The Massachusetts Register

Issue: 1151, Date: 3/5/2010

Published by: The Secretary of the Commonwealth, William Francis Galvin, Secretary $10.00

THE COMMONWEALTH OF MASSACHUSETTS Secretary of the Commonwealth - William Francis Galvin The Massachusetts Register

TABLE OF CONTENTS

Page - THE GENERAL COURT Acts and Resolves 1

- Division of Health Care Finance and Policy Administrative Bulletin 10-05: 114.3 CMR 47.00: Freestanding Ambulatory 3 Surgical Facilities - ADMINISTRATIVE PROCEDURES Notice of Public Review of Prospective Regulations 10

Cumulative Table 25

Emergency Regulations 31

Permanent Regulations 35

MASSACHUSETTS REGISTER (THE) (ISSN-08963681) is published biweekly for $300.00 per year by the Secretary fo the Commonwelath, State House, Boston, MA 02133. Second Class postage is paid at Boston, MA. POSTMASTER: Send address chagne to: Massachusetts Register, State Bookstore, Room 116, State House, Boston, MA 02133.The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Page

Emergency Regulations

211 CMR Insurance, Division of

43.00 Health Maintenance Organizations (HMOs) 31 The purpose of 211 CMR 43.00 is primarily to implement M.G.L. c. 176G which governs health care maintenance organizations (HMO’s). HMO’s provide or arrange for the provision of health services to enrolled members in exchange for a fee.

527 CMR Fire Prevention Regulations, Board of

10.00 Fire Prevention, General Provisions 33 Adds 527 CMR 10.13(8), which contains special fire safety provisions for certain places of worship which have been issued a valid Certificate of Occupancy for use as a temporary overnight shelter from the cold pursuant to 780 CMR, The State Building Code.

Permanent Regulations

106 CMR Transitional Assistance, Department of

204.000 Transitional Aid to Families with Dependent Children: Financial Eligibility 35 State Letter 1357 transmits a change in the TAFDC Eligibility, Need and Payment Standards regulations for the month of February 2010 and thereafter. Beginning in 2010, the Department will be able to provide a nonrecurring clothing allowance or other one-time nonrecurring payment to eligible TAFDC recipients, in the event such an allowance or payment is authorized in the budget, without an annual change in these regulations.

114.3 114.3 CMR Health Care Finance and Policy, Division of CMR 47.00 Freestanding Ambulatory Surgical Facilities 37 Governs the rates of payment to freestanding ambulatory surgical facilities for surgical services rendered to publicly-aided individuals. The amendments are effective January 1, 2010.

130 CMR Medical Assistance, Division of

409.000 Durable Medical Equipment and Medical Supplies Services 39

211 CMR Insurance, Division of

130.00 Credit for Reinsurance 41 211 CMR 130.00 sets forth rules and procedural requirements that the Commissioner deems necessary to carry out the provisions of M.G.L. c. 175, § 20A relating to credit insurance.

430 CMR Unemployment Assistance, Division of

4.00 Benefit Series 43 Provides that a claimant whose preferred language is listed in M.G.L. c. 151A, § 62A (Spanish, Chinese, Haitian Creole, Italian, Portuguese, Vietnamese, Laotian, Khmer, and Russian) and who did not receive a determination in that language shall have an extended time period in which to request a hearing.

7.00 Medical Security Plan for the Unemployed 45

527 CMR Fire Prevention Regulations, Board of

10.00 Fire Prevention, General Provisions 47

19 S 2236 Relative to the Lowell Civic Stadium Commission. 2/1/2010

20 S 2308 Authorizing the Town of Charlton to Acquire Dams Within the 2/4/2010 Town, to Make Improvements to Dams and to Authorize the Assessment of Betterments to Pay Costs Associated Therewith.

21 S 2228 Establishing a Sick Leave Bank for Catherine Ann Ouellette, an 2/4/2010 Employee of the Trial Court.

22 H 4159 Relative to the Board of Public Accountancy and Regulating the 2/4/2010 Registration of Certified Public Accountants.

23 S 2212 Relative to Harrassment Prevention Orders. 2/9/2010

24 S 253 Relative to Vocational Education. 2/9/2010

25 H 3210 Naming a Certain Bridge in the City of Malden as the Joseph E. 2/9/2010 Croken Memorial Bridge.

26 H 3588 Relative to the Collection of Unpaid Municipal Fines. 2/10/2010

27 H 4400 Establishing a Sick Leave Bank for Tree Borden, an Employee of 2/11/2010 the Norfolk District Attorney's Office.

28 H 1134 Authorizing the Town of Spencer to Grant Tax Abatements to 2/11/2010 Certain Military Personnel.

29 S 1302 Authorizing the Board of Assessors of the City of Quincy to Grant 2/11/2010 Tax Abatements to Certain Military Personnel.

30 S 2114 Authorizing Berkshire Community College to Lease Certain Land 2/11/2010 to the Pittsfield Young Men's Christian Association.

31 H 1976 Relative to the Wareham Fire District. 2/18/2010

32 H 4190 Prohibiting Certain Dumping in the City of Brockton. 2/18/2010

33 H 4267 Authorizing the City of Leominster to Grant an Additional License 2/18/2010 for the Sale of All Alcoholic Beverages not to be Drunk on the Premises.

34 H 4470 Relative to Unemployment Insurance Rates. 2/18/2010

35 S 1890 Designating a Certain Bridge in the Towns of Orange and 2/23/2010 Wendell as the Franklin County Purple Heart Memorial Bridge.

36 H 4361 Establishing a Sick Leave Bank for Olivia Mulhall, an Employee 2/24/2010 of the Trial Court.

37 H 4407 Relative to a Wastewater Management District in the Town of 2/26/2010 Harvard.

38 S 2237 Relative to Certain Affordable Housing in the City of Boston. 2/26/2010

39 S 2163 Relative to the Certification of Wareham Library. 2/26/2010

NOTICES OF PUBLIC REVIEW OF PROSPECTIVE REGULATIONS PUBLISHED IN COMPLIANCE WITH M.G.L. c. 30A, SECTIONS 2 AND 3

Published March 05, 2010

Public Health, Department of 105 CMR 590.000 3/12/10 @ 10:00 A.M. Testimony accepted until 3/26/10 @ 5:00 P.M.

Water Pollution Control, 314 CMR 19.00 3/23/10, 1:00 P.M. - 3:00 P.M. Division of Comments accepted until 3/23/10 @ 5:00 P.M.

Public Health, Department of 105 CMR 700.000; 243 CMR 4/6/10 @ 10:00 A.M. Testimony 2.00; 247 CMR 16.00 accepted until 4/9/10 @ 5:00 P.M. Hearing held with The Boards of Registration in Medicine and Pharmacy

Economic Assistance 402 CMR 2.00 3/15/10 @ 12:00 P.M. Written Coordinating Council comments accepted until close of business on 3/15/10.

Medical Assistance, Division 130 CMR 520.000 Comments accepted through of 3/12/10.

Conservation and Recreation 302 CMR 14.00 Comments accepted 2/25/10 - Department of 3/12/10.

Public Safety, Department of 526 CMR 10.00 3/31/10 @ 11:00 A.M. Written comments accepted prior to hearing date.

Medicine, Board of 243 CMR 14.00 4/14/10 @ 1:30 P.M. Comments Registration in accepted until 4/16/10 @ 5:00 P.M.

Unemployment Assistance, 430 CMR 5.00 3/15/10 @ 10:00 A.M. Written Division of presentations may be made prior to close of business on 3/15/10.

The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State 11 Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State 12 Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State 24 Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 2010 CUMULATIVE TABLE TO THE MASSACHUSETTS REGISTER 1147 - 1151

The cumulative Table lists all regulations and amendments thereto published in the Massachusetts Register during the current year. The Table is published in each Register.

State agencies are listed in the Table as they appear in the Code of Massachusetts Regulations (CMR or Code) in CMR numerical order which is based on the cabinet structure. For example, all Human Service agencies are prefaced by the number “1" and are designated as 101 CMR through 130 CMR.

The Cumulative Tables published in the last issue of previous years will have a listing of all regulations published for that year. These Registers are: April 6, 1976 - 1977 Register: # 88 Date: 1994 Register: #755 1978 138 1995 871 1979 193 1996 Supp. # 2 807 1980 241 1997 833 1981 292 1998 859 1982 344 1999 885 1983 396 2000 911 1984 448 2001 937 1985 500 2002 963 1986 546 2003 989 1987 572 2004 1016 1988 598 2005 1042 1989 624 2006 1068 1990 650 2007 1094 1991 676 2008 1120 1992 702 2009 1146 1993 729

Effective Issue Date

102 CMR Office of Child Care Services 7.00 Standards for the Licensure or Approval of Group Day Care and School Age Child Care Programs ...... 1148 1/22/10 8.00 Standards for the Licensure of Family Child Care and Large Family Child Care Homes ...... 1148 1/22/10

105 CMR Department of Public Health 220.000 Immunization of Students Before Admission to School ...... 1147 1/8/10

23 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Effective Issue Date

106 CMR Department of Transitional Assistance 204.000 Transitional Aid to Families with Dependent Children: Financial Eligibility ...... 1151 3/5/10 364.000 Supplemental Nutrition Assistance Program: Determining Household Eligibility and Benefit Level - Compliance (MA Reg. # 1146) . . . . . 1148 10/1/09 366.000 Supplemental Nutrition Assistance Program: Additional Certification Functions - Compliance - (MA Reg. # 1146) ...... 1148 10/1/09

110 CMR Department of Children and Families 6.00 Service Plans and Case Reviews ...... 1150 2/19/10

114 CMR Division of Health Care Finance and Quality 114.3 17.00 Medicine - Compliance (MA Reg. # 1142) ...... 1147 10/18/09 46.00 Rates for Certain Substance Abuse Programs ...... 1148 1/21/10 47.00 Freestanding Ambulatory Surgical Facilities ...... 1151 1/1/10 114.4 11.00 Rates for Certain Placement and Support Services ...... 1148 10/1/09 114.5 20.00 Pediatric Immunization Program Assessment ...... 1149 1/1/10 114.6 14.00 Health Safety Net Payments and Funding ...... 1150 2/1/10

129 CMR Health Care Quality and Cost Council 3.00 Disclosure of Health Care Claims Data ...... 1147 1/8/10

130 CMR Division of Medical Assistance 409.000 Durable Medical Equipment and Medical Supplies Services ...... 1151 3/5/10 420.000 Dental Services - Emergency ...... 1148 10/1/09 450.000 Administrative and Billing Regulations - Emergency ...... 1147 10/1/09 - Emergency Correction (MA Reg. # 1147) ...... 1150 10/1/09 ...... 1149 2/15/10 501.000 Health Care Reform: MassHealth: General Policies - Emergency ... 1150 7/1/09 505.000 Health Care Reform: MassHealth: Coverage Types - Emergency ... 1147 10/1/09 - Emergency Correction (MA Reg. # 1147) ...... 1150 10/1/09 506.000 Health Care Reform: MassHealth: Financial Requirements - Emergency ...... 1150 7/1/09 515.000 MassHealth: General Policies - Emergency ...... 1150 7/1/09 519.000 MassHealth: Coverage Types - Compliance (MA Reg. # 1144) . . . . . 1149 1/1/09 - emergency ...... 1150 2/1/10 520.000 MassHealth: Financial Eligibility - Compliance (MA Reg. # 1144) . . 1149 1/1/09 - Emergency ...... 1150 7/1/09 - Emergency ...... 1150 7/1/09

24 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Effective Issue Date

211 CMR Division of Insurance 29.00 Valuation of Life Insurance Policies ...... 1149 2/5/10 43.00 Health Maintenance Organizations (HMOs) - Emergency ...... 1151 2/10/10 58.00 Permitting Preferred Mortality Tables For Determining Minimum Reserve Liabilities ...... 1149 2/5/10 130.00 Credit for Reinsurance...... 1151 3/5/10 132.00 Actuarial Opinion and Memorandum Regulation ...... 1149 2/5/10

220 CMR Department of Public Utilities 19.00 Standards of Performance for Emergency Preparation and Restoration of Service for Electric Distribution and Gas Companies - Emergency 1150 2/2/10

225 CMR Department of Energy Resources 14.00 Renewable Energy Portfolio Standard – Class I - Emergency ...... 1148 1/8/10

271 CMR Board of Examiners of Sheet Metal Workers 2.00 Definitions ...... 1150 2/19/10 3.00 Individual Licensure ...... 1150 2/19/10 4.00 Continuing Education ...... 1150 2/19/10 5.00 Code of Professional Ethics and Standards of Professional Practice . 1150 2/19/10 6.00 Uniform Sheet Metal Installation Rules ...... 1150 2/19/10 7.00 Business Licensure ...... 1150 2/19/10 8.00 Sheet Metal Worker Training Programs ...... 1150 2/19/10 9.00 Permits and Inspections ...... 1150 2/19/10

310 CMR Department of Environmental Protection 7.00 Air Pollution Control ...... 1148 1/22/10 22.00 Drinking Water - Correction (MA Reg. # 1146)...... 1150 12/25/09

314 CMR Division of Water Pollution Control 19.00 Oil Spill Prevention and Response - Emergency ...... 1149 1/20/10

321 CMR Division of Fisheries and Wildlife 2.00 Miscellaneous Regulations Relative to Fisheries and Wildlife ...... 1150 2/19/10 3.00 Hunting - Correction (MA Reg. # 1142)...... 1148 10/30/09 ...... 1147 1/8/10 ...... 1150 2/19/10 ...... 1150 2/19/10

402 CMR Economic Assistance Coordinating Council 2.00 Economic Development Incentive Program - Emergency ...... 1150 2/5/10

25 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Effective Issue Date

430 CMR Division of Unemployment Assistance 4.00 Benefit Series...... 1151 3/5/10 7.00 Medical Security Plan for the Unemployed - Compliance (MA Reg. # 1146) ...... 1151 12/1/09

503 CMR Underground Storage Tank Petroleum Product Cleanup Fund Administrative Review Board 2.00 Underground Storage Tank Petroleum Product Cleanup Fund Regulations Implementing M.G.L. c. 21J - Compliance (MA Reg. # 1143) ...... 1147 10/30/09 ...... 1150 2/19/10

527 CMR Board of Fire Prevention Regulations 10.00 Fire Prevention, General Provisions - Emergency ...... 1151 2/19/10 - Compliance (MA Reg. # 1151) ...... 1151 2/19/10

603 CMR Department of Elementary and Secondary Education 1.00 Charter Schools ...... 1147 1/8/10

605 CMR Board of Library Commissioners 6.00 Library Improvement Program - Public Library Construction ...... 1149 2/5/10

606 CMR Department of Early Education and Care 7.00 Standards for the Licensure or Approval of Family Child Care; Small Group and School Age and Large Group and School Age Child Care Programs ...... 1148 1/22/10

700 CMR Massachusetts Department of Transportation 5.00 Regulation of Certain Roadways and Bridges - Compliance (MA Reg. # 1144) ...... 1148 11/2/09 11.00 Maurice J. Tobin Memorial Bridge - Emergency ...... 1148 1/1/10

711 CMR Outdoor Advertising Board 3.00 Control and Restriction of Billboards, Signs and Other Advertising Devices - Compliance (MA Reg. # 1144) ...... 1148 11/2/09

26 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Effective Issue Date

780 CMR State Board of Building Regulations and Standards 1.00 Administration - Compliance (MA Reg. # 1142) ...... 1149 10/16/09 ...... 1149 2/5/10 2.00 Definitions - Compliance (MA Reg.# 1142) ...... 1149 10/16/09 4.00 Special Detailed Requirements Based on Use and Occupancy ...... 1149 2/5/10 13.00 Energy Efficiency - Emergency ...... 1147 1/1/10 34.00 Existing Structures - Emergency ...... 1147 1/1/10 ...... 1149 2/5/10 51.00 Administration for Single- and Two-family Dwellings ...... 1149 2/5/10 61.00 Energy Efficiency - Emergency ...... 1147 1/1/10 93.00 Repair, Renovation, Alteration, Addition, Demolition and Change of Use of Existing One- and Two-family Dwellings - Emergency ..... 1147 1/1/10 110.00 Special Regulations - Emergency ...... 1149 1/19/10 - Emergency ...... 1149 1/19/10 120.00 Appendices...... 1149 2/5/10

801 CMR Executive Office for Administration and Finance 4.00 Rates - Emergency ...... 1147 12/21/09 ...... 1148 1/22/10 ...... 1150 2/19/10

830 CMR Department of Revenue 62B.00 Withholding and Estimated Taxes - Emergency ...... 1150 1/29/10 62C.00 State Tax Administration...... 1148 1/22/10 62E.00 Wage Reporting System ...... 1147 1/8/10 63.00 Taxation of Corporations - Emergency ...... 1147 12/22/09

940 CMR Office of the Attorney General 6.00 Retail Advertising - Correction (MA Reg. # 1146)...... 1148 1/22/10 26.00 Discount Health Plans and Discount Health Plan Programs ...... 1148 1/22/10 27.00 Safeguard of Personal Information ...... 1148 1/22/10

956 CMR Commonwealth Health Insurance Connector Authority 5.00 Minimum Credible Coverage - Correction (MA Reg. # 1146) ...... 1150 12/25/09

961 CMR State Lottery Commission 2.00 Rules and Regulations - Emergency ...... 1150 1/29/10

974 CMR Devens Enterprise Commission 3.00 Site Plan...... 1149 2/5/10 5.00 Residential ...... 1149 2/5/10

27 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Effective Issue Date

980 CMR Energy Facilities Siting Council 1.00 Rules for the Conduct of Adjudicatory Proceedings ...... 1150 2/19/10 2.00 General Information and Conduct of Board Business ...... 1150 2/19/10

28 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Docket # 630

THE COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth

Regulation Filing To be completed by filing agency

CHAPTER NUMBER: 211 CMR 43.00

CHAPTER TITLE: Health Maintenance Organizations (HMOs)

AGENCY: Division of Insurance

SUMMARY OF REGULATION: State the general requirements and purposes of this regulation. The purpose of 211 CMR 43.00 is primarily to implement MGL c. 176G which governs health care maintenance organizations (HMO’s). HMO’s provide or arrange for the provision of health services to enrolled members in exchange for a fee.

REGULATORY AUTHORITY: M. G. L. c. 175J, § 9; M. G. L. c. 176D, § 11; M. G. L. c. 176G, § 17; M. G. L. c. 176O, § 17. AGENCY CONTACT: Joseph G. Murphy, Commissioner of Insurance PHONE: (617) 521-7302

ADDRESS: Division of Insurance, One South Station, Boston, MA 02110-2208

Compliance with M.G.L. c. 30A

EMERGENCY ADOPTION - if this regulation is adopted as an emergency, state the nature of the emergency. Governor Patrick recognized small group insurance premiums have increased so dramatically that many small employers are in crisis. These amendments require HMOs that file proposed small group rates or changes to previously filed rates to file before their effective date to be reviewed by the Division and disapproved if the filing does not meet the requirements of M.G.L. c. 176G, § 16. PRIOR NOTIFICATION AND/OR APPROVAL - If prior notification to and/or approval of the Governor, Legislature or others was required, list each notification, and/or approval and date, including notice to the Local Government Advisory Commission. Notice to Local Government Advisory Commission will be mailed on February 10, 2010, when emergency regulation is filed with Regulations Division.

PUBLIC REVIEW - M.G.L. c. 30A sections 2 and/or 3 requires notice of the hearing or comment period be filed with the Secretary of the Commonwealth, published in appropriate newspapers, and sent to persons to whom specific notice must be given at least 21 days prior to such hearing or comment period.

Date of public hearing or comment period: N/A

For the first five years: Unknown at this time.

No fiscal effect: Unknown at this time.

SMALL BUSINESS IMPACT - State the impact of this regulation on small business. Include a description of reporting, record keeping and other compliance requirements as well as the appropriateness of performance versus design standards and whether this regulation duplicates or conflicts with any other regulation. If the purpose of this regulation is to set rates for the state, this section does not apply.

This emergency amendment to 211 CMR 43.00 will provide the Division of Insurance with the tools to examine and disapprove rates charged to small businesses if the rates are found to be excessive, inadequate or unreasonable in relation to the benefits provided.

CODE OF MASSACHUSETTS REGULATIONS INDEX - List key subjects that are relevant to this regulation: health maintenance organizations, HMO’s, health insurance, premium rates

PROMULGATION - State the action taken by this regulation and its effect on existing provisions of the Code of Massachusetts Regulations (CMR) or repeal, replace or amend. List by CMR number: Amend 211 CMR 43.08 on an emergency basis.

ATTESTATION - The regulation described herein and attached hereto is a true copy of the regulation adopted by this agency. ATTEST:

SIGNATURE: SIGNATURE ON FILE DATE: Feb 10 2010

Publication - To be completed by the Regulations Division

MASSACHUSETTS REGISTER NUMBER: 1151 DATE: 03/05/2010

EFFECTIVE DATE: 02/10/2010

CODE OF MASSACHUSETTS REGULATIONS Remove these pages: Insert these pages: This is an emergency There are no replacement regulation. pages.

02/10/2010 mrs

43.07: Net Worth Requirements

(1) Initial Net Worth. The Commissioner shall require upon issuance of an initial license under this chapter that a HMO shall have an initial adjusted net worth of $1,500,000.

(2) Ongoing Net Worth. Except as provided by 211 CMR 43.07(3) or 211 CMR 43.07(4), the adjusted net worth of a HMO shall be maintained subsequent to initial licensure in an amount equal to the greater of the following amounts: (a) $1,000,000; (b) 2% of annual premium revenues as reported on the most recent annual financial statement filed with the Commissioner on the first $150,000,000 of premium and 1% of annual premium on the premium in excess of $150,000,000; (c) An amount equal to the sum of three months uncovered expenditures as reported on the most recent financial statement filed with the Commissioner; (d) An amount equal to the sum of: 1. 8% of annual health care expenditures except those paid on a capitated basis or managed hospital payment basis as reported on the most recent financial statement filed with the Commissioner; and 2. 4% of annual hospital expenditures paid on a managed hospital payment basis as reported on the most recent financial statement filed with the Commissioner.

(3) Adjusted Net Worth. A health maintenance organization licensed before January 1, 2004 must maintain a minimum adjusted net worth of: (a) 10% of the amount required by 211 CMR 43.07(1) by December 31, 2004; (b) 25% of the amount required by 211 CMR 43.07(1) by December 31, 2005; (c) 40% of the amount required by 211 CMR 43.07(1) by December 31, 2006; (d) 55% of the amount required by 211 CMR 43.07(1) by December 31, 2007; (e) 70% of the amount required by 211 CMR 43.07(1) by December 31, 2008; (f) 85% of the amount required by 211 CMR 43.07(1) by December 31, 2009; and (g) 100% of the amount required by 211 CMR 43.07(1) by December 31, 2010.

(4) In determining adjusted net worth, no debt shall be considered fully subordinated unless the subordination clause is in a form acceptable to the Commissioner, which shall at a minimum meet the following requirements: (a) The effective date, amount, interest and parties involved in such debt are clearly set forth; (b) The principal sum and any interest accrued thereon are subject to and subordinate to all other liabilities of the HMO, and upon dissolution or liquidation, no payment of any kind shall be made until all other liabilities of the HMO have been paid; (c) The instrument states that the parties agree that the HMO must obtain written approval from the Commissioner prior to any payment of interest or repayment of principal; and (d) The debt is deemed fully subordinated by the Commissioner in his discretion.

(5) Any debt incurred by a note meeting the requirements of 211 CMR 43.07(4) shall not be considered a liability and shall be recorded as equity.

43.08: Premium Rates

Each HMO shall file all proposed rates, or changes to previously filed rates not disapproved, on or before their effective dates, except in the case of small group health coverage rate increases or changes to small group rating factors, as defined in M.G.L. c. 176J, with effective dates on or after April 1, 2010, which shall be filed at least 30 days before their effective dates. Filings are subject to the Commissioner's disapproval if the benefits and rates do not meet the requirements of M.G.L. c. 176G, § 16. A submission shall not be deemed filed until it is complete. A filing is not complete unless it contains an actuarial memorandum and all of the following documentation:

(1) Three years of historic claims payment experience, shown separately for each year and differentiating among: (a) Inpatient hospital care;

3/5/10 (Effective 2/10/10) 241 EMERGENCY The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 211 CMR: DIVISION OF INSURANCE

43.08: continued

(b) Outpatient hospital care, with separate experience for: 1. Radiological/laboratory/pathology costs; and 2. All other outpatient costs; (c) Health care provider charges for: 1. Medical and osteopathic physicians; 2. Mental health providers; and 3. All other health care practitioners. (d) Supplies; and (e) Outpatient prescription drugs.

(2) Three years of historic utilization experience, shown separately for each year and differentiating among: (a) Inpatient hospital care; (b) Outpatient hospital care, with separate experience for: 1. Radiological/laboratory/pathology costs; and 2. All other outpatient costs; (c) Health care provider charges for: 1. Medical and osteopathic physicians; 2. Mental health providers; and 3. All other health care practitioners. (d) Supplies; and (e) Outpatient prescription drugs.

(3) Trend factors differentiating among: (a) Inpatient hospital care; (b) Outpatient hospital care, with separate experience for: 1. Radiological/laboratory/pathology costs; and 2. All other outpatient costs; (c) Health care provider charges for: 1. Medical and osteopathic physicians; 2. Mental health providers; and 3. All other health care practitioners. (d) Supplies; and (e) Outpatient prescription drugs.

(4) The actuarial basis for all trend factors, including all relevant studies used to derive the factors;

(5) All non-fee-for-service payments to providers, differentiating among: (a) Inpatient hospital care; (b) Outpatient hospital care, with separate experience for: 1. Radiological/laboratory/pathology costs; and 2. All other outpatient costs; (c) Health care provider charges for: 1. Medical and osteopathic physicians; 2. Mental health providers; and 3. All other health care practitioners. (d) Supplies; and (e) Outpatient prescription drugs.

(6) Administrative expense load factors, including an explanation of all changes to any administrative expense loads that were used in the prior period's rates and where changes in administrative expenses may be caused by regulatory requirements or efforts to contain health care delivery costs;

(7) Contribution-to-surplus load factors, including an explanation of all changes to the contribution-to-surplus load factor that are caused by regulatory requirements or other external events;

3/5/10 (Effective 2/10/10) 242 EMERGENCY The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 211 CMR: DIVISION OF INSURANCE

43.08: continued

(8) The anticipated loss ratios for the one year period during which rates will be in effect;

(9) A detailed description of all cost containment programs of the HMO to address health care delivery costs and the realized past savings and projected savings from all such programs; and

(10) If the HMO intends to pay similarly situated providers different rates of reimbursement, a detailed description of the bases for the different rates including, but not limited to: (a) Quality of care delivered; (b) Mix of patients; (c) Geographic location at which care is provided; and (d) Intensity of services provided. A filing of a change to any small group health plan rating factor is not complete unless it contains all of the following documentation: 1. A description of the exact rating factor that has changed and the reasons for such change; 2. A signed actuarial opinion as set forth in 211 CMR 66.90: Appendix A that the carrier's rating methodologies and rates comply with the requirements of M.G.L. c. 176J and 211 CMR 66.00; 3. A detailed description of the method used to derive the changed factors, including a description of the data sources and assumptions used; and 4. If the company is modifying its benefit level rate adjustment, the filing must include an actuarial demonstration that the ratio of the actuarial value of the benefit level, including the health care delivery network, of one health benefit plan as compared to the actuarial value of the benefit level of another health benefit plan, measured on the basis of a census that is representative of Massachusetts eligible individuals and eligible small businesses for that carrier; and If the Commissioner disapproves a filing, he shall notify the HMO in writing no later than the effective date of the rates or changes, and he shall state the reason(s) for the disapproval. The HMO may request a hearing on the disapproval to be held within 30 days of the notice by filing a written request with the Division of Insurance for a hearing within 15 days of its receipt of such notice. The Commissioner shall issue a written decision within 30 days after the conclusion of the hearing. The HMO may not implement the disapproved rates, or changes at any time unless the Commissioner reverses the disapproval after a hearing or unless a court vacates the Commissioner's decision.

43.09: Evidence of Coverage

The evidence of coverage for each product offered by the HMO must be submitted to the Commissioner, and is subject to the disapproval of the Commissioner if it does not meet the requirements of M.G.L. c. 176G, M.G.L. c. 176O, 211 CMR 43.00 and 211 CMR 52.13.

43.10: Agents

(1) All agents of licensed HMOs must be duly licensed to sell accident and health insurance products pursuant to M.G.L. c. 175, § 162I.

(2) Nothing in 211 CMR 43.08(1) shall require an HMO to appoint agents.

43.11: Books and Records

Every HMO shall keep and maintain its books of account and other records on a current basis and within Massachusetts. In addition, every HMO shall make, or cause to be made, and retain books and records which accurately reflect:

(1) The names and last known addresses of all current subscribers to the HMO;

(2) All contracts required to be submitted to the Commissioner and all other contracts entered into by the HMO;

3/5/10 (Effective 2/10/10) 243 EMERGENCY The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 211 CMR: DIVISION OF INSURANCE

43.11: continued

(3) All requests made to the HMO for payment of monies for health care services, the date of such requests, and the dispositions thereof;

(4) The names and last known addresses of persons who solicit or obtain members for an HMO, including but not limited to employees, insurance producers and agents;

(5) The amount of any commissions paid to persons who obtained members for the HMO and the manner in which said commissions are determined; and

(6) the total number and disposition of malpractice claims and other claims relating to the service or care rendered by the HMO made by, or on behalf of, members of the HMO that were settled or resulted in a judgment during the year by the HMO. Every HMO shall preserve for a period of not less than five years, the last two years of which shall be in an easily accessible place at the main offices of the HMO, the books of account and other records required under the provisions of, and for the purposes of 211 CMR 43.00. After such books and records have been preserved for two years, they may be stored subject to their availability to the Commissioner not more than five days after he or she may request them

43.12: Penalties

(1) If the Commissioner issues a finding of neglect on the part of an HMO, the Commissioner shall notify the HMO in writing that the HMO has failed to make and file the materials required by M.G.L. c. 176G, M.G.L. c. 176O, 211 CMR 43.00 or 211 CMR 52.00 in the form and within the time required. The notice shall identify all deficiencies and the manner in which the neglect must be remedied. Following the written notice, the Commissioner shall fine the HMO $5000 for each day during which the neglect continues.

(2) Following notice and hearing, the Commissioner shall suspend the HMO’s authority to do new business until all required reports or materials are received in a form satisfactory to the Commissioner and the Commissioner has determined that the finding of neglect can be removed.

43.13: Health Maintenance Organization Holding Company System Requirements

(1) All HMOs shall meet the requirements of M.G.L. c. 176G, §§ 27 through 29.

(2) HMOs shall comply with the provisions of 211 CMR 7.00 where consistent with M.G.L. c. 176G. References to terms such as “foreign insurer,” “insurer,” “policyholders,” “shareholders,” and “M.G.L. c. 175, §§ 206 through 206D” in 211 CMR 7.00 et seq. shall correspond to terms “foreign HMO,” “HMO,” “members” and “enrolled members,” and “M.G.L. c. 176G, §§ 25 through 29,” respectively.

43.14: Severability

If any provision of 211 CMR 43.00 or application thereof to any regulatee is held invalid, such invalidity shall not affect other provisions of 211 CMR 43.00 and, to that end, the provisions of 211 CMR 43.00 are severable.

REGULATORY AUTHORITY

211 CMR 43.00: M.G.L. c. 175J, § 9; c. 176D, § 11; c. 176G, § 17 and c. 176O, § 17.

3/5/10 (Effective 2/10/10) 244 EMERGENCY The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Docket # 563

THE COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth

Regulation Filing To be completed by filing agency

CHAPTER NUMBER: 527 CMR 10.00

CHAPTER TITLE: FIRE PREVENTION, GENERAL PROVISIONS

AGENCY: Board of Fire Prevention Regulations

SUMMARY OF REGULATION: State the general requirements and purposes of this regulation. 527 CMR 10.00 contains general provisions of the state fire safety code. The particular amendment to 527 CMR 10.13 adds a new subsection (8), which contains special fire safety provisions for certain places of worship which have been issued a valid Certificate of Occupancy for use as a temporary overnight shelter from the cold pursuant to 780 CMR, The State Building Code.

REGULATORY AUTHORITY: M.G.L. c. 22D, s. 4; c. 148 s. 9, 10, 28

AGENCY CONTACT: Peter A. Senopoulos, Esq. PHONE: 978-567-3181

ADDRESS: Board of Fire Prevention Regulations, P.O. Box 1025, State Road, Stow, MA

Compliance with M.G.L. c. 30A

EMERGENCY ADOPTION - if this regulation is adopted as an emergency, state the nature of the emergency. The regulation contains special fire safety provisions to allow certain places of worship to be operated as temporary overnight shelters from the cold. The regulation is filed on an emergency basis, since the regulation relates to matters immediately impacting the health and safety of individuals as we are in the cold weather season. PRIOR NOTIFICATION AND/OR APPROVAL - If prior notification to and/or approval of the Governor, Legislature or others was required, list each notification, and/or approval and date, including notice to the Local Government Advisory Commission. Building Code Coordinating Council - November 19, 2009 E.O. 485 Approval - December 9, 2009 E.O. 145 Notice sent - December 22, 2009

Date of public hearing or comment period: Public hearing - February 4, 2010

For the first five years: see above

No fiscal effect:

No small business impact anticipated.

CODE OF MASSACHUSETTS REGULATIONS INDEX - List key subjects that are relevant to this regulation: Emergency shelters Temporary overnight shelters from the cold

ATTESTATION - The regulation described herein and attached hereto is a true copy of the regulation adopted by this agency. ATTEST:

SIGNATURE: SIGNATURE ON FILE DATE: Feb 18 2010

Publication - To be completed by the Regulations Division

MASSACHUSETTS REGISTER NUMBER: 1151 DATE: 03/05/2010

EFFECTIVE DATE: 02/19/2010

CODE OF MASSACHUSETTS REGULATIONS Remove these pages: Insert these pages: This emergency is being Please see 527 CMR 10.00 complied with in Register Notice of Compliance in #1151. Register #1151 for replacement pages. 02/19/2010 mrs

THE COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth SL 1357 Regulation Filing To be completed by filing agency

CHAPTER NUMBER: 106 CMR 204.000

CHAPTER TITLE: Transitional Aid to Families with Dependent Children: Financial Eligibility

AGENCY: Department of Transitional Assistance

SUMMARY OF REGULATION: State the general requirements and purposes of this regulation. This State Letter transmits a change in the TAFDC Eligibility, Need and Payment Standards regulations for the month of February 2010 and thereafter. Beginning in 2010, the Department will be able to provide a nonrecurring clothing allowance or other one-time nonrecurring payment to eligible TAFDC recipients, in the event such an allowance or payment is authorized in the budget, without an annual change in these regulations. This material is effective March 5, 2010.

REGULATORY AUTHORITY: M.G.L.c. 18S.10

AGENCY CONTACT: Thomas Santry, Director, Cash and Full PHONE: 617 348 5286 Engagement Program ADDRESS: 600 Washington Street Boston, MA 02111

Compliance with M.G.L. c. 30A

EMERGENCY ADOPTION - if this regulation is adopted as an emergency, state the nature of the emergency.

Date of public hearing or comment period: 9/4/2009 - 9/25/2009

For the first five years:

No fiscal effect:

CODE OF MASSACHUSETTS REGULATIONS INDEX - List key subjects that are relevant to this regulation:

ATTESTATION - The regulation described herein and attached hereto is a true copy of the regulation adopted by this agency. ATTEST:

SIGNATURE: SIGNATURE ON FILE DATE: Feb 17 2010

Publication - To be completed by the Regulations Division

MASSACHUSETTS REGISTER NUMBER: 1151 DATE: 03/05/2010

EFFECTIVE DATE: 03/05/2010

CODE OF MASSACHUSETTS REGULATIONS Remove these pages: Insert these pages: 221 - 224 221 - 224

02/19/2010 mrs

204.330: continued

(1) Persons who are not required to be in the filing unit and are not applying for or receiving TAFDC for themselves shall have their income deemed available to the filing unit in accordance with 106 CMR 204.235. (2) Persons who are required to be in the filing unit but are excluded from the assistance unit because they failed to cooperate and/or have been sanctioned in accordance with 106 CMR 203.400, 203.610, 203.700, 203.770, 203.800, 204.550, 207.200 or 706.305 shall have their income made available to the filing unit in accordance with 106 CMR 204.310.

204.400: Table of Eligibility Standards - Exempt Assistance Units

The figures in the Eligibility Standards columns are used in the 185% test of financial eligibility (See 106 CMR 204.260(A)) for exempt assistance units. If in any month the total gross income of the filing unit, excluding only the types of noncountable income listed in 106 CMR 204.250, is above the appropriate Eligibility Standard for the exempt assistance unit, the assistance unit is ineligible. Column A is used for assistance units that are not eligible for the Rent Allowance, and Column B is used for assistance units that are eligible for the Rent Allowance (See 106 CMR 705.910).

A. Eligibility Standards B. Eligibility Standards Assistance Unit Size No Rent Allowance With Rent Allowance 1 $717.80 $791.80 2 908.35 982.35 3 1,097.05 1,171.05 4 1,278.35 1,352.35 5 1,465.20 1,539.20 6 1,657.60 1,731.60 7 1,844.45 1,918.45 8 2,029.45 2,103.45 9 2,214.45 2,288.45 10 2,401.30 2,475.30 Incremental 194.25 194.25

In the event a clothing allowance or other one-time nonrecurring payment is authorized in the General Appropriations Act which temporarily increases the Eligibility Standards, the revised Eligibility Standards will be specified at Mass.gov/dta at Program Eligibility Charts and Tables during the effected time period. Paper copies are available upon request.

204.405: Table of Eligibility Standards - Nonexempt Assistance Units

The figures in the Eligibility Standards columns are used in the 185% test of financial eligibility (See 106 CMR 204.260(A)) for nonexempt assistance units. If in any month the total gross income of the filing unit, excluding only the types of noncountable income listed in 106 CMR 204.250, is above the appropriate Eligibility Standard for the nonexempt assistance unit, the assistance unit is ineligible. Column A is used for assistance units that are not eligible for the Rent Allowance, and Column B is used for assistance units that are eligible for the Rent Allowance (See 106 CMR 705.910).

A. Eligibility Standards B. Eligibility Standards Assistance Unit Size No Rent Allowance With Rent Allowance 1 $699.30 $ 773.30 2 884.30 958.30 3 1,069.30 1,143.30 4 1,245.05 1,319.05 5 1,428.20 1,502.20 6 1,613.20 1,687.20 7 1,796.35 1,870.35 8 1,973.95 2,047.95 9 2,155.25 2,229.25 10 2,336.55 2,410.55 Incremental 190.55 190.55

3/5/10 106 CMR - 221 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 106 CMR: DEPARTMENT OF TRANSITIONAL ASSISTANCE

204.405: continued

204.410: Table of Need Standards - Exempt Assistance Units

The figures in the Need Standards columns are used in the test of financial eligibility. Column A is used for exempt assistance units that are not eligible for the Rent Allowance, and Column B is used for exempt assistance units that are eligible for the Rent Allowance (See 106 CMR 705.910). If the countable monthly income of the filing unit is at or below the appropriate Need Standard for the exempt assistance unit, the assistance unit is financially eligible. The monthly grant is the difference between the appropriate Need Standard and countable income after appropriate disregards have been applied so long as the difference does not exceed the appropriate Payment Standard (See 106 CMR 204.425). If the difference between the appropriate Need Standard and countable income exceeds the appropriate Payment Standard, the monthly grant shall equal the Payment Standard.

A. Need Standards B. Need Standards Assistance Unit Size No Rent Allowance With Rent Allowance 1 $388.00 $428.00 2 491.00 531.00 3 593.00 633.00 4 691.00 731.00 5 792.00 832.00 6 896.00 936.00 7 997.00 1,037.00 8 1,097.00 1,137.00 9 1,197.00 1,237.00 10 1,298.00 1,338.00 Incremental 105.00 105.00

In the event a clothing allowance or other one-time nonrecurring payment is authorized in the General Appropriations Act which temporarily increases the Need Standards, the revised Need Standards will be specified at Mass.gov/dta at Program Eligibility Charts and Tables during the effected time period. Paper copies are available upon request.

204.415: Table of Need Standards - Nonexempt Assistance Units

The figures in the Need Standards columns are used in the test of financial eligibility. Column A is used for nonexempt assistance units that are not eligible for the Rent Allowance, and Column B is used for nonexempt assistance units that are eligible for the Rent Allowance (See 106 CMR 705.910). If the countable monthly income of the filing unit is at or below the appropriate Need Standard for the nonexempt assistance unit, the assistance unit is financially eligible. The monthly grant is the difference between the appropriate Need Standard and countable income after appropriate disregards have been applied so long as the difference does not exceed the appropriate Payment Standard (See 106 CMR 204.425). If the difference between the appropriate Need Standard and countable income exceeds the appropriate Payment Standard, the monthly grant shall equal the Payment Standard.

A. Need Standards B. Need Standards Assistance Unit Size No Rent Allowance With Rent Allowance 1 $ 378.00 $418.00 2 478.00 518.00 3 578.00 618.00 4 673.00 713.00 5 772.00 812.00 6 872.00 912.00 7 971.00 1,011.00 8 1,067.00 1,107.00 9 1,165.00 1,205.00 10 1,263.00 1,303.00 Incremental 103.00 103.00

3/5/10 106 CMR - 222 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 106 CMR: DEPARTMENT OF TRANSITIONAL ASSISTANCE

204.415: continued

204.420: Table of Payment Standards - Exempt Assistance Units

The figures in the Payment Standards columns are the maximum amounts that an exempt assistance unit may receive as a monthly grant. Column A is used for exempt assistance units that are not eligible for the Rent Allowance, and Column B is used for exempt assistance units that are eligible for the Rent Allowance. (See 106 CMR 705.910.)

A. Payment Standards B. Payment Standards Assistance Unit Size No Rent Allowance With Rent Allowance 1 $ 388.00 $428.00 2 491.00 531.00 3 593.00 633.00 4 691.00 731.00 5 792.00 832.00 6 896.00 936.00 7 997.00 1,037.00 8 1,097.00 1,137.00 9 1,197.00 1,237.00 10 1,298.00 1,338.00 Incremental 105.00 105.00

In the event a clothing allowance or other one-time nonrecurring payment is authorized in the General Appropriations Act which temporarily increases the Payment Standards, the revised Payment Standards will be specified at Mass.gov/dta at Program Eligibility Charts and Tables during the effected time period. Paper copies are available upon request.

204.425: Table of Payment Standards - Nonexempt Assistance Units

The figures in the Payment Standards columns are the maximum amounts that an nonexempt assistance unit may receive as a monthly grant. Column A is used for nonexempt assistance units that are not eligible for the Rent Allowance, and Column B is used for nonexempt assistance units that are eligible for the Rent Allowance. (See 106 CMR 705.910.)

A. Payment Standards B. Payment Standards Assistance Unit Size No Rent Allowance With Rent Allowance 1 $378.00 $ 418.00 2 478.00 518.00 3 578.00 618.00 4 673.00 713.00 5 772.00 812.00 6 872.00 912.00 7 971.00 1,011.00 8 1,067.00 1,107.00 9 1,165.00 1,205.00 10 1,263.00 1,303.00 Incremental 103.00 103.00

3/5/10 106 CMR - 223 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 106 CMR: DEPARTMENT OF TRANSITIONAL ASSISTANCE

204.500: Calculation of the Grant Amount

The grant amount is calculated as follows:

Step 1: Identify the earned income of each member of the filing unit, excluding any earned income specified in 106 CMR 204.250: Noncountable Income and: (1) the income from the Full Employment Program as specified in 106 CMR 207.180; (2) the earned income of a dependent child(ren) who is a full-time student or a part-time student who is a part-time employee or (3) the earned income of a dependent child(ren) who is not a student or is a part-time student and a full-time employee and is a participant in a Job Training Partnership Act (JTPA) program during the same six months in a calendar year used in the 185% Test of Financial Eligibility (See 106 CMR 204.260(A)).

Step 2: Subtract sequentially from the remaining gross earnings of each member of the assistance unit an amount of income equal to: (a) the work-related expense deduction (See 106 CMR 204.270: Work-Related Expense Deduction); and (b) if appropriate, from the remaining income of each member of the exempt assistance unit, $30 and one-third of the remainder (See 106 CMR 204.280: Eligibility for the $30 and One-Third Disregard) or from the remaining income of each member of the nonexempt assistance unit, $30 and one-half of the remainder (See 106 CMR 204.285: Eligibility for the $30 and One-Half Disregard)

Step 3: Subtract the appropriate dependent-care deduction (See 106 CMR 204.275: Dependent Care Deduction).

Step 4: Total the countable earned income of all members of the filing unit.

Step 5: Total all unearned and other income not excluded under 106 CMR 204.250: Noncountable Income. This total includes deemed income in accordance with 106 CMR 204.235 plus the gross income for those members of the filing unit that are excluded from the assistance unit.

Step 6: Add the results of Step 4 and Step 5.

Step 7: Subtract the result of Step 6 from the applicable Need Standard (See 106 CMR 204.410 and 204.415) for the number of persons in the assistance unit. Round this amount down to the next lower whole dollar. The result, if $10 or greater, but less than the applicable Payment Standard (See 106 CMR 204.420 and 204.425), is the amount to be paid monthly. If the result is less than or equal to the applicable Need Standard but greater than the applicable Payment Standard, the amount to be paid monthly shall equal the applicable Payment Standard. If the result is zero or greater but less than $10, the assistance unit is considered to be receiving assistance but will not receive a monthly grant. If the result is less than zero, the assistance unit is financially ineligible.

Step 8: Multiply the grant amount by a percentage determined by the Department.

204.510: Guide for Income-in-Kind

The following table provides the amounts for specific items in the Payment Standard. These amounts are to be used to determine:

(A) The amount to be authorized as vendor payments to meet the immediate needs of applicants in accordance with 106 CMR 702.125(F): Immediate Needs; and

(B) The value of shelter (rent, mortgage, fuel, utilities) and/or food provided at no cost to an applicant or recipient. This also applies to a family in a temporary emergency shelter.

8/16/02 (effective 4/26/02) 106 CMR - 224 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Docket # 5,851

THE COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth

Regulation Filing To be completed by filing agency

CHAPTER NUMBER: 114.3 CMR 47.00

CHAPTER TITLE: Freestanding Ambulatory Surgical Facilities

AGENCY: Division of 114.3 CMR Health Care Finance and Policy

SUMMARY OF REGULATION: State the general requirements and purposes of this regulation. This regulation governs the rates of payment to freestanding ambulatory surgical facilities for surgical services rendered to publicly-aided individuals. The amendments are effective January 1, 2010.

