General Rate Provisions and Payment

(1) Rate Determination. Rates of payment for authorized FASC services to which 101 CMR 347.00 applies are the lowest of (a) the eligible provider's usual fee to the general public; (b) the eligible provider's actual charge submitted; and (c) the schedule of allowable rates set forth in 101 CMR 347.03(6). (2) Maximum Allowable Rates. Rates of payment are for the facility component only. The maximum allowable payment rate for each FASC service is listed next to the HCPCS code in the fee schedule set forth in 101 CMR 347.03(6). Service codes listed in 101 CMR 347.03(6) with $0 rates are packaged services for which no separate payment is made. (3) Individual Consideration and Non-listed Services. Rates of payment to eligible providers for FASC services that are authorized but not listed in 101 CMR 347.00, services performed in unusual circumstances, and services whose fees are designated by the letters “IC” are determined on an individual consideration basis. (4) Terminated Procedures. The purchasing governmental unit determines payment on an individual consideration (IC) basis for any procedure that has been terminated after the procedure has been initiated. (5) Modifiers. (a) 50: Bilateral Procedure. Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate five-digit code. (Only one claim line is billed for both procedures. If a reimbursable surgical procedure provided in a single operative session is performed bilaterally, the full maximum fee is 150% of the allowable fee contained in 101 CMR 347.00 for the operative procedure.) (b) 51: Multiple Procedures. When multiple procedures, other than E/M services, physical medicine and rehabilitation services or provision of supplies (e.g., vaccines), are performed at the same session by the same individual, the primary procedure or services may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). Note: This modifier should not be appended to designated “add-on” codes. (The addition of the modifier 51 to the second and subsequent service codes allows 50% of the allowable fee contained in 101 CMR 347.00 to be paid to the eligible provider.) (c) 73: Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia. Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s), or general). Under these circumstances, the intended service that is prepared for, but cancelled, can be reported by its usual service code and the addition of the modifier 73. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. (d) 74: Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia. Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (e.g., incision made, intubation started, scope inserted). Under these circumstances, the procedure started, but terminated, can be reported by its usual service code and the addition of the modifier 74. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. (e) SG: Ambulatory surgical center (ASC) facility service (f) Modifiers for Provider Preventable Conditions. Modifiers for reporting “provider preventable conditions” that are National Coverage Determinations, in accordance with 42 CFR 447.26, are listed in 101 CMR 347.03(5)(e). Modifier Description PA Surgical or other invasive procedure on wrong body part PB Surgical or other invasive procedure on wrong patient PC Wrong surgery or other invasive procedure on patient (6) Fee Schedule: Surgical Services. For code descriptions, see the FASC service code spreadsheet at www.mass.gov/regulations/101-CMR-34700-rates-for-freestanding-ambulatory-surgery-center-services. D4210 D4211 D4212 D4260 D4263 D4270 D4273 D7111 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7270 D7280 D7310 D7311 D7320 D7321 D7410 D7411 D7412 D7413 D7414 D7415 D7450 D7451 D7460 D7461 D7471 D7472 D7473 D7485 D7510 D7511 D7520 D7521 D7530 D7540 D7550 D7950 G0104 G0105 G0121 G0186 G0260 G0269 G0276 G0330 G0429 G0516 G0517 G0518 G0564 G0565