Policies for Individual Service Types

(1) Acupuncture. (a) Eligible Providers. An Eligible Provider is any person licensed by the Board of Registration in Acupuncture under M.G.L. c. 112, §§ 148 through 162, to practice acupuncture. (b) Acupuncture Services. Acupuncture is the insertion of needles through the skin at certain points on the body in an attempt to relieve pain or improve bodily function. Services include examinations, Evaluation and Management services (E/M), acupuncture treatments and supportive services. The acupuncture treatment codes include a patient assessment. Additional E/M services may be reported separately using the modifier '-25', if the patient's condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure. (c) Fees. Payment rates for acupuncture services are set forth in 114.3 CMR 40.06(1). (d) Modalities and Supportive Procedures. A charge may be assessed for modalities only in conjunction with an acupuncture treatment performed during the course of the same visit. (e) Nutritional Supplements. The payment rate for nutritional supplements is the invoice cost, plus a handling fee of $3.00. (2) Anesthesia Services. (a) Eligible Providers. An Eligible Provider is: 1. a licensed medical doctor or licensed osteopath, other than an intern or resident, authorized by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112; or 2. a certified registered nurse anesthetist (CRNA) licensed and subject to the rules and requirements in accordance with the provisions of M.G.L. c. 112 and 244 CMR 4.00 to practice as a CRNA. The CRNA is limited to those procedures within the scope of CRNA services and subject to the rules of physician relationship for reimbursement defined by the Commonwealth's Nurse Practice Act, M.G.L. c. 112, §§ 74 through 81. The CRNA is an employee of the eligible physician provider and not salaried by the health care facility. Availability by telephone is not direct supervision; however, the physician need not be in the room where the services are being performed. (b) Anesthesia Services. Services include, but are not limited to, general, regional, supplementation to local anesthesia, or other supportive services for optimal anesthesia care to the patient. These services include anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services, (eg, ECG, temperature, blood pressure, oximetry, capnography, and mass spectrometry). These services do not include preoperative and postoperative services or pain management services that may be billable separately. Unusual forms of monitoring beyond the basic anesthesia service (eg, intra-arterial, central venous, and Swan-Ganz catheters) are not included and are reimbursed separately based on the appropriate medical or surgical fee schedule. (c) Fees. The payment rates for anesthesia services are set forth in 114.3 CMR 40.05(2)(g) for use with base units set forth in 114.3 CMR 40.06(2). Fees for supplies and materials provided by the physician (eg, sterile trays, drugs) over and above those usually included with the office visit or other services rendered may be listed separately using code 99070. (d) Payments for Qualified CRNAs. Payment rates are established using the appropriate 2 digit modifier listed in 114.3 CMR 40.07: Appendix A to denote services rendered by a non-physician provider. Payments to employers billing for eligible CRNA services as specified in 114.3 CMR 40.05(2)(a)2. are: 1. 50% of the fees specified in 114.3 CMR 40.05(2)(c) for CRNA services with medical direction of 2, 3 or 4 concurrent procedures by a physician, or 2. 100% of the allowable fee specified in 114.3 CMR 40.05(2)(c) for CRNA services with medical direction of one CRNA or without direction by a physician. (e) Time Reporting. Anesthesia time begins when the anesthesiologist begins to prepare the patient for the induction of anesthesia in the operating suite (or its equivalent area) and ends when the anesthesiologist is no longer in personal attendance, i.e., when the patient is placed in postoperative supervision. (f) Qualifying Circumstances. If anesthesia services are provided under particularly difficult circumstances, based on factors such as extraordinary condition of the patient, notable operative conditions, and/or unusual risk factors, CPT codes 99100 to 99140 may be listed as additional procedure codes as follows: Qualifying Circumstances in CPT Description Unit Value Anesthesia for a patient of extreme age, under one year old and 70 years of age or older Anesthesia complicated by utilization of total body hypothermia Anesthesia complicated by utilization of controlled hypotension Anesthesia complicated by emergency conditions (an emergency is defined as existing when delay in treatment of the patient would lead to a significant increase in the threat to life or body part.) (g) Determining Payment for Anesthesia Services. Providers must use anesthesia codes and report time in minutes to ensure proper payment. Payments are determined by adding base units, time units and modifying units (if any) and multiplying this sum by a rate per unit. Each time unit equals 15 minutes. Partial time units should be reported rounded to one decimal place. PAYMENT EQUALS : (TIME UNITS + BASE UNITS + MODIFYING UNITS) TIMES $39.00 (Rate per UNIT) (h) Special Coding Situations. 