Maximum Allowable Fees - Surgical Services

(1) Surgical and Obstetrical Services. Except as provided elsewhere in this 101 CMR 316.05(1), the allowable fees for surgical and obstetrical services are the fees listed in 101 CMR 316.05(4)(b), subject to 101 CMR 316.03 and appropriate modifiers, as applicable. (Anesthesia procedure codes (00100-01999) and corresponding base anesthesia units for purposes of 101 CMR 316.04 are listed in 101 CMR 316.05(4)(a)). Certain codes in 101 CMR 316.05(4)(b) are identified with an asterisk (*). The allowable fees for these codes are as set forth in 101 CMR 316.05(4)(b), except when any of those codes are billed as part of a facial feminization surgery to treat gender dysphoria, in which case the allowable fees are those set forth in 101 CMR 316.05(4)(c). (2) Unless otherwise specified, guidelines, notes, and definitions provided in the 2023 CPT Coding Handbook are applicable to the use of the procedure codes and modifiers listed below, as well as their corresponding descriptions. For code descriptions, see the anesthesia and surgery service code spreadsheets at www.mass.gov/regulations/101-CMR-31600-surgery-and- anesthesia-services. (3) Modifiers. (a) 26: Professional Component. The component of a service or procedure representing the physician’s or other qualified health care professional’s work interpreting or performing the service or procedure. (When the physician or other qualified health care professional component is reported separately, the addition of modifier 26 to the procedure code will allow payment of the professional component allowable fee (PC Fee) contained in 101 CMR 316.05(4)(b), adjusted by 101 CMR 316.03 as applicable.) (b) 50: Bilateral Procedure. Payment for bilateral procedures performed at the same operative session must be identified by the appropriate service code and modifier 50. Only one claim line is billed for both procedures. (The addition of modifier 50 to the bilateral code will allow payment of 150% of the allowable fee contained in 101 CMR 316.05(4)(b), adjusted by 101 CMR 316.03 as applicable, to the eligible provider for performance of both bilateral procedures.) (c) 51: 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 modifier 51 to the end of the service code for the secondary procedure(s). (The addition of modifier 51 to the second and subsequent procedure codes allows payment of 50% of the allowable fee contained in 101 CMR 316.05(4)(b), adjusted by 101 CMR 316.03 as applicable, to the eligible provider. Note: This modifier should not be used with designated “add-on” codes or with codes in which the narrative begins with “each additional.”) (d) 52: Reduced Services. Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician's or other qualified health care professional’s election. Under these circumstances, the service provided can be identified by its usual procedure number and addition of modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. (e) 54: Surgical Care Only. When one eligible physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the appropriate procedure code. (This allows payment of 85% of the allowable fee contained in 101 CMR 316.05(4)(b), adjusted by 101 CMR 316.03 as applicable, to the physician or other qualified health care professional performing the surgery.) (f) 55: Postoperative Management Only. When one eligible physician or other qualified health care professional performs the postoperative management and another performed the surgical procedure, the postoperative component may be identified by adding modifier 55 to the appropriate procedure code. (This allows payment of 15% of the allowable fee contained in 101 CMR 316.05(4)(b), adjusted by 101 CMR 316.03 as applicable, to the physician or other qualified health care professional.) (g) 58: Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period. It may be necessary to indicate the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure. Note: for treatment of a problem that requires a return to the operating/procedure room (e.g., unanticipated clinical condition), see modifier 78. (h) 59: Distinct Procedural Service. To identify a procedure distinct or independent from other services performed on the same day, add modifier 59 to the end of the appropriate service code. Modifier 59 is used to identify services/procedures that are not normally reported together, but are appropriate under certain circumstances; for example, different site or organ system. However, when another already established modifier is appropriate, it should be used rather than modifier 59. (i) 62: Two Surgeons. When two eligible surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report their distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the procedure once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate codes(s) may also be reported with modifier 62 added.) (The addition of modifier 62 to the procedure code allows payment of 57.5% of the allowable fee contained in 101 CMR 316.05(4)(b), adjusted by 101 CMR 316.03 as applicable, to each surgeon. No separate payment will be made for assisting surgical services in these cases; it is included in the total surgical fee listed.) (j) 66: Surgical Team. This modifier must be used to identify highly complex procedures (requiring the concomitant services of several eligible physicians, often of different specialties, plus other highly skilled, specially trained personnel, and various types of complex equipment) carried out under the “surgical team” concept. 