Definitions

Terms used in 101 CMR 319.00 have the meanings set forth in 101 CMR 319.02. The descriptions and five-digit codes included in 101 CMR 319.00 utilize the Healthcare Common Procedure Code System (HCPCS) for Level I and Level II coding. Level 1 CPT-4 codes are obtained from the Physicians’ 2023 Current Procedural Terminology® by the American Medical Association (AMA), unless otherwise specified. Level II codes are obtained from 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 healthcare professionals, as well as associated non- physician services. 101 CMR 319.00 includes only HCPCS numeric and alpha-numeric identifying codes and modifiers for reporting medical services and procedures that were selected by EOHHS. Any use of CPT outside the fee schedule should refer to the Physicians’ 2023 Current Procedural Terminology®. Center. The Center for Health Information and Analysis established under M.G.L. c. 12C. Doula. A qualified professional who provides non-medical emotional, informational, and physical support to individuals and families during pregnancy, delivery, and the post-pregnancy period. Eligible Doula Provider. (1) A provider of doula services who meets the conditions of participation of a governmental unit purchasing such services. (2) MassHealth providers of doula services must satisfy the provider eligibility requirements set forth in 130 CMR 463.000: Doula Services and 130 CMR 450.000: Administrative and Billing Regulations. EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A. Governmental Unit. The Commonwealth of Massachusetts or any of its departments, agencies, boards, commissions, or political subdivisions. Individual Consideration (I.C.). Doula services that are authorized but not listed in 101 CMR 319.00, doula services performed in unusual circumstances, and services whose fees are designated by the letters "I.C." are individually considered items. The governmental unit or purchaser analyzes the eligible provider’s operative report, which must contain a diagnosis, a pertinent medical history, a description of the services rendered, and the length of time spent with the patient. In making the determination of whether the service is appropriately classified as an individually considered item the following criteria are used: (1) policies, procedures, and practices of other third-party purchasers of care, both governmental and private; (2) the severity and complexity of the patient's disorder or disability; (3) prevailing provider ethics and accepted practice; and (4) time, degree of skill, and cost including equipment cost required to perform the procedure(s). Labor and Delivery. Childbirth or delivery of a fetus following pregnancy, inclusive of all pregnancy outcomes. Modifiers. Listed services may be modified under certain circumstances. When applicable, the modifying circumstances must be identified by the addition of the appropriate two-digit number or letters. Perinatal. The period encompassing pregnancy and labor and delivery, through 12 months following delivery, inclusive of all pregnancy outcomes. Publicly Aided Individual. 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.