1. Multiple Procedures. When multiple surgical procedures are performed during a single anesthetic administration, providers must report only the anesthesia procedure with the highest unit value. The provider must report time as the combined total for all procedures performed. 2. Anesthesia Modifiers. Physical status and common CPT modifiers used in conjunction with anesthesia codes are set forth in 114.3 CMR 40.07(1): Appendix A. 3. Postoperative Pain Management. Postoperative pain management is payable as an additional procedure. (3) Chiropractic Services. (a) Eligible Providers. An Eligible Provider is an individual licensed by the Board of Registration of Chiropractors in accordance with the provisions of M.G.L. c. 112. (b) Chiropractic Services. Chiropractic Services include examinations, Evaluation and Management services (E/M), Chiropractic Manipulative Treatment (CMT), therapeutic (supportive) procedures and modalities. The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional E/M services may be reported separately using the modifier '-25' if the patient's condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure. When an extraspinal manipulation (code 98943) is performed in conjunction with CMT codes 98940 through 98942, the Multiple Procedure modifier -51 must be added to code 98943 indicating payment at 50% of the allowable fee set forth in 114.3 CMR 40.06. (c) Fees. Payment rates for chiropractic services are set forth in 114.3 CMR 40.06(3). (d) Modalities and Supportive Procedures. A charge may be assessed for modalities (97012-97039) only in conjunction with a chiropractic treatment performed over the course of treatment of the patient. Service provisions pertaining to physical medicine are set forth in 114.3 CMR 40.05(13) and rates of payment for supportive procedures are listed in 114.3 CMR 40.06(12). No charge will be allowed for application of hot and cold packs (CPT code 97010). (e) Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS). Payment rates for durable medical equipment, prosthetic/orthotics and supplies are set forth in 114.3 CMR 40.06(6) and subject to the provisions and guidelines set forth in 114.3 CMR 40.05(6). (f) Nutritional Supplements. The payment rate for nutritional supplements is the invoice cost, plus a handling fee of $3.00. (g) Radiology. Payment rates for radiological services are set forth in 114.3 CMR 40.06(7) subject to the provisions and guidelines set forth in 114.3 CMR 40.05(12). (4) Clinical Laboratory Services. (a) Eligible Providers. An Eligible Provider is an independent licensed clinical diagnostic laboratory, a diagnostic laboratory in a physician's office or a hospital laboratory. Payment for clinical laboratory tests subject to 114.3 CMR 40.06(4) applies to the person or entity that performs or supervises the performance of the tests. (b) Clinical Laboratory Services. Clinical Laboratory Services include microbiological, chemical, hematological, biophysical, cytological, immunohematological, or pathological examinations performed in a laboratory on materials derived from the human body to provide information for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition. (c) Fees. Payment rates for clinical laboratory services are set forth in 114.3 CMR 40.06(4). Payment Rates for physician laboratory services, i.e., anatomic and surgical pathology are set forth in 114.3 CMR 40.06(8). (d) Items Over and Above Usual Service. If the physician's administration of supplies and drugs includes items over and above the usual service rendered (eg, sterile trays, drugs, supplies and materials), the provider may list these separately using code 99070. To report physician attendance and monitoring during the test, providers must use the appropriate evaluation and management code, including the prolonged physician care codes if appropriate. Prolonged physician care codes are not separately reported when evocative/ suppression testing involves prolonged descriptors where reference is made to a particular analyte (eg, Cortisol (82533 x 2) where the "x 2" refers to the number of times the test for that particular analyte is performed). (e) Pricing of Automated Tests. The payment for automated tests is based on the total