REGULATORY AUTHORITY: M.G.L. c. 118G

AGENCY CONTACT: Nancy Panaro, General Counsel PHONE: 617-988-3128

ADDRESS: 2 Boylston Street, Boston, MA 02116

Compliance with M.G.L. c. 30A

EMERGENCY ADOPTION - if this regulation is adopted as an emergency, state the nature of the emergency.

PRIOR NOTIFICATION AND/OR APPROVAL - If prior notification to and/or approval of the Governor, Legislature or others was required, list each notification, and/or approval and date, including notice to the Local Government Advisory Commission. John Robertson (12/4/09) Marilyn Contreas (12/4/09) MA Municipal Assoc. Dept. of Housing & Com. Dev. 1 Winthrop Sq, Boston MA 02110 100 Cambridge St, Boston MA 02114

Date of public hearing or comment period: 1/28/10

For the first five years: N/A

No fiscal effect: No fiscal impact on MassHealth and other governmental purchasers is expected as a result of these amendments. SMALL BUSINESS IMPACT - State the impact of this regulation on small business. Include a description of reporting, record keeping and other compliance requirements as well as the appropriateness of performance versus design standards and whether this regulation duplicates or conflicts with any other regulation. If the purpose of this regulation is to set rates for the state, this section does not apply.

N/A

CODE OF MASSACHUSETTS REGULATIONS INDEX - List key subjects that are relevant to this regulation: Freestanding Ambulatory Surgical Facilities

ATTESTATION - The regulation described herein and attached hereto is a true copy of the regulation adopted by this agency. ATTEST:

SIGNATURE: SIGNATURE ON FILE DATE: Feb 19 2010

Publication - To be completed by the Regulations Division

MASSACHUSETTS REGISTER NUMBER: 1151 DATE: 03/05/2010

EFFECTIVE DATE: 01/01/2010

CODE OF MASSACHUSETTS REGULATIONS Remove these pages: Insert these pages: 17, 18 17, 18 1475 - 1548 1475 - 1552.18

02/19/2010 mrs

Table of Contents Page

114.3 CMR 47.00: FREESTANDING AMBULATORY SURGICAL FACILITIES 1475

Section 47.01: General Provisions 1475 Section 47.02: Definitions 1476 Section 47.03: General Rate Provisions and Payment 1477 Section 47.04: Reporting Requirements 1552.18 Section 47.05: Severability 1552.18

114.3 CMR 48.00: DAY HABILITATION PROGRAM SERVICES 1553

Section 48.01: General Provisions 1553 Section 48.02: General Definitions 1553 Section 48.03: General Rate Provisions 1554 Section 48.04: Filing and Reporting Requirements 1554.2 Section 48.05: Severability 1555

114.3 CMR 49.00: RATES FOR EARLY INTERVENTION PROGRAM SERVICES 1556.1

Section 49.01: General Provisions 1556.1 Section 49.02: Definitions 1556.1 Section 49.03: Filing and Reporting Requirements 1556.3 Section 49.04: Rate Provisions 1556.3 Section 49.05: Administrative Information Bulletins 1556.4 Section 49.06: Severability 1556.4

114.3 CMR 50.00: HOME HEALTH SERVICES 1556.5

Section 50.01: General Provisions 1556.5 Section 50.02: General Definitions 1556.5 Section 50.03: General Rate Provisions 1556.9 Section 50.04: Rates of Payment 1556.9 Section 50.05: Provisions for New Agencies 1556.10 Section 50.06: Administrative Adjustment 1556.11 Section 50.07: Filing and Reporting Requirements 1556.11 Section 50.08: Severability 1556.12

114.3 CMR 51.00: ADULT FOSTER CARE 1556.15

Section 51.01: General Provisions 1556.15 Section 51.02: General Definitions 1556.15 Section 51.03: Rate Provisions 1556.16 Section 51.04: Filing Requirements 1556.16 Section 51.05: Other Provisions 1556.16

114.3 CMR 52.00: RATES OF PAYMENT FOR CERTAIN CHILDREN’S BEHAVIORAL HEALTH SERVICES 1556.19

Section 52.01: General Provisions 1556.19 Section 52.02: General Definitions 1556.19 Section 52.03: Rate Provisions 1556.21 Section 52.04: Reporting Requirements and Sanctions 1556.22 Section 52.05: Severability of the Provisions of 114.3 CMR 52.00 1556.23

114.3 CMR 53.00: PAYMENT FOR PRIMARY CARE CLINICIAN PLAN SERVICES INCLUDING PAY FOR PERFORMANCE PROGRAM 1556.25

Section 53.01: General Provisions 1556.25 Section 53.02: General Definitions 1556.25 Section 53.03: General Payment Provisions 1556.26 Section 53.04: Severability 1556.28

3/5/10 114 CMR - 17 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY

Table of Contents Page

114.4 CMR: BUREAU OF EDUCATIONAL AND SOCIAL SERVICES

(114.4 CMR 1.00 THROUGH 9.00: RESERVED) 1557

114.4 CMR 10.00: RATES FOR COMPETITIVE INTEGRATED EMPLOYMENT SERVICES 1558.1

Section 10.01: General Provisions 1558.1 Section 10.02: Definitions 1558.1 Section 10.03: Rate Provisions 1558.2 Section 10.04: Filing and Reporting Requirements 1558.4 Section 10.05: Severability of the Provisions of 114.4 CMR 10.00 1558.5

114.4 CMR 11.00: RATES FOR CERTAIN PLACEMENT AND SUPPORT SERVICES 1558.7

Section 11.01: General Provisions 1558.7 Section 11.02: Definitions 1558.7 Section 11.03: Rate Provisions 1558.8 Section 11.04: Filing and Reporting Requirements 1558.8 Section 11.05: Severability 1558.9

114.5 CMR: BUREAU OF ADMINISTRATIVE SERVICES

(114.5 CMR 1.00: RESERVED) 1559

114.5 CMR 2.00: DISCLOSURE OF HOSPITAL CASE MIX AND CHARGE DATA 1561

Section 2.01: General Provisions 1561 Section 2.02: Definitions 1561 Section 2.03: Procedures for Data Requests 1562 Section 2.04: Data Disclosure Restrictions 1564 Section 2:05: Other Provisions 1564 Section 2.06: Sanctions 1564.1 Section 2.07: Severability 1564.1

(114.5 CMR 3.00: RESERVED) 1565

114.5 CMR 4.00: RATES FOR CERTAIN SOCIAL, REHABILITATION AND HEALTH CARE SERVICES 1567

Section 4.01: General Provisions 1567 Section 4.02: General Definitions 1567 Section 4.03: Filing and Reporting Requirements 1571 Section 4.04: Rate Determination, Cost Principles 1571 Section 4.05: Rate Determination 1574 Section 4.06: Rate Determination System #2 (Special) 1575 Section 4.07: Administrative Review 1576 Section 4.08: Rate Filings 1576 Section 4.09: Administrative Information Bulletins 1576 Section 4.10: Severability 1576 Section 4.11: Reporting Forms, Schedules, and Instructions 1576

(114.5 CMR 5.00 THROUGH 7.00: RESERVED) 1581

1/22/10 114 CMR - 18 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

114.3 CMR 47.00: FREESTANDING AMBULATORY SURGICAL FACILITIES

Section

47.01: General Provisions 47.02: Definitions 47.03: General Rate Provisions and Payment 47.04: Reporting Requirements 47.05: Severability

47.01: General Provisions

(1) Scope, Purpose and Effective Date. 114.3 CMR 47.00 governs the rates of payment to eligible freestanding ambulatory surgical facilities to be used by all Governmental Units for services provided to Publicly-aided Individuals. Rates for purchases under the Worker's Compensation Act, M.G.L. c. 152, are set forth in 114.3 CMR 40.00. 114.3 CMR 47.00 shall be effective January 1, 2010.

(2) Coverage. 114.3 CMR 47.00 and the rates of payment contained in 114.3 CMR 47.00 are full compensation for facility services furnished in connection with surgical procedures that can be performed safely on an ambulatory basis in an ambulatory surgical center under the scope of covered services and condition for payment for facility services by the governmental purchaser. Payment from any other sources shall be used to offset the amount of the purchasing Governmental Unit's obligation for services rendered to the Publicly-aided Individuals. 114.3 CMR 47.00 does not cover professional services which are billed by a physician, dentist or podiatrist separately from the health care facility and who receives no other compensation for professional services rendered. Covered ambulatory surgical facility services do not include services performed in a hospital-based facility or medical, dental or podiatric surgical procedures that are customarily performed in an office setting.

(3) Disclaimer of Authorization of Services. 114.3 CMR 47.00 is not authorization for or approval of the procedures for which rates are determined pursuant to 114.3 CMR 47.00. Governmental Units that purchase care are responsible for the definition, authorization, and approval of care and services extended to Publicly-aided Individuals.

(4) Coding Updates and Corrections. The Division may publish procedure code updates and corrections in the form of an Administrative Bulletin. Updates may reference coding systems including but not limited to the American Medical Association's Current Procedural Terminology (CPT). The publication of such updates and corrections will list: (a) codes for which only the code numbers change, with the corresponding cross references between existing and new codes; (b) codes for which the code number remains the same but the description has changed; (c) deleted codes for which there are no corresponding new codes; and (d) codes for entirely new services that require pricing. The Division will list these codes and apply individual consideration (I.C.) reimbursement for these codes until appropriate rates can be developed.

(5) Administrative Bulletins. The Division may issue administrative bulletins to clarify its policy on and understanding of substantive provisions of 114.3 CMR 47.00.

(6) Authority. 114.3 CMR 47.00 is adopted pursuant to M.G.L. c.118G.

3/5/10 (Effective 1/1/10) 114.3 CMR - 1475 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.02: Definitions

Meaning of Terms. The descriptions and five-digit codes included in 114.3 CMR 47.00 utilize the Healthcare Common Procedure Code System (HCPCS) for Level I and Level II coding. Level 1 CPT-4 codes are obtained from the Physicians' Current Procedural Terminology© 2009 by the American Medical Association, unless otherwise specified. Level II codes are obtained from 2009 HCPCS maintained jointly by the Centers for Medicare and Medicaid Services (CMS), the Blue Cross and Blue Shield Association, and the Health Insurance Association of America. HCPCS is a listing of descriptive terms and identifying codes and modifiers for reporting medical services and procedures performed by physicians and other healthcare professionals, as well as associated non-physician services. 114.3 CMR 47.00 includes only HCPCS numeric and alpha-numeric identifying codes and modifiers for reporting medical services and procedures that were selected by the Division. Any use of CPT outside the fee schedule should refer to the Physicians' Current Procedural Terminology© 2009. In addition, terms used in 114.3 CMR 47.00 shall have the meanings set forth in 114.3 CMR 47.02.

Division. The Division of Health Care Finance and Policy established under M.G.L. c.118G.

Eligible Provider. A licensed ambulatory freestanding surgical facility that meets the conditions of participation adopted by a Governmental Unit.

Facility Component. Rate of payment for a freestanding surgical facility's costs. The facility component does not include payment for physician, dentist or podiatrist's services in performing a surgical procedure.

Freestanding Ambulatory Surgical Center (FASC). A distinct entity that operates exclusively for the purpose of providing surgical services that do not require the availability of hospital facilities, is licensed by the Massachusetts Department of Public Health and meets the conditions for payment by the purchaser for facility services.

Governmental Unit. The Commonwealth of Massachusetts or any of its departments, agencies, boards, commissions or political subdivisions.

Individual Consideration (I.C.). Freestanding facility services which are authorized but not listed in 114.3 CMR 47.00, and FASC services performed in unusual circumstances and services whose fees are designated by the letters "I.C." are individually considered items. The Governmental Unit or purchaser shall analyze the Eligible Provider's operative report which shall 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 shall be 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; (d) time, degree of skill, and cost including equipment cost required to perform the procedure(s).

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.

Separate Procedure. Some of the listed procedures are commonly carried out as an integral part of a total service and as such, do not warrant a separate identification. When, however, such a procedure is performed independently of, and is not immediately related to, other services, it may be listed as a separate procedure in the procedure description. Thus, when a procedure that is ordinarily a component of a larger procedure is performed alone for a specific purpose, it may be considered to be a separate procedure.

3/5/10 (Effective 1/1/10) 114.3 CMR - 1476 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: General Rate Provisions and Payment

(1) Rate Determination. Rates of payment for authorized freestanding ambulatory surgical facility services to which 114.3 CMR 47.00 applies shall be the lower of: (a) the Eligible Provider's usual charge to the general public; or (b) the schedule of allowable rates set forth in 114.3 CMR 47.03.

(2) Maximum Allowable Rates. Rates of payment will be for the facility component only. The payment rate for each FASC procedure is listed next to the HCPCS code and its description as described in 114.3 CMR 47.03(5).

(3) Individual Consideration and Non-listed Procedures. Rates of payment to Eligible Providers for freestanding facility services which are authorized but not listed in 114.3 CMR 47.03; services performed in unusual circumstances; and services whose fees are designated by the letters "I.C." shall be determined on an Individual Consideration basis.

(4) Modifiers.

-50: Bilateral Procedure. Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by the appropriate service code describing the first procedure. The second bilateral procedure is identified by adding the modifier '-50' to the end of the service code. If a reimbursable surgical procedure provided in a single operative session is performed bilaterally, the full maximum fee is 150% of the payment group contained in 114.3 CMR 47.00 for the operative procedure.

-51: Multiple Procedures. This modifier must be used to report multiple procedures performed at the same operative session. The service code for the major procedure or service must be reported without a modifier and will receive 100% of the payment for the procedure with the highest fee. The secondary, additional or lesser procedure(s) must be identified by adding the modifier '-51' to the end of the service code for the secondary procedure(s). The addition of the modifier '-51' to the second and subsequent procedure codes allows 50% of the allowable fee contained in 114.3 CMR 47.00 to be paid to the Eligible Provider. NOTE: This modifier should not be used with designated "add-on" codes or with codes in which the narrative contains the words "each additional".

-73: Discountinued Out-patient 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 procedure number and the addition of the modifier '-73'. Note: the elective anesthesia and/or surgical preparation of the patient should not be reported.

-74: Discontinued Out-patient 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 (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number 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.

Terminated Procedures. The purchaser shall determine payment on an individual consideration (I.C.) basis for any procedure that has been terminated after the procedure has been initiated.

3/5/10 (Effective 1/1/10) 114.3 CMR - 1477 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

(5) Fee Schedules. (a) Surgical Services.

Code Fee Description

10021 52.03 Fine needle aspiration; without imaging guidance 10022 162.48 Fine needle aspiration; with imaging guidance 10040 30.08 Acne surgery (e.g., marsupialization, opening or removal of multiple milia, comedones, cysts, pustules) 10060 45.77 Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single 10061 51.32 Incision and drainage of abscess (e.g., carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); complicated or multiple 10080 51.32 Incision and drainage of pilonidal cyst; simple 10081 118.15 Incision and drainage of pilonidal cyst; complicated 10120 64.27 Incision and removal of foreign body, subcutaneous tissues; simple 10121 484.44 Incision and removal of foreign body, subcutaneous tissues; complicated 10140 68.17 Incision and drainage of hematoma, seroma or fluid collection 10160 51.32 Puncture aspiration of abscess, hematoma, bulla, or cyst 10180 547.84 Incision and drainage, complex, postoperative wound infection 11000 22.08 Debridement of extensive eczematous or infected skin; up to 10% of body surface 11001 7.47 Debridement of extensive eczematous or infected skin; each additional 10% of the body surface (List separately in addition to code for primary procedure) 11010 191.66 Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin and subcutaneous tissues 11011 191.66 Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, and muscle 11012 191.66 Debridement including removal of foreign material associated with open fracture(s) and/or dislocation(s); skin, subcutaneous tissue, muscle fascia, muscle, and bone 11040 20.12 Debridement; skin, partial thickness 11041 22.40 Debridement; skin, full thickness 11042 121.71 Debridement; skin, and subcutaneous tissue 11043 121.71 Debridement; skin, subcutaneous tissue, and muscle 11044 316.91 Debridement; skin, subcutaneous tissue, muscle, and bone 11055 23.70 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion 11056 25.97 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); two to four lesions 11057 30.08 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); more than four lesions 11100 55.11 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion 11101 12.99 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; each separate/additional lesion (List separately in addition to code for primary procedure) 11200 30.08 Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions 11201 5.19 Removal of skin tags, multiple fibrocutaneous tags, any area; each additional ten lesions (List separately in addition to code for primary procedure) 11300 30.08 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.5 cm or less 11301 30.08 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 0.6 to 1.0 cm 11302 30.08 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter 1.1 to 2.0 cm 11303 55.11 Shaving of epidermal or dermal lesion, single lesion, trunk, arms or legs; lesion diameter over 2.0 cm 11305 30.08 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less

3/5/10 (Effective 1/1/10) 114.3 CMR - 1478 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

11306 30.08 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm 11307 30.08 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm 11308 30.08 Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia; lesion diameter over 2.0 cm 11310 30.08 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less 11311 30.08 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm 11312 30.08 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm 11313 30.08 Shaving of epidermal or dermal lesion, single lesion, face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 2.0 cm 11400 62.00 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.5 cm or less 11401 69.79 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm 11402 76.61 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm 11403 81.80 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 2.1 to 3.0 cm 11404 434.86 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 3.1 to 4.0 cm 11406 484.44 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter over 4.0 cm 11420 58.10 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less 11421 70.43 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm 11422 76.93 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm 11423 85.70 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm 11424 484.44 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm 11426 592.43 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm 11440 66.55 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.5 cm or less 11441 76.93 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 0.6 to 1.0 cm 11442 84.72 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 1.1 to 2.0 cm 11443 93.81 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 2.1 to 3.0 cm 11444 296.08 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm 11446 592.43 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter over 4.0 cm

3/5/10 (Effective 1/1/10) 114.3 CMR - 1479 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

11450 592.43 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with simple or intermediate repair 11451 592.43 Excision of skin and subcutaneous tissue for hidradenitis, axillary; with complex repair 11462 592.43 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with simple or intermediate repair 11463 592.43 Excision of skin and subcutaneous tissue for hidradenitis, inguinal; with complex repair 11470 592.43 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with simple or intermediate repair 11471 592.43 Excision of skin and subcutaneous tissue for hidradenitis, perianal, perineal, or umbilical; with complex repair 11600 87.32 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.5 cm or less 11601 105.82 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 0.6 to 1.0 cm 11602 116.53 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 1.1 to 2.0 cm 11603 123.67 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 2.1 to 3.0 cm 11604 333.59 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter 3.1 to 4.0 cm 11606 484.44 Excision, malignant lesion including margins, trunk, arms, or legs; excised diameter over 4.0 cm 11620 90.24 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.5 cm or less 11621 107.12 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 0.6 to 1.0 cm 11622 119.12 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 1.1 to 2.0 cm 11623 128.21 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 2.1 to 3.0 cm 11624 484.44 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter 3.1 to 4.0 cm 11626 592.43 Excision, malignant lesion including margins, scalp, neck, hands, feet, genitalia; excised diameter over 4.0 cm 11640 95.44 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.5 cm or less 11641 112.64 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 0.6 to 1.0 cm 11642 125.62 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 1.1 to 2.0 cm 11643 135.36 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 2.1 to 3.0 cm 11644 484.44 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter 3.1 to 4.0 cm 11646 592.43 Excision, malignant lesion including margins, face, ears, eyelids, nose, lips; excised diameter over 4.0 cm 11719 11.03 Trimming of nondystrophic nails, any number 11720 13.64 Debridement of nail(s) by any method(s); one to five 11721 16.55 Debridement of nail(s) by any method(s); six or more 11730 30.08 Avulsion of nail plate, partial or complete, simple; single 11732 16.55 Avulsion of nail plate, partial or complete, simple; each additional nail plate (List separately in addition to code for primary procedure) 11740 15.19 Evacuation of subungual hematoma

3/5/10 (Effective 1/1/10) 114.3 CMR - 1480 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

11750 87.64 Excision of nail and nail matrix, partial or complete, (e.g., ingrown or deformed nail) for permanent removal; 11752 121.73 Excision of nail and nail matrix, partial or complete, (e.g., ingrown or deformed nail) for permanent removal; with amputation of tuft of distal phalanx 11755 60.70 Biopsy of nail unit (e.g., plate, bed, matrix, hyponychium, proximal and lateral nail folds) (separate procedure) 11760 125.01 Repair of nail bed 11762 111.66 Reconstruction of nail bed with graft 11765 30.08 Wedge excision of skin of nail fold (e.g., for ingrown toenail) 11770 620.52 Excision of pilonidal cyst or sinus; simple 11771 620.52 Excision of pilonidal cyst or sinus; extensive 11772 620.52 Excision of pilonidal cyst or sinus; complicated 11900 27.59 Injection, intralesional; up to and including seven lesions 11901 30.08 Injection, intralesional; more than seven lesions 11920 87.32 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less 11921 96.08 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm 11922 31.16 Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; each additional 20.0 sq cm (List separately in addition to code for primary procedure) 11950 31.82 Subcutaneous injection of filling material (e.g., collagen); 1 cc or less 11951 39.60 Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc 11952 47.67 Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc 11954 47.67 Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc 11960 578.32 Insertion of tissue expander(s) for other than breast, including subsequent expansion 11970 1,047.54 Replacement of tissue expander with permanent prosthesis 11971 542.85 Removal of tissue expander(s) without insertion of prosthesis 11976 58.10 Removal, implantable contraceptive capsules 11980 23.47 Subcutaneous hormone pellet implantation (implantation of estradiol and/or testosterone pellets beneath the skin) 11981 23.47 Insertion, non-biodegradable drug delivery implant 11982 23.47 Removal, non-biodegradable drug delivery implant 11983 23.47 Removal with reinsertion, non-biodegradable drug delivery implant 12001 47.67 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less 12002 47.67 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm 12004 47.67 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm 12005 63.87 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 12.6 cm to 20.0 cm 12006 63.87 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 20.1 cm to 30.0 cm 12007 63.87 Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); over 30.0 cm 12011 47.67 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less 12013 47.67 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm 12014 47.67 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm 12015 47.67 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm 12016 63.87 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm

3/5/10 (Effective 1/1/10) 114.3 CMR - 1481 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

12017 63.87 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm 12018 63.87 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm 12020 120.51 Treatment of superficial wound dehiscence; simple closure 12021 102.54 Treatment of superficial wound dehiscence; with packing 12031 47.67 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.5 cm or less 12032 125.01 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 cm to 7.5 cm 12034 63.87 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm 12035 63.87 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm 12036 102.54 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 20.1 cm to 30.0 cm 12037 204.36 Layer closure of wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); over 30.0 cm 12041 47.67 Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.5 cm or less 12042 47.67 Layer closure of wounds of neck, hands, feet and/or external genitalia; 2.6 cm to 7.5 cm 12044 63.87 Layer closure of wounds of neck, hands, feet and/or external genitalia; 7.6 cm to 12.5 cm 12045 102.54 Layer closure of wounds of neck, hands, feet and/or external genitalia; 12.6 cm to 20.0 cm 12046 102.54 Layer closure of wounds of neck, hands, feet and/or external genitalia; 20.1 cm to 30.0 cm 12047 204.36 Layer closure of wounds of neck, hands, feet and/or external genitalia; over 30.0 cm 12051 47.67 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less 12052 47.67 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm 12053 47.67 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 5.1 cm to 7.5 cm 12054 63.87 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm 12055 102.54 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 12.6 cm to 20.0 cm 12056 102.54 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 20.1 cm to 30.0 cm 12057 204.36 Layer closure of wounds of face, ears, eyelids, nose, lips and/or mucous membranes; over 30.0 cm 13100 222.33 Repair, complex, trunk; 1.1 cm to 2.5 cm 13101 222.33 Repair, complex, trunk; 2.6 cm to 7.5 cm 13102 120.51 Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure) 13120 102.54 Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm 13121 102.54 Repair, complex, scalp, arms, and/or legs; 2.6 cm to 7.5 cm 13122 102.54 Repair, complex, scalp, arms, and/or legs; each additional 5 cm or less (List separately in addition to code for primary procedure) 13131 102.54 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 1.1 cm to 2.5 cm 13132 102.54 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm

3/5/10 (Effective 1/1/10) 114.3 CMR - 1482 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

13133 102.54 Repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; each additional 5 cm or less (List separately in addition to code for primary procedure) 13150 222.33 Repair, complex, eyelids, nose, ears and/or lips; 1.0 cm or less 13151 222.33 Repair, complex, eyelids, nose, ears and/or lips; 1.1 cm to 2.5 cm 13152 222.33 Repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 cm 13153 102.54 Repair, complex, eyelids, nose, ears and/or lips; each additional 5 cm or less (List separately in addition to code for primary procedure) 13160 578.32 Secondary closure of surgical wound or dehiscence, extensive or complicated 14000 485.86 Adjacent tissue transfer or rearrangement, trunk; defect 10 sq cm or less 14001 513.94 Adjacent tissue transfer or rearrangement, trunk; defect 10.1 sq cm to 30.0 sq cm 14020 513.94 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10 sq cm or less 14021 513.94 Adjacent tissue transfer or rearrangement, scalp, arms and/or legs; defect 10.1 sq cm to 30.0 sq cm 14040 485.86 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10 sq cm or less 14041 513.94 Adjacent tissue transfer or rearrangement, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; defect 10.1 sq cm to 30.0 sq cm 14060 513.94 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less 14061 513.94 Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10.1 sq cm to 30.0 sq cm 14300 659.06 Adjacent tissue transfer or rearrangement, more than 30 sq cm, unusual or complicated, any area 14350 606.40 Filleted finger or toe flap, including preparation of recipient site 15002 222.33 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children 15003 222.33 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) 15004 222.33 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children 15005 222.33 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) 15040 102.54 Harvest of skin for tissue cultured skin autograft, 100 sq cm or less 15050 222.33 Pinch graft, single or multiple, to cover small ulcer, tip of digit, or other minimal open area (except on face), up to defect size 2 cm diameter 15100 578.32 Split-thickness autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) 15101 606.40 Split-thickness autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15110 276.17 Epidermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children

3/5/10 (Effective 1/1/10) 114.3 CMR - 1483 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

15111 226.59 Epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15115 276.17 Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 15116 226.59 Epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15120 578.32 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children (except 15050) 15121 606.40 Split-thickness autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15130 485.86 Dermal autograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 15131 436.27 Dermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15135 485.86 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 15136 436.27 Dermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15150 276.17 Tissue cultured epidermal autograft, trunk, arms, legs; first 25 sq cm or less 15151 226.59 Tissue cultured epidermal autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) 15152 226.59 Tissue cultured epidermal autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15155 276.17 Tissue cultured epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less 15156 226.59 Tissue cultured epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm (List separately in addition to code for primary procedure) 15157 226.59 Tissue cultured epidermal autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15170 125.01 Acellular dermal replacement, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 15171 125.01 Acellular dermal replacement, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15175 160.95 Acellular dermal replacement, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 15176 160.95 Acellular dermal replacement, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1484 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

15200 513.94 Full thickness graft, free, including direct closure of donor site, trunk; 20 sq cm or less 15201 432.01 Full thickness graft, free, including direct closure of donor site, trunk; each additional 20 sq cm (List separately in addition to code for primary procedure) 15220 485.86 Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less 15221 222.33 Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; each additional 20 sq cm (List separately in addition to code for primary procedure) 15240 513.94 Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; 20 sq cm or less 15241 222.33 Full thickness graft, free, including direct closure of donor site, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands, and/or feet; each additional 20 sq cm (List separately in addition to code for primary procedure) 15260 485.86 Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; 20 sq cm or less 15261 432.01 Full thickness graft, free, including direct closure of donor site, nose, ears, eyelids, and/or lips; each additional 20 sq cm (List separately in addition to code for primary procedure) 15300 222.33 Allograft skin for temporary wound closure, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 15301 222.33 Allograft skin for temporary wound closure, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15320 222.33 Allograft skin for temporary wound closure, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 15321 222.33 Allograft skin for temporary wound closure, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15330 222.33 Acellular dermal allograft, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 15331 222.33 Acellular dermal allograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15335 222.33 Acellular dermal allograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 15336 222.33 Acellular dermal allograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15340 125.01 Tissue cultured allogeneic skin substitute; first 25 sq cm or less 15341 125.01 Tissue cultured allogeneic skin substitute; each additional 25 sq cm 15360 125.01 Tissue cultured allogeneic dermal substitute, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 15361 125.01 Tissue cultured allogeneic dermal substitute, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15365 125.01 Tissue cultured allogeneic dermal substitute, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children

3/5/10 (Effective 1/1/10) 114.3 CMR - 1485 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

15366 125.01 Tissue cultured allogeneic dermal substitute, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15400 222.33 Xenograft, skin (dermal), for temporary wound closure, trunk, arms, legs; first 100 sq cm or less, or 1% of body area of infants and children 15401 222.33 Xenograft, skin (dermal), for temporary wound closure, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15420 222.33 Xenograft skin (dermal), for temporary wound closure, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 100 sq cm or less, or 1% of body area of infants and children 15421 222.33 Xenograft skin (dermal), for temporary wound closure, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15430 222.33 Acellular xenograft implant; first 100 sq cm or less, or 1% of body area of infants and children 15431 222.33 Acellular xenograft implant; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof (List separately in addition to code for primary procedure) 15570 606.40 Formation of direct or tubed pedicle, with or without transfer; trunk 15572 606.40 Formation of direct or tubed pedicle, with or without transfer; scalp, arms, or legs 15574 606.40 Formation of direct or tubed pedicle, with or without transfer; forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands or feet 15576 606.40 Formation of direct or tubed pedicle, with or without transfer; eyelids, nose, ears, lips, or intraoral 15600 606.40 Delay of flap or sectioning of flap (division and inset); at trunk 15610 606.40 Delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs 15620 659.06 Delay of flap or sectioning of flap (division and inset); at forehead, cheeks, chin, neck, axillae, genitalia, hands, or feet 15630 606.40 Delay of flap or sectioning of flap (division and inset); at eyelids, nose, ears, or lips 15650 697.23 Transfer, intermediate, of any pedicle flap (e.g., abdomen to wrist, Walking tube), any location 15731 606.40 Forehead flap with preservation of vascular pedicle (e.g., axial pattern flap, paramedian forehead flap) 15732 606.40 Muscle, myocutaneous, or fasciocutaneous flap; head and neck (e.g., temporalis, masseter muscle, sternocleidomastoid, levator scapulae) 15734 606.40 Muscle, myocutaneous, or fasciocutaneous flap; trunk 15736 606.40 Muscle, myocutaneous, or fasciocutaneous flap; upper extremity 15738 606.40 Muscle, myocutaneous, or fasciocutaneous flap; lower extremity 15740 485.86 Flap; island pedicle 15750 578.32 Flap; neurovascular pedicle 15760 578.32 Graft; composite (e.g., full thickness of external ear or nasal ala), including primary closure, donor area 15770 606.40 Graft; derma-fat-fascia 15775 165.69 Punch graft for hair transplant; 1 to 15 punch grafts 15776 165.69 Punch graft for hair transplant; more than 15 punch grafts 15780 369.40 Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis) 15781 162.59 Dermabrasion; segmental, face 15782 162.59 Dermabrasion; regional, other than face 15783 99.13 Dermabrasion; superficial, any site, (e.g., tattoo removal) 15786 30.08 Abrasion; single lesion (e.g., keratosis, scar) 15787 27.27 Abrasion; each additional four lesions or less (List separately in addition to code for primary procedure)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1486 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

15788 30.08 Chemical peel, facial; epidermal 15789 55.11 Chemical peel, facial; dermal 15792 55.11 Chemical peel, nonfacial; epidermal 15793 30.08 Chemical peel, nonfacial; dermal 15819 125.01 Cervicoplasty 15820 606.40 Blepharoplasty, lower eyelid; 15821 606.40 Blepharoplasty, lower eyelid; with extensive herniated fat pad 15822 606.40 Blepharoplasty, upper eyelid; 15823 697.23 Blepharoplasty, upper eyelid; with excessive skin weighting down lid 15824 606.40 Rhytidectomy; forehead 15825 606.40 Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) 15826 606.40 Rhytidectomy; glabellar frown lines 15828 606.40 Rhytidectomy; cheek, chin, and neck 15829 697.23 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap 15830 620.52 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy 15832 620.52 Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh 15833 620.52 Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg 15834 620.52 Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip 15835 538.59 Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock 15836 512.53 Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm 15837 577.49 Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand 15838 577.49 Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad 15839 512.53 Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area 15840 659.06 Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) 15841 659.06 Graft for facial nerve paralysis; free muscle graft (including obtaining graft) 15842 765.23 Graft for facial nerve paralysis; free muscle flap by microsurgical technique 15845 659.06 Graft for facial nerve paralysis; regional muscle transfer 15847 620.52 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure) 15850 99.13 Removal of sutures under anesthesia (other than local), same surgeon 15851 45.12 Removal of sutures under anesthesia (other than local), other surgeon 15852 23.47 Dressing change (for other than burns) under anesthesia (other than local) 15860 23.47 Intravenous injection of agent (e.g., fluorescein) to test vascular flow in flap or graft 15876 606.40 Suction assisted lipectomy; head and neck 15877 606.40 Suction assisted lipectomy; trunk 15878 606.40 Suction assisted lipectomy; upper extremity 15879 606.40 Suction assisted lipectomy; lower extremity 15920 191.66 Excision, coccygeal pressure ulcer, with coccygectomy; with primary suture 15922 659.06 Excision, coccygeal pressure ulcer, with coccygectomy; with flap closure 15931 620.52 Excision, sacral pressure ulcer, with primary suture; 15933 620.52 Excision, sacral pressure ulcer, with primary suture; with ostectomy 15934 606.40 Excision, sacral pressure ulcer, with skin flap closure; 15935 659.06 Excision, sacral pressure ulcer, with skin flap closure; with ostectomy 15936 566.60 Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; 15937 659.06 Excision, sacral pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy 15940 620.52 Excision, ischial pressure ulcer, with primary suture; 15941 620.52 Excision, ischial pressure ulcer, with primary suture; with ostectomy (ischiectomy) 15944 606.40 Excision, ischial pressure ulcer, with skin flap closure; 15945 659.06 Excision, ischial pressure ulcer, with skin flap closure; with ostectomy

3/5/10 (Effective 1/1/10) 114.3 CMR - 1487 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

15946 659.06 Excision, ischial pressure ulcer, with ostectomy, in preparation for muscle or myocutaneous flap or skin graft closure 15950 620.52 Excision, trochanteric pressure ulcer, with primary suture; 15951 673.17 Excision, trochanteric pressure ulcer, with primary suture; with ostectomy 15952 513.94 Excision, trochanteric pressure ulcer, with skin flap closure; 15953 566.60 Excision, trochanteric pressure ulcer, with skin flap closure; with ostectomy 15956 513.94 Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; 15958 566.60 Excision, trochanteric pressure ulcer, in preparation for muscle or myocutaneous flap or skin graft closure; with ostectomy 16000 24.35 Initial treatment, first degree burn, when no more than local treatment is required 16020 37.01 Dressings and/or debridement of partial-thickness burns, initial or subsequent; small (less than 5% total body surface area) 16025 57.00 Dressings and/or debridement of partial-thickness burns, initial or subsequent; medium (e.g., whole face or whole extremity, or 5% to 10% total body surface area) 16030 71.36 Dressings and/or debridement of partial-thickness burns, initial or subsequent; large (e.g., more than one extremity, or greater than 10% total body surface area) 16035 55.11 Escharotomy; initial incision 17000 30.08 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses); first lesion 17004 78.55 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (e.g., actinic keratoses), 15 or more lesions 17106 99.13 Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq cm 17107 99.13 Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 10.0 to 50.0 sq cm 17108 99.13 Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq cm 17110 30.08 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; up to 14 lesions 17111 55.11 Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular lesions; 15 or more lesions 17250 41.55 Chemical cauterization of granulation tissue (proud flesh, sinus or fistula) 17260 44.47 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.5 cm or less 17261 55.11 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 0.6 to 1.0 cm 17262 55.11 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 1.1 to 2.0 cm 17263 55.11 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 2.1 to 3.0 cm 17264 55.11 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter 3.1 to 4.0 cm 17266 99.13 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), trunk, arms or legs; lesion diameter over 4.0 cm 17270 55.11 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.5 cm or less

3/5/10 (Effective 1/1/10) 114.3 CMR - 1488 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

17271 55.11 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 0.6 to 1.0 cm 17272 55.11 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 1.1 to 2.0 cm 17273 99.13 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 2.1 to 3.0 cm 17274 99.13 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter 3.1 to 4.0 cm 17276 99.13 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), scalp, neck, hands, feet, genitalia; lesion diameter over 4.0 cm 17280 55.11 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.5 cm or less 17281 82.13 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 0.6 to 1.0 cm 17282 93.81 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 1.1 to 2.0 cm 17283 99.13 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 2.1 to 3.0 cm 17284 99.13 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter 3.1 to 4.0 cm 17286 99.13 Destruction, malignant lesion (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), face, ears, eyelids, nose, lips, mucous membrane; lesion diameter over 4.0 cm 17311 163.64 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; first stage, up to 5 tissue blocks 17312 163.64 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), head, neck, hands, feet, genitalia, or any location with surgery directly involving muscle, cartilage, bone, tendon, major nerves, or vessels; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure) 17313 163.64 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; first stage, up to 5 tissue blocks

3/5/10 (Effective 1/1/10) 114.3 CMR - 1489 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

17314 163.64 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), of the trunk, arms, or legs; each additional stage after the first stage, up to 5 tissue blocks (List separately in addition to code for primary procedure) 17315 37.01 Mohs micrographic technique, including removal of all gross tumor, surgical excision of tissue specimens, mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) (e.g., hematoxylin and eosin, toluidine blue), each additional block after the first 5 tissue blocks, any stage (List separately in addition to code for primary procedure) 17340 13.31 Cryotherapy (CO2 slush, liquid N2) for acne 17360 30.08 Chemical exfoliation for acne (e.g., acne paste, acid) 17380 30.08 Electrolysis epilation, each 30 minutes 19000 62.65 Puncture aspiration of cyst of breast; 19001 8.44 Puncture aspiration of cyst of breast; each additional cyst (List separately in addition to code for primary procedure) 19020 547.84 Mastotomy with exploration or drainage of abscess, deep 19100 186.55 Biopsy of breast; percutaneous, needle core, not using imaging guidance (separate procedure) 19101 585.94 Biopsy of breast; open, incisional 19102 239.50 Biopsy of breast; percutaneous, needle core, using imaging guidance 19103 419.18 Biopsy of breast; percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance 19105 1,219.63 Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma 19110 585.94 Nipple exploration, with or without excision of a solitary lactiferous duct or a papilloma lactiferous duct 19112 614.03 Excision of lactiferous duct fistula 19120 614.03 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion, nipple or areolar lesion (except 19300), open, male or female, one or more lesions 19125 614.03 Excision of breast lesion identified by preoperative placement of radiological marker, open; single lesion 19126 614.03 Excision of breast lesion identified by preoperative placement of radiological marker, open; each additional lesion separately identified by a preoperative radiological marker (List separately in addition to code for primary procedure) 19296 1,679.45 Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy 19297 1,679.45 Placement of radiotherapy afterloading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure) 19298 1,679.45 Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance 19300 666.68 Mastectomy for gynecomastia 19301 614.03 Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy); 19302 1,172.72 Mastectomy, partial (e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy); with axillary lymphadenectomy 19303 886.26 Mastectomy, simple, complete 19304 886.26 Mastectomy, subcutaneous 19316 886.26 Mastopexy 19318 1,012.55 Reduction mammaplasty

3/5/10 (Effective 1/1/10) 114.3 CMR - 1490 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

19324 1,012.55 Mammaplasty, augmentation; without prosthetic implant 19325 1,679.45 Mammaplasty, augmentation; with prosthetic implant 19328 755.94 Removal of intact mammary implant 19330 755.94 Removal of mammary implant material 19340 931.82 Immediate insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19342 1,315.68 Delayed insertion of breast prosthesis following mastopexy, mastectomy or in reconstruction 19350 666.68 Nipple/areola reconstruction 19355 886.26 Correction of inverted nipples 19357 1,406.51 Breast reconstruction, immediate or delayed, with tissue expander, including subsequent expansion 19366 924.44 Breast reconstruction with other technique 19370 886.26 Open periprosthetic capsulotomy, breast 19371 886.26 Periprosthetic capsulectomy, breast 19380 1,050.73 Revision of reconstructed breast 19396 1,219.63 Preparation of moulage for custom breast implant 20000 51.32 Incision of soft tissue abscess (e.g., secondary to osteomyelitis); superficial 20005 591.31 Incision of soft tissue abscess (e.g., secondary to osteomyelitis); deep or complicated 20103 580.31 Exploration of penetrating wound (separate procedure); extremity 20150 1,647.51 Excision of epiphyseal bar, with or without autogenous soft tissue graft obtained through same fascial incision 20200 484.44 Biopsy, muscle; superficial 20205 512.53 Biopsy, muscle; deep 20206 239.50 Biopsy, muscle, percutaneous needle 20220 260.33 Biopsy, bone, trocar, or needle; superficial (e.g., ilium, sternum, spinous process, ribs) 20225 472.37 Biopsy, bone, trocar, or needle; deep (e.g., vertebral body, femur) 20240 592.43 Biopsy, bone, open; superficial (e.g., ilium, sternum, spinous process, ribs, trochanter of femur) 20245 620.52 Biopsy, bone, open; deep (e.g., humerus, ischium, femur) 20250 619.40 Biopsy, vertebral body, open; thoracic 20251 619.40 Biopsy, vertebral body, open; lumbar or cervical 20500 51.29 Injection of sinus tract; therapeutic (separate procedure) 20520 86.35 Removal of foreign body in muscle or tendon sheath; simple 20525 620.52 Removal of foreign body in muscle or tendon sheath; deep or complicated 20526 27.92 Injection, therapeutic (e.g., local anesthetic, corticosteroid), carpal tunnel 20550 21.10 Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar fascia) 20551 20.77 Injection(s); single tendon origin/insertion 20552 20.12 Injection(s); single or multiple trigger point(s), one or two muscle(s) 20553 22.40 Injection(s); single or multiple trigger point(s), three or more muscle(s) 20555 1,085.48 Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure) 20600 21.42 Arthrocentesis, aspiration and/or injection; small joint or bursa (e.g., fingers, toes) 20605 24.02 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa) 20610 33.76 Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa) 20612 22.73 Aspiration and/or injection of ganglion cyst(s) any location 20615 95.11 Aspiration and injection for treatment of bone cyst 20650 619.40 Insertion of wire or pin with application of skeletal traction, including removal (separate procedure) 20662 791.22 Application of halo, including removal; pelvic 20663 791.22 Application of halo, including removal; femoral 20665 23.47 Removal of tongs or halo applied by another physician 20670 434.86 Removal of implant; superficial, (e.g., buried wire, pin or rod) (separate procedure) 20680 620.52 Removal of implant; deep (e.g., buried wire, pin, screw, metal band, nail, rod or plate)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1491 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

20690 738.44 Application of a uniplane (pins or wires in one plane), unilateral, external fixation system 20692 766.53 Application of a multiplane (pins or wires in more than one plane), unilateral, external fixation system (e.g., Ilizarov, Monticelli type) 20693 619.40 Adjustment or revision of external fixation system requiring anesthesia (e.g., new pin(s) or wire(s) and/or new ring(s) or bar(s)) 20694 541.73 Removal, under anesthesia, of external fixation system 20696 1,085.48 Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (e.g., spatial frame), including imaging; initial and subsequent alignment(s), assessment(s), and computation(s) of adjustment 20697 721.89 Application of multiplane (pins or wires in more than one plane), unilateral, external fixation with stereotactic computer-assisted adjustment (e.g., spatial frame), including imaging; exchange (ie, removal and replacement) of strut, each 20822 1,017.11 Replantation, digit, excluding thumb (includes distal tip to sublimis tendon insertion), complete amputation 20900 766.53 Bone graft, any donor area; minor or small (e.g., dowel or button) 20902 819.18 Bone graft, any donor area; major or large 20910 606.40 Cartilage graft; costochondral 20912 606.40 Cartilage graft; nasal septum 20920 566.60 Fascia lata graft; by stripper 20922 513.94 Fascia lata graft; by incision and area exposure, complex or sheet 20924 819.18 Tendon graft, from a distance (e.g., palmaris, toe extensor, plantaris) 20926 356.91 Tissue grafts, other (e.g., paratenon, fat, dermis) 20950 51.32 Monitoring of interstitial fluid pressure (includes insertion of device, e.g., wick catheter technique, needle manometer technique) in detection of muscle compartment syndrome 20972 1,717.92 Free osteocutaneous flap with microvascular anastomosis; metatarsal 20973 1,717.92 Free osteocutaneous flap with microvascular anastomosis; great toe with web space 20979 21.10 Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative) 20982 1,647.51 Ablation, bone tumor(s) (e.g., osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidance 21010 645.34 Arthrotomy, temporomandibular joint 21015 536.92 Radical resection of tumor (e.g., malignant neoplasm), soft tissue of face or scalp 21025 956.26 Excision of bone (e.g., for osteomyelitis or bone abscess); mandible 21026 956.26 Excision of bone (e.g., for osteomyelitis or bone abscess); facial bone(s) 21029 956.26 Removal by contouring of benign tumor of facial bone (e.g., fibrous dysplasia) 21030 225.59 Excision of benign tumor or cyst of maxilla or zygoma by enucleation and curettage 21031 186.64 Excision of torus mandibularis 21032 190.22 Excision of maxillary torus palatinus 21034 984.35 Excision of malignant tumor of maxilla or zygoma 21040 645.34 Excision of benign tumor or cyst of mandible, by enucleation and/or curettage 21044 956.26 Excision of malignant tumor of mandible; 21046 956.26 Excision of benign tumor or cyst of mandible; requiring intra-oral osteotomy (e.g., locally aggressive or destructive lesion(s)) 21047 956.26 Excision of benign tumor or cyst of mandible; requiring extra-oral osteotomy and partial mandibulectomy (e.g., locally aggressive or destructive lesion(s)) 21048 1,521.12 Excision of benign tumor or cyst of maxilla; requiring intra-oral osteotomy (e.g., locally aggressive or destructive lesion(s)) 21050 984.35 Condylectomy, temporomandibular joint (separate procedure) 21060 956.26 Meniscectomy, partial or complete, temporomandibular joint (separate procedure) 21070 984.35 Coronoidectomy (separate procedure) 21073 175.28 Manipulation of temporomandibular joint(s) (TMJ), therapeutic, requiring an anesthesia service (ie, general or monitored anesthesia care) 21076 304.15 Impression and custom preparation; surgical obturator prosthesis 21077 735.22 Impression and custom preparation; orbital prosthesis

3/5/10 (Effective 1/1/10) 114.3 CMR - 1492 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

