Provider. The rates established in 101 CMR 316.00 apply in accordance with 101 CMR 316.01 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 generally 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, and licensed dentist. (b) 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 physically and financially independent of a hospital or a physician’s office. (c) A clinic licensed by the Massachusetts Department of Public Health in accordance with 105 CMR 140.000: Licensure of Clinics to provide surgical diagnostic services. (d) 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. (e) 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). (f) 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. Facility Setting Fee. Payments for services provided by an individual eligible provider in a hospital (including without limitation a hospital inpatient department, outpatient department, emergency department, and hospital licensed health center), or skilled nursing facility or freestanding ambulatory surgical center (ASC), will be made according to a facility setting fee when an applicable facility setting fee has been established for that procedure. Global Delivery. Includes direct provision and supervision of case management, maternal education (including but not limited to nutrition, pregnancy and childbirth, and reproductive health), and obstetrical risk assessment and monitoring, in addition to pelvic or Cesarean-section delivery, all routine prenatal visits, and one postpartum visit. Governmental Unit. The Commonwealth, any department, agency, board, or commission of the Commonwealth and any political subdivision of the Commonwealth. Individual Consideration (I.C.). Surgical procedures that are authorized but not listed in 101 CMR 316.00, surgical procedures 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 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 to the procedure code. Primary Care Clinician (PCC) Plan. A managed care option administered by the MassHealth agency through which enrolled members receive primary care and certain other medical services. 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. 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. Surgical Team Fee. Reimbursement for highly complex surgical procedures requiring the expertise of several physicians (usually of different specialties) and other highly skilled, specially trained personnel. More than one surgeon may be performing parts of the procedure simultaneously. The unit fee is payable to the director of the surgical team and includes all assistant surgeon fees; there are no separate payments for assisting surgical services. The director of the surgical team is expected to distribute the unit fee to the members of the surgical team. Unlisted Procedure or Service. A service or procedure that may be provided that is not listed in 101 CMR 316.05. When reporting such a service, the appropriate "Unlisted Procedure" code may be used to indicate the service.