number of actual tests whether billed individually or as part of a panel. For example, if three automated tests are performed on one blood draw from a patient, the total fee allowed for these tests will be $9.29, the pricing equivalent for three tests. (5) Dental Services. (a) Eligible Providers. An Eligible Provider is: 1. a dentist registered by the Board of Registration in Dentistry in accordance with the provisions of M.G.L. c. 112; or 2. an authorized governmental, nonprofit or charitably incorporated dental clinic not involved with teaching dental students; or 3. an authorized dental clinic that wholly or partially derives support from Title V Funds under the Social Security Act; or 4. a teaching dental clinic operated by dental education institutions. (b) Dental Services. Dental services include, but are not limited to, diagnostic, consultative and evaluative oral examinations, X-rays, preventive, restorative, endodontic, periodontic, prosthodontic, surgical, exodontic and orthodontic procedures and appliances. (c) Fees. Payment rates for dental services are set forth in 114.3 CMR 40.06(5). (d) Surgery. Payment rates for surgical dental services are set forth in 114.3 CMR 40.06(8) and subject to the provisions and guidelines set forth in 114.3 CMR 40.05(14). (e) Codes and Descriptions. All codes and descriptions are copyrighted by the American Dental Association's Current Dental Terminology, (CDT-4). (6) Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS). (a) Eligible Providers. An Eligible Provider is: 1. any person, partnership, corporation, or other entity authorized by the Commonwealth of Massachusetts to engage in the business of furnishing Durable Medical Equipment (DME), Medical and surgical supplies, Customized equipment, Oxygen or respiratory therapy equipment, Mobility systems, Intravenous and enteral therapy equipment, and/or related supplies and services; 2. a provider authorized under 114.3 CMR 40.05 to provide equipment or supplies relative to his or her specialty in an office setting; 3. an eligible prosthesis provider certified by the American Board for Certification in Prosthetics and Orthotics (P&O) with experience and knowledge of upper and lower extremity prostheses, cosmetic restoration and devices for traumatic or congenital deformities, their design, fabrication and fitting; or 4. any person, partnership, corporation or other entity authorized by the Commonwealth of Massachusetts to engage in the business of furnishing orthotic devices. At the discretion of the purchasing agency, a provider of certain orthotic devices may be a certified orthotist who has experience in and knowledge of upper and lower extremity bracing, torso, and spinal bracing, devices for congenital deformities, their design, fabrication and fitting. (b) Exclusions. 114.3 CMR 40.00 does not govern the payment rates for the following services: 1. Respiratory therapy services rendered by a qualified respiratory therapist; 2. Oxygen provided to a nursing home that is reimbursed under the per diem rate for such nursing home; 3. Services for inpatients at a facility licensed as an acute or chronic hospital. (c) General Provisions. 1. Coverage. 114.3 CMR 40.05 governs the payment rates for the following situations: a. the purchase or rental of durable medical equipment; b. the purchase or rental of medical/surgical supplies; c. the purchase or rental of prescribed oxygen delivery systems and respiratory therapy equipment and related supplies; d. the purchase or rental of seating, positioning, mobility systems and related accessories; e. the purchase or rental of intravenous and enteral supplies, equipment and services; and f. the repair of the listed types of equipment in 114.3 CMR 40.05(6)(c)1.a. through e. 2. Pre-authorization. Insurers and other payers under 114.3 CMR 40.00 may require pre-authorization, recertification and/or other requirements documenting medical necessity for equipment and related supplies and services under 114.3 CMR 40.05(6). In most cases, the physician's prescription for the equipment and other medical information available are sufficient to establish that the equipment is necessary and suitable in the treatment of the illness or injury. Providers should determine if there are documentation and coverage requirements associated with a prescription for durable medical supplies prior to dispensing. (d) Fees. Payment rates for DMEPOS, are set forth in 114.3 CMR 40.06(6). (e) Payment Methodology. DME fee schedules are calculated for the following DME payment classes: 1. Inexpensive and Other Routinely Purchased Items (IN). These items have a purchase price of $150 or less, or are generally purchased 75% of the time or more, or are accessories used in conjunction with certain nebulizers, aspirators, and ventilators. These items can be purchased new or used and can be rented; however, total payments cannot exceed the purchase new fee for the item. 2. Frequently Serviced Items (FS). These items require frequent and substantial servicing. These items can be rented as long as they are medically necessary. 