21079 526.50 Impression and custom preparation; interim obturator prosthesis 21080 603.76 Impression and custom preparation; definitive obturator prosthesis 21081 556.36 Impression and custom preparation; mandibular resection prosthesis 21082 529.43 Impression and custom preparation; palatal augmentation prosthesis 21083 521.63 Impression and custom preparation; palatal lift prosthesis 21084 600.18 Impression and custom preparation; speech aid prosthesis 21085 238.26 Impression and custom preparation; oral surgical splint 21086 518.71 Impression and custom preparation; auricular prosthesis 21087 519.36 Impression and custom preparation; nasal prosthesis 21088 1,521.12 Impression and custom preparation; facial prosthesis 21100 956.26 Application of halo type appliance for maxillofacial fixation, includes removal (separate procedure) 21110 273.65 Application of interdental fixation device for conditions other than fracture or dislocation, includes removal 21120 886.24 Genioplasty; augmentation (autograft, allograft, prosthetic material) 21121 886.24 Genioplasty; sliding osteotomy, single piece 21122 886.24 Genioplasty; sliding osteotomies, two or more osteotomies (e.g., wedge excision or bone wedge reversal for asymmetrical chin) 21123 886.24 Genioplasty; sliding, augmentation with interpositional bone grafts (includes obtaining autografts) 21125 886.24 Augmentation, mandibular body or angle; prosthetic material 21127 1,348.10 Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft) 21137 899.28 Reduction forehead; contouring only 21138 1,521.12 Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) 21139 1,521.12 Reduction forehead; contouring and setback of anterior frontal sinus wall 21150 1,521.12 Reconstruction midface, LeFort II; anterior intrusion (e.g., Treacher-Collins Syndrome) 21181 886.24 Reconstruction by contouring of benign tumor of cranial bones (e.g., fibrous dysplasia), extracranial 21198 1,521.12 Osteotomy, mandible, segmental; 21199 1,521.12 Osteotomy, mandible, segmental; with genioglossus advancement 21206 1,075.18 Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard) 21208 1,197.16 Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant) 21209 1,075.18 Osteoplasty, facial bones; reduction 21210 1,197.16 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft) 21215 1,197.16 Graft, bone; mandible (includes obtaining graft) 21230 1,197.16 Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) 21235 886.24 Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) 21240 1,037.00 Arthroplasty, temporomandibular joint, with or without autograft (includes obtaining graft) 21242 1,075.18 Arthroplasty, temporomandibular joint, with allograft 21243 1,075.18 Arthroplasty, temporomandibular joint, with prosthetic joint replacement 21244 1,197.16 Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate) 21245 1,197.16 Reconstruction of mandible or maxilla, subperiosteal implant; partial 21246 1,197.16 Reconstruction of mandible or maxilla, subperiosteal implant; complete 21248 1,197.16 Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); partial 21249 1,197.16 Reconstruction of mandible or maxilla, endosteal implant (e.g., blade, cylinder); complete 21260 1,521.12 Periorbital osteotomies for orbital hypertelorism, with bone grafts; extracranial approach 21267 1,197.16 Orbital repositioning, periorbital osteotomies, unilateral, with bone grafts; extracranial approach

3/5/10 (Effective 1/1/10) 114.3 CMR - 1493 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

21270 1,075.18 Malar augmentation, prosthetic material 21275 1,197.16 Secondary revision of orbitocraniofacial reconstruction 21280 1,075.18 Medial canthopexy (separate procedure) 21282 627.75 Lateral canthopexy 21295 282.94 Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy); extraoral approach 21296 595.76 Reduction of masseter muscle and bone (e.g., for treatment of benign masseteric hypertrophy); intraoral approach 21310 86.31 Closed treatment of nasal bone fracture without manipulation 21315 379.27 Closed treatment of nasal bone fracture; without stabilization 21320 508.83 Closed treatment of nasal bone fracture; with stabilization 21325 726.08 Open treatment of nasal fracture; uncomplicated 21330 764.25 Open treatment of nasal fracture; complicated, with internal and/or external skeletal fixation 21335 886.24 Open treatment of nasal fracture; with concomitant open treatment of fractured septum 21336 738.59 Open treatment of nasal septal fracture, with or without stabilization 21337 508.83 Closed treatment of nasal septal fracture, with or without stabilization 21338 726.08 Open treatment of nasoethmoid fracture; without external fixation 21339 764.25 Open treatment of nasoethmoid fracture; with external fixation 21340 1,037.00 Percutaneous treatment of nasoethmoid complex fracture, with splint, wire or headcap fixation, including repair of canthal ligaments and/or the nasolacrimal apparatus 21345 886.24 Closed treatment of nasomaxillary complex fracture (LeFort II type), with interdental wire fixation or fixation of denture or splint 21355 984.35 Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation 21356 673.43 Open treatment of depressed zygomatic arch fracture (e.g., Gillies approach) 21360 899.28 Open treatment of depressed malar fracture, including zygomatic arch and malar tripod 21390 1,521.12 Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other implant 21400 332.52 Closed treatment of fracture of orbit, except blowout; without manipulation 21401 536.92 Closed treatment of fracture of orbit, except blowout; with manipulation 21406 1,521.12 Open treatment of fracture of orbit, except blowout; without implant 21407 1,521.12 Open treatment of fracture of orbit, except blowout; with implant 21421 726.08 Closed treatment of palatal or maxillary fracture (LeFort I type), with interdental wire fixation or fixation of denture or splint 21440 305.78 Closed treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) 21445 726.08 Open treatment of mandibular or maxillary alveolar ridge fracture (separate procedure) 21450 126.20 Closed treatment of mandibular fracture; without manipulation 21451 340.49 Closed treatment of mandibular fracture; with manipulation 21452 508.83 Percutaneous treatment of mandibular fracture, with external fixation 21453 984.35 Closed treatment of mandibular fracture with interdental fixation 21454 764.25 Open treatment of mandibular fracture with external fixation 21461 1,037.00 Open treatment of mandibular fracture; without interdental fixation 21462 1,075.18 Open treatment of mandibular fracture; with interdental fixation 21465 1,037.00 Open treatment of mandibular condylar fracture 21480 86.31 Closed treatment of temporomandibular dislocation; initial or subsequent 21485 508.83 Closed treatment of temporomandibular dislocation; complicated (e.g., recurrent requiring intermaxillary fixation or splinting), initial or subsequent 21490 984.35 Open treatment of temporomandibular dislocation 21495 626.27 Open treatment of hyoid fracture 21497 508.83 Interdental wiring, for condition other than fracture

3/5/10 (Effective 1/1/10) 114.3 CMR - 1494 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

21501 547.84 Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; 21502 591.31 Incision and drainage, deep abscess or hematoma, soft tissues of neck or thorax; with partial rib ostectomy 21550 577.49 Biopsy, soft tissue of neck or thorax 21555 592.43 Excision tumor, soft tissue of neck or thorax; subcutaneous 21556 592.43 Excision tumor, soft tissue of neck or thorax; deep, subfascial, intramuscular 21557 793.47 Radical resection of tumor (e.g., malignant neoplasm), soft tissue of neck or thorax 21600 738.44 Excision of rib, partial 21610 738.44 Costotransversectomy (separate procedure) 21685 273.65 Hyoid myotomy and suspension 21700 591.31 Division of scalenus anticus; without resection of cervical rib 21720 619.40 Division of sternocleidomastoid for torticollis, open operation; without cast application 21725 64.48 Division of sternocleidomastoid for torticollis, open operation; with cast application 21800 74.48 Closed treatment of rib fracture, uncomplicated, each 21805 657.85 Open treatment of rib fracture without fixation, each 21820 74.48 Closed treatment of sternum fracture 21920 132.44 Biopsy, soft tissue of back or flank; superficial 21925 592.43 Biopsy, soft tissue of back or flank; deep 21930 592.43 Excision, tumor, soft tissue of back or flank 21935 620.52 Radical resection of tumor (e.g., malignant neoplasm), soft tissue of back or flank 22102 1,765.70 Partial excision of posterior vertebral component (e.g., spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; lumbar 22103 1,765.70 Partial excision of posterior vertebral component (e.g., spinous process, lamina or facet) for intrinsic bony lesion, single vertebral segment; each additional segment (List separately in addition to code for primary procedure) 22305 74.48 Closed treatment of vertebral process fracture(s) 22310 157.13 Closed treatment of vertebral body fracture(s), without manipulation, requiring and including casting or bracing 22315 406.41 Closed treatment of vertebral fracture(s) and/or dislocation(s) requiring casting or bracing, with and including casting and/or bracing, with or without anesthesia, by manipulation or traction 22505 478.45 Manipulation of spine requiring anesthesia, any region 22520 1,130.28 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; thoracic 22521 1,130.28 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; lumbar 22522 1,130.28 Percutaneous vertebroplasty, one vertebral body, unilateral or bilateral injection; each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) 22523 3,145.69 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); thoracic 22524 3,145.69 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); lumbar 22525 3,145.69 Percutaneous vertebral augmentation, including cavity creation (fracture reduction and bone biopsy included when performed) using mechanical device, one vertebral body, unilateral or bilateral cannulation (e.g., kyphoplasty); each additional thoracic or lumbar vertebral body (List separately in addition to code for primary procedure) 22900 673.17 Excision, abdominal wall tumor, subfascial (e.g., desmoid) 23000 484.44 Removal of subdeltoid calcareous deposits, open 23020 1,019.46 Capsular contracture release (e.g., Sever type procedure) 23030 498.25 Incision and drainage, shoulder area; deep abscess or hematoma 23031 575.92 Incision and drainage, shoulder area; infected bursa 23035 619.40 Incision, bone cortex (e.g., osteomyelitis or bone abscess), shoulder area

3/5/10 (Effective 1/1/10) 114.3 CMR - 1495 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

23040 766.53 Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of foreign body 23044 819.18 Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, or removal of foreign body 23065 91.54 Biopsy, soft tissue of shoulder area; superficial 23066 592.43 Biopsy, soft tissue of shoulder area; deep 23075 484.44 Excision, soft tissue tumor, shoulder area; subcutaneous 23076 592.43 Excision, soft tissue tumor, shoulder area; deep, subfascial, or intramuscular 23077 620.52 Radical resection of tumor (e.g., malignant neoplasm), soft tissue of shoulder area 23100 591.31 Arthrotomy, glenohumeral joint, including biopsy 23101 979.34 Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or excision of torn cartilage 23105 819.18 Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy 23106 819.18 Arthrotomy; sternoclavicular joint, with synovectomy, with or without biopsy 23107 819.18 Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body 23120 857.36 Claviculectomy; partial 23125 857.36 Claviculectomy; total 23130 1,138.37 Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release 23140 672.05 Excision or curettage of bone cyst or benign tumor of clavicle or scapula; 23145 857.36 Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with autograft (includes obtaining graft) 23146 857.36 Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with allograft 23150 819.18 Excision or curettage of bone cyst or benign tumor of proximal humerus; 23155 857.36 Excision or curettage of bone cyst or benign tumor of proximal humerus; with autograft (includes obtaining graft) 23156 857.36 Excision or curettage of bone cyst or benign tumor of proximal humerus; with allograft 23170 738.44 Sequestrectomy (e.g., for osteomyelitis or bone abscess), clavicle 23172 738.44 Sequestrectomy (e.g., for osteomyelitis or bone abscess), scapula 23174 738.44 Sequestrectomy (e.g., for osteomyelitis or bone abscess), humeral head to surgical neck 23180 819.18 Partial excision (craterization, saucerization, or diaphysectomy) bone (e.g., osteomyelitis), clavicle 23182 819.18 Partial excision (craterization, saucerization, or diaphysectomy) bone (e.g., osteomyelitis), scapula 23184 819.18 Partial excision (craterization, saucerization, or diaphysectomy) bone (e.g., osteomyelitis), proximal humerus 23190 819.18 Ostectomy of scapula, partial (e.g., superior medial angle) 23195 857.36 Resection, humeral head 23330 296.08 Removal of foreign body, shoulder; subcutaneous 23331 542.85 Removal of foreign body, shoulder; deep (e.g., Neer hemiarthroplasty removal) 23395 1,138.37 Muscle transfer, any type, shoulder or upper arm; single 23397 2,009.45 Muscle transfer, any type, shoulder or upper arm; multiple 23400 979.34 Scapulopexy (e.g., Sprengels deformity or for paralysis) 23405 738.44 Tenotomy, shoulder area; single tendon 23406 738.44 Tenotomy, shoulder area; multiple tendons through same incision 23410 1,138.37 Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; acute 23412 1,260.35 Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; chronic 23415 1,138.37 Coracoacromial ligament release, with or without acromioplasty 23420 1,260.35 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty) 23430 1,100.20 Tenodesis of long tendon of biceps 23440 1,100.20 Resection or transplantation of long tendon of biceps

3/5/10 (Effective 1/1/10) 114.3 CMR - 1496 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

23450 1,887.46 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation 23455 2,009.45 Capsulorrhaphy, anterior; with labral repair (e.g., Bankart procedure) 23460 1,887.46 Capsulorrhaphy, anterior, any type; with bone block 23462 1,260.35 Capsulorrhaphy, anterior, any type; with coracoid process transfer 23465 1,887.46 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block 23466 1,260.35 Capsulorrhaphy, glenohumeral joint, any type multi-directional instability 23480 1,100.20 Osteotomy, clavicle, with or without internal fixation; 23485 2,009.45 Osteotomy, clavicle, with or without internal fixation; with bone graft for nonunion or malunion (includes obtaining graft and/or necessary fixation) 23490 1,047.54 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; clavicle 23491 1,796.63 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; proximal humerus 23500 74.48 Closed treatment of clavicular fracture; without manipulation 23505 406.41 Closed treatment of clavicular fracture; with manipulation 23515 1,360.23 Open treatment of clavicular fracture, with or without internal or external fixation 23520 157.13 Closed treatment of sternoclavicular dislocation; without manipulation 23525 157.13 Closed treatment of sternoclavicular dislocation; with manipulation 23530 1,002.36 Open treatment of sternoclavicular dislocation, acute or chronic; 23532 738.59 Open treatment of sternoclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) 23540 74.48 Closed treatment of acromioclavicular dislocation; without manipulation 23545 157.13 Closed treatment of acromioclavicular dislocation; with manipulation 23550 1,002.36 Open treatment of acromioclavicular dislocation, acute or chronic; 23552 1,055.02 Open treatment of acromioclavicular dislocation, acute or chronic; with fascial graft (includes obtaining graft) 23570 74.48 Closed treatment of scapular fracture; without manipulation 23575 157.13 Closed treatment of scapular fracture; with manipulation, with or without skeletal traction (with or without shoulder joint involvement) 23585 1,360.23 Open treatment of scapular fracture (body, glenoid or acromion) with or without internal fixation 23600 58.04 Closed treatment of proximal humeral (surgical or anatomical neck) fracture; without manipulation 23605 406.41 Closed treatment of proximal humeral (surgical or anatomical neck) fracture; with manipulation, with or without skeletal traction 23615 1,412.88 Open treatment of proximal humeral (surgical or anatomical neck) fracture, with or without internal or external fixation, with or without repair of tuberosity(s); 23616 1,412.88 Open treatment of proximal humeral (surgical or anatomical neck) fracture, with or without internal or external fixation, with or without repair of tuberosity(s); with proximal humeral prosthetic replacement 23620 58.04 Closed treatment of greater humeral tuberosity fracture; without manipulation 23625 406.41 Closed treatment of greater humeral tuberosity fracture; with manipulation 23630 1,451.06 Open treatment of greater humeral tuberosity fracture, with or without internal or external fixation 23650 74.48 Closed treatment of shoulder dislocation, with manipulation; without anesthesia 23655 428.87 Closed treatment of shoulder dislocation, with manipulation; requiring anesthesia 23660 1,002.36 Open treatment of acute shoulder dislocation 23665 157.13 Closed treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with manipulation 23670 1,360.23 Open treatment of shoulder dislocation, with fracture of greater humeral tuberosity, with or without internal or external fixation 23675 74.48 Closed treatment of shoulder dislocation, with surgical or anatomical neck fracture, with manipulation 23680 1,002.36 Open treatment of shoulder dislocation, with surgical or anatomical neck fracture, with or without internal or external fixation

3/5/10 (Effective 1/1/10) 114.3 CMR - 1497 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

23700 428.87 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded) 23800 1,849.28 Arthrodesis, glenohumeral joint; 23802 1,260.35 Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) 23921 432.01 Disarticulation of shoulder; secondary closure or scar revision 23930 498.25 Incision and drainage, upper arm or elbow area; deep abscess or hematoma 23931 547.84 Incision and drainage, upper arm or elbow area; bursa 23935 591.31 Incision, deep, with opening of bone cortex (e.g., for osteomyelitis or bone abscess), humerus or elbow 24000 819.18 Arthrotomy, elbow, including exploration, drainage, or removal of foreign body 24006 819.18 Arthrotomy of the elbow, with capsular excision for capsular release (separate procedure) 24065 126.92 Biopsy, soft tissue of upper arm or elbow area; superficial 24066 484.44 Biopsy, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular) 24075 484.44 Excision, tumor, soft tissue of upper arm or elbow area; subcutaneous 24076 592.43 Excision, tumor, soft tissue of upper arm or elbow area; deep (subfascial or intramuscular) 24077 620.52 Radical resection of tumor (e.g., malignant neoplasm), soft tissue of upper arm or elbow area 24100 541.73 Arthrotomy, elbow; with synovial biopsy only 24101 819.18 Arthrotomy, elbow; with joint exploration, with or without biopsy, with or without removal of loose or foreign body 24102 819.18 Arthrotomy, elbow; with synovectomy 24105 619.40 Excision, olecranon bursa 24110 591.31 Excision or curettage of bone cyst or benign tumor, humerus; 24115 766.53 Excision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining graft) 24116 766.53 Excision or curettage of bone cyst or benign tumor, humerus; with allograft 24120 619.40 Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; 24125 766.53 Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with autograft (includes obtaining graft) 24126 766.53 Excision or curettage of bone cyst or benign tumor of head or neck of radius or olecranon process; with allograft 24130 766.53 Excision, radial head 24134 738.44 Sequestrectomy (e.g., for osteomyelitis or bone abscess), shaft or distal humerus 24136 738.44 Sequestrectomy (e.g., for osteomyelitis or bone abscess), radial head or neck 24138 738.44 Sequestrectomy (e.g., for osteomyelitis or bone abscess), olecranon process 24140 766.53 Partial excision (craterization, saucerization, or diaphysectomy) bone (e.g., osteomyelitis), humerus 24145 766.53 Partial excision (craterization, saucerization, or diaphysectomy) bone (e.g., osteomyelitis), radial head or neck 24147 738.44 Partial excision (craterization, saucerization, or diaphysectomy) bone (e.g., osteomyelitis), olecranon process 24149 1,085.48 Radical resection of capsule, soft tissue, and heterotopic bone, elbow, with contracture release (separate procedure) 24152 1,647.51 Radical resection for tumor, radial head or neck; 24153 3,145.69 Radical resection for tumor, radial head or neck; with autograft (includes obtaining graft) 24155 1,047.54 Resection of elbow joint (arthrectomy) 24160 738.44 Implant removal; elbow joint 24164 766.53 Implant removal; radial head 24200 92.84 Removal of foreign body, upper arm or elbow area; subcutaneous 24201 484.44 Removal of foreign body, upper arm or elbow area; deep (subfascial or intramuscular) 24300 565.50 Manipulation, elbow, under anesthesia

3/5/10 (Effective 1/1/10) 114.3 CMR - 1498 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

24301 819.18 Muscle or tendon transfer, any type, upper arm or elbow, single (excluding 24320-24331) 24305 819.18 Tendon lengthening, upper arm or elbow, each tendon 24310 619.40 Tenotomy, open, elbow to shoulder, each tendon 24320 1,047.54 Tenoplasty, with muscle transfer, with or without free graft, elbow to shoulder, single (Seddon-Brookes type procedure) 24330 1,796.63 Flexor-plasty, elbow (e.g., Steindler type advancement); 24331 1,047.54 Flexor-plasty, elbow (e.g., Steindler type advancement); with extensor advancement 24332 791.22 Tenolysis, triceps 24340 1,047.54 Tenodesis of biceps tendon at elbow (separate procedure) 24341 1,047.54 Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff) 24342 1,047.54 Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft 24343 1,085.48 Repair lateral collateral ligament, elbow, with local tissue 24344 3,145.69 Reconstruction lateral collateral ligament, elbow, with tendon graft (includes harvesting of graft) 24345 738.44 Repair medial collateral ligament, elbow, with local tissue 24346 1,647.51 Reconstruction medial collateral ligament, elbow, with tendon graft (includes harvesting of graft) 24357 1,085.48 Tenotomy, elbow, lateral or medial (e.g., epicondylitis, tennis elbow, golfer's elbow); percutaneous 24358 1,085.48 Tenotomy, elbow, lateral or medial (e.g., epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open 24359 1,085.48 Tenotomy, elbow, lateral or medial (e.g., epicondylitis, tennis elbow, golfer's elbow); debridement, soft tissue and/or bone, open with tendon repair or reattachment 24360 1,001.75 Arthroplasty, elbow; with membrane (e.g., fascial) 24361 5,477.06 Arthroplasty, elbow; with distal humeral prosthetic replacement 24362 1,280.22 Arthroplasty, elbow; with implant and fascia lata ligament reconstruction 24363 5,599.04 Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (e.g., total elbow) 24365 1,001.75 Arthroplasty, radial head; 24366 5,477.06 Arthroplasty, radial head; with implant 24400 819.18 Osteotomy, humerus, with or without internal fixation 24410 819.18 Multiple osteotomies with realignment on intramedullary rod, humeral shaft (Sofield type procedure) 24420 1,047.54 Osteoplasty, humerus (e.g., shortening or lengthening) (excluding 64876) 24430 1,796.63 Repair of nonunion or malunion, humerus; without graft (e.g., compression technique) 24435 1,849.28 Repair of nonunion or malunion, humerus; with iliac or other autograft (includes obtaining graft) 24470 1,047.54 Hemiepiphyseal arrest (e.g., cubitus varus or valgus, distal humerus) 24495 738.44 Decompression fasciotomy, forearm, with brachial artery exploration 24498 1,796.63 Prophylactic treatment (nailing, pinning, plating or wiring), with or without methylmethacrylate, humeral shaft 24500 74.48 Closed treatment of humeral shaft fracture; without manipulation 24505 74.48 Closed treatment of humeral shaft fracture; with manipulation, with or without skeletal traction 24515 1,412.88 Open treatment of humeral shaft fracture with plate/screws, with or without cerclage 24516 1,412.88 Treatment of humeral shaft fracture, with insertion of intramedullary implant, with or without cerclage and/or locking screws 24530 74.48 Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; without manipulation 24535 157.13 Closed treatment of supracondylar or transcondylar humeral fracture, with or without intercondylar extension; with manipulation, with or without skin or skeletal traction 24538 657.85 Percutaneous skeletal fixation of supracondylar or transcondylar humeral fracture, with or without intercondylar extension

3/5/10 (Effective 1/1/10) 114.3 CMR - 1499 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

24545 1,412.88 Open treatment of humeral supracondylar or transcondylar fracture, with or without internal or external fixation; without intercondylar extension 24546 1,451.06 Open treatment of humeral supracondylar or transcondylar fracture, with or without internal or external fixation; with intercondylar extension 24560 74.48 Closed treatment of humeral epicondylar fracture, medial or lateral; without manipulation 24565 74.48 Closed treatment of humeral epicondylar fracture, medial or lateral; with manipulation 24566 657.85 Percutaneous skeletal fixation of humeral epicondylar fracture, medial or lateral, with manipulation 24575 1,360.23 Open treatment of humeral epicondylar fracture, medial or lateral, with or without internal or external fixation 24576 74.48 Closed treatment of humeral condylar fracture, medial or lateral; without manipulation 24577 157.13 Closed treatment of humeral condylar fracture, medial or lateral; with manipulation 24579 1,360.23 Open treatment of humeral condylar fracture, medial or lateral, with or without internal or external fixation 24582 657.85 Percutaneous skeletal fixation of humeral condylar fracture, medial or lateral, with manipulation 24586 1,412.88 Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); 24587 1,451.06 Open treatment of periarticular fracture and/or dislocation of the elbow (fracture distal humerus and proximal ulna and/or proximal radius); with implant arthroplasty 24600 74.48 Treatment of closed elbow dislocation; without anesthesia 24605 478.45 Treatment of closed elbow dislocation; requiring anesthesia 24615 1,360.23 Open treatment of acute or chronic elbow dislocation 24620 406.41 Closed treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with manipulation 24635 1,360.23 Open treatment of Monteggia type of fracture dislocation at elbow (fracture proximal end of ulna with dislocation of radial head), with or without internal or external fixation 24640 50.31 Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation 24650 58.04 Closed treatment of radial head or neck fracture; without manipulation 24655 157.13 Closed treatment of radial head or neck fracture; with manipulation 24665 1,055.02 Open treatment of radial head or neck fracture, with or without internal fixation or radial head excision; 24666 1,412.88 Open treatment of radial head or neck fracture, with or without internal fixation or radial head excision; with radial head prosthetic replacement 24670 74.48 Closed treatment of ulnar fracture, proximal end (olecranon process); without manipulation 24675 74.48 Closed treatment of ulnar fracture, proximal end (olecranon process); with manipulation 24685 1,002.36 Open treatment of ulnar fracture proximal end (olecranon process), with or without internal or external fixation 24800 1,100.20 Arthrodesis, elbow joint; local 24802 1,138.37 Arthrodesis, elbow joint; with autogenous graft (includes obtaining graft) 24925 619.40 Amputation, arm through humerus; secondary closure or scar revision 25000 619.40 Amputation, arm through humerus; secondary closure or scar revision 25001 791.22 Incision, flexor tendon sheath, wrist (e.g., flexor carpi radialis) 25020 619.40 Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; without debridement of nonviable muscle and/or nerve 25023 766.53 Decompression fasciotomy, forearm and/or wrist, flexor OR extensor compartment; with debridement of nonviable muscle and/or nerve 25024 766.53 Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; without debridement of nonviable muscle and/or nerve 25025 766.53 Decompression fasciotomy, forearm and/or wrist, flexor AND extensor compartment; with debridement of nonviable muscle and/or nerve

3/5/10 (Effective 1/1/10) 114.3 CMR - 1500 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

25028 541.73 Incision and drainage, forearm and/or wrist; deep abscess or hematoma 25031 591.31 Incision and drainage, forearm and/or wrist; bursa 25035 591.31 Incision, deep, bone cortex, forearm and/or wrist (e.g., osteomyelitis or bone abscess) 25040 857.36 Arthrotomy, radiocarpal or midcarpal joint, with exploration, drainage, or removal of foreign body 25065 128.86 Biopsy, soft tissue of forearm and/or wrist; superficial 25066 592.43 Biopsy, soft tissue of forearm and/or wrist; deep (subfascial or intramuscular) 25075 484.44 Excision, tumor, soft tissue of forearm and/or wrist area; subcutaneous 25076 620.52 Excision, tumor, soft tissue of forearm and/or wrist area; deep (subfascial or intramuscular) 25077 620.52 Radical resection of tumor (e.g., malignant neoplasm), soft tissue of forearm and/or wrist area 25085 619.40 Capsulotomy, wrist (e.g., contracture) 25100 591.31 Arthrotomy, wrist joint; with biopsy 25101 766.53 Arthrotomy, wrist joint; with joint exploration, with or without biopsy, with or without removal of loose or foreign body 25105 819.18 Arthrotomy, wrist joint; with synovectomy 25107 766.53 Arthrotomy, distal radioulnar joint including repair of triangular cartilage, complex 25109 791.22 Excision of tendon, forearm and/or wrist, flexor or extensor, each 25110 619.40 Excision, lesion of tendon sheath, forearm and/or wrist 25111 619.40 Excision of ganglion, wrist (dorsal or volar); primary 25112 672.05 Excision of ganglion, wrist (dorsal or volar); recurrent 25115 672.05 Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (e.g., tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); flexors 25116 672.05 Radical excision of bursa, synovia of wrist, or forearm tendon sheaths (e.g., tenosynovitis, fungus, Tbc, or other granulomas, rheumatoid arthritis); extensors, with or without transposition of dorsal retinaculum 25118 738.44 Synovectomy, extensor tendon sheath, wrist, single compartment; 25119 766.53 Synovectomy, extensor tendon sheath, wrist, single compartment; with resection of distal ulna 25120 766.53 Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); 25125 766.53 Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with autograft (includes obtaining graft) 25126 766.53 Excision or curettage of bone cyst or benign tumor of radius or ulna (excluding head or neck of radius and olecranon process); with allograft 25130 766.53 Excision or curettage of bone cyst or benign tumor of carpal bones; 25135 766.53 Excision or curettage of bone cyst or benign tumor of carpal bones; with autograft (includes obtaining graft) 25136 766.53 Excision or curettage of bone cyst or benign tumor of carpal bones; with allograft 25145 738.44 Sequestrectomy (e.g., for osteomyelitis or bone abscess), forearm and/or wrist 25150 738.44 Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis); ulna 25151 738.44 Partial excision (craterization, saucerization, or diaphysectomy) of bone (e.g., for osteomyelitis); radius 25210 766.53 Carpectomy; one bone 25215 819.18 Carpectomy; all bones of proximal row 25230 819.18 Radial styloidectomy (separate procedure) 25240 819.18 Excision distal ulna partial or complete (e.g., Darrach type or matched resection) 25248 591.31 Exploration with removal of deep foreign body, forearm or wrist 25250 688.86 Removal of wrist prosthesis; (separate procedure) 25251 688.86 Removal of wrist prosthesis; complicated, including total wrist 25259 721.89 Manipulation, wrist, under anesthesia 25260 819.18 Repair, tendon or muscle, flexor, forearm and/or wrist; primary, single, each tendon or muscle

3/5/10 (Effective 1/1/10) 114.3 CMR - 1501 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

25263 738.44 Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, single, each tendon or muscle 25265 766.53 Repair, tendon or muscle, flexor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle 25270 819.18 Repair, tendon or muscle, extensor, forearm and/or wrist; primary, single, each tendon or muscle 25272 766.53 Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, single, each tendon or muscle 25274 819.18 Repair, tendon or muscle, extensor, forearm and/or wrist; secondary, with free graft (includes obtaining graft), each tendon or muscle 25275 819.18 Repair, tendon sheath, extensor, forearm and/or wrist, with free graft (includes obtaining graft) (e.g., for extensor carpi ulnaris subluxation) 25280 819.18 Lengthening or shortening of flexor or extensor tendon, forearm and/or wrist, single, each tendon 25290 766.53 Tenotomy, open, flexor or extensor tendon, forearm and/or wrist, single, each tendon 25295 619.40 Tenolysis, flexor or extensor tendon, forearm and/or wrist, single, each tendon 25300 766.53 Tenodesis at wrist; flexors of fingers 25301 766.53 Tenodesis at wrist; extensors of fingers 25310 1,047.54 Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; each tendon 25312 1,100.20 Tendon transplantation or transfer, flexor or extensor, forearm and/or wrist, single; with tendon graft(s) (includes obtaining graft), each tendon 25315 1,047.54 Flexor origin slide (e.g., for cerebral palsy, Volkmann contracture), forearm and/or wrist; 25316 1,796.63 Flexor origin slide (e.g., for cerebral palsy, Volkmann contracture), forearm and/or wrist; with tendon(s) transfer 25320 1,047.54 Capsulorrhaphy or reconstruction, wrist, open (e.g., capsulodesis, ligament repair, tendon transfer or graft) (includes synovectomy, capsulotomy and open reduction) for carpal instability 25332 1,001.75 Arthroplasty, wrist, with or without interposition, with or without external or internal fixation 25335 1,047.54 Centralization of wrist on ulna (e.g., radial club hand) 25337 1,138.37 Reconstruction for stabilization of unstable distal ulna or distal radioulnar joint, secondary by soft tissue stabilization (e.g., tendon transfer, tendon graft or weave, or tenodesis) with or without open reduction of distal radioulnar joint 25350 1,796.63 Osteotomy, radius; distal third 25355 1,047.54 Osteotomy, radius; middle or proximal third 25360 766.53 Osteotomy; ulna 25365 766.53 Osteotomy; radius AND ulna 25370 1,047.54 Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius OR ulna 25375 1,100.20 Multiple osteotomies, with realignment on intramedullary rod (Sofield type procedure); radius AND ulna 25390 766.53 Osteoplasty, radius OR ulna; shortening 25391 1,100.20 Osteoplasty, radius OR ulna; lengthening with autograft 25392 766.53 Osteoplasty, radius AND ulna; shortening (excluding 64876) 25393 1,100.20 Osteoplasty, radius AND ulna; lengthening with autograft 25394 1,647.51 Osteoplasty, carpal bone, shortening 25400 1,047.54 Repair of nonunion or malunion, radius OR ulna; without graft (e.g., compression technique) 25405 1,849.28 Repair of nonunion or malunion, radius OR ulna; with autograft (includes obtaining graft) 25415 1,796.63 Repair of nonunion or malunion, radius AND ulna; without graft (e.g., compression technique) 25420 1,849.28 Repair of nonunion or malunion, radius AND ulna; with autograft (includes obtaining graft)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1502 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

25425 1,047.54 Repair of defect with autograft; radius OR ulna 25426 1,100.20 Repair of defect with autograft; radius AND ulna 25430 1,647.51 Insertion of vascular pedicle into carpal bone (e.g., Hori procedure) 25431 1,647.51 Repair of nonunion of carpal bone (excluding carpal scaphoid (navicular)) (includes obtaining graft and necessary fixation), each bone 25440 1,849.28 Repair of nonunion, scaphoid carpal (navicular) bone, with or without radial styloidectomy (includes obtaining graft and necessary fixation) 25441 5,477.06 Arthroplasty with prosthetic replacement; distal radius 25442 5,477.06 Arthroplasty with prosthetic replacement; distal ulna 25443 1,280.22 Arthroplasty with prosthetic replacement; scaphoid carpal (navicular) 25444 1,280.22 Arthroplasty with prosthetic replacement; lunate 25445 1,280.22 Arthroplasty with prosthetic replacement; trapezium 25446 5,599.04 Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist) 25447 1,001.75 Arthroplasty, interposition, intercarpal or carpometacarpal joints 25449 1,001.75 Revision of arthroplasty, including removal of implant, wrist joint 25450 1,047.54 Epiphyseal arrest by epiphysiodesis or stapling; distal radius OR ulna 25455 1,047.54 Epiphyseal arrest by epiphysiodesis or stapling; distal radius AND ulna 25490 1,047.54 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius 25491 1,047.54 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; ulna 25492 1,047.54 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate; radius AND ulna 25500 58.04 Closed treatment of radial shaft fracture; without manipulation 25505 157.13 Closed treatment of radial shaft fracture; with manipulation 25515 1,002.36 Open treatment of radial shaft fracture, with or without internal or external fixation 25520 157.13 Closed treatment of radial shaft fracture and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation) 25525 1,055.02 Open treatment of radial shaft fracture, with internal and/or external fixation and closed treatment of dislocation of distal radioulnar joint (Galeazzi fracture/dislocation), with or without percutaneous skeletal fixation 25526 1,093.19 Open treatment of radial shaft fracture, with internal and/or external fixation and open treatment, with or without internal or external fixation of distal radioulnar joint (Galeazzi fracture/dislocation), includes repair of triangular fibrocartilage complex 25530 58.04 Closed treatment of ulnar shaft fracture; without manipulation 25535 74.48 Closed treatment of ulnar shaft fracture; with manipulation 25545 1,002.36 Open treatment of ulnar shaft fracture, with or without internal or external fixation 25560 58.04 Closed treatment of radial and ulnar shaft fractures; without manipulation 25565 157.13 Closed treatment of radial and ulnar shaft fractures; with manipulation 25574 1,360.23 Open treatment of radial AND ulnar shaft fractures, with internal or external fixation; of radius OR ulna 25575 1,360.23 Open treatment of radial AND ulnar shaft fractures, with internal or external fixation; of radius AND ulna 25600 58.04 Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; without manipulation 25605 157.13 Closed treatment of distal radial fracture (e.g., Colles or Smith type) or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation 25606 685.94 Percutaneous skeletal fixation of distal radial fracture or epiphyseal separation 25607 1,451.06 Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation 25608 1,451.06 Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 2 fragments

3/5/10 (Effective 1/1/10) 114.3 CMR - 1503 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

25609 1,451.06 Open treatment of distal radial intra-articular fracture or epiphyseal separation; with internal fixation of 3 or more fragments 25622 58.04 Closed treatment of carpal scaphoid (navicular) fracture; without manipulation 25624 157.13 Closed treatment of carpal scaphoid (navicular) fracture; with manipulation 25628 1,002.36 Open treatment of carpal scaphoid (navicular) fracture, with or without internal or external fixation 25630 58.04 Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); without manipulation, each bone 25635 157.13 Closed treatment of carpal bone fracture (excluding carpal scaphoid (navicular)); with manipulation, each bone 25645 1,002.36 Open treatment of carpal bone fracture (other than carpal scaphoid (navicular)), each bone 25650 58.04 Closed treatment of ulnar styloid fracture 25651 924.29 Percutaneous skeletal fixation of ulnar styloid fracture 25652 1,557.14 Open treatment of ulnar styloid fracture 25660 74.48 Closed treatment of radiocarpal or intercarpal dislocation, one or more bones, with manipulation 25670 685.94 Open treatment of radiocarpal or intercarpal dislocation, one or more bones 25671 608.27 Percutaneous skeletal fixation of distal radioulnar dislocation 25675 74.48 Closed treatment of distal radioulnar dislocation with manipulation 25676 657.85 Open treatment of distal radioulnar dislocation, acute or chronic 25680 74.48 Closed treatment of trans-scaphoperilunar type of fracture dislocation, with manipulation 25685 685.94 Open treatment of trans-scaphoperilunar type of fracture dislocation 25690 406.41 Closed treatment of lunate dislocation, with manipulation 25695 657.85 Open treatment of lunate dislocation 25800 1,849.28 Arthrodesis, wrist; complete, without bone graft (includes radiocarpal and/or intercarpal and/or carpometacarpal joints) 25805 1,138.37 Arthrodesis, wrist; with sliding graft 25810 1,887.46 Arthrodesis, wrist; with iliac or other autograft (includes obtaining graft) 25820 1,100.20 Arthrodesis, wrist; limited, without bone graft (e.g., intercarpal or radiocarpal) 25825 1,887.46 Arthrodesis, wrist; with autograft (includes obtaining graft) 25830 1,887.46 Arthrodesis, distal radioulnar joint with segmental resection of ulna, with or without bone graft (e.g., Sauve-Kapandji procedure) 25907 619.40 Amputation, forearm, through radius and ulna; secondary closure or scar revision 25922 619.40 Disarticulation through wrist; secondary closure or scar revision 25929 513.94 Transmetacarpal amputation; secondary closure or scar revision 25931 791.22 Transmetacarpal amputation; re-amputation 26010 51.32 Drainage of finger abscess; simple 26011 374.89 Drainage of finger abscess; complicated (e.g., felon) 26020 497.43 Drainage of tendon sheath, digit and/or palm, each 26025 447.84 Drainage of palmar bursa; single, bursa 26030 497.43 Drainage of palmar bursa; multiple bursa 26034 497.43 Incision, bone cortex, hand or finger (e.g., osteomyelitis or bone abscess) 26035 603.45 Decompression fingers and/or hand, injection injury (e.g., grease gun) 26040 785.00 Fasciotomy, palmar (e.g., Dupuytrens contracture); percutaneous 26045 732.34 Fasciotomy, palmar (e.g., Dupuytrens contracture); open, partial 26055 497.43 Tendon sheath incision (e.g., for trigger finger) 26060 497.43 Tenotomy, percutaneous, single, each digit 26070 497.43 Arthrotomy, with exploration, drainage, or removal of loose or foreign body; carpometacarpal joint 26075 578.17 Arthrotomy, with exploration, drainage, or removal of loose or foreign body; metacarpophalangeal joint, each 26080 578.17 Arthrotomy, with exploration, drainage, or removal of loose or foreign body; interphalangeal joint, each 26100 497.43 Arthrotomy with biopsy; carpometacarpal joint, each

3/5/10 (Effective 1/1/10) 114.3 CMR - 1504 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

26105 447.84 Arthrotomy with biopsy; metacarpophalangeal joint, each 26110 447.84 Arthrotomy with biopsy; interphalangeal joint, each 26115 592.43 Excision, tumor or vascular malformation, soft tissue of hand or finger; subcutaneous 26116 592.43 Excision, tumor or vascular malformation, soft tissue of hand or finger; deep (subfascial or intramuscular) 26117 620.52 Radical resection of tumor (e.g., malignant neoplasm), soft tissue of hand or finger 26121 785.00 Fasciectomy, palm only, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft) 26123 785.00 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); 26125 578.17 Fasciectomy, partial palmar with release of single digit including proximal interphalangeal joint, with or without Z-plasty, other local tissue rearrangement, or skin grafting (includes obtaining graft); each additional digit (List separately in addition to code for primary procedure) 26130 525.51 Synovectomy, carpometacarpal joint 26135 785.00 Synovectomy, metacarpophalangeal joint including intrinsic release and extensor hood reconstruction, each digit 26140 497.43 Synovectomy, proximal interphalangeal joint, including extensor reconstruction, each interphalangeal joint 26145 525.51 Synovectomy, tendon sheath, radical (tenosynovectomy), flexor tendon, palm and/or finger, each tendon 26160 525.51 Excision of lesion of tendon sheath or joint capsule (e.g., cyst, mucous cyst, or ganglion), hand or finger 26170 525.51 Excision of tendon, palm, flexor or extensor, single, each tendon 26180 525.51 Excision of tendon, finger, flexor or extensor, each tendon 26185 578.17 Sesamoidectomy, thumb or finger (separate procedure) 26200 497.43 Excision or curettage of bone cyst or benign tumor of metacarpal; 26205 732.34 Excision or curettage of bone cyst or benign tumor of metacarpal; with autograft (includes obtaining graft) 26210 497.43 Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; 26215 525.51 Excision or curettage of bone cyst or benign tumor of proximal, middle, or distal phalanx of finger; with autograft (includes obtaining graft) 26230 737.42 Partial excision (craterization, saucerization, or diaphysectomy) bone (e.g., osteomyelitis); metacarpal 26235 525.51 Partial excision (craterization, saucerization, or diaphysectomy) bone (e.g., osteomyelitis); proximal or middle phalanx of finger 26236 525.51 Partial excision (craterization, saucerization, or diaphysectomy) bone (e.g., osteomyelitis); distal phalanx of finger 26250 525.51 Radical resection, metacarpal (e.g., tumor); 26255 732.34 Radical resection, metacarpal (e.g., tumor); with autograft (includes obtaining graft) 26260 525.51 Radical resection, proximal or middle phalanx of finger (e.g., tumor); 26261 525.51 Radical resection, proximal or middle phalanx of finger (e.g., tumor); with autograft (includes obtaining graft) 26262 497.43 Radical resection, distal phalanx of finger (e.g., tumor) 26320 484.44 Removal of implant from finger or hand 26340 223.33 Manipulation, finger joint, under anesthesia, each joint 26350 654.67 Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (e.g., no mans land); primary or secondary without free graft, each tendon 26352 785.00 Repair or advancement, flexor tendon, not in zone 2 digital flexor tendon sheath (e.g., no mans land); secondary with free graft (includes obtaining graft), each tendon 26356 785.00 Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (e.g., no mans land); primary, without free graft, each tendon 26357 785.00 Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (e.g., no mans land); secondary, without free graft, each tendon

3/5/10 (Effective 1/1/10) 114.3 CMR - 1505 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

26358 785.00 Repair or advancement, flexor tendon, in zone 2 digital flexor tendon sheath (e.g., no mans land); secondary, with free graft (includes obtaining graft), each tendon 26370 785.00 Repair or advancement of profundus tendon, with intact superficialis tendon; primary, each tendon 26372 785.00 Repair or advancement of profundus tendon, with intact superficialis tendon; secondary with free graft (includes obtaining graft), each tendon 26373 732.34 Repair or advancement of profundus tendon, with intact superficialis tendon; secondary without free graft, each tendon 26390 785.00 Excision flexor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod 26392 732.34 Removal of synthetic rod and insertion of flexor tendon graft, hand or finger (includes obtaining graft), each rod 26410 525.51 Repair, extensor tendon, hand, primary or secondary; without free graft, each tendon 26412 732.34 Repair, extensor tendon, hand, primary or secondary; with free graft (includes obtaining graft), each tendon 26415 785.00 Excision of extensor tendon, with implantation of synthetic rod for delayed tendon graft, hand or finger, each rod 26416 732.34 Removal of synthetic rod and insertion of extensor tendon graft (includes obtaining graft), hand or finger, each rod 26418 578.17 Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon 26420 785.00 Repair, extensor tendon, finger, primary or secondary; with free graft (includes obtaining graft) each tendon 26426 732.34 Repair of extensor tendon, central slip, secondary (e.g., boutonniere deformity); using local tissue(s), including lateral band(s), each finger 26428 732.34 Repair of extensor tendon, central slip, secondary (e.g., boutonniere deformity); with free graft (includes obtaining graft), each finger 26432 525.51 Closed treatment of distal extensor tendon insertion, with or without percutaneous pinning (e.g., mallet finger) 26433 525.51 Repair of extensor tendon, distal insertion, primary or secondary; without graft (e.g., mallet finger) 26434 732.34 Repair of extensor tendon, distal insertion, primary or secondary; with free graft (includes obtaining graft) 26437 525.51 Realignment of extensor tendon, hand, each tendon 26440 525.51 Tenolysis, flexor tendon; palm OR finger, each tendon 26442 732.34 Tenolysis, flexor tendon; palm AND finger, each tendon 26445 525.51 Tenolysis, extensor tendon, hand OR finger, each tendon 26449 732.34 Tenolysis, complex, extensor tendon, finger, including forearm, each tendon 26450 525.51 Tenotomy, flexor, palm, open, each tendon 26455 525.51 Tenotomy, flexor, finger, open, each tendon 26460 525.51 Tenotomy, extensor, hand or finger, open, each tendon 26471 497.43 Tenodesis; of proximal interphalangeal joint, each joint 26474 497.43 Tenodesis; of distal joint, each joint 26476 447.84 Lengthening of tendon, extensor, hand or finger, each tendon 26477 447.84 Shortening of tendon, extensor, hand or finger, each tendon 26478 447.84 Lengthening of tendon, flexor, hand or finger, each tendon 26479 447.84 Shortening of tendon, flexor, hand or finger, each tendon 26480 732.34 Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; without free graft, each tendon 26483 732.34 Transfer or transplant of tendon, carpometacarpal area or dorsum of hand; with free tendon graft (includes obtaining graft), each tendon 26485 704.26 Transfer or transplant of tendon, palmar; without free tendon graft, each tendon 26489 732.34 Transfer or transplant of tendon, palmar; with free tendon graft (includes obtaining graft), each tendon 26490 732.34 Opponensplasty; superficialis tendon transfer type, each tendon 26492 732.34 Opponensplasty; tendon transfer with graft (includes obtaining graft), each tendon 26494 732.34 Opponensplasty; hypothenar muscle transfer

