Definitions

As used in 101 CMR 355.00, unless the context requires otherwise, terms have the meanings in 101 CMR 355.02. The descriptions and five-digit codes included in 101 CMR 355.00 utilize the Healthcare Common Procedure Code System (HCPCS) for Level I and Level II coding. Level I CPT-4 codes are obtained from the Physicians’ 2025 Current Procedural Terminology® by the American Medical Association, unless otherwise specified. Level II codes are obtained from 2025 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 list of descriptive terms and identifying codes and modifiers for reporting medical services and procedures performed by physicians and other health care professionals, as well as associated non-physician services. 101 CMR 355.00 includes only HCPCS numeric and alphanumeric 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’ 2025 Current Procedural Terminology®. Center. The Center for Health Information and Analysis established under M.G.L. c. 12C. Certified Nurse-midwife (CNM). An advanced practice registered nurse (APRN) who has completed a program of study and clinical experience for nurse-midwives, and is licensed by the Board of Registration in Nursing to practice as a certified nurse-midwife, whose eligibility is limited to those procedures specified by the governmental unit purchasing such services, and who also meets such conditions of participation as may be adopted by a governmental unit. Certified Nurse Practitioner (CNP). An APRN who has completed a program of study and clinical experience for nurse practitioners, and is licensed by the Board of Registration in Nursing to practice as a certified nurse practitioner, whose eligibility is limited to those procedures specified by the governmental unit purchasing such services, and who also meets such conditions of participation as may be adopted by a governmental unit. Clinical Staff. The physician, certified nurse-midwife, certified nurse practitioner, registered nurse, licensed practical nurse, and other licensed health care practitioners appointed by the governing authority to practice within the birthing center and governed by rules approved by the governing body. EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A. Facility Component. Rates of payment for a freestanding birth center’s facility component costs. The facility component does not include payment for physician, certified nurse-midwife, or certified nurse practitioner services in performing a procedure or service. The facility component does include payment for the services of other clinical staff, e.g., registered nurses and licensed practical nurses. The facility component also includes payment for the component of a service or procedure representing the cost of rent, equipment, utilities, supplies, drugs and biologicals, clinical laboratory services, malpractice insurance, administrative and technical salaries and benefits, all related administrative or supervisory duties performed in connection with the provision of the service or procedure, and all other overhead expenses of the service or procedure. Freestanding. Existing independently or physically separated from another health care facility and administered by separate staff with separate records. Freestanding Birth Center (FBC). A health facility not operated under a hospital license that is licensed by the Department of Public Health (DPH) as a birth center, pursuant to 105 CMR 140.000: Licensure of Clinics. Governmental Unit. The Commonwealth of Massachusetts or any of its departments, agencies, boards, commissions, or political subdivisions. Individual Consideration (IC). Freestanding birth center services that are authorized but not listed in 101 CMR 355.00, freestanding birth center services performed in unusual circumstances, and services whose fees are designated by the letters "IC" 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: (a) policies, procedures, and practices of other third-party purchasers of care, both governmental and private; (b) the severity and complexity of the patient's disorder or disability; (c) prevailing provider ethics and accepted practice; and (d) time, degree of skill, and cost including equipment cost required to perform the procedure(s). 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. 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.