3. Oxygen and Oxygen Equipment. Payment for oxygen and oxygen equipment is made on a monthly basis. One bundled monthly payment amount is made for all covered stationary equipment, stationary and portable contents, and all accessories used in conjunction with the oxygen equipment. A monthly payment is made for oxygen contents only. An additional monthly payment may be made for portable oxygen. 4. Other Covered Items. Supplies necessary for the effective use of the DME. 5. Capped Rental Items (CR). Items that do not fall under any other DME payment category, generally expensive items that are routinely rented. Items designated as "capped rental" in the code description are rented for a maximum period of 15 months or until the rental fees paid equal the purchase price, at which point the provider stops billing. The provider may bill for repairs as needed to maintain proper working condition th of the equipment for the patient's use after the 15 month. The methodology for payment of items on a capped rental basis is as follows: a. for the first three months of rental, 10% of the new purchase fee; b. for months four through 15, 75% of the monthly fee for months one through three; c. if provided equipment is used for less than one month, the payment will be prorated. The payment is determined by dividing the monthly rental fee by the number of days in the applicable month, and multiplying the daily rate by the number of rental days. For purchase of capped rental items, the purchase price may not exceed the sum of the capped rental methodology applied for ten months. 6. Unlisted Items. Items that are not listed but may be prescribed as medically necessary for the treatment of illness or injury or to improve patient function are payable using the Medicare fee for the locality in which the item is prescribed. If no Medicare fee is available then the item shall be paid under the reimbursement policies for individually considered (I.C.) items in accordance with 114.3 CMR 40.05(6). In this case a code not listed in 114.3 CMR 40.06(6) should be assigned an unlisted service or procedure code such as A9900 (Miscellaneous DME supply, accessory, and/or service component of another HCPCS code) or E1399 (Durable Medical Equipment, miscellaneous.) Customized items that are deemed medically necessary are payable at individual consideration (I.C.). (f) Individual Consideration (I.C.). The payment for individually considered items is the lower of: 1. The Eligible Provider's usual and customary charge to the general public; or 2. The adjusted acquisition cost to the Eligible Provider plus a markup not to exceed: a. 30% for inexpensive and routinely purchased items; or b. 40% for frequently serviced items, customized equipment, prosthetics and orthotics; or c. as priced in 114.3 CMR 40.06(6) (g) Labor Rate for Repair Services. 1. Payments for labor costs for repair code E1340 to an Eligible Provider for items that require additional service, intensive time or procedures, or that require repair, may be billed at the rate of $21.00 per 15 minutes. 2. Payments for labor costs for orthotic repair code L4205 and prosthetic repair code L7520 to an Eligible Provider for items that require additional service, intensive time or procedures, or that require repair, may be billed at the rate of $21.00 per 15 minutes. (7) Freestanding Diagnostic Facilities. (a) Eligible Provider. An Eligible Provider is a licensed freestanding diagnostic imaging facility or hospital. (b) Fees. Payment rates for freestanding diagnostic facilities and imaging technical components are set forth in 114.3 CMR 40.06(7). (c) General Rate Guidelines. 1. The TC payment for CAT and MRI procedures that specify "with contrast" include payment for contrast media. 