Hospital Outpatient Rates

(1) General. Except as specified below, payments for outpatient services provided by Massachusetts hospitals shall be made at the rates established for comparable services in accordance with 114.3 CMR 40.00, Rates for Services Under M.G.L. c. 152, Workers’ Compensation Act. (a) Rehabilitation Clinic Services and Restorative Services. 1. Fees for Sites of Service After July 1, 1993. Payment for rehabilitation clinic or restorative services provided in a program or location established after July 1, 1993, shall be equal to the rates specified in 114.3 CMR 40.00. 2. Fees for Sites of Service Before July 1, 1993. The rates for individual outpatient physical, occupational, and speech therapyservices that a Hospital provided in a program established before July 1, 1993 are listed below. A list of these sites of service is available on the Division's web site at www.mass.gov/dhcfp. a. Fees for Physical Therapy and Occupational Therapy in Out Patient Department (OPD) Clinics and Satellites Owned and Operated by a Hospital Prior to July 1, 1993. CODE FEE DESCRIPTION Physical therapy re-evaluation (per 30 minutes) Occupational therapy re-evaluation (per 30 minutes) Application of a modality to one or more areas; traction, mechanical G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care Application of a modality to one or more areas; vasopneumatic devices Application of a modality to one or more areas; paraffin bath Application of a modality to one or more areas; whirlpool Application of a modality to one or more areas; diathermy Application of a modality to one or more areas; infrared Application of a modality to one or more areas; ultraviolet Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes Application of a modality to one or more areas; contrast baths, each 15 minutes Application of a modality to one or more areas; ultrasound, each 15 minutes Application of a modality to one or more areas; Hubbard tank, each 15 minutes Unlisted modality (specify type and time if constant attendance) Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing) Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) Therapeutic procedure, one or more areas, each 15 minutes; unlisted therapeutic procedure (specify) Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Therapeutic procedure(s), group (two or more individuals) Therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes Self care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures,and instructions in use of assistive technology devices/adaptive equipment) direct one on one contact by provider, each 15 minutes Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis), direct one–on-one contact by provider, each 15 minutes Wheelchair management/propulsion training, each 15 minutes Work hardening/conditioning; initial two hours Work hardening/conditioning; each additional hour Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes I.C. Unlisted physical medicine/rehabilitation service or procedure b. Fees for Speech Therapy in OPD Clinics and Satellites Owned and Operated by a Hospital Prior to July 1, 1993. CODE FEE DESCRIPTION Treatment of speech, language, voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual Treatment of speech, language, voice, communication, and/ or auditory processing disorder (includes aural rehabilitation); group, two or more individuals Treatment of swallowing dysfunction and/or oral function for feeding c. Exceptions. To comply with the requirements of M.G.L. c. 152, § 13, the rates for the following Hospitals shall equal the higher of the rates contained in 114.3 CMR 40.00 or the product of the fees listed in 114.1 CMR 41.04(1)(b)2.a. and 114.1 CMR 41.04(1)(b)2.b. and the Hospital specific percentage listed below: Hospital Name Physical Therapy: Fee X % Occupational Therapy: Fee X % Speech Therapy: Fee X % Brockton Hospital Fairlawn Hospital Mass. Eye and Ear New England Rehabilitation Hospital North Shore Medical Center – Shaughnessy Kaplan Rehab Southwood Community Hospital 3. Functional Capacity Assessments. To report a functional capacity assessment (or Key functional assessment), hospitals shall use CPT code 97750 that may be billed up to a maximum of nine units per session. 4. Work Hardening and Work Conditioning. Work hardening and work conditioning are goal-oriented therapies designed to prepare injured workers for their return to work. Hospitals shall use CPT codes 97545 and 97456 to report these services. 5. Modalities. Hospitals may assess a Charge for supportive services (CPT codes 97012-97039) only in conjunction with a procedure performed during the course of the same visit. When determining the correct units allowed, Hospitals shall round partial units to one decimal place. (b) Outpatient Services Available Only in Hospitals. Payers shall pay for the following services and any other services incidental to the visit by applying the Hospital's PAF, as established in 114.1 CMR 41.03, to the Charges for services. 1. Emergency Department Services. All Emergency Department Services shall be paid using the PAF. Non-emergent visits shall be paid pursuant to 114.3 CMR 40.00. 2. Observation Services. All Observation Services shall be paid using the PAF. Other services provided during a visit that results in an observation stay shall be paid pursuant to the other provisions of 114.1 CMR 41.00 or, when applicable, the provisions of 114.3 CMR 40.00. 3. Ambulatory Surgery. All surgical procedures performed in an outpatient surgical department not approved by Medicare to be performed in a free-standing Ambulatory Surgery Centers (ASC) shall be paid using the PAF. A CPT code described as an unlisted procedure, typically one denoted by “xxx99”, shall be paid using the PAF only if documentation supports the necessity to perform the operation in a hospital based ASC. (c) Individual Consideration (I.C.). Services that are authorized but for which there are no established rates are designated as I.C. services. The purchaser will determine the appropriate payment rate in accordance with the following standards and criteria: 1. the amount of time required to perform the procedure; 2. the degree of skill required to perform the procedure; 3. the severity or complexity of the patient’s disease, disorder or disability; and 4. the policies, procedures, and practices of other third party insurers. (d) Acute Hospital Uniform Assessment. For payments for outpatient services provided by a Massachusetts Acute Hospital, payers shall pay a separate and additional Health Safety Net fee to reflect the costs that such Hospitals incur for their gross liability to the Health Safety Net. The additional fee is the hospital uniform assessment percentage multiplied by the total Charges billed for outpatient services. No additional fee shall be paid when payment is made to Massachusetts Acute Hospitals for services provided pursuant to 114.1 CMR 41.03(2), or when payment is made to Massachusetts Non-acute Hospitals or to out-of-state Hospitals (2) Out of State Outpatient Services. (a) Payers shall compensate out of state Hospitals for outpatient services listed in 114.1 CMR 41.04(1)(b) by applying the out of state PAF, as established in 114.1 CMR 41.03(3). (b) Industrial accident payers shall compensate out of state Hospitals for all other outpatient services as provided in 114.3 CMR 40.00.