3/5/10 (Effective 1/1/10) 114.3 CMR - 1506 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

26496 732.34 Opponensplasty; other methods 26497 732.34 Transfer of tendon to restore intrinsic function; ring and small finger 26498 785.00 Transfer of tendon to restore intrinsic function; all four fingers 26499 732.34 Correction claw finger, other methods 26500 578.17 Reconstruction of tendon pulley, each tendon; with local tissues (separate procedure) 26502 785.00 Reconstruction of tendon pulley, each tendon; with tendon or fascial graft (includes obtaining graft) (separate procedure) 26508 525.51 Release of thenar muscle(s) (e.g., thumb contracture) 26510 732.34 Cross intrinsic transfer, each tendon 26516 654.67 Capsulodesis, metacarpophalangeal joint; single digit 26517 732.34 Capsulodesis, metacarpophalangeal joint; two digits 26518 732.34 Capsulodesis, metacarpophalangeal joint; three or four digits 26520 525.51 Capsulectomy or capsulotomy; metacarpophalangeal joint, each joint 26525 525.51 Capsulectomy or capsulotomy; interphalangeal joint, each joint 26530 910.92 Arthroplasty, metacarpophalangeal joint; each joint 26531 1,402.21 Arthroplasty, metacarpophalangeal joint; with prosthetic implant, each joint 26535 1,001.75 Arthroplasty, interphalangeal joint; each joint 26536 1,280.22 Arthroplasty, interphalangeal joint; with prosthetic implant, each joint 26540 578.17 Repair of collateral ligament, metacarpophalangeal or interphalangeal joint 26541 945.15 Reconstruction, collateral ligament, metacarpophalangeal joint, single; with tendon or fascial graft (includes obtaining graft) 26542 578.17 Reconstruction, collateral ligament, metacarpophalangeal joint, single; with local tissue (e.g., adductor advancement) 26545 785.00 Reconstruction, collateral ligament, interphalangeal joint, single, including graft, each joint 26546 785.00 Repair non-union, metacarpal or phalanx, (includes obtaining bone graft with or without external or internal fixation) 26548 785.00 Repair and reconstruction, finger, volar plate, interphalangeal joint 26550 704.26 Pollicization of a digit 26555 732.34 Transfer, finger to another position without microvascular anastomosis 26560 497.43 Repair of syndactyly (web finger) each web space; with skin flaps 26561 732.34 Repair of syndactyly (web finger) each web space; with skin flaps and grafts 26562 785.00 Repair of syndactyly (web finger) each web space; complex (e.g., involving bone, nails) 26565 823.17 Osteotomy; metacarpal, each 26567 823.17 Osteotomy; phalanx of finger, each 26568 732.34 Osteoplasty, lengthening, metacarpal or phalanx 26580 616.34 Repair cleft hand 26587 616.34 Reconstruction of polydactylous digit, soft tissue and bone 26590 616.34 Repair macrodactylia, each digit 26591 732.34 Repair, intrinsic muscles of hand, each muscle 26593 525.51 Release, intrinsic muscles of hand, each muscle 26596 497.43 Excision of constricting ring of finger, with multiple Z-plasties 26600 58.04 Closed treatment of metacarpal fracture, single; without manipulation, each bone 26605 74.48 Closed treatment of metacarpal fracture, single; with manipulation, each bone 26607 406.41 Closed treatment of metacarpal fracture, with manipulation, with external fixation, each bone 26608 738.59 Percutaneous skeletal fixation of metacarpal fracture, each bone 26615 1,055.02 Open treatment of metacarpal fracture, single, with or without internal or external fixation, each bone 26641 58.04 Closed treatment of carpometacarpal dislocation, thumb, with manipulation 26645 157.13 Closed treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation 26650 657.85 Percutaneous skeletal fixation of carpometacarpal fracture dislocation, thumb (Bennett fracture), with manipulation, with or without external fixation

3/5/10 (Effective 1/1/10) 114.3 CMR - 1507 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

26665 1,055.02 Open treatment of carpometacarpal fracture dislocation, thumb (Bennett fracture), with or without internal or external fixation 26670 58.04 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; without anesthesia 26675 157.13 Closed treatment of carpometacarpal dislocation, other than thumb, with manipulation, each joint; requiring anesthesia 26676 657.85 Percutaneous skeletal fixation of carpometacarpal dislocation, other than thumb, with manipulation, each joint 26685 685.94 Open treatment of carpometacarpal dislocation, other than thumb; with or without internal or external fixation, each joint 26686 1,360.23 Open treatment of carpometacarpal dislocation, other than thumb; complex, multiple or delayed reduction 26700 58.04 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; without anesthesia 26705 74.48 Closed treatment of metacarpophalangeal dislocation, single, with manipulation; requiring anesthesia 26706 406.41 Percutaneous skeletal fixation of metacarpophalangeal dislocation, single, with manipulation 26715 738.59 Open treatment of metacarpophalangeal dislocation, single, with or without internal or external fixation 26720 58.04 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; without manipulation, each 26725 58.04 Closed treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb; with manipulation, with or without skin or skeletal traction, each 26727 898.75 Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with manipulation, each 26735 738.59 Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, with or without internal or external fixation, each 26740 58.04 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; without manipulation, each 26742 74.48 Closed treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint; with manipulation, each 26746 776.76 Open treatment of articular fracture, involving metacarpophalangeal or interphalangeal joint, with or without internal or external fixation, each 26750 58.04 Closed treatment of distal phalangeal fracture, finger or thumb; without manipulation, each 26755 58.04 Closed treatment of distal phalangeal fracture, finger or thumb; with manipulation, each 26756 657.85 Percutaneous skeletal fixation of distal phalangeal fracture, finger or thumb, each 26765 738.59 Open treatment of distal phalangeal fracture, finger or thumb, with or without internal or external fixation, each 26770 58.04 Closed treatment of interphalangeal joint dislocation, single, with manipulation; without anesthesia 26775 155.16 Closed treatment of interphalangeal joint dislocation, single, with manipulation; requiring anesthesia 26776 657.85 Percutaneous skeletal fixation of interphalangeal joint dislocation, single, with manipulation 26785 657.85 Open treatment of interphalangeal joint dislocation, with or without internal or external fixation, single 26820 823.17 Fusion in opposition, thumb, with autogenous graft (includes obtaining graft) 26841 785.00 Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; 26842 785.00 Arthrodesis, carpometacarpal joint, thumb, with or without internal fixation; with autograft (includes obtaining graft) 26843 732.34 Arthrodesis, carpometacarpal joint, digit, other than thumb, each; 26844 732.34 Arthrodesis, carpometacarpal joint, digit, other than thumb, each; with autograft (includes obtaining graft)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1508 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

26850 785.00 Arthrodesis, metacarpophalangeal joint, with or without internal fixation; 26852 785.00 Arthrodesis, metacarpophalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) 26860 732.34 Arthrodesis, interphalangeal joint, with or without internal fixation; 26861 704.26 Arthrodesis, interphalangeal joint, with or without internal fixation; each additional interphalangeal joint (List separately in addition to code for primary procedure) 26862 785.00 Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft) 26863 732.34 Arthrodesis, interphalangeal joint, with or without internal fixation; with autograft (includes obtaining graft), each additional joint (List separately in addition to code for primary procedure) 26910 732.34 Amputation, metacarpal, with finger or thumb (ray amputation), single, with or without interosseous transfer 26951 497.43 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure 26952 578.17 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with local advancement flaps (V-Y, hood) 26990 541.73 Incision and drainage, pelvis or hip joint area; deep abscess or hematoma 26991 541.73 Incision and drainage, pelvis or hip joint area; infected bursa 27000 591.31 Tenotomy, adductor of hip, percutaneous (separate procedure) 27001 766.53 Tenotomy, adductor of hip, open 27003 766.53 Tenotomy, adductor, subcutaneous, open, with obturator neurectomy 27033 1,047.54 Arthrotomy, hip, including exploration or removal of loose or foreign body 27035 1,100.20 Denervation, hip joint, intrapelvic or extrapelvic intra-articular branches of sciatic, femoral, or obturator nerves 27040 296.08 Biopsy, soft tissue of pelvis and hip area; superficial 27041 333.59 Biopsy, soft tissue of pelvis and hip area; deep, subfascial or intramuscular 27047 592.43 Excision, tumor, pelvis and hip area; subcutaneous tissue 27048 620.52 Excision, tumor, pelvis and hip area; deep, subfascial, intramuscular 27049 620.52 Radical resection of tumor, soft tissue of pelvis and hip area (e.g., malignant neoplasm) 27050 619.40 Arthrotomy, with biopsy; sacroiliac joint 27052 619.40 Arthrotomy, with biopsy; hip joint 27060 710.23 Excision; ischial bursa 27062 710.23 Excision; trochanteric bursa or calcification 27065 710.23 Excision of bone cyst or benign tumor; superficial (wing of ilium, symphysis pubis, or greater trochanter of femur) with or without autograft 27066 857.36 Excision of bone cyst or benign tumor; deep, with or without autograft 27067 857.36 Excision of bone cyst or benign tumor; with autograft requiring separate incision 27080 738.44 Coccygectomy, primary 27086 296.08 Removal of foreign body, pelvis or hip; subcutaneous tissue 27087 619.40 Removal of foreign body, pelvis or hip; deep (subfascial or intramuscular) 27097 766.53 Release or recession, hamstring, proximal 27098 766.53 Transfer, adductor to ischium 27100 1,100.20 Transfer external oblique muscle to greater trochanter including fascial or tendon extension (graft) 27105 1,100.20 Transfer paraspinal muscle to hip (includes fascial or tendon extension graft) 27110 1,100.20 Transfer iliopsoas; to greater trochanter of femur 27111 1,100.20 Transfer iliopsoas; to femoral neck 27193 74.48 Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; without manipulation 27194 478.45 Closed treatment of pelvic ring fracture, dislocation, diastasis or subluxation; with manipulation, requiring more than local anesthesia 27200 58.04 Closed treatment of coccygeal fracture 27202 974.28 Open treatment of coccygeal fracture 27220 58.04 Closed treatment of acetabulum (hip socket) fracture(s); without manipulation

3/5/10 (Effective 1/1/10) 114.3 CMR - 1509 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

27230 74.48 Closed treatment of femoral fracture, proximal end, neck; without manipulation 27238 157.13 Closed treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; without manipulation 27246 157.13 Closed treatment of greater trochanteric fracture, without manipulation 27250 74.48 Closed treatment of hip dislocation, traumatic; without anesthesia 27252 478.45 Closed treatment of hip dislocation, traumatic; requiring anesthesia 27256 58.04 Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; without anesthesia, without manipulation 27257 506.54 Treatment of spontaneous hip dislocation (developmental, including congenital or pathological), by abduction, splint or traction; with manipulation, requiring anesthesia 27265 74.48 Closed treatment of post hip arthroplasty dislocation; without anesthesia 27266 478.45 Closed treatment of post hip arthroplasty dislocation; requiring regional or general anesthesia 27267 58.04 Closed treatment of femoral fracture, proximal end, head; without manipulation 27275 478.45 Manipulation, hip joint, requiring general anesthesia 27301 575.92 Incision and drainage, deep abscess, bursa, or hematoma, thigh or knee region 27305 591.31 Fasciotomy, iliotibial (tenotomy), open 27306 619.40 Tenotomy, percutaneous, adductor or hamstring; single tendon (separate procedure) 27307 619.40 Tenotomy, percutaneous, adductor or hamstring; multiple tendons 27310 819.18 Arthrotomy, knee, with exploration, drainage, or removal of foreign body (e.g., infection) 27323 296.08 Biopsy, soft tissue of thigh or knee area; superficial 27324 542.85 Biopsy, soft tissue of thigh or knee area; deep (subfascial or intramuscular) 27325 531.92 Neurectomy, hamstring muscle 27326 531.92 Neurectomy, popliteal (gastrocnemius) 27327 592.43 Excision, tumor, thigh or knee area; subcutaneous 27328 620.52 Excision, tumor, thigh or knee area; deep, subfascial, or intramuscular 27329 673.17 Radical resection of tumor (e.g., malignant neoplasm), soft tissue of thigh or knee area 27330 819.18 Arthrotomy, knee; with synovial biopsy only 27331 819.18 Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies 27332 819.18 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral 27333 819.18 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral 27334 819.18 Arthrotomy, with synovectomy, knee; anterior OR posterior 27335 819.18 Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area 27340 619.40 Excision, prepatellar bursa 27345 672.05 Excision of synovial cyst of popliteal space (e.g., Bakers cyst) 27347 672.05 Excision of lesion of meniscus or capsule (e.g., cyst, ganglion), knee 27350 819.18 Patellectomy or hemipatellectomy 27355 766.53 Excision or curettage of bone cyst or benign tumor of femur; 27356 819.18 Excision or curettage of bone cyst or benign tumor of femur; with allograft 27357 857.36 Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes obtaining graft) 27358 857.36 Excision or curettage of bone cyst or benign tumor of femur; with internal fixation (List in addition to code for primary procedure) 27360 857.36 Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, proximal tibia and/or fibula (e.g., osteomyelitis or bone abscess) 27372 833.34 Removal of foreign body, deep, thigh region or knee area 27380 541.73 Suture of infrapatellar tendon; primary 27381 619.40 Suture of infrapatellar tendon; secondary reconstruction, including fascial or tendon graft 27385 619.40 Suture of quadriceps or hamstring muscle rupture; primary

3/5/10 (Effective 1/1/10) 114.3 CMR - 1510 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

27386 619.40 Suture of quadriceps or hamstring muscle rupture; secondary reconstruction, including fascial or tendon graft 27390 541.73 Tenotomy, open, hamstring, knee to hip; single tendon 27391 591.31 Tenotomy, open, hamstring, knee to hip; multiple tendons, one leg 27392 619.40 Tenotomy, open, hamstring, knee to hip; multiple tendons, bilateral 27393 738.44 Lengthening of hamstring tendon; single tendon 27394 766.53 Lengthening of hamstring tendon; multiple tendons, one leg 27395 1,047.54 Lengthening of hamstring tendon; multiple tendons, bilateral 27396 766.53 Transplant, hamstring tendon to patella; single tendon 27397 1,047.54 Transplant, hamstring tendon to patella; multiple tendons 27400 1,047.54 Transfer, tendon or muscle, hamstrings to femur (e.g., Eggers type procedure) 27403 819.18 Arthrotomy with meniscus repair, knee 27405 1,100.20 Repair, primary, torn ligament and/or capsule, knee; collateral 27407 1,849.28 Repair, primary, torn ligament and/or capsule, knee; cruciate 27409 1,100.20 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments 27416 1,647.51 Osteochondral autograft(s), knee, open (e.g., mosaicplasty) (includes harvesting of autograft[s]) 27418 1,047.54 Anterior tibial tubercleplasty (e.g., Maquet type procedure) 27420 1,047.54 Reconstruction of dislocating patella; (e.g., Hauser type procedure) 27422 1,260.35 Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (e.g., Campbell, Goldwaite type procedure) 27424 1,047.54 Reconstruction of dislocating patella; with patellectomy 27425 979.34 Lateral retinacular release, open 27427 1,047.54 Ligamentous reconstruction (augmentation), knee; extra-articular 27428 1,849.28 Ligamentous reconstruction (augmentation), knee; intra-articular (open) 27429 1,849.28 Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular 27430 1,100.20 Quadricepsplasty (e.g., Bennett or Thompson type) 27435 1,100.20 Capsulotomy, posterior capsular release, knee 27437 963.57 Arthroplasty, patella; without prosthesis 27438 1,280.22 Arthroplasty, patella; with prosthesis 27440 1,374.26 Arthroplasty, knee, tibial plateau; 27441 1,001.75 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy 27442 1,001.75 Arthroplasty, femoral condyles or tibial plateau(s), knee; 27443 1,001.75 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy 27446 9,829.05 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment 27496 710.23 Decompression fasciotomy, thigh and/or knee, one compartment (flexor or extensor or adductor); 27497 619.40 Decompression fasciotomy, thigh and/or knee, one compartment (flexor or extensor or adductor); with debridement of nonviable muscle and/or nerve 27498 619.40 Decompression fasciotomy, thigh and/or knee, multiple compartments; 27499 619.40 Decompression fasciotomy, thigh and/or knee, multiple compartments; with debridement of nonviable muscle and/or nerve 27500 157.13 Closed treatment of femoral shaft fracture, without manipulation 27501 74.48 Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, without manipulation 27502 406.41 Closed treatment of femoral shaft fracture, with manipulation, with or without skin or skeletal traction 27503 74.48 Closed treatment of supracondylar or transcondylar femoral fracture with or without intercondylar extension, with manipulation, with or without skin or skeletal traction 27508 74.48 Closed treatment of femoral fracture, distal end, medial or lateral condyle, without manipulation 27509 685.94 Percutaneous skeletal fixation of femoral fracture, distal end, medial or lateral condyle, or supracondylar or transcondylar, with or without intercondylar extension, or distal femoral epiphyseal separation

3/5/10 (Effective 1/1/10) 114.3 CMR - 1511 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

27510 157.13 Closed treatment of femoral fracture, distal end, medial or lateral condyle, with manipulation 27516 74.48 Closed treatment of distal femoral epiphyseal separation; without manipulation 27517 74.48 Closed treatment of distal femoral epiphyseal separation; with manipulation, with or without skin or skeletal traction 27520 74.48 Closed treatment of patellar fracture, without manipulation 27530 74.48 Closed treatment of tibial fracture, proximal (plateau); without manipulation 27532 406.41 Closed treatment of tibial fracture, proximal (plateau); with or without manipulation, with skeletal traction 27538 74.48 Closed treatment of intercondylar spine(s) and/or tuberosity fracture(s) of knee, with or without manipulation 27550 74.48 Closed treatment of knee dislocation; without anesthesia 27552 428.87 Closed treatment of knee dislocation; requiring anesthesia 27560 74.48 Closed treatment of patellar dislocation; without anesthesia 27562 428.87 Closed treatment of patellar dislocation; requiring anesthesia 27566 974.28 Open treatment of patellar dislocation, with or without partial or total patellectomy 27570 428.87 Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices) 27594 619.40 Amputation, thigh, through femur, any level; secondary closure or scar revision 27600 619.40 Decompression fasciotomy, leg; anterior and/or lateral compartments only 27601 619.40 Decompression fasciotomy, leg; posterior compartment(s) only 27602 619.40 Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s) 27603 547.84 Incision and drainage, leg or ankle; deep abscess or hematoma 27604 591.31 Incision and drainage, leg or ankle; infected bursa 27605 538.82 Tenotomy, percutaneous, Achilles tendon (separate procedure); local anesthesia 27606 541.73 Tenotomy, percutaneous, Achilles tendon (separate procedure); general anesthesia 27607 591.31 Incision (e.g., osteomyelitis or bone abscess), leg or ankle 27610 738.44 Arthrotomy, ankle, including exploration, drainage, or removal of foreign body 27612 766.53 Arthrotomy, posterior capsular release, ankle, with or without Achilles tendon lengthening 27613 121.73 Biopsy, soft tissue of leg or ankle area; superficial 27614 592.43 Biopsy, soft tissue of leg or ankle area; deep (subfascial or intramuscular) 27615 766.53 Radical resection of tumor (e.g., malignant neoplasm), soft tissue of leg or ankle area 27618 484.44 Excision, tumor, leg or ankle area; subcutaneous tissue 27619 620.52 Excision, tumor, leg or ankle area; deep (subfascial or intramuscular) 27620 819.18 Arthrotomy, ankle, with joint exploration, with or without biopsy, with or without removal of loose or foreign body 27625 819.18 Arthrotomy, with synovectomy, ankle; 27626 819.18 Arthrotomy, with synovectomy, ankle; including tenosynovectomy 27630 619.40 Excision of lesion of tendon sheath or capsule (e.g., cyst or ganglion), leg and/or ankle 27635 766.53 Excision or curettage of bone cyst or benign tumor, tibia or fibula; 27637 766.53 Excision or curettage of bone cyst or benign tumor, tibia or fibula; with autograft (includes obtaining graft) 27638 766.53 Excision or curettage of bone cyst or benign tumor, tibia or fibula; with allograft 27640 1,019.46 Partial excision (craterization, saucerization, or diaphysectomy) bone (e.g., osteomyelitis or exostosis); tibia 27641 738.44 Partial excision (craterization, saucerization, or diaphysectomy) bone (e.g., osteomyelitis or exostosis); fibula 27647 1,047.54 Radical resection of tumor, bone; talus or calcaneus 27650 1,047.54 Repair, primary, open or percutaneous, ruptured Achilles tendon; 27652 1,796.63 Repair, primary, open or percutaneous, ruptured Achilles tendon; with graft (includes obtaining graft) 27654 1,047.54 Repair, secondary, Achilles tendon, with or without graft 27656 591.31 Repair, fascial defect of leg 27658 541.73 Repair, flexor tendon, leg; primary, without graft, each tendon 27659 591.31 Repair, flexor tendon, leg; secondary, with or without graft, each tendon

3/5/10 (Effective 1/1/10) 114.3 CMR - 1512 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

27664 591.31 Repair, extensor tendon, leg; primary, without graft, each tendon 27665 738.44 Repair, extensor tendon, leg; secondary, with or without graft, each tendon 27675 591.31 Repair, dislocating peroneal tendons; without fibular osteotomy 27676 766.53 Repair, dislocating peroneal tendons; with fibular osteotomy 27680 766.53 Tenolysis, flexor or extensor tendon, leg and/or ankle; single, each tendon 27681 738.44 Tenolysis, flexor or extensor tendon, leg and/or ankle; multiple tendons (through separate incision(s)) 27685 766.53 Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure) 27686 766.53 Lengthening or shortening of tendon, leg or ankle; multiple tendons (through same incision), each 27687 766.53 Gastrocnemius recession (e.g., Strayer procedure) 27690 1,100.20 Transfer or transplant of single tendon (with muscle redirection or rerouting); superficial (e.g., anterior tibial extensors into midfoot) 27691 1,100.20 Transfer or transplant of single tendon (with muscle redirection or rerouting); deep (e.g., anterior tibial or posterior tibial through interosseous space, flexor digitorum longus, flexor hallucis longus, or peroneal tendon to midfoot or hindfoot) 27692 1,047.54 Transfer or transplant of single tendon (with muscle redirection or rerouting); each additional tendon (List separately in addition to code for primary procedure) 27695 738.44 Repair, primary, disrupted ligament, ankle; collateral 27696 738.44 Repair, primary, disrupted ligament, ankle; both collateral ligaments 27698 738.44 Repair, secondary, disrupted ligament, ankle, collateral (e.g., Watson-Jones procedure) 27700 1,001.75 Arthroplasty, ankle; 27704 591.31 Removal of ankle implant 27705 1,019.46 Osteotomy; tibia 27707 591.31 Osteotomy; fibula 27709 738.44 Osteotomy; tibia and fibula 27726 924.29 Repair of fibula nonunion and/or malunion with internal fixation 27730 738.44 Arrest, epiphyseal (epiphysiodesis), open; distal tibia 27732 738.44 Arrest, epiphyseal (epiphysiodesis), open; distal fibula 27734 738.44 Arrest, epiphyseal (epiphysiodesis), open; distal tibia and fibula 27740 738.44 Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; 27742 1,019.46 Arrest, epiphyseal (epiphysiodesis), any method, combined, proximal and distal tibia and fibula; and distal femur 27745 1,796.63 Prophylactic treatment (nailing, pinning, plating or wiring) with or without methylmethacrylate, tibia 27750 74.48 Closed treatment of tibial shaft fracture (with or without fibular fracture); without manipulation 27752 406.41 Closed treatment of tibial shaft fracture (with or without fibular fracture); with manipulation, with or without skeletal traction 27756 685.94 Percutaneous skeletal fixation of tibial shaft fracture (with or without fibular fracture) (e.g., pins or screws) 27758 1,055.02 Open treatment of tibial shaft fracture, (with or without fibular fracture) with plate/screws, with or without cerclage 27759 1,412.88 Treatment of tibial shaft fracture (with or without fibular fracture) by intramedullary implant, with or without interlocking screws and/or cerclage 27760 74.48 Closed treatment of medial malleolus fracture; without manipulation 27762 406.41 Closed treatment of medial malleolus fracture; with manipulation, with or without skin or skeletal traction 27766 1,002.36 Open treatment of medial malleolus fracture, with or without internal or external fixation 27767 58.04 Closed treatment of posterior malleolus fracture; without manipulation 27768 58.04 Closed treatment of posterior malleolus fracture; with manipulation 27769 1,557.14 Open treatment of posterior malleolus fracture, includes internal fixation, when performed

3/5/10 (Effective 1/1/10) 114.3 CMR - 1513 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

27780 74.48 Closed treatment of proximal fibula or shaft fracture; without manipulation 27781 406.41 Closed treatment of proximal fibula or shaft fracture; with manipulation 27784 1,002.36 Open treatment of proximal fibula or shaft fracture, with or without internal or external fixation 27786 74.48 Closed treatment of distal fibular fracture (lateral malleolus); without manipulation 27788 74.48 Closed treatment of distal fibular fracture (lateral malleolus); with manipulation 27792 1,002.36 Open treatment of distal fibular fracture (lateral malleolus), with or without internal or external fixation 27808 74.48 Closed treatment of bimalleolar ankle fracture, (including Potts); without manipulation 27810 157.13 Closed treatment of bimalleolar ankle fracture, (including Potts); with manipulation 27814 1,002.36 Open treatment of bimalleolar ankle fracture, with or without internal or external fixation 27816 74.48 Closed treatment of trimalleolar ankle fracture; without manipulation 27818 157.13 Closed treatment of trimalleolar ankle fracture; with manipulation 27822 1,002.36 Open treatment of trimalleolar ankle fracture, with or without internal or external fixation, medial and/or lateral malleolus; without fixation of posterior lip 27823 1,360.23 Open treatment of trimalleolar ankle fracture, with or without internal or external fixation, medial and/or lateral malleolus; with fixation of posterior lip 27824 74.48 Closed treatment of fracture of weight bearing articular portion of distal tibia (e.g., pilon or tibial plafond), with or without anesthesia; without manipulation 27825 406.41 Closed treatment of fracture of weight bearing articular portion of distal tibia (e.g., pilon or tibial plafond), with or without anesthesia; with skeletal traction and/or requiring manipulation 27826 1,002.36 Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), with internal or external fixation; of fibula only 27827 1,360.23 Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), with internal or external fixation; of tibia only 27828 1,412.88 Open treatment of fracture of weight bearing articular surface/portion of distal tibia (e.g., pilon or tibial plafond), with internal or external fixation; of both tibia and fibula 27829 974.28 Open treatment of distal tibiofibular joint (syndesmosis) disruption, with or without internal or external fixation 27830 74.48 Closed treatment of proximal tibiofibular joint dislocation; without anesthesia 27831 406.41 Closed treatment of proximal tibiofibular joint dislocation; requiring anesthesia 27832 974.28 Open treatment of proximal tibiofibular joint dislocation, with or without internal or external fixation, or with excision of proximal fibula 27840 157.13 Closed treatment of ankle dislocation; without anesthesia 27842 428.87 Closed treatment of ankle dislocation; requiring anesthesia, with or without percutaneous skeletal fixation 27846 1,002.36 Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; without repair or internal fixation 27848 1,002.36 Open treatment of ankle dislocation, with or without percutaneous skeletal fixation; with repair or internal or external fixation 27860 428.87 Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus) 27870 1,849.28 Arthrodesis, ankle, open 27871 1,849.28 Arthrodesis, tibiofibular joint, proximal or distal 27884 619.40 Amputation, leg, through tibia and fibula; secondary closure or scar revision 27889 766.53 Ankle disarticulation 27892 619.40 Decompression fasciotomy, leg; anterior and/or lateral compartments only, with debridement of nonviable muscle and/or nerve 27893 619.40 Decompression fasciotomy, leg; posterior compartment(s) only, with debridement of nonviable muscle and/or nerve 27894 619.40 Decompression fasciotomy, leg; anterior and/or lateral, and posterior compartment(s), with debridement of nonviable muscle and/or nerve

3/5/10 (Effective 1/1/10) 114.3 CMR - 1514 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

28001 118.80 Incision and drainage, bursa, foot 28002 619.40 Incision and drainage below fascia, with or without tendon sheath involvement, foot; single bursal space 28003 619.40 Incision and drainage below fascia, with or without tendon sheath involvement, foot; multiple areas 28005 616.49 Incision, bone cortex (e.g., osteomyelitis or bone abscess), foot 28008 616.49 Fasciotomy, foot and/or toe 28010 87.32 Tenotomy, percutaneous, toe; single tendon 28011 616.49 Tenotomy, percutaneous, toe; multiple tendons 28020 588.40 Arthrotomy, including exploration, drainage, or removal of loose or foreign body; intertarsal or tarsometatarsal joint 28022 588.40 Arthrotomy, including exploration, drainage, or removal of loose or foreign body; metatarsophalangeal joint 28024 588.40 Arthrotomy, including exploration, drainage, or removal of loose or foreign body; interphalangeal joint 28035 612.66 Release, tarsal tunnel (posterior tibial nerve decompression) 28043 592.43 Excision, tumor, foot; subcutaneous tissue 28045 616.49 Excision, tumor, foot; deep, subfascial, intramuscular 28046 616.49 Radical resection of tumor (e.g., malignant neoplasm), soft tissue of foot 28050 588.40 Arthrotomy with biopsy; intertarsal or tarsometatarsal joint 28052 588.40 Arthrotomy with biopsy; metatarsophalangeal joint 28054 588.40 Arthrotomy with biopsy; interphalangeal joint 28055 612.66 Neurectomy, intrinsic musculature of foot 28060 588.40 Fasciectomy, plantar fascia; partial (separate procedure) 28062 616.49 Fasciectomy, plantar fascia; radical (separate procedure) 28070 616.49 Synovectomy; intertarsal or tarsometatarsal joint, each 28072 616.49 Synovectomy; metatarsophalangeal joint, each 28080 616.49 Excision, interdigital (Morton) neuroma, single, each 28086 588.40 Synovectomy, tendon sheath, foot; flexor 28088 588.40 Synovectomy, tendon sheath, foot; extensor 28090 616.49 Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (e.g., cyst or ganglion); foot 28092 616.49 Excision of lesion, tendon, tendon sheath, or capsule (including synovectomy) (e.g., cyst or ganglion); toe(s), each 28100 588.40 Excision or curettage of bone cyst or benign tumor, talus or calcaneus; 28102 1,082.75 Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with iliac or other autograft (includes obtaining graft) 28103 1,082.75 Excision or curettage of bone cyst or benign tumor, talus or calcaneus; with allograft 28104 588.40 Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; 28106 1,082.75 Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; with iliac or other autograft (includes obtaining graft) 28107 1,082.75 Excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus; with allograft 28108 588.40 Excision or curettage of bone cyst or benign tumor, phalanges of foot 28110 616.49 Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure) 28111 616.49 Ostectomy, complete excision; first metatarsal head 28112 616.49 Ostectomy, complete excision; other metatarsal head (second, third or fourth) 28113 616.49 Ostectomy, complete excision; fifth metatarsal head 28114 616.49 Ostectomy, complete excision; all metatarsal heads, with partial proximal phalangectomy, excluding first metatarsal (e.g., Clayton type procedure) 28116 616.49 Ostectomy, excision of tarsal coalition 28118 669.14 Ostectomy, calcaneus; 28119 669.14 Ostectomy, calcaneus; for spur, with or without plantar fascial release 28120 829.31 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (e.g., osteomyelitis or bossing); talus or calcaneus

3/5/10 (Effective 1/1/10) 114.3 CMR - 1515 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

28122 616.49 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (e.g., osteomyelitis or bossing); tarsal or metatarsal bone, except talus or calcaneus 28124 200.93 Partial excision (craterization, saucerization, sequestrectomy, or diaphysectomy) bone (e.g., osteomyelitis or bossing); phalanx of toe 28126 616.49 Resection, partial or complete, phalangeal base, each toe 28130 616.49 Talectomy (astragalectomy) 28140 616.49 Metatarsectomy 28150 616.49 Phalangectomy, toe, each toe 28153 616.49 Resection, condyle(s), distal end of phalanx, each toe 28160 616.49 Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each 28171 616.49 Radical resection of tumor, bone; tarsal (except talus or calcaneus) 28173 616.49 Radical resection of tumor, bone; metatarsal 28175 616.49 Radical resection of tumor, bone; phalanx of toe 28190 122.70 Removal of foreign body, foot; subcutaneous 28192 484.44 Removal of foreign body, foot; deep 28193 333.59 Removal of foreign body, foot; complicated 28200 616.49 Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon 28202 616.49 Repair, tendon, flexor, foot; secondary with free graft, each tendon (includes obtaining graft) 28208 616.49 Repair, tendon, extensor, foot; primary or secondary, each tendon 28210 1,082.75 Repair, tendon, extensor, foot; secondary with free graft, each tendon (includes obtaining graft) 28220 189.24 Tenolysis, flexor, foot; single tendon 28222 538.82 Tenolysis, flexor, foot; multiple tendons 28225 538.82 Tenolysis, extensor, foot; single tendon 28226 538.82 Tenolysis, extensor, foot; multiple tendons 28230 185.67 Tenotomy, open, tendon flexor; foot, single or multiple tendon(s) (separate procedure) 28232 177.55 Tenotomy, open, tendon flexor; toe, single tendon (separate procedure) 28234 588.40 Tenotomy, open, extensor, foot or toe, each tendon 28238 1,082.75 Reconstruction (advancement), posterior tibial tendon with excision of accessory tarsal navicular bone (e.g., Kidner type procedure) 28240 588.40 Tenotomy, lengthening, or release, abductor hallucis muscle 28250 616.49 Division of plantar fascia and muscle (e.g., Steindler stripping) (separate procedure) 28260 616.49 Capsulotomy, midfoot; medial release only (separate procedure) 28261 616.49 Capsulotomy, midfoot; with tendon lengthening 28262 669.14 Capsulotomy, midfoot; extensive, including posterior talotibial capsulotomy and tendon(s) lengthening (e.g., resistant clubfoot deformity) 28264 1,005.08 Capsulotomy, midtarsal (e.g., Heyman type procedure) 28270 616.49 Capsulotomy; metatarsophalangeal joint, with or without tenorrhaphy, each joint (separate procedure) 28272 171.39 Capsulotomy; interphalangeal joint, each joint (separate procedure) 28280 588.40 Syndactylization, toes (e.g., webbing or Kelikian type procedure) 28285 616.49 Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy) 28286 669.14 Correction, cock-up fifth toe, with plastic skin closure (e.g., Ruiz-Mora type procedure) 28288 616.49 Ostectomy, partial, exostectomy or condylectomy, metatarsal head, each metatarsal head 28289 616.49 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint 28290 759.91 Correction, hallux valgus (bunion), with or without sesamoidectomy; simple exostectomy (e.g., Silver type procedure) 28292 759.91 Correction, hallux valgus (bunion), with or without sesamoidectomy; Keller, McBride, or Mayo type procedure

3/5/10 (Effective 1/1/10) 114.3 CMR - 1516 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

28293 787.99 Correction, hallux valgus (bunion), with or without sesamoidectomy; resection of joint with implant 28294 787.99 Correction, hallux valgus (bunion), with or without sesamoidectomy; with tendon transplants (e.g., Joplin type procedure) 28296 787.99 Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy (e.g., Mitchell, Chevron, or concentric type procedures) 28297 787.99 Correction, hallux valgus (bunion), with or without sesamoidectomy; Lapidus-type procedure 28298 787.99 Correction, hallux valgus (bunion), with or without sesamoidectomy; by phalanx osteotomy 28299 878.81 Correction, hallux valgus (bunion), with or without sesamoidectomy; by double osteotomy 28300 1,054.67 Osteotomy; calcaneus (e.g., Dwyer or Chambers type procedure), with or without internal fixation 28302 588.40 Osteotomy; talus 28304 1,054.67 Osteotomy, tarsal bones, other than calcaneus or talus; 28305 1,082.75 Osteotomy, tarsal bones, other than calcaneus or talus; with autograft (includes obtaining graft) (e.g., Fowler type) 28306 669.14 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal 28307 669.14 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft (other than first toe) 28308 588.40 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each 28309 1,135.40 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; multiple (e.g., Swanson type cavus foot procedure) 28310 616.49 Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure) 28312 616.49 Osteotomy, shortening, angular or rotational correction; other phalanges, any toe 28313 588.40 Reconstruction, angular deformity of toe, soft tissue procedures only (e.g., overlapping second toe, fifth toe, curly toes) 28315 669.14 Sesamoidectomy, first toe (separate procedure) 28320 1,135.40 Repair, nonunion or malunion; tarsal bones 28322 1,135.40 Repair, nonunion or malunion; metatarsal, with or without bone graft (includes obtaining graft) 28340 669.14 Reconstruction, toe, macrodactyly; soft tissue resection 28341 669.14 Reconstruction, toe, macrodactyly; requiring bone resection 28344 669.14 Reconstruction, toe(s); polydactyly 28345 669.14 Reconstruction, toe(s); syndactyly, with or without skin graft(s), each web 28400 74.48 Closed treatment of calcaneal fracture; without manipulation 28405 406.41 Closed treatment of calcaneal fracture; with manipulation 28406 657.85 Percutaneous skeletal fixation of calcaneal fracture, with manipulation 28415 1,360.23 Open treatment of calcaneal fracture, with or without internal or external fixation; 28420 1,055.02 Open treatment of calcaneal fracture, with or without internal or external fixation; with primary iliac or other autogenous bone graft (includes obtaining graft) 28430 58.04 Closed treatment of talus fracture; without manipulation 28435 74.48 Closed treatment of talus fracture; with manipulation 28436 657.85 Percutaneous skeletal fixation of talus fracture, with manipulation 28445 1,002.36 Open treatment of talus fracture, with or without internal or external fixation 28446 1,717.92 Open osteochondral autograft, talus (includes obtaining graft[s]) 28450 58.04 Treatment of tarsal bone fracture (except talus and calcaneus); without manipulation, each 28455 58.04 Treatment of tarsal bone fracture (except talus and calcaneus); with manipulation, each 28456 657.85 Percutaneous skeletal fixation of tarsal bone fracture (except talus and calcaneus), with manipulation, each

3/5/10 (Effective 1/1/10) 114.3 CMR - 1517 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

28465 1,002.36 Open treatment of tarsal bone fracture (except talus and calcaneus), with or without internal or external fixation, each 28470 58.04 Closed treatment of metatarsal fracture; without manipulation, each 28475 58.04 Closed treatment of metatarsal fracture; with manipulation, each 28476 657.85 Percutaneous skeletal fixation of metatarsal fracture, with manipulation, each 28485 1,055.02 Open treatment of metatarsal fracture, with or without internal or external fixation, each 28490 58.04 Closed treatment of fracture great toe, phalanx or phalanges; without manipulation 28495 58.04 Closed treatment of fracture great toe, phalanx or phalanges; with manipulation 28496 657.85 Percutaneous skeletal fixation of fracture great toe, phalanx or phalanges, with manipulation 28505 685.94 Open treatment of fracture great toe, phalanx or phalanges, with or without internal or external fixation 28510 52.26 Closed treatment of fracture, phalanx or phalanges, other than great toe; without manipulation, each 28515 58.04 Closed treatment of fracture, phalanx or phalanges, other than great toe; with manipulation, each 28525 685.94 Open treatment of fracture, phalanx or phalanges, other than great toe, with or without internal or external fixation, each 28530 50.31 Closed treatment of sesamoid fracture 28531 685.94 Open treatment of sesamoid fracture, with or without internal fixation 28540 58.04 Closed treatment of tarsal bone dislocation, other than talotarsal; without anesthesia 28545 608.27 Closed treatment of tarsal bone dislocation, other than talotarsal; requiring anesthesia 28546 657.85 Percutaneous skeletal fixation of tarsal bone dislocation, other than talotarsal, with manipulation 28555 974.28 Open treatment of tarsal bone dislocation, with or without internal or external fixation 28570 75.30 Closed treatment of talotarsal joint dislocation; without anesthesia 28575 406.41 Closed treatment of talotarsal joint dislocation; requiring anesthesia 28576 685.94 Percutaneous skeletal fixation of talotarsal joint dislocation, with manipulation 28585 685.94 Open treatment of talotarsal joint dislocation, with or without internal or external fixation 28600 58.04 Closed treatment of tarsometatarsal joint dislocation; without anesthesia 28605 74.48 Closed treatment of tarsometatarsal joint dislocation; requiring anesthesia 28606 657.85 Percutaneous skeletal fixation of tarsometatarsal joint dislocation, with manipulation 28615 1,002.36 Open treatment of tarsometatarsal joint dislocation, with or without internal or external fixation 28630 58.04 Closed treatment of metatarsophalangeal joint dislocation; without anesthesia 28635 428.87 Closed treatment of metatarsophalangeal joint dislocation; requiring anesthesia 28636 685.94 Percutaneous skeletal fixation of metatarsophalangeal joint dislocation, with manipulation 28645 685.94 Open treatment of metatarsophalangeal joint dislocation, with or without internal or external fixation 28660 41.55 Closed treatment of interphalangeal joint dislocation; without anesthesia 28665 428.87 Closed treatment of interphalangeal joint dislocation; requiring anesthesia 28666 685.94 Percutaneous skeletal fixation of interphalangeal joint dislocation, with manipulation 28675 685.94 Open treatment of interphalangeal joint dislocation, with or without internal or external fixation 28705 1,135.40 Arthrodesis; pantalar 28715 1,849.28 Arthrodesis; triple 28725 1,135.40 Arthrodesis; subtalar 28730 1,135.40 Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; 28735 1,135.40 Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (e.g., flatfoot correction) 28737 1,173.57 Arthrodesis, with tendon lengthening and advancement, midtarsal, tarsal navicular-cuneiform (e.g., Miller type procedure)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1518 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

28740 1,135.40 Arthrodesis, midtarsal or tarsometatarsal, single joint 28750 1,135.40 Arthrodesis, great toe; metatarsophalangeal joint 28755 669.14 Arthrodesis, great toe; interphalangeal joint 28760 1,135.40 Arthrodesis, with extensor hallucis longus transfer to first metatarsal neck, great toe, interphalangeal joint (e.g., Jones type procedure) 28810 588.40 Amputation, metatarsal, with toe, single 28820 588.40 Amputation, toe; metatarsophalangeal joint 28825 588.40 Amputation, toe; interphalangeal joint 28890 155.48 Extracorporeal shock wave, high energy, performed by a physician, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia 29000 39.39 Application of halo type body cast (see 20661-20663 for insertion) 29010 88.29 Application of Risser jacket, localizer, body; only 29015 88.29 Application of Risser jacket, localizer, body; including head 29020 39.39 Application of turnbuckle jacket, body; only 29025 39.39 Application of turnbuckle jacket, body; including head 29035 88.29 Application of body cast, shoulder to hips; 29040 39.39 Application of body cast, shoulder to hips; including head, Minerva type 29044 88.29 Application of body cast, shoulder to hips; including one thigh 29046 88.29 Application of body cast, shoulder to hips; including both thighs 29049 35.70 Application, cast; figure-of-eight 29055 88.29 Application, cast; shoulder spica 29058 39.39 Application, cast; plaster Velpeau 29065 41.88 Application, cast; shoulder to hand (long arm) 29075 40.25 Application, cast; elbow to finger (short arm) 29085 39.39 Application, cast; hand and lower forearm (gauntlet) 29086 33.76 Application, cast; finger (e.g., contracture) 29105 36.35 Application of long arm splint (shoulder to hand) 29125 31.48 Application of short arm splint (forearm to hand); static 29126 33.44 Application of short arm splint (forearm to hand); dynamic 29130 14.28 Application of finger splint; static 29131 20.77 Application of finger splint; dynamic 29200 20.12 Strapping; thorax 29220 21.74 Strapping; low back 29240 22.73 Strapping; shoulder (e.g., Velpeau) 29260 21.74 Strapping; elbow or wrist 29280 22.08 Strapping; hand or finger 29305 88.29 Application of hip spica cast; one leg 29325 88.29 Application of hip spica cast; one and one-half spica or both legs 29345 54.86 Application of long leg cast (thigh to toes); 29355 53.88 Application of long leg cast (thigh to toes); walker or ambulatory type 29358 66.87 Application of long leg cast brace 29365 51.94 Application of cylinder cast (thigh to ankle) 29405 38.63 Application of short leg cast (below knee to toes); 29425 39.28 Application of short leg cast (below knee to toes); walking or ambulatory type 29435 49.66 Application of patellar tendon bearing (PTB) cast 29440 21.10 Adding walker to previously applied cast 29445 52.26 Application of rigid total contact leg cast 29450 39.39 Application of clubfoot cast with molding or manipulation, long or short leg 29505 35.06 Application of long leg splint (thigh to ankle or toes) 29515 29.86 Application of short leg splint (calf to foot) 29520 21.42 Strapping; hip 29530 21.74 Strapping; knee 29540 16.23 Strapping; ankle and/or foot 29550 16.55 Strapping; toes 29580 22.40 Strapping; Unna boot

3/5/10 (Effective 1/1/10) 114.3 CMR - 1519 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

29590 18.18 Denis-Browne splint strapping 29700 30.19 Removal or bivalving; gauntlet, boot or body cast 29705 25.64 Removal or bivalving; full arm or full leg cast 29710 45.12 Removal or bivalving; shoulder or hip spica, Minerva, or Risser jacket, etc. 29715 39.39 Removal or bivalving; turnbuckle jacket 29720 37.66 Repair of spica, body cast or jacket 29730 24.67 Windowing of cast 29740 33.76 Wedging of cast (except clubfoot casts) 29750 35.38 Wedging of clubfoot cast 29800 758.05 Arthroscopy, temporomandibular joint, diagnostic, with or without synovial biopsy (separate procedure) 29804 758.05 Arthroscopy, temporomandibular joint, surgical 29805 758.05 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure) 29806 1,117.68 Arthroscopy, shoulder, surgical; capsulorrhaphy 29807 1,117.68 Arthroscopy, shoulder, surgical; repair of SLAP lesion 29819 1,117.68 Arthroscopy, shoulder, surgical; with removal of loose body or foreign body 29820 1,117.68 Arthroscopy, shoulder, surgical; synovectomy, partial 29821 1,117.68 Arthroscopy, shoulder, surgical; synovectomy, complete 29822 758.05 Arthroscopy, shoulder, surgical; debridement, limited 29823 1,117.68 Arthroscopy, shoulder, surgical; debridement, extensive 29824 848.88 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) 29825 1,117.68 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation 29826 1,117.68 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release 29827 1,208.51 Arthroscopy, shoulder, surgical; with rotator cuff repair 29828 1,787.80 Arthroscopy, shoulder, surgical; biceps tenodesis 29830 758.05 Arthroscopy, elbow, diagnostic, with or without synovial biopsy (separate procedure) 29834 758.05 Arthroscopy, elbow, surgical; with removal of loose body or foreign body 29835 758.05 Arthroscopy, elbow, surgical; synovectomy, partial 29836 758.05 Arthroscopy, elbow, surgical; synovectomy, complete 29837 758.05 Arthroscopy, elbow, surgical; debridement, limited 29838 758.05 Arthroscopy, elbow, surgical; debridement, extensive 29840 758.05 Arthroscopy, wrist, diagnostic, with or without synovial biopsy (separate procedure) 29843 758.05 Arthroscopy, wrist, surgical; for infection, lavage and drainage 29844 758.05 Arthroscopy, wrist, surgical; synovectomy, partial 29845 758.05 Arthroscopy, wrist, surgical; synovectomy, complete 29846 758.05 Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement 29847 1,117.68 Arthroscopy, wrist, surgical; internal fixation for fracture or instability 29848 1,121.81 Endoscopy, wrist, surgical, with release of transverse carpal ligament 29850 810.70 Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; without internal or external fixation (includes arthroscopy) 29851 1,170.34 Arthroscopically aided treatment of intercondylar spine(s) and/or tuberosity fracture(s) of the knee, with or without manipulation; with internal or external fixation (includes arthroscopy) 29855 1,170.34 Arthroscopically aided treatment of tibial fracture, proximal (plateau); unicondylar, with or without internal or external fixation (includes arthroscopy) 29856 1,170.34 Arthroscopically aided treatment of tibial fracture, proximal (plateau); bicondylar, with or without internal or external fixation (includes arthroscopy) 29860 1,170.34 Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) 29861 1,170.34 Arthroscopy, hip, surgical; with removal of loose body or foreign body

