General Rate Provisions

(1) General Rate Provisions for the Purchase of Prostheses, Prosthetic Devices, and Orthotic Devices. Payment to a provider of prosthetic or orthotic devices or services are the lower of: (a) the provider's usual and customary charge; or (b) the rates set forth in 101 CMR 334.03(10) or any applicable administrative bulletin. (2) Rates for New Codes. New codes that have established Medicare fees as of the date of the Administrative Bulletin will have rates established at: (a) 94.00% of the corresponding Medicare fee for any item described as being custom fabricated; or (b) 82.00% of the corresponding Medicare fee for any item described as being prefabricated; or (c) 70.76% of the corresponding Medicare fee for any item described as being off-the-shelf. When Medicare fees are not available for new codes, and for certain orthotics and prosthetics, rates will be established at individual consideration at adjusted acquisition cost plus the standard markup as defined in 101 CMR 334.03(9). (3) Effect of Rates. The rates of payment contained in 101 CMR 334.00 are maximum allowable rates that a governmental unit or purchaser under M.G.L. c. 152 may pay for prostheses, prosthetic devices, or orthotic devices. A governmental unit may pay less than the rates established for a provider under 101 CMR 334.00 provided that any such discount or reduction in charge by the provider is equally available to all governmental units purchasing prostheses, prosthetic devices and orthotic devices from the provider. No rate of payment under 101 CMR 334.00 may exceed the provider's usual and customary charge for the same or similar device. (4) Terms and Warranties. All terms and warranties, expressed and implied, that are customarily extended by the provider or manufacturer must apply to purchases made under 101 CMR 334.00. A purchaser will not pay for replacement or repair of any item or service covered by such terms or warranties. (5) Repairs. For repair services providers must maintain and submit adequate documentation on the repair performed as indicated by the purchasing governmental unit. Repair may be billed using codes for the labor component (L7520 for prosthetics or L4205 for orthotic devices) and the parts used in the repair (L7510 for prosthetics or L4210 for orthotic devices). (6) Modifiers. The following list of letter modifiers must be added, where appropriate, to Healthcare Common Procedure Coding System (HCPCS) procedure codes to determine the percent fee to be paid on claims. Refer to purchasers' manuals for specific coding instructions. (a) Informational modifiers: 1. LT – Left 2. RT – Right 3. CG – Policy Criteria Applied (b) Additional modifiers used for MassHealth reimbursement when using the following miscellaneous codes, L0999, L1499, L2999, L3999, L5999, L7499, and L8499: 1. U1 – AAC 40% Off the Shelf (used for not otherwise classified (NOC) codes only – identified in 334.03(10) 2. U2 – AAC 50% Prefabricated (used for NOC codes only – identified in 334.03(10) 3. U3 – AAC 70% Custom (used for NOC codes only – identified in 334.03(10) (7) Recall Provisions. Whenever an orthotic or prosthetic is subject to recall, the provider will fully address the recall as specified in the manufacturer’s recall instructions. For recalls of potentially dangerous or defective orthotic or prosthetic that predictably could cause serious health problems, including death, the provider must provide the publicly aided individual with a copy of the recall notice and fully address the recall as specified in the recall instructions no later than five business days from the date the provider receives the recall notice. Any costs not covered by the manufacturer or other third party for activity associated with amelioration, repair or replacement of recalled equipment is included in the general rate provision. (8) AAC Methodology and Documentation. (a) Except where otherwise stipulated in 101 CMR 334.03, payment to an eligible provider is for the AAC as defined in 101 CMR 334.02, plus a standard markup. (b) The eligible provider must accurately indicate the amount of any discounts set forth in the definition of AAC at 101 CMR 334.02. The provider must maintain documentation evidencing the amount and application of discounts. (c) Current Catalogue Price. The AAC to the eligible provider will not exceed the manufacturer's current catalogue price. (d) Where the manufacturer is the provider, the AAC cannot exceed the actual cost of raw materials. Low-cost items (those with an AAC less than $5.00) may be grouped together and billed at $5.00 plus the mark-up listed in 101 CMR 334.03(9). (9) Individual Consideration. Except where otherwise stipulated in 101 CMR 334.03, payment to an eligible provider for individual consideration will be the lower of: (a) the eligible provider’s usual and customary charge; or (b) the AAC to the provider, plus a markup not to exceed: 1. 70% for any item described as being custom fabricated; or 2. 50% for any item described as being prefabricated; or 3. 40% for any item described as being off-the-shelf; or (c) Such schedule of allowable fees as may be issued as an amendment or revision to 101 CMR 334.00. (10) Payment Rates. For code descriptions, see the O&P service code spreadsheet at www.mass.gov/regulations/101-CMR-33400-prostheses-prosthetic-devices-and-orthotic-devices AAC+ 70% AAC+ 70% AAC+ 70% AAC+ 70% AAC+ 40% AAC+ 70% K0672 K1007 L0450CG L0454CG L0621CG L0625CG L0628CG L0999 U1 L0999 U2 L0999 U3 AAC+ 70% L1499 U1 L1499 U2 L1499 U3 L2999 U1 L2999 U2 L2999 U3 L3999 U1 L3999 U2 L3999 U3 AAC+ 40% L5999 U1 L5999 U2 L5999 U3 AAC+ 70% AAC+ 70% AAC+ 70% AAC+ 70% AAC+ 70% AAC+ 70% AAC+ 70% AAC+ 70% AAC+ 70% AAC+ 70% AAC+ 70% AAC+ 70% L7499 U1 L7499 U2 L7499 U3 L8499 U1 L8499 U2 L8499 U3 S1040