Maximum Allowable Fees – Medical Services

(1) Drugs, Medications, Supplies, and Laboratory Specimen Collections. (a) Payment rates for drugs, vaccines, and immune globulins administered in a physician’s office are equal to the fee listed in the Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing File. For drugs, vaccines, and immune globulins administered in a physician’s office that are not listed in the Quarterly ASP Medicare Part B Drug Pricing File, codes are listed in 101 CMR 317.04(4) with payment set by IC, which will apply until such time as the code is listed in the Quarterly ASP Medicare Part B Drug Pricing File. (b) Supplies and materials used in preparation for or as part of a procedure (e.g., bandages, laboratory kits, syringes, or disposable gloves) are not reimbursed separately, but are included in the office visit rate. In addition, no supplemental charge can be submitted nor payment allowed for routine specimen collection in a physician's office and preparation for clinical laboratory analysis (and activities related thereto), e.g., venipuncture, urine, fecal and sputum samples, culturing, swabbing, and scraping for removal of tissues. (c) Where applicable, payments for drugs, medicines, supplies, and related materials dispensed to patients are in accordance with rates that are the subject matter of other regulations that may be in effect and germane to the item in question (e.g., laboratory, pharmacy, medical supplies, etc.). In other instances where the use of another regulation is not appropriate, certain supplies and materials (except eyeglasses), provided by the physician over and above those usually included with the office visit or other services rendered should be billed under code 99070. (d) Payment for drugs and/or biologicals may be claimed in addition to an office visit. Drugs that are considered routine and integral to the delivery of a physician’s professional services in the course of diagnosis or treatment are not reimbursable. Such drugs are commonly provided without charge or are included in the physician’s fee for the service. Drugs and/or biologicals available free of charge from the Massachusetts Department of Public Health are not payable items. When an immunization or injection is the primary purpose of an office or other outpatient visit, the provider may bill only for the injectable material and its administration. Payment for both vaccine administration and an office visit is allowable only when the vaccine administration is a medically necessary, separately identifiable service. (e) Allowable Fee for COVID-19 Treatment. The allowable fees for monoclonal antibodies and their administration for the treatment of COVID-19 are 100% of the corresponding Medicare Part B payment rates, without geographic adjustment. Payment for the administration of monoclonal antibodies provided by eligible providers who are certified nurse practitioners, psychiatric clinical nurse specialists, clinical nurse specialists, physician assistants, registered nurses, pharmacies that utilize pharmacists, or other health care professionals certified in accordance with 105 CMR 700.000: Implementation of M.G.L. c. 94C, and home health agencies as specified in 101 CMR 317.02 is 85% of the allowable fee. (f) Allowable Fee for COVID-19 Vaccine and Vaccine Administration. The allowable fees for COVID-19 vaccines and their administration are 100% of the corresponding Medicare Part B payment rates, without geographic adjustment. Payment for administration of the COVID-19 vaccine provided by eligible providers who are certified nurse practitioners, psychiatric clinical nurse specialists, clinical nurse specialists, physician assistants, registered nurses, pharmacies that utilize pharmacists, or other health care professionals certified in accordance with 105 CMR 700.000: Implementation of M.G.L. c. 94C, and home health agencies as specified in 101 CMR 317.02 is 85% of the allowable fee. (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 medicine services code spreadsheet at www.mass.gov/regulations/101-CMR-31700-medicine. (3) Modifiers. (a) 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During 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. Modifier 25 is used to facilitate billing of evaluation and management services on the day of a procedure for which separate payment may be made. The physician or other qualified health care professional may indicate that on the day a procedure or service code was performed, the patient’s condition required a significant, separately identifiable evaluation and management service above and beyond the usual preoperative and postoperative care associated with the procedure or service that was performed. (c) 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 appropriate procedure code will allow payment of the professional component allowable fee (PC Fee) contained in 101 CMR 317.04(4), adjusted by 101 CMR 317.03 as applicable.) (d) 50: Bilateral Procedures. 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 317.04(4), adjusted by 101 CMR 317.03 as applicable, to the eligible provider for performance of both bilateral procedures.) (e) 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 317.04(4), adjusted by 101 CMR 317.03 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.”) (f) 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. (g) 57: Decision for Surgery. (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) GO: Services Delivered Personally by an Occupational Therapist or under an Outpatient Occupational Therapy Plan of Care. (j) GP: Services Delivered Personally by a Physical Therapist or under an Outpatient Physical Therapy Plan of Care. (k) HA: Child and Adolescent Needs and Strengths (CANS): Psychiatric Diagnostic Interview Examination for Children and Adolescents Younger than 21 Years Old. This modifier should only be applied to service code 90791 billed by psychiatrists or psychiatric clinical nurse specialists to identify a Psychiatric Diagnostic Interview Examination for a MassHealth child or adolescent younger than 21 years old using the CANS. (l) LM: Left Main Coronary Artery. (m) 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. (n) 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. (o) 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. (p) RI: Ramus Intermedius Coronary Artery. (q) 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. (r) SL: State-supplied Vaccine. This modifier is to be applied to the vaccine code to identify the administration of vaccines provided at no cost by the Massachusetts Department of Public Health for individuals younger than 18 years old, including those administered under the Vaccine for Children Program (VFC). (s) 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 or other qualified health care professional’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 317.04(4), as adjusted by 101 CMR 317.03 as applicable.) (t) XE: Separate Encounter. A service that is distinct because it occurred during a separate encounter. (u) XS: Separate Structure. A service that is distinct because it was performed on a separate organ/structure. (v) XP: Separate Practitioner. A service that is distinct because it was performed by a different practitioner. (w) 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) Fee Schedule. (a) NFAC – “Nonfacility.” These amounts apply when the service is performed in a nonfacility setting. (b) FAC – “Facility.” These amounts, also known as the Facility Setting Fee, apply when the service is performed in a facility setting (c) Global Fee. These amounts apply when no site of service differential rate is specified. 0121A 0141A 0142A 0151A 0171A 0172A 0173A 0174A $128.70 $109.68 $144.56 $125.28 $1,318.43 $1,240.77 $60.24 $49.28 $15.47 $13.06 $249.10 $132.32 $77.57 $31.30 $67.52 $29.54 $121.09 $69.20 $40.18 $15.84 $1,071.17 $293.51 $116.42 $114.82 $153.54 $150.60 $153.08 $149.86 $186.22 $182.47 $187.05 $183.30 $235.52 $231.24 $214.07 $209.25 $299.51 $293.62 $1,400.03 $242.03 $1,157.99 $19.79 $18.19 $164.48 $133.14 $134.43 $105.50 $157.82 $133.18 $204.56 $155.81 $205.02 $142.88 $154.70 $103.01 $209.49 $140.38 A9593 A9594 A9595 A9596 A9800 G0108 G0109 G0270 G0271 G0310 G0311 G0312 G0313 G0314 G0315 G0399 S0302 S3005- U1 S3005- U2 T1023 T2023 T2023- U1 S0013 Behavioral Health and Developmental Screening Services Description (see medicine services code spreadsheet at 96110 U1 96110 U2 96127 U1 96127 U2 Tobacco Cessation Codes Description (see medicine services code spreadsheet at www.mass.gov/regulations/101-CMR-31700-medicine) $58.08 $54.04 99407 SA $58.08 $54.04 99407 TD $49.37 $45.93 99407 U1 $49.37 $45.93 99407 TF $87.12 $81.06 99407 U2 $74.05 $68.90 99407 HQ $37.03 $34.45 99407 U3 $31.47 $29.28