3/5/10 (Effective 1/1/10) 114.3 CMR - 1520 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

29862 1,481.45 Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum 29863 1,170.34 Arthroscopy, hip, surgical; with synovectomy 29866 1,787.80 Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting of the autograft) 29870 758.05 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) 29871 758.05 Arthroscopy, knee, surgical; for infection, lavage and drainage 29873 758.05 Arthroscopy, knee, surgical; with lateral release 29874 758.05 Arthroscopy, knee, surgical; for removal of loose body or foreign body (e.g., osteochondritis dissecans fragmentation, chondral fragmentation) 29875 810.70 Arthroscopy, knee, surgical; synovectomy, limited (e.g., plica or shelf resection) (separate procedure) 29876 810.70 Arthroscopy, knee, surgical; synovectomy, major, two or more compartments (e.g., medial or lateral) 29877 810.70 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) 29879 758.05 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture 29880 810.70 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) 29881 810.70 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) 29882 758.05 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) 29883 758.05 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) 29884 758.05 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure) 29885 1,117.68 Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) 29886 758.05 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion 29887 758.05 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation 29888 1,117.68 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction 29889 1,117.68 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction 29891 1,117.68 Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia, including drilling of the defect 29892 1,117.68 Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy) 29893 943.63 Endoscopic plantar fasciotomy 29894 758.05 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body 29895 758.05 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial 29897 758.05 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, limited 29898 758.05 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive 29899 1,117.68 Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis 29900 758.05 Arthroscopy, metacarpophalangeal joint, diagnostic, includes synovial biopsy 29901 758.05 Arthroscopy, metacarpophalangeal joint, surgical; with debridement 29902 758.05 Arthroscopy, metacarpophalangeal joint, surgical; with reduction of displaced ulnar collateral ligament (e.g., Stenar lesion) 29904 1,068.53 Arthroscopy, subtalar joint, surgical; with removal of loose body or foreign body 29905 1,068.53 Arthroscopy, subtalar joint, surgical; with synovectomy 29906 1,068.53 Arthroscopy, subtalar joint, surgical; with debridement 29907 1,787.80 Arthroscopy, subtalar joint, surgical; with subtalar arthrodesis 30000 120.13 Drainage abscess or hematoma, nasal, internal approach

3/5/10 (Effective 1/1/10) 114.3 CMR - 1521 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

30020 120.13 Drainage abscess or hematoma, nasal septum 30100 77.90 Biopsy, intranasal 30110 120.43 Excision, nasal polyp(s), simple 30115 508.83 Excision, nasal polyp(s), extensive 30117 536.92 Excision or destruction (e.g., laser), intranasal lesion; internal approach 30118 673.43 Excision or destruction (e.g., laser), intranasal lesion; external approach (lateral rhinotomy) 30120 459.25 Excision or surgical planing of skin of nose for rhinophyma 30124 273.65 Excision dermoid cyst, nose; simple, skin, subcutaneous 30125 956.26 Excision dermoid cyst, nose; complex, under bone or cartilage 30130 536.92 Excision inferior turbinate, partial or complete, any method 30140 645.34 Submucous resection inferior turbinate, partial or complete, any method 30150 984.35 Rhinectomy; partial 30160 1,037.00 Rhinectomy; total 30200 61.35 Injection into turbinate(s), therapeutic 30210 77.90 Displacement therapy (Proetz type) 30220 340.49 Insertion, nasal septal prosthesis (button) 30300 23.47 Removal foreign body, intranasal; office type procedure 30310 459.25 Removal foreign body, intranasal; requiring general anesthesia 30320 508.83 Removal foreign body, intranasal; by lateral rhinotomy 30400 1,037.00 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip 30410 1,075.18 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip 30420 1,075.18 Rhinoplasty, primary; including major septal repair 30430 673.43 Rhinoplasty, secondary; minor revision (small amount of nasal tip work) 30435 1,075.18 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) 30450 1,197.16 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) 30460 1,197.16 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only 30462 1,348.10 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies 30465 1,348.10 Repair of nasal vestibular stenosis (e.g., spreader grafting, lateral nasal wall reconstruction) 30520 726.08 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft 30540 1,075.18 Repair choanal atresia; intranasal 30545 1,075.18 Repair choanal atresia; transpalatine 30560 126.20 Lysis intranasal synechia 30580 1,037.00 Repair fistula; oromaxillary (combine with 31030 if antrotomy is included) 30600 1,037.00 Repair fistula; oronasal 30620 1,197.16 Septal or other intranasal dermatoplasty (does not include obtaining graft) 30630 886.24 Repair nasal septal perforations 30801 282.94 Cautery and/or ablation, mucosa of inferior turbinates, unilateral or bilateral, any method; superficial 30802 282.94 Cautery and/or ablation, mucosa of inferior turbinates, unilateral or bilateral, any method; intramural 30901 40.36 Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method 30903 51.98 Control nasal hemorrhage, anterior, complex (extensive cautery and/or packing) any method 30905 51.98 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial 30906 51.98 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; subsequent 30915 692.67 Ligation arteries; ethmoidal 30920 720.76 Ligation arteries; internal maxillary artery, transantral

3/5/10 (Effective 1/1/10) 114.3 CMR - 1522 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

30930 589.57 Fracture nasal inferior turbinate(s), therapeutic 31000 100.31 Lavage by cannulation; maxillary sinus (antrum puncture or natural ostium) 31002 273.65 Lavage by cannulation; sphenoid sinus 31020 645.34 Sinusotomy, maxillary (antrotomy); intranasal 31030 984.35 Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) without removal of antrochoanal polyps 31032 1,037.00 Sinusotomy, maxillary (antrotomy); radical (Caldwell-Luc) with removal of antrochoanal polyps 31040 899.28 Pterygomaxillary fossa surgery, any approach 31050 956.26 Sinusotomy, sphenoid, with or without biopsy; 31051 1,037.00 Sinusotomy, sphenoid, with or without biopsy; with mucosal stripping or removal of polyp(s) 31070 645.34 Sinusotomy frontal; external, simple (trephine operation) 31075 1,037.00 Sinusotomy frontal; transorbital, unilateral (for mucocele or osteoma, Lynch type) 31080 1,037.00 Sinusotomy frontal; obliterative without osteoplastic flap, brow incision (includes ablation) 31081 1,037.00 Sinusotomy frontal; obliterative, without osteoplastic flap, coronal incision (includes ablation) 31084 1,037.00 Sinusotomy frontal; obliterative, with osteoplastic flap, brow incision 31085 1,037.00 Sinusotomy frontal; obliterative, with osteoplastic flap, coronal incision 31086 1,037.00 Sinusotomy frontal; nonobliterative, with osteoplastic flap, brow incision 31087 1,037.00 Sinusotomy frontal; nonobliterative, with osteoplastic flap, coronal incision 31090 1,075.18 Sinusotomy, unilateral, three or more paranasal sinuses (frontal, maxillary, ethmoid, sphenoid) 31200 956.26 Ethmoidectomy; intranasal, anterior 31201 1,075.18 Ethmoidectomy; intranasal, total 31205 984.35 Ethmoidectomy; extranasal, total 31231 65.67 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure) 31233 70.74 Nasal/sinus endoscopy, diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture) 31235 480.61 Nasal/sinus endoscopy, diagnostic with sphenoid sinusoscopy (via puncture of sphenoidal face or cannulation of ostium) 31237 530.19 Nasal/sinus endoscopy, surgical; with biopsy, polypectomy or debridement (separate procedure) 31238 480.61 Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage 31239 701.54 Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy 31240 530.19 Nasal/sinus endoscopy, surgical; with concha bullosa resection 31254 648.88 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior) 31255 739.71 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior) 31256 648.88 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; 31267 648.88 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus 31276 648.88 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus 31287 648.88 Nasal/sinus endoscopy, surgical, with sphenoidotomy; 31288 648.88 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus 31300 764.25 Laryngotomy (thyrotomy, laryngofissure); with removal of tumor or laryngocele, cordectomy 31320 956.26 Laryngotomy (thyrotomy, laryngofissure); diagnostic 31400 956.26 Arytenoidectomy or arytenoidopexy, external approach 31420 956.26 Epiglottidectomy 31500 87.84 Intubation, endotracheal, emergency procedure 31502 50.51 Tracheotomy tube change prior to establishment of fistula tract 31505 29.84 Laryngoscopy, indirect; diagnostic (separate procedure) 31510 530.19 Laryngoscopy, indirect; with biopsy

3/5/10 (Effective 1/1/10) 114.3 CMR - 1523 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

31511 70.74 Laryngoscopy, indirect; with removal of foreign body 31512 530.19 Laryngoscopy, indirect; with removal of lesion 31513 70.74 Laryngoscopy, indirect; with vocal cord injection 31515 480.61 Laryngoscopy direct, with or without tracheoscopy; for aspiration 31520 65.67 Laryngoscopy direct, with or without tracheoscopy; diagnostic, newborn 31525 480.61 Laryngoscopy direct, with or without tracheoscopy; diagnostic, except newborn 31526 620.80 Laryngoscopy direct, with or without tracheoscopy; diagnostic, with operating microscope or telescope 31527 571.21 Laryngoscopy direct, with or without tracheoscopy; with insertion of obturator 31528 530.19 Laryngoscopy direct, with or without tracheoscopy; with dilation, initial 31529 530.19 Laryngoscopy direct, with or without tracheoscopy; with dilation, subsequent 31530 620.80 Laryngoscopy, direct, operative, with foreign body removal; 31531 648.88 Laryngoscopy, direct, operative, with foreign body removal; with operating microscope or telescope 31535 620.80 Laryngoscopy, direct, operative, with biopsy; 31536 648.88 Laryngoscopy, direct, operative, with biopsy; with operating microscope or telescope 31540 648.88 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; 31541 701.54 Laryngoscopy, direct, operative, with excision of tumor and/or stripping of vocal cords or epiglottis; with operating microscope or telescope 31545 701.54 Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with local tissue flap(s) 31546 701.54 Laryngoscopy, direct, operative, with operating microscope or telescope, with submucosal removal of non-neoplastic lesion(s) of vocal cord; reconstruction with graft(s) (includes obtaining autograft) 31560 739.71 Laryngoscopy, direct, operative, with arytenoidectomy; 31561 739.71 Laryngoscopy, direct, operative, with arytenoidectomy; with operating microscope or telescope 31570 530.19 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; 31571 620.80 Laryngoscopy, direct, with injection into vocal cord(s), therapeutic; with operating microscope or telescope 31575 56.48 Laryngoscopy, flexible fiberoptic; diagnostic 31576 620.80 Laryngoscopy, flexible fiberoptic; with biopsy 31577 183.38 Laryngoscopy, flexible fiberoptic; with removal of foreign body 31578 620.80 Laryngoscopy, flexible fiberoptic; with removal of lesion 31579 100.63 Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy 31580 1,075.18 Laryngoplasty; for laryngeal web, two stage, with keel insertion and removal 31582 1,075.18 Laryngoplasty; for laryngeal stenosis, with graft or core mold, including tracheotomy 31588 1,075.18 Laryngoplasty, not otherwise specified (e.g., for burns, reconstruction after partial laryngectomy) 31590 1,075.18 Laryngeal reinnervation by neuromuscular pedicle 31595 956.26 Section recurrent laryngeal nerve, therapeutic (separate procedure), unilateral 31603 282.94 Tracheostomy, emergency procedure; transtracheal 31605 273.65 Tracheostomy, emergency procedure; cricothyroid membrane 31611 673.43 Construction of tracheoesophageal fistula and subsequent insertion of an alaryngeal speech prosthesis (e.g., voice button, Blom-Singer prosthesis) 31612 595.76 Tracheal puncture, percutaneous with transtracheal aspiration and/or injection 31613 645.34 Tracheostoma revision; simple, without flap rotation 31614 956.26 Tracheostoma revision; complex, with flap rotation 31615 282.94 Tracheobronchoscopy through established tracheostomy incision 31622 331.37 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; diagnostic, with or without cell washing (separate procedure) 31623 380.95 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with brushing or protected brushings

3/5/10 (Effective 1/1/10) 114.3 CMR - 1524 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

31624 380.95 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial alveolar lavage 31625 380.95 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with bronchial or endobronchial biopsy(s), single or multiple sites 31628 380.95 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial lung biopsy(s), single lobe 31629 380.95 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial needle aspiration biopsy(s), trachea, main stem and/or lobar bronchus(i) 31630 652.80 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with tracheal/bronchial dilation or closed reduction of fracture 31631 652.80 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with placement of tracheal stent(s) (includes tracheal/bronchial dilation as required) 31632 370.50 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial lung biopsy(s), each additional lobe (List separately in addition to code for primary procedure) 31633 370.50 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with transbronchial needle aspiration biopsy(s), each additional lobe (List separately in addition to code for primary procedure) 31635 380.95 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with removal of foreign body 31636 652.80 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with placement of bronchial stent(s) (includes tracheal/bronchial dilation as required), initial bronchus 31637 331.37 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; each additional major bronchus stented (List separately in addition to code for primary procedure) 31638 652.80 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with revision of tracheal or bronchial stent inserted at previous session (includes tracheal/bronchial dilation as required) 31640 652.80 Bronchoscopy, rigid or flexible, with or without fluoroscopic guidance; with excision of tumor 31641 652.80 Bronchoscopy, (rigid or flexible); with destruction of tumor or relief of stenosis by any method other than excision (e.g., laser therapy, cryotherapy) 31643 380.95 Bronchoscopy, (rigid or flexible); with placement of catheter(s) for intracavitary radioelement application 31645 331.37 Bronchoscopy, (rigid or flexible); with therapeutic aspiration of tracheobronchial tree, initial (e.g., drainage of lung abscess) 31646 331.37 Bronchoscopy, (rigid or flexible); with therapeutic aspiration of tracheobronchial tree, subsequent 31656 331.37 Bronchoscopy, (rigid or flexible); with injection of contrast material for segmental bronchography (fiberscope only) 31717 183.38 Catheterization with bronchial brush biopsy 31720 28.08 Catheter aspiration (separate procedure); nasotracheal 31730 183.38 Transtracheal (percutaneous) introduction of needle wire dilator/stent or indwelling tube for oxygen therapy 31750 1,075.18 Tracheoplasty; cervical 31755 956.26 Tracheoplasty; tracheopharyngeal fistulization, each stage 31820 459.25 Surgical closure tracheostomy or fistula; without plastic repair 31825 645.34 Surgical closure tracheostomy or fistula; with plastic repair 31830 645.34 Revision of tracheostomy scar 32400 320.09 Biopsy, pleura; percutaneous needle 32405 320.09 Biopsy, lung or mediastinum, percutaneous needle 32420 194.64 Pneumocentesis, puncture of lung for aspiration 32421 194.64 Thoracentesis, puncture of pleural cavity for aspiration, initial or subsequent

3/5/10 (Effective 1/1/10) 114.3 CMR - 1525 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

32422 193.78 Thoracentesis with insertion of tube, includes water seal (e.g., for pneumothorax), when performed (separate procedure) 32550 1,084.95 Insertion of indwelling tunneled pleural catheter with cuff 32960 193.78 Pneumothorax, therapeutic, intrapleural injection of air 32998 1,689.21 Ablation therapy for reduction or eradication of one or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral 33010 194.64 Pericardiocentesis; initial 33011 194.64 Pericardiocentesis; subsequent 33206 6,244.88 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial 33207 6,244.88 Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular 33208 7,745.43 Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular 33210 1,833.83 Insertion or replacement of temporary transvenous single chamber cardiac electrode or pacemaker catheter (separate procedure) 33211 1,833.83 Insertion or replacement of temporary transvenous dual chamber pacing electrodes (separate procedure) 33212 4,904.46 Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular 33213 5,660.80 Insertion or replacement of pacemaker pulse generator only; dual chamber 33214 7,745.43 Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator) 33215 803.79 Repositioning of previously implanted transvenous pacemaker or pacing cardioverter-defibrillator (right atrial or right ventricular) electrode 33216 1,833.83 Insertion of a transvenous electrode; single chamber (one electrode) permanent pacemaker or single chamber pacing cardioverter-defibrillator 33217 1,833.83 Insertion of a transvenous electrode; dual chamber (two electrodes) permanent pacemaker or dual chamber pacing cardioverter-defibrillator 33218 803.79 Repair of single transvenous electrode for a single chamber, permanent pacemaker or single chamber pacing cardioverter-defibrillator 33220 803.79 Repair of two transvenous electrodes for a dual chamber permanent pacemaker or dual chamber pacing cardioverter-defibrillator 33222 485.86 Revision or relocation of skin pocket for pacemaker 33223 485.86 Revision of skin pocket for single or dual chamber pacing cardioverter-defibrillator 33224 7,310.96 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter-defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of generator) 33225 7,310.96 Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter-defibrillator or pacemaker pulse generator (including upgrade to dual chamber system) (List separately in addition to code for primary procedure) 33226 803.79 Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of generator) 33233 597.60 Removal of permanent pacemaker pulse generator 33234 803.79 Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular 33235 803.79 Removal of transvenous pacemaker electrode(s); dual lead system 33240 18,224.36 Insertion of single or dual chamber pacing cardioverter-defibrillator pulse generator 33241 803.79 Subcutaneous removal of single or dual chamber pacing cardioverter-defibrillator pulse generator 33249 24,321.80 Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator 33282 3,845.43 Implantation of patient-activated cardiac event recorder

3/5/10 (Effective 1/1/10) 114.3 CMR - 1526 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

33284 299.93 Removal of an implantable, patient-activated cardiac event recorder 34490 1,464.36 Thrombectomy, direct or with catheter; axillary and subclavian vein, by arm incision 35188 1,008.62 Repair, acquired or traumatic arteriovenous fistula; head and neck 35207 1,008.62 Repair blood vessel, direct; hand, finger 35473 1,756.67 Transluminal balloon angioplasty, percutaneous; iliac 35476 1,756.67 Transluminal balloon angioplasty, percutaneous; venous 35492 3,278.66 Transluminal peripheral atherectomy, percutaneous; iliac 35761 1,054.70 Exploration (not followed by surgical repair), with or without lysis of artery; other vessels 35875 1,319.72 Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); 35876 1,319.72 Thrombectomy of arterial or venous graft (other than hemodialysis graft or fistula); with revision of arterial or venous graft 36002 84.23 Injection procedures (e.g., thrombin) for percutaneous treatment of extremity pseudoaneurysm 36260 764.09 Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver) 36261 597.60 Revision of implanted intra-arterial infusion pump 36262 548.01 Removal of implanted intra-arterial infusion pump 36420 7.94 Venipuncture, cutdown; younger than age 1 year 36425 7.94 Venipuncture, cutdown; age 1 or over 36430 30.51 Transfusion, blood or blood components 36440 121.85 Push transfusion, blood, 2 years or younger 36450 121.85 Exchange transfusion, blood; newborn 36455 121.85 Exchange transfusion, blood; other than newborn 36468 30.08 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); limb or trunk 36469 30.08 Single or multiple injections of sclerosing solutions, spider veins (telangiectasia); face 36470 30.08 Injection of sclerosing solution; single vein 36471 30.08 Injection of sclerosing solution; multiple veins, same leg 36475 1,382.94 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated 36476 1,084.51 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) 36478 1,084.51 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated 36479 1,084.51 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; second and subsequent veins treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) 36511 417.76 Therapeutic apheresis; for white blood cells 36512 417.76 Therapeutic apheresis; for red blood cells 36513 417.76 Therapeutic apheresis; for platelets 36514 417.76 Therapeutic apheresis; for plasma pheresis 36515 1,118.35 Therapeutic apheresis; with extracorporeal immunoadsorption and plasma reinfusion 36516 1,118.35 Therapeutic apheresis; with extracorporeal selective adsorption or selective filtration and plasma reinfusion 36522 1,118.35 Photopheresis, extracorporeal 36555 347.10 Insertion of non-tunneled centrally inserted central venous catheter; younger than 5 years of age 36556 347.10 Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older 36557 648.24 Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; younger than 5 years of age 36558 648.24 Insertion of tunneled centrally inserted central venous catheter, without subcutaneous port or pump; age 5 years or older

3/5/10 (Effective 1/1/10) 114.3 CMR - 1527 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

36560 764.09 Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; younger than 5 years of age 36561 764.09 Insertion of tunneled centrally inserted central venous access device, with subcutaneous port; age 5 years or older 36563 764.09 Insertion of tunneled centrally inserted central venous access device with subcutaneous pump 36565 764.09 Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites; without subcutaneous port or pump (e.g., Tesio type catheter) 36566 764.09 Insertion of tunneled centrally inserted central venous access device, requiring two catheters via two separate venous access sites; with subcutaneous port(s) 36568 347.10 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; younger than 5 years of age 36569 347.10 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump; age 5 years or older 36570 676.32 Insertion of peripherally inserted central venous access device, with subcutaneous port; younger than 5 years of age 36571 676.32 Insertion of peripherally inserted central venous access device, with subcutaneous port; age 5 years or older 36575 279.17 Repair of tunneled or non-tunneled central venous access catheter, without subcutaneous port or pump, central or peripheral insertion site 36576 396.68 Repair of central venous access device, with subcutaneous port or pump, central or peripheral insertion site 36578 648.24 Replacement, catheter only, of central venous access device, with subcutaneous port or pump, central or peripheral insertion site 36580 347.10 Replacement, complete, of a non-tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access 36581 648.24 Replacement, complete, of a tunneled centrally inserted central venous catheter, without subcutaneous port or pump, through same venous access 36582 764.09 Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous port, through same venous access 36583 764.09 Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous pump, through same venous access 36584 347.10 Replacement, complete, of a peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, through same venous access 36585 676.32 Replacement, complete, of a peripherally inserted central venous access device, with subcutaneous port, through same venous access 36589 229.59 Removal of tunneled central venous catheter, without subcutaneous port or pump 36590 347.10 Removal of tunneled central venous access device, with subcutaneous port or pump, central or peripheral insertion 36593 23.05 Declotting by thrombolytic agent of implanted vascular access device or catheter 36595 905.08 Mechanical removal of pericatheter obstructive material (e.g., fibrin sheath) from central venous device via separate venous access 36596 401.96 Mechanical removal of intraluminal (intracatheter) obstructive material from central venous device through device lumen 36597 401.96 Repositioning of previously placed central venous catheter under fluoroscopic guidance 36598 74.33 Contrast injection(s) for radiologic evaluation of existing central venous access device, including fluoroscopy, image documentation and report 36640 686.42 Arterial catheterization for prolonged infusion therapy (chemotherapy), cutdown 36680 52.03 Placement of needle for intraosseous infusion 36800 822.55 Insertion of cannula for hemodialysis, other purpose (separate procedure); vein to vein 36810 822.55 Insertion of cannula for hemodialysis, other purpose (separate procedure); arteriovenous, external (Scribner type) 36815 822.55 Insertion of cannula for hemodialysis, other purpose (separate procedure); arteriovenous, external revision, or closure

3/5/10 (Effective 1/1/10) 114.3 CMR - 1528 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

36818 955.97 Arteriovenous anastomosis, open; by upper arm cephalic vein transposition 36819 955.97 Arteriovenous anastomosis, open; by upper arm basilic vein transposition 36820 955.97 Arteriovenous anastomosis, open; by forearm vein transposition 36821 955.97 Arteriovenous anastomosis, open; direct, any site (e.g., Cimino type) (separate procedure) 36825 1,008.62 Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); autogenous graft 36830 1,008.62 Creation of arteriovenous fistula by other than direct arteriovenous anastomosis (separate procedure); nonautogenous graft (e.g., biological collagen, thermoplastic graft) 36831 1,319.72 Thrombectomy, open, arteriovenous fistula without revision, autogenous or nonautogenous dialysis graft (separate procedure) 36832 1,008.62 Revision, open, arteriovenous fistula; without thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) 36833 1,008.62 Revision, open, arteriovenous fistula; with thrombectomy, autogenous or nonautogenous dialysis graft (separate procedure) 36834 955.97 Plastic repair of arteriovenous aneurysm (separate procedure) 36835 875.21 Insertion of Thomas shunt (separate procedure) 36860 100.45 External cannula declotting (separate procedure); without balloon catheter 36861 822.55 External cannula declotting (separate procedure); with balloon catheter 36870 1,438.51 Thrombectomy, percutaneous, arteriovenous fistula, autogenous or nonautogenous graft (includes mechanical thrombus extraction and intra-graft thrombolysis) 37184 1,464.36 Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); initial vessel 37185 1,464.36 Primary percutaneous transluminal mechanical thrombectomy, noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injection(s); second and all subsequent vessel(s) within the same vascular family (List separately in addition to code for primary mechanical thrombectomy procedure) 37186 1,464.36 Secondary percutaneous transluminal thrombectomy (e.g., nonprimary mechanical, snare basket, suction technique), noncoronary, arterial or arterial bypass graft, including fluoroscopic guidance and intraprocedural pharmacological thrombolytic injections, provided in conjunction with another percutaneous intervention other than primary mechanical thrombectomy (List separately in addition to code for primary procedure) 37187 1,464.36 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance 37188 1,464.36 Percutaneous transluminal mechanical thrombectomy, vein(s), including intraprocedural pharmacological thrombolytic injections and fluoroscopic guidance, repeat treatment on subsequent day during course of thrombolytic therapy 37200 1,080.61 Transcatheter biopsy 37203 1,080.61 Transcatheter retrieval, percutaneous, of intravascular foreign body (e.g., fractured venous or arterial catheter) 37500 1,019.19 Vascular endoscopy, surgical, with ligation of perforator veins, subfascial (SEPS) 37607 720.76 Ligation or banding of angioaccess arteriovenous fistula 37609 484.44 Ligation or biopsy, temporal artery 37650 692.67 Ligation of femoral vein 37700 692.67 Ligation and division of long saphenous vein at saphenofemoral junction, or distal interruptions 37718 720.76 Ligation, division, and stripping, short saphenous vein 37722 1,019.19 Ligation, division, and stripping, long (greater) saphenous veins from saphenofemoral junction to knee or below 37735 1,019.19 Ligation and division and complete stripping of long or short saphenous veins with radical excision of ulcer and skin graft and/or interruption of communicating veins of lower le.g., with excision of deep fascia

3/5/10 (Effective 1/1/10) 114.3 CMR - 1529 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

37760 720.76 Ligation of perforator veins, subfascial, radical (Linton type), with or without skin graft, open 37765 993.93 Stab phlebectomy of varicose veins, one extremity; 10-20 stab incisions 37766 993.93 Stab phlebectomy of varicose veins, one extremity; more than 20 incisions 37780 720.76 Ligation and division of short saphenous vein at saphenopopliteal junction (separate procedure) 37785 720.76 Ligation, division, and/or excision of varicose vein cluster(s), one leg 37790 869.73 Penile venous occlusive procedure 38205 417.76 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; allogenic 38206 417.76 Blood-derived hematopoietic progenitor cell harvesting for transplantation, per collection; autologous 38220 95.76 Bone marrow; aspiration only 38221 100.31 Bone marrow; biopsy, needle or trocar 38230 1,118.35 Bone marrow harvesting for transplantation 38241 1,118.35 Bone marrow or blood-derived peripheral stem cell transplantation; autologous 38242 417.76 Bone marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions 38300 374.89 Drainage of lymph node abscess or lymphadenitis; simple 38305 547.84 Drainage of lymph node abscess or lymphadenitis; extensive 38308 625.98 Lymphangiotomy or other operations on lymphatic channels 38500 625.98 Biopsy or excision of lymph node(s); open, superficial 38505 239.50 Biopsy or excision of lymph node(s); by needle, superficial (e.g., cervical, inguinal, axillary) 38510 625.98 Biopsy or excision of lymph node(s); open, deep cervical node(s) 38520 625.98 Biopsy or excision of lymph node(s); open, deep cervical node(s) with excision scalene fat pad 38525 625.98 Biopsy or excision of lymph node(s); open, deep axillary node(s) 38530 625.98 Biopsy or excision of lymph node(s); open, internal mammary node(s) 38542 1,053.12 Dissection, deep jugular node(s) 38550 654.07 Excision of cystic hygroma, axillary or cervical; without deep neurovascular dissection 38555 706.72 Excision of cystic hygroma, axillary or cervical; with deep neurovascular dissection 38570 1,428.92 Laparoscopy, surgical; with retroperitoneal lymph node sampling (biopsy), single or multiple 38571 1,857.56 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy 38572 1,428.92 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy and peri-aortic lymph node sampling (biopsy), single or multiple 38700 860.55 Suprahyoid lymphadenectomy 38740 1,053.12 Axillary lymphadenectomy; superficial 38745 1,133.86 Axillary lymphadenectomy; complete 38760 625.98 Inguinofemoral lymphadenectomy, superficial, including Cloquets node (separate procedure) 40490 63.95 Biopsy of lip 40500 508.83 Vermilionectomy (lip shave), with mucosal advancement 40510 645.34 Excision of lip; transverse wedge excision with primary closure 40520 508.83 Excision of lip; V-excision with primary direct linear closure 40525 645.34 Excision of lip; full thickness, reconstruction with local flap (e.g., Estlander or fan) 40527 645.34 Excision of lip; full thickness, reconstruction with cross lip flap (Abbe-Estlander) 40530 645.34 Resection of lip, more than one-fourth, without reconstruction 40650 340.49 Repair lip, full thickness; vermilion only 40652 340.49 Repair lip, full thickness; up to half vertical height 40654 340.49 Repair lip, full thickness; over one-half vertical height, or complex 40700 1,197.16 Plastic repair of cleft lip/nasal deformity; primary, partial or complete, unilateral 40701 1,197.16 Plastic repair of cleft lip/nasal deformity; primary bilateral, one stage procedure 40702 1,521.12 Plastic repair of cleft lip/nasal deformity; primary bilateral, one of two stages

3/5/10 (Effective 1/1/10) 114.3 CMR - 1530 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

40720 1,197.16 Plastic repair of cleft lip/nasal deformity; secondary, by recreation of defect and reclosure 40761 984.35 Plastic repair of cleft lip/nasal deformity; with cross lip pedicle flap (Abbe-Estlander type), including sectioning and inserting of pedicle 40800 51.32 Drainage of abscess, cyst, hematoma, vestibule of mouth; simple 40801 332.52 Drainage of abscess, cyst, hematoma, vestibule of mouth; complicated 40804 23.47 Removal of embedded foreign body, vestibule of mouth; simple 40805 158.73 Removal of embedded foreign body, vestibule of mouth; complicated 40806 73.04 Incision of labial frenum (frenotomy) 40808 108.41 Biopsy, vestibule of mouth 40810 112.31 Excision of lesion of mucosa and submucosa, vestibule of mouth; without repair 40812 140.88 Excision of lesion of mucosa and submucosa, vestibule of mouth; with simple repair 40814 508.83 Excision of lesion of mucosa and submucosa, vestibule of mouth; with complex repair 40816 645.34 Excision of lesion of mucosa and submucosa, vestibule of mouth; complex, with excision of underlying muscle 40818 126.20 Excision of mucosa of vestibule of mouth as donor graft 40819 282.94 Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) 40820 161.97 Destruction of lesion or scar of vestibule of mouth by physical methods (e.g., laser, thermal, cryo, chemical) 40830 120.13 Closure of laceration, vestibule of mouth; 2.5 cm or less 40831 282.94 Closure of laceration, vestibule of mouth; over 2.5 cm or complex 40840 645.34 Vestibuloplasty; anterior 40842 673.43 Vestibuloplasty; posterior, unilateral 40843 673.43 Vestibuloplasty; posterior, bilateral 40844 1,075.18 Vestibuloplasty; entire arch 40845 1,075.18 Vestibuloplasty; complex (including ridge extension, muscle repositioning) 41000 80.51 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; lingual 41005 126.20 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, superficial 41006 595.76 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; sublingual, deep, supramylohyoid 41007 459.25 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submental space 41008 459.25 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; submandibular space 41009 126.20 Intraoral incision and drainage of abscess, cyst, or hematoma of tongue or floor of mouth; masticator space 41010 282.94 Incision of lingual frenum (frenotomy) 41015 126.20 Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; sublingual 41016 282.94 Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submental 41017 282.94 Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; submandibular 41018 282.94 Extraoral incision and drainage of abscess, cyst, or hematoma of floor of mouth; masticator space 41019 899.28 Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application 41100 84.72 Biopsy of tongue; anterior two-thirds 41105 83.75 Biopsy of tongue; posterior one-third 41108 77.58 Biopsy of floor of mouth 41110 112.31 Excision of lesion of tongue without closure 41112 508.83 Excision of lesion of tongue with closure; anterior two-thirds 41113 508.83 Excision of lesion of tongue with closure; posterior one-third

3/5/10 (Effective 1/1/10) 114.3 CMR - 1531 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

41114 645.34 Excision of lesion of tongue with closure; with local tongue flap 41115 130.82 Excision of lingual frenum (frenectomy) 41116 459.25 Excision, lesion of floor of mouth 41120 764.25 Glossectomy; less than one-half tongue 41250 86.31 Repair of laceration 2.5 cm or less; floor of mouth and/or anterior two-thirds of tongue 41251 126.20 Repair of laceration 2.5 cm or less; posterior one-third of tongue 41252 332.52 Repair of laceration of tongue, floor of mouth, over 2.6 cm or complex 41500 595.76 Fixation of tongue, mechanical, other than suture (e.g., K-wire) 41510 459.25 Suture of tongue to lip for micrognathia (Douglas type procedure) 41520 332.52 Frenoplasty (surgical revision of frenum, e.g., with Z-plasty) 41530 626.27 Submucosal ablation of the tongue base, radiofrequency, one or more sites, per session 41800 64.48 Drainage of abscess, cyst, hematoma from dentoalveolar structures 41805 139.58 Removal of embedded foreign body from dentoalveolar structures; soft tissues 41806 172.04 Removal of embedded foreign body from dentoalveolar structures; bone 41820 273.65 Gingivectomy, excision gingiva, each quadrant 41821 273.65 Operculectomy, excision pericoronal tissues 41822 142.50 Excision of fibrous tuberosities, dentoalveolar structures 41823 207.75 Excision of osseous tuberosities, dentoalveolar structures 41825 114.26 Excision of lesion or tumor (except listed above), dentoalveolar structures; without repair 41826 143.80 Excision of lesion or tumor (except listed above), dentoalveolar structures; with simple repair 41827 645.34 Excision of lesion or tumor (except listed above), dentoalveolar structures; with complex repair 41828 129.84 Excision of hyperplastic alveolar mucosa, each quadrant (specify) 41830 184.37 Alveolectomy, including curettage of osteitis or sequestrectomy 41850 626.27 Destruction of lesion (except excision), dentoalveolar structures 41870 899.28 Periodontal mucosal grafting 41872 184.37 Gingivoplasty, each quadrant (specify) 41874 177.88 Alveoloplasty, each quadrant (specify) 42000 126.20 Drainage of abscess of palate, uvula 42100 72.06 Biopsy of palate, uvula 42104 107.12 Excision, lesion of palate, uvula; without closure 42106 134.39 Excision, lesion of palate, uvula; with simple primary closure 42107 645.34 Excision, lesion of palate, uvula; with local flap closure 42120 1,037.00 Resection of palate or extensive resection of lesion 42140 332.52 Uvulectomy, excision of uvula 42145 764.25 Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty) 42160 127.24 Destruction of lesion, palate or uvula (thermal, cryo or chemical) 42180 126.20 Repair, laceration of palate; up to 2 cm 42182 956.26 Repair, laceration of palate; over 2 cm or complex 42200 1,075.18 Palatoplasty for cleft palate, soft and/or hard palate only 42205 1,075.18 Palatoplasty for cleft palate, with closure of alveolar ridge; soft tissue only 42210 1,075.18 Palatoplasty for cleft palate, with closure of alveolar ridge; with bone graft to alveolar ridge (includes obtaining graft) 42215 1,197.16 Palatoplasty for cleft palate; major revision 42220 1,075.18 Palatoplasty for cleft palate; secondary lengthening procedure 42226 1,075.18 Lengthening of palate, and pharyngeal flap 42235 627.75 Repair of anterior palate, including vomer flap 42260 726.08 Repair of nasolabial fistula 42280 70.11 Maxillary impression for palatal prosthesis 42281 626.27 Insertion of pin-retained palatal prosthesis 42300 459.25 Drainage of abscess; parotid, simple 42305 508.83 Drainage of abscess; parotid, complicated 42310 126.20 Drainage of abscess; submaxillary or sublingual, intraoral 42320 126.20 Drainage of abscess; submaxillary, external

3/5/10 (Effective 1/1/10) 114.3 CMR - 1532 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

42330 108.41 Sialolithotomy; submandibular (submaxillary), sublingual or parotid, uncomplicated, intraoral 42335 179.83 Sialolithotomy; submandibular (submaxillary), complicated, intraoral 42340 508.83 Sialolithotomy; parotid, extraoral or complicated intraoral 42400 61.03 Biopsy of salivary gland; needle 42405 508.83 Biopsy of salivary gland; incisional 42408 536.92 Excision of sublingual salivary cyst (ranula) 42409 536.92 Marsupialization of sublingual salivary cyst (ranula) 42410 984.35 Excision of parotid tumor or parotid gland; lateral lobe, without nerve dissection 42415 1,197.16 Excision of parotid tumor or parotid gland; lateral lobe, with dissection and preservation of facial nerve 42420 1,197.16 Excision of parotid tumor or parotid gland; total, with dissection and preservation of facial nerve 42425 1,197.16 Excision of parotid tumor or parotid gland; total, en bloc removal with sacrifice of facial nerve 42440 984.35 Excision of submandibular (submaxillary) gland 42450 645.34 Excision of sublingual gland 42500 673.43 Plastic repair of salivary duct, sialodochoplasty; primary or simple 42505 1,037.00 Plastic repair of salivary duct, sialodochoplasty; secondary or complicated 42507 984.35 Parotid duct diversion, bilateral (Wilke type procedure); 42508 1,037.00 Parotid duct diversion, bilateral (Wilke type procedure); with excision of one submandibular gland 42509 1,037.00 Parotid duct diversion, bilateral (Wilke type procedure); with excision of both submandibular glands 42510 1,037.00 Parotid duct diversion, bilateral (Wilke type procedure); with ligation of both submandibular (Whartons) ducts 42600 459.25 Closure salivary fistula 42650 39.92 Dilation salivary duct 42660 46.75 Dilation and catheterization of salivary duct, with or without injection 42665 886.24 Ligation salivary duct, intraoral 42700 126.20 Incision and drainage abscess; peritonsillar 42720 459.25 Incision and drainage abscess; retropharyngeal or parapharyngeal, intraoral approach 42725 956.26 Incision and drainage abscess; retropharyngeal or parapharyngeal, external approach 42800 77.26 Biopsy; oropharynx 42802 459.25 Biopsy; hypopharynx 42804 459.25 Biopsy; nasopharynx, visible lesion, simple 42806 645.34 Biopsy; nasopharynx, survey for unknown primary lesion 42808 508.83 Excision or destruction of lesion of pharynx, any method 42809 23.47 Removal of foreign body from pharynx 42810 673.43 Excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues 42815 1,075.18 Excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into pharynx 42820 673.43 Tonsillectomy and adenoidectomy; younger than age 12 42821 764.25 Tonsillectomy and adenoidectomy; age 12 or over 42825 726.08 Tonsillectomy, primary or secondary; younger than age 12 42826 726.08 Tonsillectomy, primary or secondary; age 12 or over 42830 726.08 Adenoidectomy, primary; younger than age 12 42831 726.08 Adenoidectomy, primary; age 12 or over 42835 726.08 Adenoidectomy, secondary; younger than age 12 42836 726.08 Adenoidectomy, secondary; age 12 or over 42860 673.43 Excision of tonsil tags 42870 673.43 Excision or destruction lingual tonsil, any method (separate procedure) 42890 1,197.16 Limited pharyngectomy 42892 1,197.16 Resection of lateral pharyngeal wall or pyriform sinus, direct closure by advancement of lateral and posterior pharyngeal walls 42900 282.94 Suture pharynx for wound or injury

3/5/10 (Effective 1/1/10) 114.3 CMR - 1533 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

42950 645.34 Pharyngoplasty (plastic or reconstructive operation on pharynx) 42955 645.34 Pharyngostomy (fistulization of pharynx, external for feeding) 42960 51.98 Control oropharyngeal hemorrhage, primary or secondary (e.g., post-tonsillectomy); simple 42962 956.26 Control oropharyngeal hemorrhage, primary or secondary (e.g., post-tonsillectomy); with secondary surgical intervention 42970 40.36 Control of nasopharyngeal hemorrhage, primary or secondary (e.g., postadenoidectomy); simple, with posterior nasal packs, with or without anterior packs and/or cautery 42972 536.92 Control of nasopharyngeal hemorrhage, primary or secondary (e.g., postadenoidectomy); with secondary surgical intervention 43030 626.27 Cricopharyngeal myotomy 43200 303.27 Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 43201 303.27 Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance 43202 303.27 Esophagoscopy, rigid or flexible; with biopsy, single or multiple 43204 303.27 Esophagoscopy, rigid or flexible; with injection sclerosis of esophageal varices 43205 303.27 Esophagoscopy, rigid or flexible; with band ligation of esophageal varices 43215 303.27 Esophagoscopy, rigid or flexible; with removal of foreign body 43216 303.27 Esophagoscopy, rigid or flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 43217 303.27 Esophagoscopy, rigid or flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 43219 612.92 Esophagoscopy, rigid or flexible; with insertion of plastic tube or stent 43220 303.27 Esophagoscopy, rigid or flexible; with balloon dilation (less than 30 mm diameter) 43226 303.27 Esophagoscopy, rigid or flexible; with insertion of guide wire followed by dilation over guide wire 43227 352.86 Esophagoscopy, rigid or flexible; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 43228 656.65 Esophagoscopy, rigid or flexible; with ablation of tumor(s), polyp(s), or other lesion(s), not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 43231 352.86 Esophagoscopy, rigid or flexible; with endoscopic ultrasound examination 43232 352.86 Esophagoscopy, rigid or flexible; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) 43234 303.27 Upper gastrointestinal endoscopy, simple primary examination (e.g., with small diameter flexible endoscope) (separate procedure) 43235 303.27 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 43236 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance 43237 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination limited to the esophagus 43238 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), esophagus (includes endoscopic ultrasound examination limited to the esophagus) 43239 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple 43240 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transmural drainage of pseudocyst

3/5/10 (Effective 1/1/10) 114.3 CMR - 1534 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

43241 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic intraluminal tube or catheter placement 43242 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate) 43243 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with injection sclerosis of esophageal and/or gastric varices 43244 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with band ligation of esophageal and/or gastric varices 43245 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with dilation of gastric outlet for obstruction (e.g., balloon, guide wire, bougie) 43246 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube 43247 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign body 43248 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with insertion of guide wire followed by dilation of esophagus over guide wire 43249 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with balloon dilation of esophagus (less than 30 mm diameter) 43250 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 43251 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 43255 352.86 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method 43256 690.59 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with transendoscopic stent placement (includes predilation) 43257 684.74 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease 43258 380.94 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 43259 380.94 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum and/or jejunum as appropriate 43260 594.05 Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 43261 594.05 Endoscopic retrograde cholangiopancreatography (ERCP); with biopsy, single or multiple

3/5/10 (Effective 1/1/10) 114.3 CMR - 1535 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

43262 594.05 Endoscopic retrograde cholangiopancreatography (ERCP); with sphincterotomy/papillotomy 43263 594.05 Endoscopic retrograde cholangiopancreatography (ERCP); with pressure measurement of sphincter of Oddi (pancreatic duct or common bile duct) 43264 594.05 Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts 43265 594.05 Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method 43267 594.05 Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde insertion of nasobiliary or nasopancreatic drainage tube 43268 662.51 Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde insertion of tube or stent into bile or pancreatic duct 43269 662.51 Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde removal of foreign body and/or change of tube or stent 43271 594.05 Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde balloon dilation of ampulla, biliary and/or pancreatic duct(s) 43272 594.05 Endoscopic retrograde cholangiopancreatography (ERCP); with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 43273 796.69 Endoscopic cannulation of papilla with direct visualization of common bile duct(s) and/or pancreatic duct(s) (List separately in addition to code(s) for primary procedure) 43450 265.23 Dilation of esophagus, by unguided sound or bougie, single or multiple passes 43453 265.23 Dilation of esophagus, over guide wire 43456 266.28 Dilation of esophagus, by balloon or dilator, retrograde 43458 304.34 Dilation of esophagus with balloon (30 mm diameter or larger) for achalasia 43600 303.27 Biopsy of stomach; by capsule, tube, peroral (one or more specimens) 43653 1,428.92 Laparoscopy, surgical; gastrostomy, without construction of gastric tube (e.g., Stamm procedure) (separate procedure) 43760 147.09 Change of gastrostomy tube 43761 303.27 Repositioning of the gastric feeding tube, any method, through the duodenum for enteric nutrition 43870 303.27 Closure of gastrostomy, surgical 43886 765.23 Gastric restrictive procedure, open; revision of subcutaneous port component only 43887 160.95 Gastric restrictive procedure, open; removal of subcutaneous port component only 43888 765.23 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only 44100 303.27 Biopsy of intestine by capsule, tube, peroral (one or more specimens) 44312 528.73 Revision of ileostomy; simple (release of superficial scar) (separate procedure) 44340 606.40 Revision of colostomy; simple (release of superficial scar) (separate procedure) 44360 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 44361 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple 44363 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of foreign body 44364 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 44365 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 44366 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1536 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