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 eligible members of the surgical team. (k) 76: Repeat Procedure by Same Physician or Other Qualified Health Care Professional. The physician or other qualified health care professional may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier 76 to the repeated procedure/service or the separate five-digit modifier code 09976 may be used. (l) 77: Repeat Procedure by Another Physician or Other Qualified Health Care Professional. The physician or other qualified health care professional may need to indicate that a basic procedure or service performed by another physician or other qualified health care professional had to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure/service or the separate five-digit modifier code 09977 may be used. (m) 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period. The physician or other qualified health care professional may need to indicate that another procedure was performed during that postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding modifier 78 to the related procedure, or by using the separate five-digit modifier 09978. (For repeat procedures on the same day, see modifier 76.) (n) 79: Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period. The physician or other qualified health care professional may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79 or by using the separate five-digit modifier 09979. (For repeat procedures on the same day, see modifier 76.) (o) 80: Assistant Surgeon. Surgical assistant services may be identified by adding modifier 80 to the usual procedure code. (This allows payment of 15% of the allowable fee contained in 101 CMR 316.05(4)(b), adjusted by 101 CMR 316.03 as applicable, to the eligible assistant surgeon.) (p) 82: Assistant Surgeon (when qualified resident surgeon not available). Surgical assistant services may be identified by adding modifier 82 to the usual procedure code when a qualified resident surgeon is not available. (This allows payment of 15% of the allowable fee contained in 101 CMR 316.05(4)(b), adjusted by 101 CMR 316.03 as applicable, to the eligible assistant surgeon.) (q) AA: Anesthesia Services Performed Personally by an Anesthesiologist. This allows payment of 100% of the Total Anesthesia Fee for the anesthesiologist’s services. (r) AS: Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery. This allows payment of 15% of the allowable fee contained in 101 CMR 316.05(4)(b), adjusted by 101 CMR 316.03 as applicable, for services of the eligible physician assistant, certified nurse practitioner, or clinical nurse specialist assisting in surgery. (s) E1: Upper left, eyelid. (t) E2: Lower left, eyelid. (u) E3: Upper right, eyelid. (v) E4: Lower right, eyelid. (w) F1: Left hand, second digit. (x) F2: Left hand, third digit. (y) F3: Left hand, fourth digit. (z) F4: Left hand, fifth digit. (aa) F5: Right hand, thumb. (bb) F6: Right hand, second digit. (cc) F7: Right hand, third digit. (dd) F8: Right hand, fourth digit. (ee) F9: Right hand, fifth digit. (ff) FA: Left hand, thumb. (gg) LC: Left circumflex coronary artery. (hh) LD: Left anterior descending coronary artery. (ii) LT: Left side. Used to identify procedures performed on the left side of the body. (jj) PA: Surgical or Other Invasive Procedure Performed on the Wrong Body Part. This modifier is applied to report Provider Preventable Conditions in accordance with 42 CFR 447.26 and results in nonpayment for services. (kk) PB: Surgical or Other Invasive Procedure Performed on the Wrong Patient. This modifier is applied to report Provider Preventable Conditions in accordance with 42 CFR 447.26 and results in nonpayment for services. (ll) PC: Wrong Surgical or Other Invasive Procedure Performed on a Patient. This modifier is applied to report Provider Preventable Conditions in accordance with 42 CFR 447.26 and results in nonpayment for services. (mm) QK: Medical Direction by a Physician of Two, Three, or Four Concurrent Anesthesia Procedures. Used to indicate physician medical direction of multiple CRNAs. This allows payment of 50% of the Total Anesthesia Fee for the physician’s services. (nn) QY: Medical Direction of One CRNA by