2. The TC rate for nuclear medicine does not include the radionuclide used in connection with the procedure. These substances are separately billed under codes A4641 and A4642 for diagnostic procedures and are paid on an I.C. basis depending on the substance used. (8) Freestanding Ambulatory Surgical Centers. (a) Eligible Provider. An Eligible Provider is a DPH licensed freestanding ambulatory surgical center (FASC) or hospital outpatient surgical center. (b) FASC Services. FASC Services are procedures that CMS recognizes as safe to perform in an ambulatory setting without requiring hospital facilities as of January 1, 2008. (c) Fees. Payment rates are based upon Medicare rates for Massachusetts effective January 1, 2008. The fees are listed in 114.3 CMR 40.06(8). For procedures that are deemed safe to perform in the ambulatory setting subsequent to January 1, 2008, the Medicare fee for Massachusetts should be used for services provided under 114.3 CMR 40.00. (d) Global Surgical Procedures Facility Coverage. The fee covers services and the normal range of care required before and after surgery that are included in the Medicare fee. (e) Services not included in the global facility rate. Services required in conjunction with the surgical procedure that are not included in the Medicare fee should be reimbursed at their respective CPT/HCPCS rates. (f) Implanted DME, implanted prosthetic devices, replacement parts (External or Internal), accessories and supplies for the implanted DME. Payment for items not included in the Medicare ASC fee but listed in 114.3 CMR 40.06(6) includes the associated fees. Otherwise payment for the items is the invoice cost as specified in 114.3 CMR 40.02. No separate payment shall be made for implanted devices that are included in the Medicare ASC fee. Fees do not include medically appropriate observation stays in hospitals which are established under 114.1 CMR 41.00. (g) Modifiers. See 114.3 CMR 40.07(1): Appendix A for a list of Level 1 CPT modifiers. (9) Homemaker Services. (a) Eligible Provider. An Eligible Provider is an individual, partnership or corporation that employs homemakers. (b) Homemaker Services. Homemaker Services are services that comply with the Homemaker Standards issued by the Executive Office of Elder Affairs to assist a client with IADL. (c) Fees. The payment rate for homemaker services is set forth in 114.3 CMR 40.06(9). (10) Medicine. (a) Eligible Providers. Eligible Providers include: 1. a physician or osteopath other than an intern, resident, or house officer licensed by the Board of Registration in Medicine in accordance with the provisions of M.G.L. c. 112. A licensed Physician Assistant (PA) authorized by the Board of Registration for Physician Assistants in accordance with the provisions of M.G.L. c. 112, may not bill separately for services rendered. 2. a licensed, registered podiatrist other than an intern, resident, or house officer authorized by the Board of Registration in Medicine or the Board of Registration in Podiatry in accordance with the provisions of M.G.L. c. 112, whose eligibility is limited to those procedures within the scope of his/her licensure. 3. a licensed registered nurse authorized by the Board of Registration in Nursing in accordance with the provisions of M.G.L. c. 112 to practice as a Nurse Practitioner (NP), limited to those procedures within the scope of NP services and subject to the rules of physician relationship for reimbursement defined by the Commonwealth's Nurse Practice Act, M.G.L. c. 112, §§ 74 through 81. (b) Fees. Payment rates for medicine services are set forth in 114.3 CMR 40.06(10). (c) Payments for Qualified NPs and PAs. Payment to employers billing for eligible NPs and PAs as specified in 114.3 CMR 40.05(10)(a)3. is 85% of the fees set forth in 114.3 CMR 40.06. Providers must use the appropriate 2-digit modifier listed in 114.3 CMR 40.07: Appendix A to denote services rendered by a non-physician provider. (d) Allowable Fees - Medical Services. 1. Office Visits. The office visit fees apply only when the Eligible Provider customarily bills for services rendered. 2. Drugs, Medications, Supplies and Laboratory Specimen Collections. Supplies and materials used in preparation for or as part of a procedure (eg, bandages, laboratory kits, syringes or disposable gloves) are not reimbursed separately, but included in the office visit rate. In addition, no supplemental charge will be submitted nor payment allowed for routine specimen collection in a physician's office and preparation for clinical laboratory analysis (and activities related thereto), eg, venipuncture, urine, fecal and sputum sample collection, culturing, swabbing and scraping for removal of tissues. 3. Payments for Other Services. Where applicable, payment for drugs, medicines, supplies, and related materials dispensed to patients are governed by provisions of other Division regulations applicable to the service provided, and may not exceed the physician's usual and customary fee. If there is no appropriate code for the supplies or materials provided by the physician over and above those usually included with the office visit, the service should be billed under code (99070). 4. Medication and Injections. Medication and injectables not available free of charge from the Department of Public Health may be billed under the appropriate J Code at A.I. cost net of any manufacturer discounts received by the provider. See 114.3 CMR