44369 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 44370 1,054.35 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation) 44372 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with placement of percutaneous jejunostomy tube 44373 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with conversion of percutaneous gastrostomy tube to percutaneous jejunostomy tube 44376 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 44377 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with biopsy, single or multiple 44378 369.57 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 44379 1,054.35 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with transendoscopic stent placement (includes predilation) 44380 319.98 Ileoscopy, through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 44382 319.98 Ileoscopy, through stoma; with biopsy, single or multiple 44383 1,054.35 Ileoscopy, through stoma; with transendoscopic stent placement (includes predilation) 44385 309.38 Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 44386 309.38 Endoscopic evaluation of small intestinal (abdominal or pelvic) pouch; with biopsy, single or multiple 44388 309.38 Colonoscopy through stoma; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 44389 309.38 Colonoscopy through stoma; with biopsy, single or multiple 44390 309.38 Colonoscopy through stoma; with removal of foreign body 44391 309.38 Colonoscopy through stoma; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 44392 309.38 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 44393 309.38 Colonoscopy through stoma; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 44394 309.38 Colonoscopy through stoma; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 44397 612.92 Colonoscopy through stoma; with transendoscopic stent placement (includes predilation) 44500 166.95 Introduction of long gastrointestinal tube (e.g., Miller-Abbott) (separate procedure) 45000 358.78 Transrectal drainage of pelvic abscess 45005 417.55 Incision and drainage of submucosal abscess, rectum 45020 417.55 Incision and drainage of deep supralevator, pelvirectal, or retrorectal abscess 45100 567.28 Biopsy of anorectal wall, anal approach (e.g., congenital megacolon) 45108 616.86 Anorectal myomectomy 45150 616.86 Division of stricture of rectum 45160 616.86 Excision of rectal tumor by proctotomy, transsacral or transcoccygeal approach 45170 616.86 Excision of rectal tumor, transanal approach 45190 1,008.70 Destruction of rectal tumor (e.g., electrodessication, electrosurgery, laser ablation, laser resection, cryosurgery) transanal approach 45300 59.72 Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1537 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

45303 331.75 Proctosigmoidoscopy, rigid; with dilation (e.g., balloon, guide wire, bougie) 45305 311.99 Proctosigmoidoscopy, rigid; with biopsy, single or multiple 45307 576.27 Proctosigmoidoscopy, rigid; with removal of foreign body 45308 311.99 Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery 45309 311.99 Proctosigmoidoscopy, rigid; with removal of single tumor, polyp, or other lesion by snare technique 45315 311.99 Proctosigmoidoscopy, rigid; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique 45317 311.99 Proctosigmoidoscopy, rigid; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 45320 576.27 Proctosigmoidoscopy, rigid; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique (e.g., laser) 45321 576.27 Proctosigmoidoscopy, rigid; with decompression of volvulus 45327 612.92 Proctosigmoidoscopy, rigid; with transendoscopic stent placement (includes predilation) 45330 78.88 Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 45331 233.25 Sigmoidoscopy, flexible; with biopsy, single or multiple 45332 233.25 Sigmoidoscopy, flexible; with removal of foreign body 45333 311.99 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 45334 311.99 Sigmoidoscopy, flexible; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 45335 233.25 Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance 45337 233.25 Sigmoidoscopy, flexible; with decompression of volvulus, any method 45338 311.99 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45339 311.99 Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 45340 311.99 Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures 45341 311.99 Sigmoidoscopy, flexible; with endoscopic ultrasound examination 45342 311.99 Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) 45345 612.92 Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation) 45355 309.38 Colonoscopy, rigid or flexible, transabdominal via colotomy, single or multiple 45378 358.97 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure) 45379 358.97 Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body 45380 358.97 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple 45381 358.97 Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance 45382 358.97 Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 45383 358.97 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 45384 358.97 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery 45385 358.97 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique 45386 358.97 Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures

3/5/10 (Effective 1/1/10) 114.3 CMR - 1538 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

45387 612.92 Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic stent placement (includes predilation) 45391 358.97 Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination 45392 358.97 Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) 45500 616.86 Proctoplasty; for stenosis 45505 759.48 Proctoplasty; for prolapse of mucous membrane 45520 30.08 Perirectal injection of sclerosing solution for prolapse 45560 759.48 Repair of rectocele (separate procedure) 45900 243.23 Reduction of procidentia (separate procedure) under anesthesia 45905 567.28 Dilation of anal sphincter (separate procedure) under anesthesia other than local 45910 567.28 Dilation of rectal stricture (separate procedure) under anesthesia other than local 45915 358.78 Removal of fecal impaction or foreign body (separate procedure) under anesthesia 45990 558.09 Anorectal exam, surgical, requiring anesthesia (general, spinal, or epidural), diagnostic 46020 644.95 Placement of seton 46030 243.23 Removal of anal seton, other marker 46040 644.95 Incision and drainage of ischiorectal and/or perirectal abscess (separate procedure) 46045 616.86 Incision and drainage of intramural, intramuscular, or submucosal abscess, transanal, under anesthesia 46050 358.78 Incision and drainage, perianal abscess, superficial 46060 616.86 Incision and drainage of ischiorectal or intramural abscess, with fistulectomy or fistulotomy, submuscular, with or without placement of seton 46070 443.68 Incision, anal septum (infant) 46080 644.95 Sphincterotomy, anal, division of sphincter (separate procedure) 46083 67.91 Incision of thrombosed hemorrhoid, external 46200 616.86 Fissurectomy, with or without sphincterotomy 46210 616.86 Cryptectomy; single 46211 616.86 Cryptectomy; multiple (separate procedure) 46220 567.28 Papillectomy or excision of single tag, anus (separate procedure) 46221 111.66 Hemorrhoidectomy, by simple ligature (e.g., rubber band) 46230 567.28 Excision of external hemorrhoid tags and/or multiple papillae 46250 644.95 Hemorrhoidectomy, external, complete 46255 644.95 Hemorrhoidectomy, internal and external, simple; 46257 644.95 Hemorrhoidectomy, internal and external, simple; with fissurectomy 46258 644.95 Hemorrhoidectomy, internal and external, simple; with fistulectomy, with or without fissurectomy 46260 644.95 Hemorrhoidectomy, internal and external, complex or extensive; 46261 697.60 Hemorrhoidectomy, internal and external, complex or extensive; with fissurectomy 46262 697.60 Hemorrhoidectomy, internal and external, complex or extensive; with fistulectomy, with or without fissurectomy 46270 644.95 Surgical treatment of anal fistula (fistulectomy/fistulotomy); subcutaneous 46275 644.95 Surgical treatment of anal fistula (fistulectomy/fistulotomy); submuscular 46280 697.60 Surgical treatment of anal fistula (fistulectomy/fistulotomy); complex or multiple, with or without placement of seton 46285 567.28 Surgical treatment of anal fistula (fistulectomy/fistulotomy); second stage 46288 697.60 Closure of anal fistula with rectal advancement flap 46320 75.64 Enucleation or excision of external thrombotic hemorrhoid 46500 104.19 Injection of sclerosing solution, hemorrhoids 46505 443.68 Chemodenervation of internal anal sphincter 46600 23.47 Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 46604 331.75 Anoscopy; with dilation (e.g., balloon, guide wire, bougie) 46606 124.65 Anoscopy; with biopsy, single or multiple 46608 311.99 Anoscopy; with removal of foreign body

3/5/10 (Effective 1/1/10) 114.3 CMR - 1539 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

46610 576.27 Anoscopy; with removal of single tumor, polyp, or other lesion by hot biopsy forceps or bipolar cautery 46611 311.99 Anoscopy; with removal of single tumor, polyp, or other lesion by snare technique 46612 576.27 Anoscopy; with removal of multiple tumors, polyps, or other lesions by hot biopsy forceps, bipolar cautery or snare technique 46614 65.57 Anoscopy; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator) 46615 625.85 Anoscopy; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique 46700 644.95 Anoplasty, plastic operation for stricture; adult 46706 709.89 Repair of anal fistula with fibrin glue 46750 787.56 Sphincteroplasty, anal, for incontinence or prolapse; adult 46753 644.95 Graft (Thiersch operation) for rectal incontinence and/or prolapse 46754 616.86 Removal of Thiersch wire or suture, anal canal 46760 759.48 Sphincteroplasty, anal, for incontinence, adult; muscle transplant 46761 787.56 Sphincteroplasty, anal, for incontinence, adult; levator muscle imbrication (Park posterior anal repair) 46762 1,000.38 Sphincteroplasty, anal, for incontinence, adult; implantation artificial sphincter 46900 99.13 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical 46910 118.48 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodesiccation 46916 55.11 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery 46917 514.06 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery 46922 514.06 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision 46924 514.06 Destruction of lesion(s), anus (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery) 46930 114.91 Destruction of internal hemorrhoid(s) by thermal energy (e.g., infrared coagulation, cautery, radiofrequency) 46937 616.86 Cryosurgery of rectal tumor; benign 46938 759.48 Cryosurgery of rectal tumor; malignant 46940 85.04 Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); initial 46942 82.77 Curettage or cautery of anal fissure, including dilation of anal sphincter (separate procedure); subsequent 46945 140.88 Ligation of internal hemorrhoids; single procedure 46946 367.96 Ligation of internal hemorrhoids; multiple procedures 46947 1,000.38 Hemorrhoidopexy (e.g., for prolapsing internal hemorrhoids) by stapling 47000 320.09 Biopsy of liver, needle; percutaneous 47382 1,689.21 Ablation, one or more liver tumor(s), percutaneous, radiofrequency 47510 748.08 Introduction of percutaneous transhepatic catheter for biliary drainage 47511 1,099.04 Introduction of percutaneous transhepatic stent for internal and external biliary drainage 47525 429.45 Change of percutaneous biliary drainage catheter 47530 429.45 Revision and/or reinsertion of transhepatic tube 47552 748.08 Biliary endoscopy, percutaneous via T-tube or other tract; diagnostic, with or without collection of specimen(s) by brushing and/or washing (separate procedure) 47553 776.16 Biliary endoscopy, percutaneous via T-tube or other tract; with biopsy, single or multiple 47554 776.16 Biliary endoscopy, percutaneous via T-tube or other tract; with removal of calculus/calculi

3/5/10 (Effective 1/1/10) 114.3 CMR - 1540 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

47555 776.16 Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct stricture(s) without stent 47556 1,099.04 Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct stricture(s) with stent 47560 911.96 Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy 47561 911.96 Laparoscopy, surgical; with guided transhepatic cholangiography with biopsy 47562 1,682.76 Laparoscopy, surgical; cholecystectomy 47563 1,682.76 Laparoscopy, surgical; cholecystectomy with cholangiography 47564 1,682.76 Laparoscopy, surgical; cholecystectomy with exploration of common duct 47630 776.16 Biliary duct stone extraction, percutaneous via T-tube tract, basket, or snare (e.g., Burhenne technique) 48102 320.09 Biopsy of pancreas, percutaneous needle 49080 194.64 Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); initial 49081 194.64 Peritoneocentesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); subsequent 49180 320.09 Biopsy, abdominal or retroperitoneal mass, percutaneous needle 49250 701.66 Umbilectomy, omphalectomy, excision of umbilicus (separate procedure) 49320 911.96 Laparoscopy, abdomen, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure) 49321 964.62 Laparoscopy, surgical; with biopsy (single or multiple) 49322 964.62 Laparoscopy, surgical; with aspiration of cavity or cyst (e.g., ovarian cyst) (single or multiple) 49324 1,376.35 Laparoscopy, surgical; with insertion of intraperitoneal cannula or catheter, permanent 49325 1,376.35 Laparoscopy, surgical; with revision of previously placed intraperitoneal cannula or catheter, with removal of intraluminal obstructive material if performed 49326 1,376.35 Laparoscopy, surgical; with omentopexy (omental tacking procedure) (List separately in addition to code for primary procedure) 49402 620.92 Removal of peritoneal foreign body from peritoneal cavity 49419 744.88 Insertion of intraperitoneal cannula or catheter, with subcutaneous reservoir, permanent (ie, totally implantable) 49420 688.59 Insertion of intraperitoneal cannula or catheter for drainage or dialysis; temporary 49421 688.59 Insertion of intraperitoneal cannula or catheter for drainage or dialysis; permanent 49422 548.01 Removal of permanent intraperitoneal cannula or catheter 49423 566.67 Exchange of previously placed abscess or cyst drainage catheter under radiological guidance (separate procedure) 49426 620.92 Revision of peritoneal-venous shunt 49429 803.79 Removal of peritoneal-venous shunt 49440 314.32 Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report 49441 314.32 Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report 49446 314.32 Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report 49450 166.95 Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report 49451 166.95 Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report 49452 166.95 Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report

3/5/10 (Effective 1/1/10) 114.3 CMR - 1541 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

49460 166.95 Mechanical removal of obstructive material from gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report 49495 851.54 Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; reducible 49496 851.54 Repair, initial inguinal hernia, full term infant younger than age 6 months, or preterm infant older than 50 weeks postconception age and younger than age 6 months at the time of surgery, with or without hydrocelectomy; incarcerated or strangulated 49500 851.54 Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; reducible 49501 1,162.64 Repair initial inguinal hernia, age 6 months to younger than 5 years, with or without hydrocelectomy; incarcerated or strangulated 49505 851.54 Repair initial inguinal hernia, age 5 years or older; reducible 49507 1,162.64 Repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated 49520 1,011.70 Repair recurrent inguinal hernia, any age; reducible 49521 1,162.64 Repair recurrent inguinal hernia, any age; incarcerated or strangulated 49525 851.54 Repair inguinal hernia, sliding, any age 49540 770.80 Repair lumbar hernia 49550 889.71 Repair initial femoral hernia, any age; reducible 49553 1,162.64 Repair initial femoral hernia, any age; incarcerated or strangulated 49555 889.71 Repair recurrent femoral hernia; reducible 49557 1,162.64 Repair recurrent femoral hernia; incarcerated or strangulated 49560 851.54 Repair initial incisional or ventral hernia; reducible 49561 1,162.64 Repair initial incisional or ventral hernia; incarcerated or strangulated 49565 851.54 Repair recurrent incisional or ventral hernia; reducible 49566 1,162.64 Repair recurrent incisional or ventral hernia; incarcerated or strangulated 49568 1,011.70 Implantation of mesh or other prosthesis for incisional or ventral hernia repair (List separately in addition to code for the incisional or ventral hernia repair) 49570 851.54 Repair epigastric hernia (e.g., preperitoneal fat); reducible (separate procedure) 49572 1,162.64 Repair epigastric hernia (e.g., preperitoneal fat); incarcerated or strangulated 49580 851.54 Repair umbilical hernia, younger than age 5 years; reducible 49582 1,162.64 Repair umbilical hernia, younger than age 5 years; incarcerated or strangulated 49585 851.54 Repair umbilical hernia, age 5 years or older; reducible 49587 1,162.64 Repair umbilical hernia, age 5 years or older; incarcerated or strangulated 49590 798.89 Repair spigelian hernia 49600 851.54 Repair of small omphalocele, with primary closure 49650 1,117.82 Laparoscopy, surgical; repair initial inguinal hernia 49651 1,277.98 Laparoscopy, surgical; repair recurrent inguinal hernia 49652 1,376.35 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); reducible 49653 1,376.35 Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed); incarcerated or strangulated 49654 1,376.35 Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); reducible 49655 1,376.35 Laparoscopy, surgical, repair, incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated 49656 1,376.35 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); reducible 49657 1,376.35 Laparoscopy, surgical, repair, recurrent incisional hernia (includes mesh insertion, when performed); incarcerated or strangulated 50200 320.09 Renal biopsy; percutaneous, by trocar or needle 50382 929.48 Removal (via snare/capture) and replacement of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation

3/5/10 (Effective 1/1/10) 114.3 CMR - 1542 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

50384 682.69 Removal (via snare/capture) of internally dwelling ureteral stent via percutaneous approach, including radiological supervision and interpretation 50385 682.69 Removal (via snare/capture) and replacement of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation 50386 261.93 Removal (via snare/capture) of internally dwelling ureteral stent via transurethral approach, without use of cystoscopy, including radiological supervision and interpretation 50387 566.67 Removal and replacement of externally accessible transnephric ureteral stent (e.g., external/internal stent) requiring fluoroscopic guidance, including radiological supervision and interpretation 50389 261.93 Removal of nephrostomy tube, requiring fluoroscopic guidance (e.g., with concurrent indwelling ureteral stent) 50390 320.09 Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous 50391 37.91 Instillation(s) of therapeutic agent into renal pelvis and/or ureter through established nephrostomy, pyelostomy or ureterostomy tube (e.g., anticarcinogenic or antifungal agent) 50392 487.46 Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous 50393 610.86 Introduction of ureteral catheter or stent into ureter through renal pelvis for drainage and/or injection, percutaneous 50395 487.46 Introduction of guide into renal pelvis and/or ureter with dilation to establish nephrostomy tract, percutaneous 50396 91.66 Manometric studies through nephrostomy or pyelostomy tube, or indwelling ureteral catheter 50398 429.45 Change of nephrostomy or pyelostomy tube 50551 277.08 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; 50553 610.86 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter 50555 277.08 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy 50557 610.86 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy 50561 610.86 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus 50562 261.93 Renal endoscopy through established nephrostomy or pyelostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with resection of tumor 50570 261.93 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; 50572 261.93 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter 50574 261.93 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy 50575 1,302.88 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with endopyelotomy (includes cystoscopy, ureteroscopy, dilation of ureter and ureteral pelvic junction, incision of ureteral pelvic junction and insertion of endopyelotomy stent)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1543 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

50576 682.69 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy 50580 682.69 Renal endoscopy through nephrotomy or pyelotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus 50590 1,522.06 Lithotripsy, extracorporeal shock wave 50592 1,689.21 Ablation, one or more renal tumor(s), percutaneous, unilateral, radiofrequency 50686 37.91 Manometric studies through ureterostomy or indwelling ureteral catheter 50688 429.45 Change of ureterostomy tube or externally accessible ureteral stent via ileal conduit 50947 1,428.92 Laparoscopy, surgical; ureteroneocystostomy with cystoscopy and ureteral stent placement 50948 1,428.92 Laparoscopy, surgical; ureteroneocystostomy without cystoscopy and ureteral stent placement 50951 277.08 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; 50953 277.08 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter 50955 610.86 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy 50957 610.86 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy 50961 610.86 Ureteral endoscopy through established ureterostomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus 50970 277.08 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; 50972 277.08 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with ureteral catheterization, with or without dilation of ureter 50974 487.46 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with biopsy 50976 487.46 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with fulguration and/or incision, with or without biopsy 50980 610.86 Ureteral endoscopy through ureterotomy, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with removal of foreign body or calculus 51020 741.19 Cystotomy or cystostomy; with fulguration and/or insertion of radioactive material 51030 741.19 Cystotomy or cystostomy; with cryosurgical destruction of intravesical lesion 51040 741.19 Cystostomy, cystotomy with drainage 51045 306.14 Cystotomy, with insertion of ureteral catheter or stent (separate procedure) 51050 741.19 Cystolithotomy, cystotomy with removal of calculus, without vesical neck resection 51065 741.19 Cystotomy, with calculus basket extraction and/or ultrasonic or electrohydraulic fragmentation of ureteral calculus 51080 498.25 Drainage of perivesical or prevesical space abscess 51100 28.89 Aspiration of bladder; by needle 51101 37.91 Aspiration of bladder; by trocar or intracatheter 51102 510.00 Aspiration of bladder; with insertion of suprapubic catheter 51500 851.54 Excision of urachal cyst or sinus, with or without umbilical hernia repair 51520 741.19 Cystotomy; for simple excision of vesical neck (separate procedure) 51700 49.34 Bladder irrigation, simple, lavage and/or instillation 51701 23.47 Insertion of non-indwelling bladder catheter (e.g., straight catheterization for residual urine)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1544 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

51702 23.47 Insertion of temporary indwelling bladder catheter; simple (e.g., Foley) 51703 37.91 Insertion of temporary indwelling bladder catheter; complicated (e.g., altered anatomy, fractured catheter/balloon) 51705 67.91 Change of cystostomy tube; simple 51710 429.45 Change of cystostomy tube; complicated 51715 779.76 Endoscopic injection of implant material into the submucosal tissues of the urethra and/or bladder neck 51720 54.53 Bladder instillation of anticarcinogenic agent (including retention time) 51725 104.76 Simple cystometrogram (CMG) (e.g., spinal manometer) 51726 144.30 Complex cystometrogram (e.g., calibrated electronic equipment) 51736 19.80 Simple uroflowmetry (UFR) (e.g., stop-watch flow rate, mechanical uroflowmeter) 51741 23.05 Complex uroflowmetry (e.g., calibrated electronic equipment) 51772 91.66 Urethral pressure profile studies (UPP) (urethral closure pressure profile), any technique 51784 37.91 Electromyography studies (EMG) of anal or urethral sphincter, other than needle, any technique 51785 63.32 Needle electromyography studies (EMG) of anal or urethral sphincter, any technique 51792 37.91 Stimulus evoked response (e.g., measurement of bulbocavernosus reflex latency time) 51795 67.91 Voiding pressure studies (VP); bladder voiding pressure, any technique 51797 67.91 Voiding pressure studies (VP); intra-abdominal voiding pressure (AP) (rectal, gastric, intraperitoneal) 51798 16.88 Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging 51880 610.86 Closure of cystostomy (separate procedure) 51992 1,156.00 Laparoscopy, surgical; sling operation for stress incontinence (e.g., fascia or synthetic) 52000 277.08 Cystourethroscopy (separate procedure) 52001 516.52 Cystourethroscopy with irrigation and evacuation of multiple obstructing clots 52005 537.04 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; 52007 660.45 Cystourethroscopy, with ureteral catheterization, with or without irrigation, instillation, or ureteropyelography, exclusive of radiologic service; with brush biopsy of ureter and/or renal pelvis 52010 306.14 Cystourethroscopy, with ejaculatory duct catheterization, with or without irrigation, instillation, or duct radiography, exclusive of radiologic service 52204 537.04 Cystourethroscopy, with biopsy(s) 52214 660.45 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) of trigone, bladder neck, prostatic fossa, urethra, or periurethral glands 52224 660.45 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) or treatment of MINOR (less than 0.5 cm) lesion(s) with or without biopsy 52234 660.45 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; SMALL bladder tumor(s) (0.5 up to 2.0 cm) 52235 688.53 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; MEDIUM bladder tumor(s) (2.0 to 5.0 cm) 52240 688.53 Cystourethroscopy, with fulguration (including cryosurgery or laser surgery) and/or resection of; LARGE bladder tumor(s) 52250 741.19 Cystourethroscopy with insertion of radioactive substance, with or without biopsy or fulguration 52260 537.04 Cystourethroscopy, with dilation of bladder for interstitial cystitis; general or conduction (spinal) anesthesia 52265 261.93 Cystourethroscopy, with dilation of bladder for interstitial cystitis; local anesthesia 52270 537.04 Cystourethroscopy, with internal urethrotomy; female 52275 660.45 Cystourethroscopy, with internal urethrotomy; male 52276 688.53 Cystourethroscopy with direct vision internal urethrotomy 52277 660.45 Cystourethroscopy, with resection of external sphincter (sphincterotomy)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1545 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

52281 537.04 Cystourethroscopy, with calibration and/or dilation of urethral stricture or stenosis, with or without meatotomy, with or without injection procedure for cystography, male or female 52282 1,238.99 Cystourethroscopy, with insertion of urethral stent 52283 660.45 Cystourethroscopy, with steroid injection into stricture 52285 537.04 Cystourethroscopy for treatment of the female urethral syndrome with any or all of the following: urethral meatotomy, urethral dilation, internal urethrotomy, lysis of urethrovaginal septal fibrosis, lateral incisions of the bladder neck, and fulguration of polyp(s) of urethra, bladder neck, and/or trigone 52290 537.04 Cystourethroscopy; with ureteral meatotomy, unilateral or bilateral 52300 660.45 Cystourethroscopy; with resection or fulguration of orthotopic ureterocele(s), unilateral or bilateral 52301 688.53 Cystourethroscopy; with resection or fulguration of ectopic ureterocele(s), unilateral or bilateral 52305 660.45 Cystourethroscopy; with incision or resection of orifice of bladder diverticulum, single or multiple 52310 516.52 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); simple 52315 660.45 Cystourethroscopy, with removal of foreign body, calculus, or ureteral stent from urethra or bladder (separate procedure); complicated 52317 610.86 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; simple or small (less than 2.5 cm) 52318 660.45 Litholapaxy: crushing or fragmentation of calculus by any means in bladder and removal of fragments; complicated or large (over 2.5 cm) 52320 779.36 Cystourethroscopy (including ureteral catheterization); with removal of ureteral calculus 52325 741.19 Cystourethroscopy (including ureteral catheterization); with fragmentation of ureteral calculus (e.g., ultrasonic or electro-hydraulic technique) 52327 847.14 Cystourethroscopy (including ureteral catheterization); with subureteric injection of implant material 52330 660.45 Cystourethroscopy (including ureteral catheterization); with manipulation, without removal of ureteral calculus 52332 660.45 Cystourethroscopy, with insertion of indwelling ureteral stent (e.g., Gibbons or double-J type) 52334 688.53 Cystourethroscopy with insertion of ureteral guide wire through kidney to establish a percutaneous nephrostomy, retrograde 52341 688.53 Cystourethroscopy; with treatment of ureteral stricture (e.g., balloon dilation, laser, electrocautery, and incision) 52342 688.53 Cystourethroscopy; with treatment of ureteropelvic junction stricture (e.g., balloon dilation, laser, electrocautery, and incision) 52343 688.53 Cystourethroscopy; with treatment of intra-renal stricture (e.g., balloon dilation, laser, electrocautery, and incision) 52344 688.53 Cystourethroscopy with ureteroscopy; with treatment of ureteral stricture (e.g., balloon dilation, laser, electrocautery, and incision) 52345 688.53 Cystourethroscopy with ureteroscopy; with treatment of ureteropelvic junction stricture (e.g., balloon dilation, laser, electrocautery, and incision) 52346 688.53 Cystourethroscopy with ureteroscopy; with treatment of intra-renal stricture (e.g., balloon dilation, laser, electrocautery, and incision) 52351 688.53 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; diagnostic 52352 741.19 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with removal or manipulation of calculus (ureteral catheterization is included) 52353 927.88 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included) 52354 741.19 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with biopsy and/or fulguration of ureteral or renal pelvic lesion

3/5/10 (Effective 1/1/10) 114.3 CMR - 1546 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

52355 741.19 Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with resection of ureteral or renal pelvic tumor 52400 688.53 Cystourethroscopy with incision, fulguration, or resection of congenital posterior urethral valves, or congenital obstructive hypertrophic mucosal folds 52402 688.53 Cystourethroscopy with transurethral resection or incision of ejaculatory ducts 52450 688.53 Transurethral incision of prostate 52500 688.53 Transurethral resection of bladder neck (separate procedure) 52601 927.88 Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included) 52630 847.14 Transurethral resection; of regrowth of obstructive tissue longer than one year postoperative 52640 660.45 Transurethral resection; of postoperative bladder neck contracture 52647 1,419.57 Laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included if performed) 52648 1,419.57 Laser vaporization of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, internal urethrotomy and transurethral resection of prostate are included if performed) 52700 660.45 Transurethral drainage of prostatic abscess 53000 506.89 Urethrotomy or urethrostomy, external (separate procedure); pendulous urethra 53010 506.89 Urethrotomy or urethrostomy, external (separate procedure); perineal urethra, external 53020 506.89 Meatotomy, cutting of meatus (separate procedure); except infant 53025 721.54 Meatotomy, cutting of meatus (separate procedure); infant 53040 556.48 Drainage of deep periurethral abscess 53060 65.90 Drainage of Skenes gland abscess or cyst 53080 584.56 Drainage of perineal urinary extravasation; uncomplicated (separate procedure) 53085 721.54 Drainage of perineal urinary extravasation; complicated 53200 506.89 Biopsy of urethra 53210 870.59 Urethrectomy, total, including cystostomy; female 53215 675.39 Urethrectomy, total, including cystostomy; male 53220 751.67 Excision or fulguration of carcinoma of urethra 53230 751.67 Excision of urethral diverticulum (separate procedure); female 53235 584.56 Excision of urethral diverticulum (separate procedure); male 53240 751.67 Marsupialization of urethral diverticulum, male or female 53250 556.48 Excision of bulbourethral gland (Cowpers gland) 53260 556.48 Excision or fulguration; urethral polyp(s), distal urethra 53265 556.48 Excision or fulguration; urethral caruncle 53270 556.48 Excision or fulguration; Skenes glands 53275 556.48 Excision or fulguration; urethral prolapse 53400 779.76 Urethroplasty; first stage, for fistula, diverticulum, or stricture (e.g., Johannsen type) 53405 751.67 Urethroplasty; second stage (formation of urethra), including urinary diversion 53410 751.67 Urethroplasty, one-stage reconstruction of male anterior urethra 53420 779.76 Urethroplasty, two-stage reconstruction or repair of prostatic or membranous urethra; first stage 53425 751.67 Urethroplasty, two-stage reconstruction or repair of prostatic or membranous urethra; second stage 53430 751.67 Urethroplasty, reconstruction of female urethra 53431 751.67 Urethroplasty with tubularization of posterior urethra and/or lower bladder for incontinence (e.g., Tenago, Leadbetter procedure) 53440 4,329.93 Sling operation for correction of male urinary incontinence (e.g., fascia or synthetic) 53442 702.09 Removal or revision of sling for male urinary incontinence (e.g., fascia or synthetic) 53444 4,329.93 Insertion of tandem cuff (dual cuff) 53445 7,273.18 Insertion of inflatable urethral/bladder neck sphincter, including placement of pump, reservoir, and cuff

3/5/10 (Effective 1/1/10) 114.3 CMR - 1547 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

53446 702.09 Removal of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff 53447 7,273.18 Removal and replacement of inflatable urethral/bladder neck sphincter including pump, reservoir, and cuff at the same operative session 53449 702.09 Repair of inflatable urethral/bladder neck sphincter, including pump, reservoir, and cuff 53450 702.09 Urethromeatoplasty, with mucosal advancement 53460 506.89 Urethromeatoplasty, with partial excision of distal urethral segment (Richardson type procedure) 53502 556.48 Urethrorrhaphy, suture of urethral wound or injury, female 53505 751.67 Urethrorrhaphy, suture of urethral wound or injury; penile 53510 556.48 Urethrorrhaphy, suture of urethral wound or injury; perineal 53515 751.67 Urethrorrhaphy, suture of urethral wound or injury; prostatomembranous 53520 751.67 Closure of urethrostomy or urethrocutaneous fistula, male (separate procedure) 53600 37.98 Dilation of urethral stricture by passage of sound or urethral dilator, male; initial 53601 37.91 Dilation of urethral stricture by passage of sound or urethral dilator, male; subsequent 53605 537.04 Dilation of urethral stricture or vesical neck by passage of sound or urethral dilator, male, general or conduction (spinal) anesthesia 53620 58.43 Dilation of urethral stricture by passage of filiform and follower, male; initial 53621 61.35 Dilation of urethral stricture by passage of filiform and follower, male; subsequent 53660 37.91 Dilation of female urethra including suppository and/or instillation; initial 53661 37.91 Dilation of female urethra including suppository and/or instillation; subsequent 53665 506.89 Dilation of female urethra, general or conduction (spinal) anesthesia 53850 1,664.06 Transurethral destruction of prostate tissue; by microwave thermotherapy 53852 1,664.06 Transurethral destruction of prostate tissue; by radiofrequency thermotherapy 54000 556.48 Slitting of prepuce, dorsal or lateral (separate procedure); newborn 54001 556.48 Slitting of prepuce, dorsal or lateral (separate procedure); except newborn 54015 628.58 Incision and drainage of penis, deep 54050 30.08 Destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; chemical 54055 61.35 Destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; electrodesiccation 54056 30.08 Destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; cryosurgery 54057 514.06 Destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; laser surgery 54060 514.06 Destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), simple; surgical excision 54065 514.06 Destruction of lesion(s), penis (e.g., condyloma, papilloma, molluscum contagiosum, herpetic vesicle), extensive (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery) 54100 434.86 Biopsy of penis; (separate procedure) 54105 542.85 Biopsy of penis; deep structures 54110 841.65 Excision of penile plaque (Peyronie disease); 54111 841.65 Excision of penile plaque (Peyronie disease); with graft to 5 cm in length 54112 841.65 Excision of penile plaque (Peyronie disease); with graft greater than 5 cm in length 54115 498.25 Removal foreign body from deep penile tissue (e.g., plastic implant) 54120 841.65 Amputation of penis; partial 54150 560.92 Circumcision, using clamp or other device with regional dorsal penile or ring block 54160 610.51 Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate (28 days of age or less) 54161 610.51 Circumcision, surgical excision other than clamp, device, or dorsal slit; older than 28 days of age 54162 610.51 Lysis or excision of penile post-circumcision adhesions 54163 610.51 Repair incomplete circumcision 54164 610.51 Frenulotomy of penis

3/5/10 (Effective 1/1/10) 114.3 CMR - 1548 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

54200 63.95 Injection procedure for Peyronie disease; 54205 922.39 Injection procedure for Peyronie disease; with surgical exposure of plaque 54220 91.66 Irrigation of corpora cavernosa for priapism 54231 60.05 Dynamic cavernosometry, including intracavernosal injection of vasoactive drugs (e.g., papaverine, phentolamine) 54235 42.53 Injection of corpora cavernosa with pharmacologic agent(s) (e.g., papaverine, phentolamine) 54240 30.19 Penile plethysmography 54250 10.71 Nocturnal penile tumescence and/or rigidity test 54300 869.73 Plastic operation of penis for straightening of chordee (e.g., hypospadias), with or without mobilization of urethra 54304 869.73 Plastic operation on penis for correction of chordee or for first stage hypospadias repair with or without transplantation of prepuce and/or skin flaps 54308 869.73 Urethroplasty for second stage hypospadias repair (including urinary diversion); less than 3 cm 54312 869.73 Urethroplasty for second stage hypospadias repair (including urinary diversion); greater than 3 cm 54316 869.73 Urethroplasty for second stage hypospadias repair (including urinary diversion) with free skin graft obtained from site other than genitalia 54318 869.73 Urethroplasty for third stage hypospadias repair to release penis from scrotum (e.g., third stage Cecil repair) 54322 869.73 One stage distal hypospadias repair (with or without chordee or circumcision); with simple meatal advancement (e.g., Magpi, V-flap) 54324 869.73 One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps (e.g., flip-flap, prepucial flap) 54326 869.73 One stage distal hypospadias repair (with or without chordee or circumcision); with urethroplasty by local skin flaps and mobilization of urethra 54328 869.73 One stage distal hypospadias repair (with or without chordee or circumcision); with extensive dissection to correct chordee and urethroplasty with local skin flaps, skin graft patch, and/or island flap 54340 869.73 Repair of hypospadias complications (ie, fistula, stricture, diverticula); by closure, incision, or excision, simple 54344 869.73 Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring mobilization of skin flaps and urethroplasty with flap or patch graft 54348 869.73 Repair of hypospadias complications (ie, fistula, stricture, diverticula); requiring extensive dissection and urethroplasty with flap, patch or tubed graft (includes urinary diversion) 54352 869.73 Repair of hypospadias cripple requiring extensive dissection and excision of previously constructed structures including re-release of chordee and reconstruction of urethra and penis by use of local skin as grafts and island flaps and skin brought in as flaps or grafts 54360 869.73 Plastic operation on penis to correct angulation 54380 869.73 Plastic operation on penis for epispadias distal to external sphincter; 54385 869.73 Plastic operation on penis for epispadias distal to external sphincter; with incontinence 54400 4,358.02 Insertion of penile prosthesis; non-inflatable (semi-rigid) 54401 7,350.85 Insertion of penile prosthesis; inflatable (self-contained) 54405 7,350.85 Insertion of multi-component, inflatable penile prosthesis, including placement of pump, cylinders, and reservoir 54406 869.73 Removal of all components of a multi-component, inflatable penile prosthesis without replacement of prosthesis 54408 869.73 Repair of component(s) of a multi-component, inflatable penile prosthesis 54410 7,350.85 Removal and replacement of all component(s) of a multi-component, inflatable penile prosthesis at the same operative session 54415 869.73 Removal of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis, without replacement of prosthesis

3/5/10 (Effective 1/1/10) 114.3 CMR - 1549 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

54416 7,350.85 Removal and replacement of non-inflatable (semi-rigid) or inflatable (self-contained) penile prosthesis at the same operative session 54420 922.39 Corpora cavernosa-saphenous vein shunt (priapism operation), unilateral or bilateral 54435 922.39 Corpora cavernosa-glans penis fistulization (e.g., biopsy needle, Winter procedure, rongeur, or punch) for priapism 54440 922.39 Plastic operation of penis for injury 54450 144.30 Foreskin manipulation including lysis of preputial adhesions and stretching 54500 391.64 Biopsy of testis, needle (separate procedure) 54505 560.92 Biopsy of testis, incisional (separate procedure) 54512 610.51 Excision of extraparenchymal lesion of testis 54520 638.59 Orchiectomy, simple (including subcapsular), with or without testicular prosthesis, scrotal or inguinal approach 54522 638.59 Orchiectomy, partial 54530 851.54 Orchiectomy, radical, for tumor; inguinal approach 54550 851.54 Exploration for undescended testis (inguinal or scrotal area) 54560 829.60 Exploration for undescended testis with abdominal exploration 54600 691.25 Reduction of torsion of testis, surgical, with or without fixation of contralateral testis 54620 638.59 Fixation of contralateral testis (separate procedure) 54640 851.54 Orchiopexy, inguinal approach, with or without hernia repair 54660 610.51 Insertion of testicular prosthesis (separate procedure) 54670 638.59 Suture or repair of testicular injury 54680 638.59 Transplantation of testis(es) to thigh (because of scrotal destruction) 54690 1,428.92 Laparoscopy, surgical; orchiectomy 54692 2,540.04 Laparoscopy, surgical; orchiopexy for intra-abdominal testis 54700 610.51 Incision and drainage of epididymis, testis and/or scrotal space (e.g., abscess or hematoma) 54800 137.03 Biopsy of epididymis, needle 54830 638.59 Excision of local lesion of epididymis 54840 691.25 Excision of spermatocele, with or without epididymectomy 54860 638.59 Epididymectomy; unilateral 54861 691.25 Epididymectomy; bilateral 54865 560.92 Exploration of epididymis, with or without biopsy 54900 691.25 Epididymovasostomy, anastomosis of epididymis to vas deferens; unilateral 54901 691.25 Epididymovasostomy, anastomosis of epididymis to vas deferens; bilateral 55000 62.33 Puncture aspiration of hydrocele, tunica vaginalis, with or without injection of medication 55040 798.89 Excision of hydrocele; unilateral 55041 889.71 Excision of hydrocele; bilateral 55060 691.25 Repair of tunica vaginalis hydrocele (Bottle type) 55100 374.89 Drainage of scrotal wall abscess 55110 610.51 Scrotal exploration 55120 610.51 Removal of foreign body in scrotum 55150 560.92 Resection of scrotum 55175 560.92 Scrotoplasty; simple 55180 610.51 Scrotoplasty; complicated 55200 610.51 Vasotomy, cannulization with or without incision of vas, unilateral or bilateral (separate procedure) 55250 610.51 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) 55400 560.92 Vasovasostomy, vasovasorrhaphy 55450 200.60 Ligation (percutaneous) of vas deferens, unilateral or bilateral (separate procedure) 55500 638.59 Excision of hydrocele of spermatic cord, unilateral (separate procedure) 55520 691.25 Excision of lesion of spermatic cord (separate procedure) 55530 691.25 Excision of varicocele or ligation of spermatic veins for varicocele; (separate procedure)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1550 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

55535 851.54 Excision of varicocele or ligation of spermatic veins for varicocele; abdominal approach 55540 889.71 Excision of varicocele or ligation of spermatic veins for varicocele; with hernia repair 55550 1,428.92 Laparoscopy, surgical, with ligation of spermatic veins for varicocele 55600 829.60 Vesiculotomy; 55680 560.92 Excision of Mullerian duct cyst 55700 361.49 Biopsy, prostate; needle or punch, single or multiple, any approach 55705 361.49 Biopsy, prostate; incisional, any approach 55706 419.48 Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance 55720 610.86 Prostatotomy, external drainage of prostatic abscess, any approach; simple 55725 660.45 Prostatotomy, external drainage of prostatic abscess, any approach; complicated 55860 727.78 Exposure of prostate, any approach, for insertion of radioactive substance; 55870 74.01 Electroejaculation 55873 5,758.44 Cryosurgical ablation of the prostate (includes ultrasonic guidance for interstitial cryosurgical probe placement) 55875 1,238.99 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy 55876 67.84 Placement of interstitial device(s) for radiation therapy guidance (e.g., fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple 55920 850.45 Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application 56405 39.60 Incision and drainage of vulva or perineal abscess 56420 51.69 Incision and drainage of Bartholins gland abscess 56440 555.04 Marsupialization of Bartholins gland cyst 56441 505.45 Lysis of labial adhesions 56442 505.45 Hymenotomy, simple incision 56501 54.53 Destruction of lesion(s), vulva; simple (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery) 56515 591.73 Destruction of lesion(s), vulva; extensive (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery) 56605 31.48 Biopsy of vulva or perineum (separate procedure); one lesion 56606 12.99 Biopsy of vulva or perineum (separate procedure); each separate additional lesion (List separately in addition to code for primary procedure) 56620 673.95 Vulvectomy simple; partial 56625 795.93 Vulvectomy simple; complete 56700 505.45 Partial hymenectomy or revision of hymenal ring 56740 583.12 Excision of Bartholins gland or cyst 56800 583.12 Plastic repair of introitus 56805 718.67 Clitoroplasty for intersex state 56810 673.95 Perineoplasty, repair of perineum, nonobstetrical (separate procedure) 56820 40.25 Colposcopy of the vulva; 56821 51.69 Colposcopy of the vulva; with biopsy(s) 57000 505.45 Colpotomy; with exploration 57010 555.04 Colpotomy; with drainage of pelvic abscess 57020 291.09 Colpocentesis (separate procedure) 57022 457.54 Incision and drainage of vaginal hematoma; obstetrical/postpartum 57023 498.25 Incision and drainage of vaginal hematoma; non-obstetrical (e.g., post-trauma, spontaneous bleeding) 57061 50.31 Destruction of vaginal lesion(s); simple (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery) 57065 505.45 Destruction of vaginal lesion(s); extensive (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery) 57100 32.14 Biopsy of vaginal mucosa; simple (separate procedure) 57105 555.04 Biopsy of vaginal mucosa; extensive, requiring suture (including cysts) 57130 555.04 Excision of vaginal septum

3/5/10 (Effective 1/1/10) 114.3 CMR - 1551 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

57135 555.04 Excision of vaginal cyst or tumor 57150 23.37 Irrigation of vagina and/or application of medicament for treatment of bacterial, parasitic, or fungoid disease 57155 291.09 Insertion of uterine tandems and/or vaginal ovoids for clinical brachytherapy 57160 33.76 Fitting and insertion of pessary or other intravaginal support device 57170 5.54 Diaphragm or cervical cap fitting with instructions 57180 103.97 Introduction of any hemostatic agent or pack for spontaneous or traumatic nonobstetrical vaginal hemorrhage (separate procedure) 57200 505.45 Colporrhaphy, suture of injury of vagina (nonobstetrical) 57210 555.04 Colpoperineorrhaphy, suture of injury of vagina and/or perineum (nonobstetrical) 57220 1,017.86 Plastic operation on urethral sphincter, vaginal approach (e.g., Kelly urethral plication) 57230 835.76 Plastic repair of urethrocele 57240 926.59 Anterior colporrhaphy, repair of cystocele with or without repair of urethrocele 57250 926.59 Posterior colporrhaphy, repair of rectocele with or without perineorrhaphy 57260 926.59 Combined anteroposterior colporrhaphy; 57265 1,230.68 Combined anteroposterior colporrhaphy; with enterocele repair 57267 1,048.57 Insertion of mesh or other prosthesis for repair of pelvic floor defect, each site (anterior, posterior compartment), vaginal approach (List separately in addition to code for primary procedure) 57268 835.76 Repair of enterocele, vaginal approach (separate procedure) 57287 1,223.95 Removal or revision of sling for stress incontinence (e.g., fascia or synthetic) 57288 1,108.69 Sling operation for stress incontinence (e.g., fascia or synthetic) 57289 926.59 Pereyra procedure, including anterior colporrhaphy 57291 926.59 Construction of artificial vagina; without graft 57300 835.76 Closure of rectovaginal fistula; vaginal or transanal approach 57320 1,223.95 Closure of vesicovaginal fistula; vaginal approach 57400 555.04 Dilation of vagina under anesthesia 57410 555.04 Pelvic examination under anesthesia 57415 555.04 Removal of impacted vaginal foreign body (separate procedure) under anesthesia 57420 41.55 Colposcopy of the entire vagina, with cervix if present; 57421 54.21 Colposcopy of the entire vagina, with cervix if present; with biopsy(s) of vagina/cervix 57452 39.28 Colposcopy of the cervix including upper/adjacent vagina; 57454 48.04 Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix and endocervical curettage 57455 50.96 Colposcopy of the cervix including upper/adjacent vagina; with biopsy(s) of the cervix 57456 49.34 Colposcopy of the cervix including upper/adjacent vagina; with endocervical curettage 57460 151.59 Colposcopy of the cervix including upper/adjacent vagina; with loop electrode biopsy(s) of the cervix 57461 161.00 Colposcopy of the cervix including upper/adjacent vagina; with loop electrode conization of the cervix 57500 69.46 Biopsy, single or multiple, or local excision of lesion, with or without fulguration (separate procedure) 57505 44.15 Endocervical curettage (not done as part of a dilation and curettage) 57510 44.79 Cautery of cervix; electro or thermal 57511 51.69 Cautery of cervix; cryocautery, initial or repeat 57513 555.04 Cautery of cervix; laser ablation 57520 555.04 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; cold knife or laser 57522 555.04 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair; loop electrode excision 57530 835.76 Trachelectomy (cervicectomy), amputation of cervix (separate procedure) 57550 835.76 Excision of cervical stump, vaginal approach; 57556 1,108.69 Excision of cervical stump, vaginal approach; with repair of enterocele 57558 583.12 Dilation and curettage of cervical stump 57700 505.45 Cerclage of uterine cervix, nonobstetrical