a Physician. Used to indicate physician medical direction of one CRNA. This allows payment of 50% of the Total Anesthesia Fee for the physician’s services. (oo) QX: CRNA Anesthesia Services with Medical Direction by a Physician. Used to indicate CRNA anesthesia services with medical direction by a physician. This allows payment of 50% of the Total Anesthesia Fee for the CRNA’s services. Not for use if CRNA is employed by the facility in which the anesthesia services were performed. (pp) QZ: CRNA Anesthesia Services without Medical Direction by a Physician. This allows payment of 100% of the Total Anesthesia Fee for the CRNA’s services. Not for use if CRNA is employed by the facility in which the anesthesia services were performed. (qq) RC: Right Coronary Artery. (rr) RT: Right side. Used to identify procedures performed on the right side of the body. (ss) SA: Nurse Practitioner Rendering Service in Collaboration with a Physician. This modifier is to be applied to service codes billed by a physician that were performed by a certified nurse practitioner employed by the physician (the physician employer must be practicing as an individual and not practicing as a professional corporation or as a member of a group practice). A certified nurse practitioner billing under his/her own individual provider number, or a group practice, should not use this modifier. (tt) T1: Left foot, second digit. (uu) T2: Left foot, third digit. (vv) T3: Left foot, fourth digit. (ww) T4: Left foot, fifth digit. (xx) T5: Right foot, great toe. (yy) T6: Right foot, second digit. (zz) T7: Right foot, third digit. (aaa) T8: Right foot, fourth digit. (bbb) T9: Right foot, fifth digit. (ccc) TA: Left foot, great toe. (ddd) TC: Technical Component. The component of a service or procedure representing the cost of rent, equipment, utilities, supplies, administrative and technical salaries and benefits, and other overhead expenses of the service or procedures, excluding the physician’s professional component. (When the technical component is reported separately, the addition of modifier TC to the procedure code will allow payment of the technical component allowable fee (TC Fee) contained in 101 CMR 316.05(4)(b), adjusted by 101 CMR 316.03 as applicable.) (eee) XE: Separate Encounter. A service that is distinct because it occurred during a separate encounter. (fff) XS: Separate Structure. A service that is distinct because it was performed on a separate organ/structure. (ggg) XP: Separate Practitioner. A service that is distinct because it was performed by a different practitioner. (hhh) XU: Unusual Non-overlapping Service. The use of a service that is distinct because it does not overlap usual components of the main service. (4) Procedure Codes; Fee Schedules. (a) Anesthesia Services – List of Procedure Codes and Base Anesthesia Units. Anesthesia Table Units Description (see anesthesia service code spreadsheet at www.mass.gov/regulations/101-CMR-31600-surgery-and-anesthesia-services) Anesthesia Table Units Description (see anesthesia service code spreadsheet at www.mass.gov/regulations/101-CMR-31600-surgery-and-anesthesia-services) Anesthesia Table Units Description (see anesthesia service code spreadsheet at www.mass.gov/regulations/101-CMR-31600-surgery-and-anesthesia-services) Anesthesia Table Units Description (see anesthesia service code spreadsheet at www.mass.gov/regulations/101-CMR-31600-surgery-and-anesthesia-services) Anesthesia Table Units Description (see anesthesia service code spreadsheet at www.mass.gov/regulations/101-CMR-31600-surgery-and-anesthesia-services) Anesthesia Table Units Description (see anesthesia service code spreadsheet at www.mass.gov/regulations/101-CMR-31600-surgery-and-anesthesia-services) Anesthesia Table Units Description (see anesthesia service code spreadsheet at www.mass.gov/regulations/101-CMR-31600-surgery-and-anesthesia-services) (b) Surgical Services – Fee Schedule. 1. NFAC – “Nonfacility”. These amounts apply when service is performed in a non- facility setting. 2. FAC – “Facility”. These amounts, also known as the Facility Setting Fee, apply when service is performed in a facility setting. 3. Global Fee. These amounts apply when no site of service differential rate is specified. 0404T I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. I.C. * * * * * * * * * * * * * * * * * G010 G012 S2260 I.C. S2265 I.C. S2266 I.C. S2267 I.C. *See 101 CMR 316.05(1) (c) Surgical Services – Fee Schedule for Facial Feminization Surgery Services to Treat Gender Dysphoria. 1. NFAC – “Nonfacility”. These amounts apply when service is performed in a non- facility setting. 2. FAC – “Facility”. These amounts, also known as the Facility Setting Fee, apply when service is performed in a facility setting. 3. Global Fee. These amounts apply when no site of service differential rate is specified. CMR-31600-surgery)