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

57720 583.12 Trachelorrhaphy, plastic repair of uterine cervix, vaginal approach 57800 23.70 Dilation of cervical canal, instrumental (separate procedure) 58100 38.95 Endometrial sampling (biopsy) with or without endocervical sampling (biopsy), without cervical dilation, any method (separate procedure) 58120 555.04 Dilation and curettage, diagnostic and/or therapeutic (nonobstetrical) 58145 926.59 Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach 58301 36.35 Removal of intrauterine device (IUD) 58321 34.08 Artificial insemination; intra-cervical 58322 35.06 Artificial insemination; intra-uterine 58323 8.12 Sperm washing for artificial insemination 58345 718.67 Transcervical introduction of fallopian tube catheter for diagnosis and/or re-establishing patency (any method), with or without hysterosalpingography 58346 555.04 Insertion of Heyman capsules for clinical brachytherapy 58350 835.76 Chromotubation of oviduct, including materials 58353 1,048.57 Endometrial ablation, thermal, without hysteroscopic guidance 58356 1,588.16 Endometrial cryoablation with ultrasonic guidance, including endometrial curettage, when performed 58545 1,275.72 Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas 58546 1,428.92 Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g 58550 1,857.56 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; 58552 1,682.76 Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) 58555 546.11 Hysteroscopy, diagnostic (separate procedure) 58558 623.78 Hysteroscopy, surgical; with sampling (biopsy) of endometrium and/or polypectomy, with or without D & C 58559 595.70 Hysteroscopy, surgical; with lysis of intrauterine adhesions (any method) 58560 889.43 Hysteroscopy, surgical; with division or resection of intrauterine septum (any method) 58561 889.43 Hysteroscopy, surgical; with removal of leiomyomata 58562 623.78 Hysteroscopy, surgical; with removal of impacted foreign body 58563 1,253.18 Hysteroscopy, surgical; with endometrial ablation (e.g., endometrial resection, electrosurgical ablation, thermoablation) 58565 1,381.63 Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce occlusion by placement of permanent implants 58600 1,223.95 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral 58615 718.67 Occlusion of fallopian tube(s) by device (e.g., band, clip, Falope ring) vaginal or suprapubic approach 58660 1,156.00 Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure) 58661 1,156.00 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/or salpingectomy) 58662 1,156.00 Laparoscopy, surgical; with fulguration or excision of lesions of the ovary, pelvic viscera, or peritoneal surface by any method 58670 1,065.17 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671 1,065.17 Laparoscopy, surgical; with occlusion of oviducts by device (e.g., band, clip, or Falope ring) 58672 1,156.00 Laparoscopy, surgical; with fimbrioplasty 58673 1,156.00 Laparoscopy, surgical; with salpingostomy (salpingoneostomy) 58800 583.12 Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); vaginal approach 58805 1,223.95 Drainage of ovarian cyst(s), unilateral or bilateral, (separate procedure); abdominal approach

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.1 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

58820 835.76 Drainage of ovarian abscess; vaginal approach, open 58900 583.12 Biopsy of ovary, unilateral or bilateral (separate procedure) 58970 162.42 Follicle puncture for oocyte retrieval, any method 58974 162.42 Embryo transfer, intrauterine 58976 162.42 Gamete, zygote, or embryo intrafallopian transfer, any method 59000 59.40 Amniocentesis; diagnostic 59001 222.97 Amniocentesis; therapeutic amniotic fluid reduction (includes ultrasound guidance) 59012 109.03 Cordocentesis (intrauterine), any method 59015 48.04 Chorionic villus sampling, any method 59020 25.32 Fetal contraction stress test 59025 13.31 Fetal non-stress test 59070 109.03 Transabdominal amnioinfusion, including ultrasound guidance 59072 109.03 Fetal umbilical cord occlusion, including ultrasound guidance 59076 109.03 Fetal shunt placement, including ultrasound guidance 59100 1,223.95 Hysterotomy, abdominal (e.g., for hydatidiform mole, abortion) 59150 1,682.76 Laparoscopic treatment of ectopic pregnancy; without salpingectomy and/or oophorectomy 59151 1,682.76 Laparoscopic treatment of ectopic pregnancy; with salpingectomy and/or oophorectomy 59160 583.12 Curettage, postpartum 59200 32.46 Insertion of cervical dilator (e.g., laminaria, prostaglandin) (separate procedure) 59300 70.11 Episiotomy or vaginal repair, by other than attending physician 59320 505.45 Cerclage of cervix, during pregnancy; vaginal 59412 718.67 External cephalic version, with or without tocolysis 59414 718.67 Delivery of placenta (separate procedure) 59812 673.95 Treatment of incomplete abortion, any trimester, completed surgically 59820 673.95 Treatment of missed abortion, completed surgically; first trimester 59821 673.95 Treatment of missed abortion, completed surgically; second trimester 59840 673.95 Induced abortion, by dilation and curettage 59841 673.95 Induced abortion, by dilation and evacuation 59866 109.03 Multifetal pregnancy reduction(s) (MPR) 59870 673.95 Uterine evacuation and curettage for hydatidiform mole 59871 673.95 Removal of cerclage suture under anesthesia (other than local) 60000 282.94 Incision and drainage of thyroglossal duct cyst, infected 60100 44.47 Biopsy thyroid, percutaneous core needle 60200 1,053.12 Excision of cyst or adenoma of thyroid, or transection of isthmus 60280 1,133.86 Excision of thyroglossal duct cyst or sinus; 60281 1,133.86 Excision of thyroglossal duct cyst or sinus; recurrent 60300 58.43 Aspiration and/or injection, thyroid cyst 61000 260.53 Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; initial 61001 260.53 Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; subsequent taps 61020 210.93 Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; without injection 61026 210.93 Ventricular puncture through previous burr hole, fontanelle, suture, or implanted ventricular catheter/reservoir; with injection of medication or other substance for diagnosis or treatment 61050 210.93 Cisternal or lateral cervical (C1-C2) puncture; without injection (separate procedure) 61055 210.93 Cisternal or lateral cervical (C1-C2) puncture; with injection of medication or other substance for diagnosis or treatment (e.g., C1-C2) 61070 164.13 Puncture of shunt tubing or reservoir for aspiration or injection procedure 61215 987.38 Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter 61330 1,521.12 Decompression of orbit only, transcranial approach 61334 1,521.12 Exploration of orbit (transcranial approach); with removal of foreign body

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.2 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

61790 560.00 Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (e.g., alcohol, thermal, electrical, radiofrequency); gasserian ganglion 61791 415.46 Creation of lesion by stereotactic method, percutaneous, by neurolytic agent (e.g., alcohol, thermal, electrical, radiofrequency); trigeminal medullary tract 61880 713.37 Revision or removal of intracranial neurostimulator electrodes 61885 10,265.47 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array 61886 15,328.85 Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to two or more electrode arrays 61888 682.77 Revision or removal of cranial neurostimulator pulse generator or receiver 62194 276.38 Replacement or irrigation, subarachnoid/subdural catheter 62225 429.45 Replacement or irrigation, ventricular catheter 62230 959.29 Replacement or revision of cerebrospinal fluid shunt, obstructed valve, or distal catheter in shunt system 62252 43.50 Reprogramming of programmable cerebrospinal shunt 62263 276.38 Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days 62264 407.15 Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day 62267 162.48 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming 62268 210.93 Percutaneous aspiration, spinal cord cyst or syrinx 62269 320.09 Biopsy of spinal cord, percutaneous needle 62270 127.29 Spinal puncture, lumbar, diagnostic 62272 127.29 Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter) 62273 212.41 Injection, epidural, of blood or clot patch 62280 276.38 Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; subarachnoid 62281 276.38 Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic 62282 276.38 Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal) 62287 1,240.70 Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method, single or multiple levels, lumbar (e.g., manual or automated percutaneous discectomy, percutaneous laser discectomy) 62292 260.53 Injection procedure for chemonucleolysis, including discography, intervertebral disc, single or multiple levels, lumbar 62294 210.93 Injection procedure, arterial, for occlusion of arteriovenous malformation, spinal 62310 276.38 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic 62311 276.38 Injection, single (not via indwelling catheter), not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal) 62318 276.38 Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; cervical or thoracic

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.3 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

62319 276.38 Injection, including catheter placement, continuous infusion or intermittent bolus, not including neurolytic substances, with or without contrast (for either localization or epidurography), of diagnostic or therapeutic substance(s) (including anesthetic, antispasmodic, opioid, steroid, other solution), epidural or subarachnoid; lumbar, sacral (caudal) 62350 959.29 Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy 62355 456.74 Removal of previously implanted intrathecal or epidural catheter 62360 959.29 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir 62361 9,847.26 Implantation or replacement of device for intrathecal or epidural drug infusion; non-programmable pump 62362 9,847.26 Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming 62365 848.85 Removal of subcutaneous reservoir or pump, previously implanted for intrathecal or epidural infusion 62367 15.58 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); without reprogramming 62368 19.80 Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion (includes evaluation of reservoir status, alarm status, drug prescription status); with reprogramming 63600 531.92 Creation of lesion of spinal cord by stereotactic method, percutaneous, any modality (including stimulation and/or recording) 63610 482.33 Stereotactic stimulation of spinal cord, percutaneous, separate procedure not followed by other surgery 63615 672.43 Stereotactic biopsy, aspiration, or excision of lesion, spinal cord 63650 2,863.04 Percutaneous implantation of neurostimulator electrode array, epidural 63655 4,193.65 Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural 63660 502.80 Revision or removal of spinal neurostimulator electrode percutaneous array(s) or plate/paddle(s) 63685 12,728.69 Insertion or replacement of spinal neurostimulator pulse generator or receiver, direct or inductive coupling 63688 682.77 Revision or removal of implanted spinal neurostimulator pulse generator or receiver 63744 987.38 Replacement, irrigation or revision of lumbosubarachnoid shunt 63746 456.74 Removal of entire lumbosubarachnoid shunt system without replacement 64400 49.99 Injection, anesthetic agent; trigeminal nerve, any division or branch 64402 47.07 Injection, anesthetic agent; facial nerve 64405 39.92 Injection, anesthetic agent; greater occipital nerve 64408 49.66 Injection, anesthetic agent; vagus nerve 64410 276.38 Injection, anesthetic agent; phrenic nerve 64412 73.04 Injection, anesthetic agent; spinal accessory nerve 64413 46.75 Injection, anesthetic agent; cervical plexus 64415 127.29 Injection, anesthetic agent; brachial plexus, single 64416 260.53 Injection, anesthetic agent; brachial plexus, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration 64417 127.29 Injection, anesthetic agent; axillary nerve 64418 65.57 Injection, anesthetic agent; suprascapular nerve 64420 127.29 Injection, anesthetic agent; intercostal nerve, single 64421 276.38 Injection, anesthetic agent; intercostal nerves, multiple, regional block 64425 45.44 Injection, anesthetic agent; ilioinguinal, iliohypogastric nerves 64430 191.26 Injection, anesthetic agent; pudendal nerve 64435 68.49 Injection, anesthetic agent; paracervical (uterine) nerve 64445 60.70 Injection, anesthetic agent; sciatic nerve, single

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.4 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

64446 522.07 Injection, anesthetic agent; sciatic nerve, continuous infusion by catheter, (including catheter placement) including daily management for anesthetic agent administration 64447 132.59 Injection, anesthetic agent; femoral nerve, single 64448 132.59 Injection, anesthetic agent; femoral nerve, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration 64449 260.53 Injection, anesthetic agent; lumbar plexus, posterior approach, continuous infusion by catheter (including catheter placement) including daily management for anesthetic agent administration 64450 40.57 Injection, anesthetic agent; other peripheral nerve or branch 64455 16.88 Injection(s), anesthetic agent and/or steroid, plantar common digital nerve(s) (e.g., Morton's neuroma) 64470 276.38 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level 64472 212.41 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, each additional level (List separately in addition to code for primary procedure) 64475 276.38 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level 64476 191.30 Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, each additional level (List separately in addition to code for primary procedure) 64479 276.38 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, single level 64480 212.41 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level (List separately in addition to code for primary procedure) 64483 276.38 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, single level 64484 212.41 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure) 64505 37.01 Injection, anesthetic agent; sphenopalatine ganglion 64508 78.55 Injection, anesthetic agent; carotid sinus (separate procedure) 64510 276.38 Injection, anesthetic agent; stellate ganglion (cervical sympathetic) 64517 191.26 Injection, anesthetic agent; superior hypogastric plexus 64520 276.38 Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic) 64530 276.38 Injection, anesthetic agent; celiac plexus, with or without radiologic monitoring 64553 2,813.45 Percutaneous implantation of neurostimulator electrodes; cranial nerve 64555 3,159.33 Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) 64560 3,159.33 Percutaneous implantation of neurostimulator electrodes; autonomic nerve 64561 2,891.12 Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 64565 3,159.33 Percutaneous implantation of neurostimulator electrodes; neuromuscular 64573 4,921.77 Incision for implantation of neurostimulator electrodes; cranial nerve 64575 3,762.29 Incision for implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) 64577 3,762.29 Incision for implantation of neurostimulator electrodes; autonomic nerve 64580 3,762.29 Incision for implantation of neurostimulator electrodes; neuromuscular 64581 3,839.96 Incision for implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) 64585 502.80 Revision or removal of peripheral neurostimulator electrodes 64590 10,265.47 Insertion or replacement of peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 64595 682.77 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.5 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

64600 407.15 Destruction by neurolytic agent, trigeminal nerve; supraorbital, infraorbital, mental, or inferior alveolar branch 64605 407.15 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale 64610 407.15 Destruction by neurolytic agent, trigeminal nerve; second and third division branches at foramen ovale under radiologic monitoring 64612 59.40 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve (e.g., for blepharospasm, hemifacial spasm) 64613 57.46 Chemodenervation of muscle(s); neck muscle(s) (e.g., for spasmodic torticollis, spasmodic dysphonia) 64614 65.57 Chemodenervation of muscle(s); extremity(s) and/or trunk muscle(s) (e.g., for dystonia, cerebral palsy, multiple sclerosis) 64620 276.38 Destruction by neurolytic agent, intercostal nerve 64622 407.15 Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, single level 64623 276.38 Destruction by neurolytic agent, paravertebral facet joint nerve; lumbar or sacral, each additional level (List separately in addition to code for primary procedure) 64626 407.15 Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level 64627 191.30 Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, each additional level (List separately in addition to code for primary procedure) 64630 284.69 Destruction by neurolytic agent; pudendal nerve 64632 30.83 Destruction by neurolytic agent; plantar common digital nerve 64640 91.86 Destruction by neurolytic agent; other peripheral nerve or branch 64650 30.83 Chemodenervation of eccrine glands; both axillae 64653 33.44 Chemodenervation of eccrine glands; other area(s) (e.g., scalp, face, neck), per day 64680 432.59 Destruction by neurolytic agent, with or without radiologic monitoring; celiac plexus 64681 456.74 Destruction by neurolytic agent, with or without radiologic monitoring; superior hypogastric plexus 64702 482.33 Neuroplasty; digital, one or both, same digit 64704 482.33 Neuroplasty; nerve of hand or foot 64708 531.92 Neuroplasty, major peripheral nerve, arm or leg; other than specified 64712 531.92 Neuroplasty, major peripheral nerve, arm or leg; sciatic nerve 64713 531.92 Neuroplasty, major peripheral nerve, arm or leg; brachial plexus 64714 531.92 Neuroplasty, major peripheral nerve, arm or leg; lumbar plexus 64716 560.00 Neuroplasty and/or transposition; cranial nerve (specify) 64718 531.92 Neuroplasty and/or transposition; ulnar nerve at elbow 64719 531.92 Neuroplasty and/or transposition; ulnar nerve at wrist 64721 531.92 Neuroplasty and/or transposition; median nerve at carpal tunnel 64722 482.33 Decompression; unspecified nerve(s) (specify) 64726 482.33 Decompression; plantar digital nerve 64727 482.33 Internal neurolysis, requiring use of operating microscope (List separately in addition to code for neuroplasty) (Neuroplasty includes external neurolysis) 64732 531.92 Transection or avulsion of; supraorbital nerve 64734 531.92 Transection or avulsion of; infraorbital nerve 64736 531.92 Transection or avulsion of; mental nerve 64738 531.92 Transection or avulsion of; inferior alveolar nerve by osteotomy 64740 531.92 Transection or avulsion of; lingual nerve 64742 531.92 Transection or avulsion of; facial nerve, differential or complete 64744 531.92 Transection or avulsion of; greater occipital nerve 64746 531.92 Transection or avulsion of; phrenic nerve 64761 672.43 Transection or avulsion of; pudendal nerve 64763 672.43 Transection or avulsion of obturator nerve, extrapelvic, with or without adductor tenotomy 64766 1,306.30 Transection or avulsion of obturator nerve, intrapelvic, with or without adductor tenotomy

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.6 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

64771 531.92 Transection or avulsion of other cranial nerve, extradural 64772 531.92 Transection or avulsion of other spinal nerve, extradural 64774 531.92 Excision of neuroma; cutaneous nerve, surgically identifiable 64776 560.00 Excision of neuroma; digital nerve, one or both, same digit 64778 531.92 Excision of neuroma; digital nerve, each additional digit (List separately in addition to code for primary procedure) 64782 560.00 Excision of neuroma; hand or foot, except digital nerve 64783 531.92 Excision of neuroma; hand or foot, each additional nerve, except same digit (List separately in addition to code for primary procedure) 64784 560.00 Excision of neuroma; major peripheral nerve, except sciatic 64786 876.93 Excision of neuroma; sciatic nerve 64787 531.92 Implantation of nerve end into bone or muscle (List separately in addition to neuroma excision) 64788 560.00 Excision of neurofibroma or neurolemmoma; cutaneous nerve 64790 560.00 Excision of neurofibroma or neurolemmoma; major peripheral nerve 64792 876.93 Excision of neurofibroma or neurolemmoma; extensive (including malignant type) 64795 531.92 Biopsy of nerve 64802 531.92 Sympathectomy, cervical 64820 672.43 Sympathectomy; digital arteries, each digit 64821 785.00 Sympathectomy; radial artery 64822 1,017.11 Sympathectomy; ulnar artery 64823 1,017.11 Sympathectomy; superficial palmar arch 64831 929.59 Suture of digital nerve, hand or foot; one nerve 64832 799.26 Suture of digital nerve, hand or foot; each additional digital nerve (List separately in addition to code for primary procedure) 64834 848.85 Suture of one nerve, hand or foot; common sensory nerve 64835 876.93 Suture of one nerve, hand or foot; median motor thenar 64836 876.93 Suture of one nerve, hand or foot; ulnar motor 64837 799.26 Suture of each additional nerve, hand or foot (List separately in addition to code for primary procedure) 64840 848.85 Suture of posterior tibial nerve 64856 848.85 Suture of major peripheral nerve, arm or le.g., except sciatic; including transposition 64857 848.85 Suture of major peripheral nerve, arm or le.g., except sciatic; without transposition 64858 848.85 Suture of sciatic nerve 64859 799.26 Suture of each additional major peripheral nerve (List separately in addition to code for primary procedure) 64861 876.93 Suture of; brachial plexus 64862 876.93 Suture of; lumbar plexus 64864 876.93 Suture of facial nerve; extracranial 64865 929.59 Suture of facial nerve; infratemporal, with or without grafting 64870 929.59 Anastomosis; facial-phrenic 64872 848.85 Suture of nerve; requiring secondary or delayed suture (List separately in addition to code for primary neurorrhaphy) 64874 876.93 Suture of nerve; requiring extensive mobilization, or transposition of nerve (List separately in addition to code for nerve suture) 64876 876.93 Suture of nerve; requiring shortening of bone of extremity (List separately in addition to code for nerve suture) 64885 848.85 Nerve graft (includes obtaining graft), head or neck; up to 4 cm in length 64886 848.85 Nerve graft (includes obtaining graft), head or neck; more than 4 cm length 64890 848.85 Nerve graft (includes obtaining graft), single strand, hand or foot; up to 4 cm length 64891 848.85 Nerve graft (includes obtaining graft), single strand, hand or foot; more than 4 cm length 64892 848.85 Nerve graft (includes obtaining graft), single strand, arm or leg; up to 4 cm length 64893 848.85 Nerve graft (includes obtaining graft), single strand, arm or leg; more than 4 cm length 64895 876.93 Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; up to 4 cm length

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.7 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

64896 876.93 Nerve graft (includes obtaining graft), multiple strands (cable), hand or foot; more than 4 cm length 64897 876.93 Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; up to 4 cm length 64898 876.93 Nerve graft (includes obtaining graft), multiple strands (cable), arm or leg; more than 4 cm length 64901 848.85 Nerve graft, each additional nerve; single strand (List separately in addition to code for primary procedure) 64902 848.85 Nerve graft, each additional nerve; multiple strands (cable) (List separately in addition to code for primary procedure) 64905 848.85 Nerve pedicle transfer; first stage 64907 799.26 Nerve pedicle transfer; second stage 64910 1,306.30 Nerve repair; with synthetic conduit or vein allograft (e.g., nerve tube), each nerve 65091 923.36 Evisceration of ocular contents; without implant 65093 923.36 Evisceration of ocular contents; with implant 65101 923.36 Enucleation of eye; without implant 65103 923.36 Enucleation of eye; with implant, muscles not attached to implant 65105 976.02 Enucleation of eye; with implant, muscles attached to implant 65110 1,014.19 Exenteration of orbit (does not include skin graft), removal of orbital contents; only 65112 1,136.18 Exenteration of orbit (does not include skin graft), removal of orbital contents; with therapeutic removal of bone 65114 1,136.18 Exenteration of orbit (does not include skin graft), removal of orbital contents; with muscle or myocutaneous flap 65125 945.58 Modification of ocular implant with placement or replacement of pegs (e.g., drilling receptacle for prosthesis appendage) (separate procedure) 65130 696.57 Insertion of ocular implant secondary; after evisceration, in scleral shell 65135 668.49 Insertion of ocular implant secondary; after enucleation, muscles not attached to implant 65140 923.36 Insertion of ocular implant secondary; after enucleation, muscles attached to implant 65150 668.49 Reinsertion of ocular implant; with or without conjunctival graft 65155 923.36 Reinsertion of ocular implant; with use of foreign material for reinforcement and/or attachment of muscles to implant 65175 496.92 Removal of ocular implant 65205 19.15 Removal of foreign body, external eye; conjunctival superficial 65210 24.35 Removal of foreign body, external eye; conjunctival embedded (includes concretions), subconjunctival, or scleral nonperforating 65220 33.92 Removal of foreign body, external eye; corneal, without slit lamp 65222 26.61 Removal of foreign body, external eye; corneal, with slit lamp 65235 499.77 Removal of foreign body, intraocular; from anterior chamber of eye or lens 65260 329.63 Removal of foreign body, intraocular; from posterior segment, magnetic extraction, anterior or posterior route 65265 681.97 Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction 65270 546.50 Repair of laceration; conjunctiva, with or without nonperforating laceration sclera, direct closure 65272 629.73 Repair of laceration; conjunctiva, by mobilization and rearrangement, without hospitalization 65275 710.47 Repair of laceration; cornea, nonperforating, with or without removal foreign body 65280 681.97 Repair of laceration; cornea and/or sclera, perforating, not involving uveal tissue 65285 969.81 Repair of laceration; cornea and/or sclera, perforating, with reposition or resection of uveal tissue 65286 169.67 Repair of laceration; application of tissue glue, wounds of cornea and/or sclera 65290 671.61 Repair of wound, extraocular muscle, tendon and/or Tenons capsule 65400 450.19 Excision of lesion, cornea (keratectomy, lamellar, partial), except pterygium 65410 499.77 Biopsy of cornea 65420 499.77 Excision or transposition of pterygium; without graft 65426 748.65 Excision or transposition of pterygium; with graft

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.8 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

65430 33.92 Scraping of cornea, diagnostic, for smear and/or culture 65435 29.54 Removal of corneal epithelium; with or without chemocauterization (abrasion, curettage) 65436 128.21 Removal of corneal epithelium; with application of chelating agent (e.g., EDTA) 65450 78.27 Destruction of lesion of cornea by cryotherapy, photocoagulation or thermocauterization 65600 151.26 Multiple punctures of anterior cornea (e.g., for corneal erosion, tattoo) 65710 1,126.19 Keratoplasty (corneal transplant); lamellar 65730 1,126.19 Keratoplasty (corneal transplant); penetrating (except in aphakia) 65750 1,126.19 Keratoplasty (corneal transplant); penetrating (in aphakia) 65755 1,126.19 Keratoplasty (corneal transplant); penetrating (in pseudophakia) 65756 1,379.17 Keratoplasty (corneal transplant); endothelial 65770 5,160.46 Keratoprosthesis 65772 580.51 Corneal relaxing incision for correction of surgically induced astigmatism 65775 580.51 Corneal wedge resection for correction of surgically induced astigmatism 65780 1,004.20 Ocular surface reconstruction; amniotic membrane transplantation 65781 1,004.20 Ocular surface reconstruction; limbal stem cell allograft (e.g., cadaveric or living donor) 65782 1,004.20 Ocular surface reconstruction; limbal conjunctival autograft (includes obtaining graft) 65800 450.19 Paracentesis of anterior chamber of eye (separate procedure); with diagnostic aspiration of aqueous 65805 450.19 Paracentesis of anterior chamber of eye (separate procedure); with therapeutic release of aqueous 65810 657.82 Paracentesis of anterior chamber of eye (separate procedure); with removal of vitreous and/or discission of anterior hyaloid membrane, with or without air injection 65815 629.73 Paracentesis of anterior chamber of eye (separate procedure); with removal of blood, with or without irrigation and/or air injection 65820 230.96 Goniotomy 65850 710.47 Trabeculotomy ab externo 65855 122.70 Trabeculoplasty by laser surgery, one or more sessions (defined treatment series) 65860 114.59 Severing adhesions of anterior segment, laser technique (separate procedure) 65865 450.19 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); goniosynechiae 65870 710.47 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); anterior synechiae, except goniosynechiae 65875 710.47 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); posterior synechiae 65880 580.51 Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); corneovitreal adhesions 65900 618.69 Removal of epithelial downgrowth, anterior chamber of eye 65920 870.63 Removal of implanted material, anterior segment of eye 65930 748.65 Removal of blood clot, anterior segment of eye 66020 450.19 Injection, anterior chamber of eye (separate procedure); air or liquid 66030 230.96 Injection, anterior chamber of eye (separate procedure); medication 66130 870.63 Excision of lesion, sclera 66150 710.47 Fistulization of sclera for glaucoma; trephination with iridectomy 66155 710.47 Fistulization of sclera for glaucoma; thermocauterization with iridectomy 66160 629.73 Fistulization of sclera for glaucoma; sclerectomy with punch or scissors, with iridectomy 66165 710.47 Fistulization of sclera for glaucoma; iridencleisis or iridotasis 66170 710.47 Fistulization of sclera for glaucoma; trabeculectomy ab externo in absence of previous surgery 66172 710.47 Fistulization of sclera for glaucoma; trabeculectomy ab externo with scarring from previous ocular surgery or trauma (includes injection of antifibrotic agents) 66180 1,058.45 Aqueous shunt to extraocular reservoir (e.g., Molteno, Schocket, Denver-Krupin)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.9 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

66185 939.55 Revision of aqueous shunt to extraocular reservoir 66220 917.16 Repair of scleral staphyloma; without graft 66225 1,020.29 Repair of scleral staphyloma; with graft 66250 499.77 Revision or repair of operative wound of anterior segment, any type, early or late, major or minor procedure 66500 230.96 Iridotomy by stab incision (separate procedure); except transfixion 66505 230.96 Iridotomy by stab incision (separate procedure); with transfixion as for iris bombe 66600 657.82 Iridectomy, with corneoscleral or corneal section; for removal of lesion 66605 657.82 Iridectomy, with corneoscleral or corneal section; with cyclectomy 66625 467.71 Iridectomy, with corneoscleral or corneal section; peripheral for glaucoma (separate procedure) 66630 657.82 Iridectomy, with corneoscleral or corneal section; sector for glaucoma (separate procedure) 66635 657.82 Iridectomy, with corneoscleral or corneal section; optical (separate procedure) 66680 657.82 Repair of iris, ciliary body (as for iridodialysis) 66682 629.73 Suture of iris, ciliary body (separate procedure) with retrieval of suture through small incision (e.g., McCannel suture) 66700 499.77 Ciliary body destruction; diathermy 66710 499.77 Ciliary body destruction; cyclophotocoagulation, transscleral 66711 499.77 Ciliary body destruction; cyclophotocoagulation, endoscopic 66720 499.77 Ciliary body destruction; cryotherapy 66740 629.73 Ciliary body destruction; cyclodialysis 66761 170.74 Iridotomy/iridectomy by laser surgery (e.g., for glaucoma) (one or more sessions) 66762 173.66 Iridoplasty by photocoagulation (one or more sessions) (e.g., for improvement of vision, for widening of anterior chamber angle) 66770 191.25 Destruction of cyst or lesion iris or ciliary body (nonexcisional procedure) 66820 169.67 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); stab incision technique (Ziegler or Wheeler knife) 66821 232.74 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (e.g., YAG laser) (one or more stages) 66825 710.47 Repositioning of intraocular lens prosthesis, requiring an incision (separate procedure) 66830 248.48 Removal of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid) with corneo-scleral section, with or without iridectomy (iridocapsulotomy, iridocapsulectomy) 66840 534.14 Removal of lens material; aspiration technique, one or more stages 66850 1,005.66 Removal of lens material; phacofragmentation technique (mechanical or ultrasonic) (e.g., phacoemulsification), with aspiration 66852 845.50 Removal of lens material; pars plana approach, with or without vitrectomy 66920 845.50 Removal of lens material; intracapsular 66930 883.67 Removal of lens material; intracapsular, for dislocated lens 66940 572.32 Removal of lens material; extracapsular (other than 66840, 66850, 66852) 66982 868.23 Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage 66983 868.23 Intracapsular cataract extraction with insertion of intraocular lens prosthesis (one stage procedure) 66984 868.23 Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification) 66985 803.73 Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal 66986 803.73 Exchange of intraocular lens

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.10 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

67005 681.97 Removal of vitreous, anterior approach (open sky technique or limbal incision); partial removal 67010 681.97 Removal of vitreous, anterior approach (open sky technique or limbal incision); subtotal removal with mechanical vitrectomy 67015 839.49 Aspiration or release of vitreous, subretinal or choroidal fluid, pars plana approach (posterior sclerotomy) 67025 551.65 Injection of vitreous substitute, pars plana or limbal approach, (fluid-gas exchange), with or without aspiration (separate procedure) 67027 969.81 Implantation of intravitreal drug delivery system (e.g., ganciclovir implant), includes concomitant removal of vitreous 67028 76.28 Intravitreal injection of a pharmacologic agent (separate procedure) 67030 551.65 Discission of vitreous strands (without removal), pars plana approach 67031 232.74 Severing of vitreous strands, vitreous face adhesions, sheets, membranes or opacities, laser surgery (one or more stages) 67036 969.81 Vitrectomy, mechanical, pars plana approach; 67039 1,129.98 Vitrectomy, mechanical, pars plana approach; with focal endolaser photocoagulation 67040 1,129.98 Vitrectomy, mechanical, pars plana approach; with endolaser panretinal photocoagulation 67041 1,386.75 Vitrectomy, mechanical, pars plana approach; with removal of preretinal cellular membrane (e.g., macular pucker) 67042 1,386.75 Vitrectomy, mechanical, pars plana approach; with removal of internal limiting membrane of retina (e.g., for repair of macular hole, diabetic macular edema), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) 67043 1,386.75 Vitrectomy, mechanical, pars plana approach; with removal of subretinal membrane (e.g., choroidal neovascularization), includes, if performed, intraocular tamponade (ie, air, gas or silicone oil) and laser photocoagulation 67101 211.70 Repair of retinal detachment, one or more sessions; cryotherapy or diathermy, with or without drainage of subretinal fluid 67105 191.25 Repair of retinal detachment, one or more sessions; photocoagulation, with or without drainage of subretinal fluid 67107 1,007.99 Repair of retinal detachment; scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), with or without implant, with or without cryotherapy, photocoagulation, and drainage of subretinal fluid 67108 1,129.98 Repair of retinal detachment; with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique 67110 307.72 Repair of retinal detachment; by injection of air or other gas (e.g., pneumatic retinopexy) 67112 1,129.98 Repair of retinal detachment; by scleral buckling or vitrectomy, on patient having previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy techniques 67113 1,386.75 Repair of complex retinal detachment (e.g., proliferative vitreoretinopathy, stage C-1 or greater, diabetic traction retinal detachment, retinopathy of prematurity, retinal tear of greater than 90 degrees), with vitrectomy and membrane peeling, may include air, gas, or silicone oil tamponade, cryotherapy, endolaser photocoagulation, drainage of subretinal fluid, scleral buckling, and/or removal of lens 67115 601.23 Release of encircling material (posterior segment) 67120 601.23 Removal of implanted material, posterior segment; extraocular 67121 601.23 Removal of implanted material, posterior segment; intraocular 67141 211.93 Prophylaxis of retinal detachment (e.g., retinal break, lattice degeneration) without drainage, one or more sessions; cryotherapy, diathermy 67145 180.80 Prophylaxis of retinal detachment (e.g., retinal break, lattice degeneration) without drainage, one or more sessions; photocoagulation (laser or xenon arc) 67208 192.82 Destruction of localized lesion of retina (e.g., macular edema, tumors), one or more sessions; cryotherapy, diathermy

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.11 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

67210 191.25 Destruction of localized lesion of retina (e.g., macular edema, tumors), one or more sessions; photocoagulation 67218 720.14 Destruction of localized lesion of retina (e.g., macular edema, tumors), one or more sessions; radiation by implantation of source (includes removal of source) 67220 211.70 Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photocoagulation (e.g., laser), one or more sessions 67221 108.74 Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photodynamic therapy (includes intravenous infusion) 67225 7.47 Destruction of localized lesion of choroid (e.g., choroidal neovascularization); photodynamic therapy, second eye, at single session (List separately in addition to code for primary eye treatment) 67227 551.65 Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; cryotherapy, diathermy 67228 191.25 Destruction of extensive or progressive retinopathy (e.g., diabetic retinopathy), one or more sessions; photocoagulation (laser or xenon arc) 67229 191.25 Treatment of extensive or progressive retinopathy, one or more sessions; preterm infant (less than 37 weeks gestation at birth), performed from birth up to 1 year of age (e.g., retinopathy of prematurity), photocoagulation or cryotherapy 67250 574.59 Scleral reinforcement (separate procedure); without graft 67255 629.32 Scleral reinforcement (separate procedure); with graft 67311 671.61 Strabismus surgery, recession or resection procedure; one horizontal muscle 67312 724.27 Strabismus surgery, recession or resection procedure; two horizontal muscles 67314 724.27 Strabismus surgery, recession or resection procedure; one vertical muscle (excluding superior oblique) 67316 724.27 Strabismus surgery, recession or resection procedure; two or more vertical muscles (excluding superior oblique) 67318 724.27 Strabismus surgery, any procedure, superior oblique muscle 67320 724.27 Transposition procedure (e.g., for paretic extraocular muscle), any extraocular muscle (specify) (List separately in addition to code for primary procedure) 67331 724.27 Strabismus surgery on patient with previous eye surgery or injury that did not involve the extraocular muscles (List separately in addition to code for primary procedure) 67332 724.27 Strabismus surgery on patient with scarring of extraocular muscles (e.g., prior ocular injury, strabismus or retinal detachment surgery) or restrictive myopathy (e.g., dysthyroid ophthalmopathy) (List separately in addition to code for primary procedure) 67334 724.27 Strabismus surgery by posterior fixation suture technique, with or without muscle recession (List separately in addition to code for primary procedure) 67335 724.27 Placement of adjustable suture(s) during strabismus surgery, including postoperative adjustment(s) of suture(s) (List separately in addition to code for specific strabismus surgery) 67340 724.27 Strabismus surgery involving exploration and/or repair of detached extraocular muscle(s) (List separately in addition to code for primary procedure) 67343 884.42 Release of extensive scar tissue without detaching extraocular muscle (separate procedure) 67345 75.64 Chemodenervation of extraocular muscle 67346 409.09 Biopsy of extraocular muscle 67400 574.59 Orbitotomy without bone flap (frontal or transconjunctival approach); for exploration, with or without biopsy 67405 749.23 Orbitotomy without bone flap (frontal or transconjunctival approach); with drainage only 67412 665.42 Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of lesion 67413 787.40 Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of foreign body 67414 1,399.16 Orbitotomy without bone flap (frontal or transconjunctival approach); with removal of bone for decompression

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.12 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

67415 496.92 Fine needle aspiration of orbital contents 67420 1,014.19 Orbitotomy with bone flap or window, lateral approach (e.g., Kroenlein); with removal of lesion 67430 1,014.19 Orbitotomy with bone flap or window, lateral approach (e.g., Kroenlein); with removal of foreign body 67440 1,014.19 Orbitotomy with bone flap or window, lateral approach (e.g., Kroenlein); with drainage 67445 1,014.19 Orbitotomy with bone flap or window, lateral approach (e.g., Kroenlein); with removal of bone for decompression 67450 1,014.19 Orbitotomy with bone flap or window, lateral approach (e.g., Kroenlein); for exploration, with or without biopsy 67500 78.27 Retrobulbar injection; medication (separate procedure, does not include supply of medication) 67505 24.35 Retrobulbar injection; alcohol 67515 24.67 Injection of medication or other substance into Tenons capsule 67550 976.02 Orbital implant (implant outside muscle cone); insertion 67560 668.49 Orbital implant (implant outside muscle cone); removal or revision 67570 976.02 Optic nerve decompression (e.g., incision or fenestration of optic nerve sheath) 67700 114.52 Blepharotomy, drainage of abscess, eyelid 67710 133.73 Severing of tarsorrhaphy 67715 496.92 Canthotomy (separate procedure) 67800 48.04 Excision of chalazion; single 67801 58.10 Excision of chalazion; multiple, same lid 67805 75.30 Excision of chalazion; multiple, different lids 67808 546.50 Excision of chalazion; under general anesthesia and/or requiring hospitalization, single or multiple 67810 114.52 Biopsy of eyelid 67820 15.90 Correction of trichiasis; epilation, by forceps only 67825 49.01 Correction of trichiasis; epilation by other than forceps (e.g., by electrosurgery, cryotherapy, laser surgery) 67830 335.51 Correction of trichiasis; incision of lid margin 67835 546.50 Correction of trichiasis; incision of lid margin, with free mucous membrane graft 67840 140.23 Excision of lesion of eyelid (except chalazion) without closure or with simple direct closure 67850 111.34 Destruction of lesion of lid margin (up to 1 cm) 67875 279.61 Temporary closure of eyelids by suture (e.g., Frost suture) 67880 527.86 Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; 67882 574.59 Construction of intermarginal adhesions, median tarsorrhaphy, or canthorrhaphy; with transposition of tarsal plate 67900 749.23 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) 67901 665.42 Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked fascia) 67902 787.40 Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) 67903 627.24 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach 67904 627.24 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach 67906 665.42 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) 67908 627.24 Repair of blepharoptosis; conjunctivo-tarso-Mullers muscle-levator resection (e.g., Fasanella-Servat type) 67909 627.24 Reduction of overcorrection of ptosis 67911 574.59 Correction of lid retraction 67912 574.59 Correction of lagophthalmos, with implantation of upper eyelid lid load (e.g., gold weight) 67914 574.59 Repair of ectropion; suture 67915 155.16 Repair of ectropion; thermocauterization

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.13 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

67916 627.24 Repair of ectropion; excision tarsal wedge 67917 627.24 Repair of ectropion; extensive (e.g., tarsal strip operations) 67921 574.59 Repair of entropion; suture 67922 150.94 Repair of entropion; thermocauterization 67923 627.24 Repair of entropion; excision tarsal wedge 67924 627.24 Repair of entropion; extensive (e.g., tarsal strip or capsulopalpebral fascia repairs operation) 67930 155.16 Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; partial thickness 67935 546.50 Suture of recent wound, eyelid, involving lid margin, tarsus, and/or palpebral conjunctiva direct closure; full thickness 67938 78.27 Removal of embedded foreign body, eyelid 67950 546.50 Canthoplasty (reconstruction of canthus) 67961 574.59 Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; up to one-fourth of lid margin 67966 574.59 Excision and repair of eyelid, involving lid margin, tarsus, conjunctiva, canthus, or full thickness, may include preparation for skin graft or pedicle flap with adjacent tissue transfer or rearrangement; over one-fourth of lid margin 67971 574.59 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; up to two-thirds of eyelid, one stage or first stage 67973 696.57 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, lower, one stage or first stage 67974 574.59 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; total eyelid, upper, one stage or first stage 67975 574.59 Reconstruction of eyelid, full thickness by transfer of tarsoconjunctival flap from opposing eyelid; second stage 68020 42.53 Incision of conjunctiva, drainage of cyst 68040 21.10 Expression of conjunctival follicles (e.g., for trachoma) 68100 84.39 Biopsy of conjunctiva 68110 108.74 Excision of lesion, conjunctiva; up to 1 cm 68115 546.50 Excision of lesion, conjunctiva; over 1 cm 68130 499.77 Excision of lesion, conjunctiva; with adjacent sclera 68135 54.53 Destruction of lesion, conjunctiva 68200 15.58 Subconjunctival injection 68320 749.23 Conjunctivoplasty; with conjunctival graft or extensive rearrangement 68325 749.23 Conjunctivoplasty; with buccal mucous membrane graft (includes obtaining graft) 68326 627.24 Conjunctivoplasty, reconstruction cul-de-sac; with conjunctival graft or extensive rearrangement 68328 749.23 Conjunctivoplasty, reconstruction cul-de-sac; with buccal mucous membrane graft (includes obtaining graft) 68330 710.47 Repair of symblepharon; conjunctivoplasty, without graft 68335 749.23 Repair of symblepharon; with free graft conjunctiva or buccal mucous membrane (includes obtaining graft) 68340 627.24 Repair of symblepharon; division of symblepharon, with or without insertion of conformer or contact lens 68360 629.73 Conjunctival flap; bridge or partial (separate procedure) 68362 629.73 Conjunctival flap; total (such as Gunderson thin flap or purse string flap) 68371 499.77 Harvesting conjunctival allograft, living donor 68400 114.52 Incision, drainage of lacrimal gland 68420 162.95 Incision, drainage of lacrimal sac (dacryocystotomy or dacryocystostomy) 68440 47.72 Snip incision of lacrimal punctum 68500 696.57 Excision of lacrimal gland (dacryoadenectomy), except for tumor; total 68505 696.57 Excision of lacrimal gland (dacryoadenectomy), except for tumor; partial 68510 496.92 Biopsy of lacrimal gland 68520 696.57 Excision of lacrimal sac (dacryocystectomy)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.14 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

68525 496.92 Biopsy of lacrimal sac 68530 114.52 Removal of foreign body or dacryolith, lacrimal passages 68540 574.59 Excision of lacrimal gland tumor; frontal approach 68550 696.57 Excision of lacrimal gland tumor; involving osteotomy 68700 546.50 Plastic repair of canaliculi 68705 108.74 Correction of everted punctum, cautery 68720 749.23 Dacryocystorhinostomy (fistulization of lacrimal sac to nasal cavity) 68745 749.23 Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); without tube 68750 749.23 Conjunctivorhinostomy (fistulization of conjunctiva to nasal cavity); with insertion of tube or stent 68760 92.51 Closure of the lacrimal punctum; by thermocauterization, ligation, or laser surgery 68761 63.95 Closure of the lacrimal punctum; by plug, each 68770 749.23 Closure of lacrimal fistula (separate procedure) 68801 33.92 Dilation of lacrimal punctum, with or without irrigation 68810 97.00 Probing of nasolacrimal duct, with or without irrigation; 68811 546.50 Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia 68815 546.50 Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent 68816 701.60 Probing of nasolacrimal duct, with or without irrigation; with transluminal balloon catheter dilation 68840 50.31 Probing of lacrimal canaliculi, with or without irrigation 69000 51.32 Drainage external ear, abscess or hematoma; simple 69005 97.06 Drainage external ear, abscess or hematoma; complicated 69020 51.32 Drainage external auditory canal, abscess 69100 58.43 Biopsy external ear 69105 82.77 Biopsy external auditory canal 69110 434.86 Excision external ear; partial, simple repair 69120 645.34 Excision external ear; complete amputation 69140 645.34 Excision exostosis(es), external auditory canal 69145 484.44 Excision soft tissue lesion, external auditory canal 69150 340.49 Radical excision external auditory canal lesion; without neck dissection 69200 23.47 Removal foreign body from external auditory canal; without general anesthesia 69205 542.85 Removal foreign body from external auditory canal; with general anesthesia 69210 19.15 Removal impacted cerumen (separate procedure), one or both ears 69220 30.08 Debridement, mastoidectomy cavity, simple (e.g., routine cleaning) 69222 126.59 Debridement, mastoidectomy cavity, complex (e.g., with anesthesia or more than routine cleaning) 69300 673.43 Otoplasty, protruding ear, with or without size reduction 69310 984.35 Reconstruction of external auditory canal (meatoplasty) (e.g., for stenosis due to injury, infection) (separate procedure) 69320 1,197.16 Reconstruction external auditory canal for congenital atresia, single stage 69400 85.04 Eustachian tube inflation, transnasal; with catheterization 69401 44.79 Eustachian tube inflation, transnasal; without catheterization 69405 117.50 Eustachian tube catheterization, transtympanic 69420 105.50 Myringotomy including aspiration and/or eustachian tube inflation 69421 536.92 Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia 69424 74.01 Ventilating tube removal requiring general anesthesia 69433 105.17 Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia 69436 536.92 Tympanostomy (requiring insertion of ventilating tube), general anesthesia 69440 673.43 Middle ear exploration through postauricular or ear canal incision 69450 906.68 Tympanolysis, transcanal 69501 1,197.16 Transmastoid antrotomy (simple mastoidectomy) 69502 886.24 Mastoidectomy; complete 69505 1,197.16 Mastoidectomy; modified radical 69511 1,197.16 Mastoidectomy; radical 69530 1,197.16 Petrous apicectomy including radical mastoidectomy

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.15 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

69540 123.67 Excision aural polyp 69550 1,075.18 Excision aural glomus tumor; transcanal 69552 1,197.16 Excision aural glomus tumor; transmastoid 69601 1,197.16 Revision mastoidectomy; resulting in complete mastoidectomy 69602 1,197.16 Revision mastoidectomy; resulting in modified radical mastoidectomy 69603 1,197.16 Revision mastoidectomy; resulting in radical mastoidectomy 69604 1,197.16 Revision mastoidectomy; resulting in tympanoplasty 69605 1,197.16 Revision mastoidectomy; with apicectomy 69610 165.55 Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch 69620 645.34 Myringoplasty (surgery confined to drumhead and donor area) 69631 1,075.18 Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction 69632 1,075.18 Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction (e.g., postfenestration) 69633 1,075.18 Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis (PORP), total ossicular replacement prosthesis (TORP)) 69635 1,197.16 Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); without ossicular chain reconstruction 69636 1,197.16 Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction 69637 1,197.16 Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis (PORP), total ossicular replacement prosthesis (TORP)) 69641 1,197.16 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction 69642 1,197.16 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with ossicular chain reconstruction 69643 1,197.16 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed wall, without ossicular chain reconstruction 69644 1,197.16 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction 69645 1,197.16 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, without ossicular chain reconstruction 69646 1,197.16 Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, with ossicular chain reconstruction 69650 886.24 Stapes mobilization 69660 1,075.18 Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; 69661 1,075.18 Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate drill out 69662 1,075.18 Revision of stapedectomy or stapedotomy 69666 1,037.00 Repair oval window fistula 69667 1,037.00 Repair round window fistula 69670 984.35 Mastoid obliteration (separate procedure) 69676 984.35 Tympanic neurectomy 69700 984.35 Closure postauricular fistula, mastoid (separate procedure)

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.16 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

69711 906.68 Removal or repair of electromagnetic bone conduction hearing device in temporal bone 69714 5,749.99 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy 69715 5,749.99 Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy 69717 5,749.99 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy 69718 5,749.99 Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy 69720 1,075.18 Decompression facial nerve, intratemporal; lateral to geniculate ganglion 69740 1,075.18 Suture facial nerve, intratemporal, with or without graft or decompression; lateral to geniculate ganglion 69745 1,075.18 Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion 69801 1,075.18 Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or perfusion of vestibuloactive drugs (single or multiple perfusions); transcanal 69802 1,197.16 Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or perfusion of vestibuloactive drugs (single or multiple perfusions); with mastoidectomy 69805 1,197.16 Endolymphatic sac operation; without shunt 69806 1,197.16 Endolymphatic sac operation; with shunt 69820 1,075.18 Fenestration semicircular canal 69840 1,075.18 Revision fenestration operation 69905 1,197.16 Labyrinthectomy; transcanal 69910 1,197.16 Labyrinthectomy; with mastoidectomy 69915 1,197.16 Vestibular nerve section, translabyrinthine approach 69930 21,643.06 Cochlear device implantation, with or without mastoidectomy C9716 1,127.56 Creations of thermal anal lesions by radiofrequency energy C9724 921.91 Endoscopic full-thickness plication in the gastric cardia using endoscopic plication system (EPS); includes endoscopy C9725 212.59 Placement of endorectal intracavitary applicator for high intensity brachytherapy C9726 780.47 Placement and removal (if performed) of applicator into breast for radiation therapy C9727 273.65 Insertion of implants into the soft palate; minimum of 3 implants C9728 491.00 Placement of interstitial device(s) for radiation therapy/surgery guidance (e.g., fiducial markers, dosimeter), other than prostate (any approach), single or multiple G0104 78.88 Colorectal cancer screening; flexible sigmoidoscopy G0105 340.90 Colorectal cancer screening; colonoscopy on individual at high risk G0121 340.90 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0127 11.03 Trimming of dystrophic nails, any number G0186 211.70 Destruction of localized lesion of choroid (for example, choroidal neovascularization); photocoagulation, feeder vessel technique (one or more sessions) G0247 20.12 Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include the local care of superficial wounds (i.e., superficial to muscle and fascia) and at least the following, if present: (1) local G0260 276.38 Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography G0364 5.19 Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.17 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 114.3 CMR: DIVISION OF HEALTH CARE FINANCE AND POLICY BUREAU OF AMBULATORY CARE

47.03: continued

Code Fee Description (continued)

G0392 1,465.88 Transluminal balloon angioplasty, percutaneous; for maintenance of hemodialysis access, arteriovenous fistula or graft; arterial G0393 1,465.88 Transluminal balloon angioplasty, percutaneous; for maintenance of hemodialysis access, arteriovenous fistula or graft; venous

(d) Modifiers.

50 Bilateral procedure 51 Multiple procedures 73 Discontinued outpt hospital/ambulatory surgery center (ASC) procedure prior to administration of anesthesia 74 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia

47.04: Reporting Requirements

(1) Required Reports. Upon request of the Division, each provider within 90 days following the end of its fiscal year, shall forward to the Division a complete and accurate cost report (FDSF-1) and certified financial statements. The provider shall also make available within 30 days all records and books relating to said operations, including such data, statistics, and records as the Division may from time to time request.

(2) Extension of Filing Date. The Division may grant an extension of time for the submission of cost reports or other information, data or statistics upon written request from the provider demonstrating that good cause exists for such an extension.

(3) Failure to File Timely Reports. Failure to submit accurate information within the time required by 114.3 CMR 47.04(1) and (2) or to submit within the stated time other acceptable data and statistics requested by the Division, may result in the delay, reduction or non-payment of the provider's rates, as well as application of other sanctions and penalties provided by law subject to the approval of the purchasing Governmental Unit.

47.05: Severability

The provisions of 114.3 CMR 47.00 are severable, and if any provision of 114.3 CMR 47.00 or application of such provision to any freestanding surgical facility or any circumstances shall be held to be invalid or unconstitutional, such invalidity shall not be construed to affect the validity or constitutionality of any remaining provisions to eligible freestanding surgical facilities or circumstances other than those held invalid.

REGULATORY AUTHORITY

114.3 CMR 47.00: M.G.L. c. 118G.

3/5/10 (Effective 1/1/10) 114.3 CMR - 1552.18 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Docket # 860

THE COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth

Regulation Filing To be completed by filing agency

CHAPTER NUMBER: 130 CMR 409.000

CHAPTER TITLE: Durable Medical Equipment and Medical Supplies Services

AGENCY: Division of Medical Assistance

SUMMARY OF REGULATION: State the general requirements and purposes of this regulation. The regulation revisions for Durable Medical Equipment and Medical Supplies (DME: 130 CMR 409.000) strengthen provider qualifications to be enrolled as a MassHealth DME provider, clarify covered and non-covered services, remove language regarding pricing, clarify and strengthen language related to prior authorization (PA), DME, and provider responsibilities, change PA and prescription requirements for PERS, describe provider responsibilities regarding Recall Notices, and clarify language related to DME provided to members in facilities. No statutory or regulatory deadlines are involved.

REGULATORY AUTHORITY: M.G.L. c. 118E, ss 7 and 12

AGENCY CONTACT: Sharon Johnson PHONE: 617-210-5650

ADDRESS: 600 Washington Street Boston, MA 02111

Compliance with M.G.L. c. 30A

EMERGENCY ADOPTION - if this regulation is adopted as an emergency, state the nature of the emergency.

PRIOR NOTIFICATION AND/OR APPROVAL - If prior notification to and/or approval of the Governor, Legislature or others was required, list each notification, and/or approval and date, including notice to the Local Government Advisory Commission. Executive Order 485: September 14, 2009 Executive Office of Communities and Development:January 22, 2010 Massachusetts Municipal Association:January 22, 2010

Date of public hearing or comment period: April 17, 2009 - May 8, 2009

For the first five years:

No fiscal effect: No Fiscal Effect.

N/A

CODE OF MASSACHUSETTS REGULATIONS INDEX - List key subjects that are relevant to this regulation: N/A

ATTESTATION - The regulation described herein and attached hereto is a true copy of the regulation adopted by this agency. ATTEST:

SIGNATURE: SIGNATURE ON FILE DATE: Feb 3 2010

Publication - To be completed by the Regulations Division

MASSACHUSETTS REGISTER NUMBER: 1151 DATE: 03/05/2010

EFFECTIVE DATE: 03/05/2010

CODE OF MASSACHUSETTS REGULATIONS Remove these pages: Insert these pages: 5, 6 5, 6 191 - 200.8 191 - 200.10

02/18/2010 mrs

Table of Contents Page

130 CMR 409.000: DURABLE MEDICAL EQUIPMENT SERVICES 191

Section 409.401: Introduction 191 Section 409.402: Definitions 191 Section 409.403: Eligible Members 194 Section 409.404: Requirements for Provider Participation 194 Section 409.405: Provider Responsibilities 196 Section 409.406: Services Provided to Members in Another State 198 Section 409.407: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services 198 Section 409.412: Subcontracted Services 198 Section 409.413: Covered Services 198 Section 409.414: Noncovered Services 199 Section 409.415: Durable Medical Equipment Provided to Members in Facilities 200 Section 409.416: Prescription and Letter of Medical Necessity Requirements 200.1 Section 409.417: Medical Necessity Criteria 200.2 Section 409.418: Prior Authorization 200.2 Section 409.419: Delivery of Durable Medical Equipment 200.4 Section 409.420: Repairs to Durable Medical Equipment 200.5 Section 409.427: Payment for Durable Medical Equipment 200.6 Section 409.428: Augmentative and Alternative Communication Devices (AAC) 200.6 Section 409.429: Personal Emergency Response System (PERS) 200.7 Section 409.430: Recordkeeping Requirements 200.8

130 CMR 410.000: OUTPATIENT HOSPITAL SERVICES 201

Section 410.401: Introduction 202 Section 410.402: Definitions 202 Section 410.403: Eligible Members 205 Section 410.404: Provider Eligibility 206 Section 410.405: Noncovered Services 206 Section 410.406: Payment 206.1 Section 410.407: Certification 207 Section 410.408: Prior Authorization 207 Section 410.409: Recordkeeping (Medical Records) Requirements 208 Section 410.410: Assurance of Member Rights 211 Section 410.411: Emergency Services 211 Section 410.412: Utilization Management Program and Mental Health and Substance Abuse Admission Screening Requirements 211 Section 410.413: Medical Services Required at a Hospital-Licensed Health Center 212 Section 410.414: Observation Services 212 Section 410.415: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services 212.1 Section 410.420: Tobacco Cessation Services 212.1 Section 410.431: Sterilization Services: Introduction 213 Section 410.432: Sterilization Services: Informed Consent 213 Section 410.433: Sterilization Services: Consent Form Requirements 214 Section 410.434: Abortion Services: Reimbursable Services 219 Section 410.435: Abortion Services: Certification for Payable Abortion Form 219 Section 410.436: Abortion Services: Out-of-State Abortions 220

3/5/10 130 CMR - 5 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 130 CMR: DIVISION OF MEDICAL ASSISTANCE

Table of Contents Page

130 CMR 410.000: OUTPATIENT HOSPITAL SERVICES (continued)

Section 410.437: Family Planning Services 220 Section 410.441: Early Intervention Program Services 221 Section 410.442: Home Health Agency Services 222 Section 410.443: Adult Day Health Program Services 222 Section 410.444: Adult Foster Care Services 222 Section 410.445: Psychiatric Day Treatment Program Services 223 Section 410.446: Dental Services 223 Section 410.451: Therapist Services: Covered Services 223 Section 410.452: Therapist Services: Service Limitations 224 Section 410.453: Therapist Services: Recordkeeping Requirements 224 Section 410.455: Laboratory Services: Introduction 225 Section 410.456: Laboratory Services: Payment 225 Section 410.457: Laboratory Services: Request for Services 226 Section 410.458: Laboratory Services: Recordkeeping Requirements 226 Section 410.459: Laboratory Services: Specimen Referral 226 Section 410.461: Pharmacy Services: Prescription Requirements 227 Section 410.462: Pharmacy Services: Covered Drugs and Medical Supplies for MassHealth Members 228 Section 410.463: Pharmacy Services: Limitations on Coverage of Drugs 228 Section 410.464: Pharmacy Services: Drugs and Medial Supplies Provided by Hospital-based Pharmacies 230 Section 410.465: Pharmacy Services: Drugs and Medical Supplies for Members in Institutions 230 Section 410.466: Pharmacy Services: Prior Authorization 230 Section 410.467: Pharmacy Services: Member Copayments 231 Section 410.468: Participation in the 340B Drug-pricing Program for Outpatient Pharmacies 231 Section 410.471: Mental Health Services: Introduction 232 Section 410.472: Mental Health Services: Noncovered Services 232 Section 410.474: Mental Health Services: Definitions 232 Section 410.475: Mental Health Services: Staffing Requirements 233 Section 410.476: Mental Health Services: Treatment Procedures 235 Section 410.477: Mental Health Services: Utilization Review Plan 235 Section 410.478: Mental Health Services: Recordkeeping Requirements 236 Section 410.479: Mental Health Services: Service Limitations 237 Section 410.480: Mental Health Services: Child and Adolescent Needs and Strengths (CANS) Data Reporting 239 Section 410.481: Vision Care Services: General Requirements 239 Section 410.482: Vision Care Services: Prescription and Dispensing Requirements 240 Section 410.483: Vision Care Services: Recordkeeping Requirement 241 Section 410.484: Vision Care Service Limitations: Visual Analysis 241 Section 410.485: Vision Care Service Limitations: Dispensing Eyeglasses 242 Section 410.486: Vision Care Service Limitations: Lenses 242 Section 410.487: Vision Care Service Limitations: Other Restrictions 243 Section 410.488: Vision Care Service Exclusions 243

130 CMR 411.000: MEDICAL ASSISTANCE PROGRAM: PSYCHOLOGIST SERVICES 245

Section 411.401: Introduction 245 Section 411.402: Definitions 245 Section 411.403: Eligible Members 245 Section 411.404: Provider Eligibility 246 Section 411.405: Payable Services 246 Section 411.406: Nonpayable Services 246 Section 411.407: Nonpayable Circumstances 246 Section 411.408: Maximum Allowable Fees 246 Section 411.410: Referral 247 Section 411.412: Procedures for Psychological Testing 247 Section 411.413: Recordkeeping Requirements 247 Section 411.414: Service Limitations 247

1/23/09 130 CMR - 6 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 130 CMR: DIVISION OF MEDICAL ASSISTANCE

130 CMR 409.000: DURABLE MEDICAL EQUIPMENT SERVICES

Section

409.401: Introduction 409.402: Definitions 409.403: Eligible Members 409.404: Requirements for Provider Participation 409.405: Provider Responsibilities 409.406: Services Provided to Members in Another State 409.407: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services 409.412: Subcontracted Services 409.413: Covered Services 409.414: Noncovered Services 409.415: Durable Medical Equipment Provided to Members in Facilities 409.416: Prescription and Letter of Medical Necessity Requirements 409.417: Medical Necessity Criteria 409.418: Prior Authorization 409.419: Delivery of Durable Medical Equipment 409.420: Repairs to Durable Medical Equipment 409.427: Payment for Durable Medical Equipment 409.428: Augmentative and Alternative Communication Devices (AAC) 409.429: Personal Emergency Response System (PERS) 409.430: Recordkeeping Requirements

409.401: Introduction

130 CMR 409.000 describes the requirements for the purchase, rental, and repair of durable medical equipment, and for the purchase of medical supplies under MassHealth. All durable medical equipment and supplies (DME) must be of proven quality and dependability, and must conform to all applicable federal and state product standards. All DME providers participating in MassHealth must comply with MassHealth regulations at 130 CMR 409.000 and 450.000. MassHealth may deny enrollment to an applicant or terminate participation of a MassHealth DME provider if the applicant or provider does not meet one or more of the requirements in 130 CMR 490.000.

409.402: Definitions

The following terms used in 130 CMR 409.000 have the meanings given in 130 CMR 409.402 unless the context clearly requires a different meaning. Payment for services defined in 130 CMR 409.402 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 409.000, and in 130 CMR 450.000.

Absorbent Products - diapers or brief-like garments, underpads, liners, and shields used to contain and/or manage symptoms of incontinence. Absorbent products may be disposable, reusable, or washable.

Accessories - products that are fabricated primarily and customarily to modify or enhance the usefulness or functional capability of another piece of equipment and that are generally not useful in the absence of that other piece of equipment.

Agent - the person who has been delegated by the applicant or provider with the authority to obligate or act on behalf of a provider or applicant.

Ambulatory Equipment - products that provide stability and security for members with impaired ambulation.

3/5/10 130 CMR - 191 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 130 CMR: DIVISION OF MEDICAL ASSISTANCE

409.402: continued

Applicant - an organization or individual who completes and submits an application to become a provider for MassHealth, but has not yet been determined by the MassHealth agency to be eligible to become a provider.

Assistive Technology Professional (ATP) - an individual with experience in assistive/ rehabilitation technology who analyzes the equipment needs of persons with disabilities, assists in the selection of the equipment, and trains the person with the disability on how to use the specific equipment. This equipment may include manual and power wheelchairs, seating and alternative positioning, ambulation assistance, environmental control, alternate computer access, augmentative and alternative communication devices, and products of daily living.

Augmentative and Alternative Communication Devices (AAC) - speech and communication aids that meet the functional speaking needs of members for whom such devices are medically necessary.

Compression Devices - products that are used for the treatment of lymphedema or chronic venous insufficiency with the goal of preventing the onset or worsening of venous stasis ulcers.

Criminal Offender Record Information (CORI) - information regulated by the Criminal History Systems Board (CHSB) and defined under CHSB regulations at 801 CMR 2.03 to include records and data in any communicable form compiled by a criminal justice agency that concern an identifiable individual and relate to the nature or disposition of a criminal charge, an arrest, a pre-trial proceeding, other judicial proceedings, sentencing, incarceration, rehabilitation, or release.

Customized Equipment - durable medical equipment that (1) is uniquely constructed, adapted, or modified solely for the full time use of the member for whom the item is purchased; (2) is made to order or adapted to meet the specific needs of the member; and (3) is uniquely constructed, adapted, or modified to permanently preclude the use of such equipment by another individual.

Date of Service - the date the DME is delivered to or picked up by the member, with the exception of 130 CMR 409.419(C).

DME - as used in 130 CMR 409.000, DME means durable medical equipment and medical supplies.

DME and Oxygen Payment and Coverage Guideline Tool - MassHealth Web-based application that contains DME and oxygen service descriptions for all covered products and services, applicable modifiers, place-of service codes, prior authorization requirements, individual consideration requirements, service limits, markup information, and links to other applicable information, such as Division of Health Care Finance and Policy (DHCFP) Web site. Subchapter 6 of the Durable Medical Equipment Manual directs providers to the MassHealth Web site for the DME and Oxygen Payment and Coverage Guideline Tool.

DME Provider - an organization or individual that has enrolled with MassHealth and has signed a provider contract with the MassHealth agency in accordance with 130 CMR 409.404 and 450.000.

Durable Medical Equipment - equipment that (1) is fabricated primarily and customarily to fulfill a medical purpose; (2) is generally not useful in the absence of illness or injury;

3/5/10 130 CMR - 192 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 130 CMR: DIVISION OF MEDICAL ASSISTANCE

409.402: continued

(3) can withstand repeated use over an extended period; and (4) is appropriate for use in the member's home.

Enteral Nutrition - nutrition requirements that are provided via the gastrointestinal cavity by mouth (orally) or through a tube or stoma that delivers the nutrients distal to the oral cavity.

Food and Drug Administration (FDA) - an agency of the United States Department of Health and Human Services that is responsible for the safety regulation of most types of foods, drugs, medical devices, and certain other products.

Glucose Monitor - a device for measuring blood glucose levels.

Home - for purposes of rental and purchase of DME, a member's home may be the member's own dwelling, an apartment, a relative's or other person's home in which the member resides, a rest home, assisted living, or another type of group residence or community setting.

Home Infusion Therapy (HIT) Services - the administration of medications to a member in a home setting using delivery devices through intravenous, subcutaneous, or epidural routes. Drug therapies commonly administered include antibiotics, chemotherapy, pain management, parenteral nutrition, and immune globulin.

Medical Supplies - consumable or disposable supplies or devices for home use necessary for the treatment of a specific illness, injury, disease, or disability, including, but not limited to test strips, syringes, ostomy products, and surgical items that are (1) fabricated primarily and customarily to fulfill a medical purpose; (2) used in the treatment of a specific medical condition; (3) generally not useful in the absence of illness or injury; (4) nonreusable and disposable; and (5) appropriate for use in the member's home.

Member - a person determined by the MassHealth agency to be eligible for MassHealth.

Mobility System - a manual or power wheelchair or other wheeled device, such as a scooter, including a base, a seating system, its components, accessories, and modifications.

Nurse Practitioner - a registered nurse who has successfully completed a formal education program for nurse practitioners as required by the Massachusetts Board of Registration of Nursing (the Board), who is in good standing with the Board, and who is responsible for oversight of the member's health care. A nurse practitioner who prescribes medication must be certified by the federal Drug Enforcement Agency (DEA).

Nutritional Supplements - commercially prepared products primarily used to treat a diagnosed deficiency in the member's diet or nutrition.

Ostomy Supplies - products used to contain diverted urine or fecal contents outside the body for patients who have a surgically created opening (stoma).

Parenteral Nutrition - nutrient requirements provided by means of a subcutaneous or intravenous route.

Personal Emergency Response System (PERS) - an electronic device connected to a person's land-line telephone. In an emergency, it can be activated either by pushing a small button on a pendant or bracelet, pressing the help button on the console unit, or by an adaptive switch set-up. When the device is activated, a person from the 24-hours-a-day, seven-days-a week central monitoring station answers the call, speaks to the member via the console unit, assesses the need for help, and takes appropriate action.

3/5/10 130 CMR - 193 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 130 CMR: DIVISION OF MEDICAL ASSISTANCE

409.402: continued

Physician Assistant - a mid-level medical practitioner who works under the supervision of a licensed physician (MD) or osteopathic physician (DO) and who has graduated from an accredited physician assistant program and is certified by and in good standing with the Massachusetts Board of Physician Assistant Registration.

Prescribing Provider - the member's physician, nurse practitioner, or physician assistant who prescribes and writes the prescription for DME in accordance with 130 CMR 409.416.

Prior Authorization (PA) Request - a request submitted by the DME provider to the MassHealth agency to determine medical necessity in accordance with 130 CMR 409.417, 409.418, 450.204, and 450.303.

Recall - action taken by the manufacturer to retrieve, replace, or repair dangerous or defective DME, whether or not such action is taken at the direction of the Food and Drug Administration (FDA).

RESNA - the Rehabilitation Engineering and Assistive Technology Society of North America, or its successor.

Seating System - a seated positioning system, including its components, accessories, and modifications, which may be attached to a base wheelchair and is designed to meet the individualized medical needs of a member.

Service Facility - a DME business or branch of a DME business where MassHealth members can obtain services, equipment, and supplies, including, but not limited to, repairs, replacements, or accessories.

Subcontractor - an individual, agency or organization (1) to which a MassHealth provider has contracted or delegated some of its management functions or responsibilities of providing medical care or services to its members; or (2) with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the MassHealth agreement.

Support Surfaces - beds, mattresses, or overlays used to reduce or relieve pressure, prevent the worsening of pressure ulcers, or promote wound healing.

409.403: Eligible Members

(A) MassHealth Members. MassHealth covers DME services provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. MassHealth regulations at 130 CMR 450.105 specifically state, for each coverage type, which services are covered, and which members are eligible to receive those services.

(B) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106.

(C) Verification of Member Eligibility. For information about verifying member eligibility and coverage type, see 130 CMR 450.107.

409.404: Requirements for Provider Participation

(A) Provider Participation Requirements. Payment for services described in 130 CMR 409.000 is made only to providers who are participating in MassHealth as a DME provider or have been assigned a DME specialty in accordance with 130 CMR 409.404(D) as of the date of service. Applicants must meet the requirements in 130 CMR 450.000 as well as the requirements in 130 CMR 409.000. Participating providers must continue to meet provider eligibility participation requirements throughout the period of their provider contract with the MassHealth agency.

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(B) Letter of Intent. All applicants must submit a letter of intent prior to receiving and completing a MassHealth provider application for DME. The letter of intent must describe (1) the applicant's primary scope of business, including which DME services and products the applicant intends to provide; (2) a list of any subcontractors the applicant intends to use and for what purpose; (3) existing contracts with other payers; and (4) the service areas in which services will be provided.

(C) General Qualifications. To qualify as a MassHealth DME provider, all applicants and providers must (1) have a service facility that (a) is available to members during regular, posted business hours; (b) is physically accessible to members with disabilities; (c) has clear access and space for individualized ordering, returns, repair, and storing of business records; (d) has a sign visible from outside the facility identifying the business name and hours that the service facility is open. If the provider's place of business is located within a building complex, the sign must be visible at the main entrance of the building where the service is located; (e) has a primary business telephone number listed in the name of the business with a local toll-free telephone number that is answered by customer service staff during business hours, and that has TTY transmission and reception capability. During business hours, this number cannot be a pager, answering service, voice message system, or cell phone; and (f) maintains a 24-hour voice message system; (2) obtain separate approval from the MassHealth agency and a separate provider number for each service facility operated by the provider. (3) except for specialty providers described in 130 CMR 409.404(D), primarily engage in the business of providing DME, or durable medical equipment repair services, to the public; (4) participate in the Medicare program as a DME provider, unless the provider supplies only PERS or absorbent products; (5) have a Medicare provider number that is assigned to the same business and service facility and location for which the applicant is applying to become a MassHealth provider; (6) be accredited by an accrediting body that is acceptable to the Centers for Medicare & Medicaid Services unless the provider supplies only PERS or absorbent products; (7) meet all applicable federal, state, and local requirements, certifications, and registrations; (8) at the time of application and recredentialing, or any other time as requested by the MassHealth agency, provide all required documentation specified in 130 CMR 450.000 as well as the following: (a) a list of contracted manufacturers used for purchased products (b) a copy of all current liability insurance policies; (c) copy of the property lease agreement pertinent to the service facility, or a copy of the most recent property tax bill if applicant owns the business site; (d) for mobility providers only, a copy of current RESNA ATP certificate for each certified staff member. DME providers who furnish mobility systems must employ at least one certified ATP at each service facility. The ATP must possess knowledge of the standards of acceptable practice in the provision of DME including ordering, assembling, adjusting, and delivering DME, and providing ongoing support and services to meet a person's rehabilitation equipment needs; (e) a copy of all current signed employee professional licenses, as applicable; (f) a copy of current accreditation letters; (g) a copy of the purchase and sale agreement if the applicant or provider has recently purchased the company for which they are applying to become a MassHealth provider; (h) a copy of subcontracts, if applicable, as described in 130 CMR 409.412. For PERS providers, the subcontract must include the central monitoring station contract, if applicable; (i) a copy of the applicant's emergency preparedness plan as approved by the accrediting body;

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(j) a copy of written policies and procedures, including the customer service protocol, customer complaint tracking and resolution protocol, the protocol on transfer and discharge of members, staff training; and (k) for PERS providers only, a copy of documentation demonstrating compliance with UL Standards 1637 in accordance with 130 CMR 409.429(C); (9) for a provider of home infusion services, be a licensed pharmacy in Massachusetts and be accredited by an accrediting body, as approved by the Centers for Medicare & Medicaid Services, and be assigned a DME specialty by the MassHealth agency. See 130 CMR 409.404(D); (10) conduct CORI checks on employees and subcontractors in accordance with procedures outlined in EOHHS CORI regulations at 101 CMR 15.00 et seq.; (11) not accept prescriptions for MassHealth DME from any prescribing provider who has a financial interest in the DME provider; and (12) cooperate with the MassHealth agency or its designee during the application and recredentialing process, including participation in a site visit.

(D) Providers Assigned DME Specialty. Applicants or providers whose primary business is not DME may qualify to provide DME services if the following conditions are met: (1) the applicant or provider is enrolled as a MassHealth provider of oxygen and respiratory therapy equipment services under 130 CMR 427.000 or pharmacy services under 130 CMR 406.000; (2) the applicant or provider meets all other conditions under 130 CMR 409.404 to provide DME services; and (3) MassHealth has assigned a specialty of DME to the applicant's or provider's existing provider number for oxygen and respiratory therapy equipment services or pharmacy services.

(E) In-state. To qualify as an in-state provider of DME, the applicant or provider must have a service facility located in Massachusetts that meets the criteria described in 130 CMR 409.404(C)(1).

(F) Out-of-state. An applicant or provider of DME with a service facility located outside of Massachusetts may qualify as a MassHealth DME provider only if the following additional conditions are met: (1) all requirements under 130 CMR 409.000 and 450.000, and 42 CFR 431.52 are met; (2) the out-of-state DME provider participates in the Medicaid program of the state in which the provider primarily conducts business, unless the out-of-state DME provider solely provides PERS; (3) the DME provider participates in the Medicare program of the state in which the provider primarily conducts business, unless the DME provider provides only PERS or absorbent products; and (4) the provider has a service facility that can readily replace and repair products when needed by the member.

409.405: Provider Responsibilities

In addition to meeting all other provider requirements set forth in 130 CMR 409.000 and 450.000, the provider must

(A) accept rates of payment established by the Division of Health Care Finance and Policy (DHCFP) for all DME provided to MassHealth members, unless otherwise determined by the MassHealth agency through a contracting process or by other means;

(B) notify the MassHealth agency in writing at least 14 days prior to any changes in any of the information submitted in the provider application in accordance with 130 CMR 450.215 and 450.223(B), including but not limited to, change of ownership, change of address, change in scope of service, and additional service locations. The provider must maintain records of all such communications and transactions and make such records available to the MassHealth agency for review upon request;

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(C) ensure that the DME provided is the most cost-effective, given the medical need for which the DME is prescribed and the member's medical condition;

(D) ensure that all DME is free from defects and is in proper working order. This includes, but is not limited to, prompt amelioration, repair or replacement of DME that has been provided to a member and is subject to recall, in accordance with the specifications in the recall notice. For recalls of potentially dangerous or defective DME that predictably could cause serious health problems or death, the DME provider must give the member 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 DME provider receives the recall notice;

(E) purchase the DME from the least costly reliable source;

(F) fill all orders from its own inventory or have a written subcontract for the purchase of items necessary to fill orders in accordance with 130 CMR 409.412;

(G) report to the proper authorities any suspected abuse or neglect that staff may observe when providing service to a member;

(H) give employees a picture identification to be presented to a member when making a delivery;

(I) adhere to the supplier standards set forth by the Centers for Medicare & Medicaid Services (CMS);

(J) not alter any invoice or medical documentation;

(K) not solicit members to purchase additional DME;

(L) submit prior authorization requests to the MassHealth agency only when the DME is medically necessary and when prior authorization is a prerequisite in accordance with 130 CMR 409.418.

(M) respond within two business days to members' complaints about their DME.

(N) not share a service facility with another provider of DME, including a physician or physician group or another supplier of DME;

(O) have a complaint resolution protocol to promptly address members' complaints and keep written complaints, related correspondence, and any notes of actions taken in response to written and oral complaints, and maintain such information in accordance with 130 CMR 409.430(I).

(P) provide MassHealth members with written notification at least 60 days in advance of any change in the DME provider's scope of business or services (for example, if a provider decides to no longer provide absorbent products). Notification to the member must include (1) a statement that the member can contact MassHealth Customer Service to request a list of DME providers in their area; and (2) if prior authorization is required for the service (a) the number of nonbilled units remaining on the PA; and (b) copy of the original PA approval from MassHealth for the member to provide to the new DME provider;

(Q) instruct the member, or the member's caregiver, in the appropriate use of the DME furnished to the member. Such instruction must include, but not be limited to, the provision of appropriate information related to setup, features, routine use, troubleshooting, cleaning, infection control practices, and other issues related to the use and maintenance of all DME provided. Instructions must be commensurate with the risks, complexity, and manufacturer's instructions and specifications for the DME. The DME provider must tailor training and instruction materials and approaches to the needs, abilities, learning preferences, and language of the member and caregivers, as appropriate. The DME provider must document the provision of such instruction in the member's record in accordance with 130 CMR 409.430(J); and

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(R) ensure that the member and the member's caregivers, as appropriate, can use all DME provided safely and effectively in the settings of anticipated use.

409.406: Services Provided to Members in Another State

The MassHealth agency pays for DME provided to MassHealth members in another state by a MassHealth DME provider in accordance with 42 CFR 431.52(b) and 130 CMR 450.109.

409.407: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

The MassHealth agency pays for all medically necessary DME services for EPSDT-eligible members in accordance with 130 CMR 450.140, without regard to service limitations described in 130 CMR 409.000, and with prior authorization.

409.412: Subcontracted Services

(A) A DME provider may subcontract with other entities to provide DME. The DME provider continues to be responsible for complying with 130 CMR 450.000 and 130 CMR 409.000 when activities are performed by a subcontractor. The subcontract must be in writing and must contain, at a minimum, the following: (1) names, addresses, phone numbers, and contact names for both companies; (2) the contract term (begin and end dates); (3) a description of the DME covered under the subcontract, including the cost of each item; (4) signatures of both parties, including signature dates and position titles; (5) an established credit limit that is reasonable, based on the value of the products and services to be provided by the contractor. Collect on delivery (COD) terms are not acceptable; and (6) provisions requiring the subcontractor to meet all requirements specified in 130 CMR 409.404 and 409.405.

(B) A DME provider must ensure that its subcontractors of DME meet all requirements specified in 130 CMR 409.404 and 409.405.

409.413: Covered Services

(A) MassHealth covers medically necessary DME that can be appropriately used in the member's home, and in certain circumstances described in 130 CMR 409.415 for use in facilities. All durable medical equipment must be approved for home use by the federal Food and Drug Administration (FDA). DME that is appropriate for use in the member's home may also be used in the community.

(B) MassHealth covers the DME listed in Subchapter 6 of the Durable Medical Equipment Manual. Providers may request prior authorization for medically necessary DME if the corresponding service code is not listed in Subchapter 6. Covered DME includes, but is not limited to (1) absorbent products; (2) ambulatory equipment, such as crutches and canes; (3) compression devices; (4) speech augmentative devices; (5) enteral and parenteral nutrition; (6) nutritional supplements; (7) home infusion equipment and supplies (pharmacy providers with DME specialty only); (8) glucose monitors and diabetic supplies; (9) mobility equipment and seating systems; (10) personal emergency response systems (PERS); (11) ostomy supplies; (12) support surfaces; (13) hospital beds and accessories; (14) patient lifts; and (15) bath and toilet equipment and supplies (commodes, grab bars, tub benches, etc.).

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(C) MassHealth covers the repair of durable medical equipment, including repairs to medically necessary back-up durable medical equipment, subject to the requirements of 130 CMR 409.420.

(D) The MassHealth agency pays for a manual wheelchair, including any necessary repairs, as a backup to a power mobility system if the member is not residing in a nursing facility, or the member is residing in a nursing facility and has a written discharge plan, and one of the following conditions applies: (1) the level of customization of the member's primary power mobility system would preclude the use of substitute rental equipment if the primary power mobility system were removed from the home for repair; (2) the member requires frequent outings to a destination that is not accessible to a power mobility system (for example, stairs without an elevator); or (3) it is not possible to fit the primary mobility system in any of the vehicles available to the member for transportation.

(E) The MassHealth agency pays for the replacement of a member's mobility system only when (1) (a) the cost of repairing or modifying the existing mobility system would exceed the value of that system; or (b) the member's physical condition has changed enough to render the existing mobility system ineffective; and (2) the DME provider has obtained prior authorization.

(F) The MassHealth agency pays for routine periodic testing, cleaning, regulating, and checking of durable medical equipment. Routine maintenance of durable medical equipment is covered through the rates established by DHCFP, unless the durable medical equipment is owned by the member.

409.414: Noncovered Services

The MassHealth agency does not pay for the following:

(A) DME that is experimental in nature;

(B) DME that is determined by the MassHealth agency not to be medically necessary pursuant to 130 CMR 450.204. This includes, but is not limited to items that: (1) cannot reasonably be expected to make a meaningful contribution to the treatment of a member's illness or injury; (2) are more costly than medically appropriate and feasible alternative pieces of equipment; or (3) serve the same purpose as DME already in use by the member with the exception of the devices described in 130 CMR 409.413(D);

(C) the repair of any durable medical equipment that is not identified as a covered service in Subchapter 6 of the Durable Medical Equipment Manual;

(D) the repair of any equipment where the cost of the repair is equal to or more than the cost of purchasing a replacement;

(E) routine periodic testing, cleaning, regulating, and checking of durable medical equipment that is owned by the member;

(F) DME that is not of proven quality and dependability;

(G) durable medical equipment that has not been approved by the federal Food and Drug Administration (FDA) for home use;

(H) evaluation or diagnostic tests conducted by the DME provider to establish the medical need for DME;

3/5/10 130 CMR - 199 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 130 CMR: DIVISION OF MEDICAL ASSISTANCE

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(I) home or vehicle modifications, such as ramps, elevators, or stair lifts;

(J) common household and personal hygiene items generally used by the public, including but not limited to washcloths, wet wipes, and non-sterile swabs;

(K) products that are not DME;

(L) certain durable medical equipment provided to members in facilities in accordance with 130 CMR 409.415; and

(M) provider claims for noncovered services under 130 CMR 409.414 for MassHealth members with other insurance, except as otherwise required by law.

409.415: Durable Medical Equipment Provided to Members in Facilities

(A) MassHealth Members Residing in Nursing Facilities. (1) The MassHealth agency pays for the following services for members residing in nursing facilities. (a) Mobility Systems for Members in Nursing Facilities with No Written Discharge Plan. The MassHealth agency pays DME providers for the purchase, rental, or repair of medically necessary mobility systems, positioning seating systems and add-ons, subject to all limitations and conditions of payment in 130 CMR 409.000 and 450.000, when purchased solely for the full-time use of the member while residing in a nursing facility, with the exception of equipment described under 130 CMR 409.415(A)(2). The nursing facility in which the member resides is responsible for payment to the DME provider for the first $500 toward the purchase of the mobility system, unless the member has a written discharge plan in accordance with 130 CMR 409.415(A)(1)(b). (b) Mobility Systems for Members in Nursing Facilities Who Have a Written Discharge Plan. The MassHealth agency pays DME providers for the purchase, rental, or repair of medically necessary mobility systems, positioning seating systems, and add-ons, subject to all limitations and conditions of payment in 130 CMR 409.000 and 450.000, when purchased solely for the full-time use of the member while residing in a nursing facility, with the exception of equipment described under 130 CMR 409.415(A)(2). The DME provider may deliver equipment to a nursing facility before the member's scheduled discharge date, for the purpose of teaching the member how to use the equipment, taking measurements, or adjusting equipment to be used in the member's home (see 130 CMR 409.419(C)). The DME provider must document the member's discharge plan and discharge date in the member's record before the equipment is delivered to the nursing facility, and provide such documentation to the MassHealth agency upon request. For equipment delivered to a nursing facility for use by a member after discharge from the facility, the date of service is the date of discharge. (c) Support Surfaces. The MassHealth agency pays DME providers for the rental or purchase of support surfaces for the exclusive full-time use of a member residing in a nursing facility. (2) The following services are not covered for members residing in nursing facilities. (a) The MassHealth agency does not pay DME providers for medical supplies, including but not limited to absorbent products, urological supplies, ostomy supplies, diabetic supplies, and enteral/parenteral products or supplies for MassHealth members residing in nursing facilities. (b) The MassHealth agency does not pay for the purchase, rental, or repair of standard, manual wheelchairs for the use of members residing in nursing facilities. This includes, but is not limited to transport chairs, standard manual wheelchairs, standard hemi wheelchairs, lightweight wheelchairs, high-strength lightweight wheelchairs, ultralightweight wheelchairs, heavy duty wheelchairs, semi-reclining wheelchairs, amputee wheelchairs, and extra heavy duty wheelchairs.

3/5/10 130 CMR - 200 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 130 CMR: DIVISION OF MEDICAL ASSISTANCE

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(B) MassHealth Members Who are Inpatients in Acute, Chronic Disease and Rehabilitation, and Psychiatric Hospitals. The MassHealth agency does not pay DME providers for medical supplies, including but not limited to absorbent products, or the purchase, rental, or repair of durable medical equipment provided to a MassHealth member who is an inpatient in a hospital, except for durable medical equipment delivered to the member in accordance with 130 CMR 409.419(C).

(C) MassHealth Members Who are Residing in Intermediate Care Facilities for the Mentally Retarded (ICF/MR). (1) Covered Services. (a) Customized Seating and Mobility Equipment. The MassHealth agency pays DME providers for the purchase, rental, or repair of customized medically necessary mobility systems, positioning seating systems, and add-ons, subject to all limitations and conditions of payment in 130 CMR 409.000 and 450.000, when purchased solely for the full-time use of a member residing in an ICF/MR (if the customization precludes the use of equipment by other individuals in the ICF/MR). (b) Other Customized Durable Medical Equipment. The MassHealth agency pays DME providers for other durable medical equipment that is purchased solely for the full-time use of a member residing in an ICF/MR (if the customization precludes the use of equipment by other individuals in the ICF/MR). (c) Durable Medical Equipment for Members to be Discharged from an ICF/MR. The MassHealth agency allows a DME provider to deliver equipment to an ICF/MR, before the member's scheduled discharge date, for the purpose of teaching the member how to use the equipment, taking measurements, or adjusting equipment to be used in the member's home (see 130 CMR 409.419(C)). The DME provider must document the member's discharge plan and discharge date in the member's record before the equipment is delivered to the ICF/MR, and provide such documentation to the MassHealth agency. (2) Noncovered Services. The MassHealth agency does not pay a DME provider for medical supplies, including but not limited to absorbent products, or the purchase, rental, or repair of non-customized DME provided to a member residing in an ICF/MR.

409.416: Prescription and Letter of Medical Necessity Requirements

(A) The DME provider must obtain a prescription and letter of medical necessity (LOMN) for the purchase or rental of DME. The prescription and the letter of medical necessity must be in writing, signed by the prescribing provider, and dated prior to the date the claim is submitted to the MassHealth agency. For certain DME that requires a prescription by specified medical professionals, the prescription and LOMN must be signed by such medical professionals. If the DME requires prior authorization, the prescription must be dated prior to the date the prior authorization request is submitted to the MassHealth agency. The initial and subsequent prescriptions must contain the following information as applicable: (1) the member's name; (2) the date of the prescription; (3) the name and quantity of the prescribed item and the number of refills (if appropriate); (4) the name, address, and signature of the prescribing provider and date signed; (5) medical justification for the item(s) being requested; (6) the equipment settings, hours to be used per day, options, or additional features, as they pertain to the equipment; (7) the recommended timetable of the prescribed item or treatment; (8) the expected outcome and therapeutic benefit of providing the requested item(s) or treatment; and (9) a summary of any previous treatment plan, including outcomes, that was used to treat the diagnosed condition for which the prescribed treatment is being recommended.

(B) The MassHealth agency accepts written prescriptions and letters of medical necessity for DME in the following formats, provided the requirements of 130 CMR 409.416(A) are met. (1) If the MassHealth agency has published a MassHealth Medical Necessity Review form for specific DME, providers may use the MassHealth Medical Necessity Review form as the prescription and letter of medical necessity specific to the DME being furnished. These forms can be found on the MassHealth Web site.

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409.416: continued

(2) If the forms described in 130 CMR 409.416(B)(1) are not used by the DME provider, the MassHealth agency accepts prescriptions and letters written on one of the following: (a) the prescribing provider's prescription pad; (b) the prescribing provider's letterhead stationery; (c) the hospital or nursing facility prescription pad, if the member is being discharged from a facility; (d) the MassHealth agency's Durable Medical Equipment and Medical Supplies General Prescription and Medical Necessity Review Form (DME-2), unless there is a product-specific Medical Necessity Review form as stated in 130 CMR 409.416(B)(1); or (e) the Region A Durable Medical Equipment Carrier (DME Medicare Administrative Contractor (MAC)) Certificate of Medical Necessity (CMN) completed in accordance with the instructions established by the Region A DME MAC and in compliance with 130 CMR 409.416(A). (3) For prescription and letter of medical necessity requirements for members residing in nursing facilities, see 130 CMR 409.416(D).

(C) Prescriptions may be transmitted electronically to the DME provider by the member's prescribing provider in accordance with the MassHealth agency's administrative and billing instructions and applicable state and federal laws.

(D) For members residing in nursing facilities, the prescription is the actual order in the member's medical record. The prescription must include a copy of the current month's order sheet that is signed and dated by the prescribing provider, a copy of the medical justification from the member's nursing facility record, and must include any additional documentation necessary to support medical necessity. Additional documentation may include physician progress notes; relevant laboratory or diagnostic test results; nursing, nutrition, or therapy assessments and notes; or wound assessments with pictures done with specialized wound photography.

(E) Refills of DME. (1) The MassHealth agency may allow payment of refills of DME prescribed up to a maximum of 12 months. (2) The absence of an indication to refill by the prescriber renders the prescription nonrefillable. (3) The MassHealth agency does not pay for any refill without approval from a member or caregiver provided at the time the prescription is to be refilled. The possession by a provider of a prescription with remaining refills authorized does not in itself constitute a request to refill the prescription.

409.417: Medical Necessity Criteria

All DME covered by MassHealth must meet the medical necessity requirements set forth in 130 CMR 409.000 and in 450.204, and medical necessity guidelines for specific DME published on the MassHealth Web site. If the MassHealth agency has not published product-specific medical necessity guidelines, DME providers must adhere to the Current Local Coverage Determination (LCD) policy developed by the Centers for Medicare & Medicaid Services (CMS) when demonstrating medical necessity.

409.418: Prior Authorization

The DME provider must obtain prior authorization from the MassHealth agency or its designee as a prerequisite for payment of DME identified in the DME and Oxygen Payment and Coverage Guideline Tool as requiring prior authorization. Prior authorization does not waive any other prerequisites for payment including, but not limited to, requirements relating to member eligibility or other health insurance payments. All prior authorization requests must be submitted in accordance with Subchapter 5 of the Durable Medical Equipment Manual.

3/5/10 130 CMR - 200.2 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 130 CMR: DIVISION OF MEDICAL ASSISTANCE

409.418: continued

(A) Documentation of Medical Necessity. (1) Prior authorization requests submitted by the provider for DME must include (a) a completed MassHealth Prior Authorization Request (PA-1) form (if request is submitted on paper); (b) a prescription and letter of medical necessity that meets the requirements of 130 CMR 409.416; (c) if diagnostic test results are used as a means to document medical necessity, the test results must be interpreted, signed, and dated by a physician, or include documentation that supports the need for DME from an appropriate health care professional other than the DME provider, including, but not limited to, physical therapists, speech therapists, nurses, respiratory therapists, and occupational therapists who have expertise in the applicable area; and (d) for DME that is identified in the DME and Oxygen Payment and Coverage Guideline Tool as requiring individual consideration (IC), a copy of the original invoice that reflects the provider's adjusted acquisition costs as set forth in the regulations of the Division of Health Care Finance and Policy (DHCFP) at 114.3 CMR 22.00. 1. MassHealth will accept a quote from a MassHealth provider for an item that does not have a rate established by the Division of Health Care Finance and Policy if the equipment has not been purchased by the provider at the time of the prior authorization request, and when the item being purchased is not an item that the provider normally purchases for its scope of business. The quote must be on the manufacturer's letterhead or form and must be addressed to the provider. 2. MassHealth will not accept a quote attached to a claim. At the time of a claim submission the provider must attach the actual manufacturer's invoice. The provider must keep a copy of the quote and the invoice on file. 3. For disposable medical supplies, the invoice must be dated within six months of the prior authorization request. 4. The MassHealth agency will not accept a printed invoice or order from a manufacturer's Web site.

(B) 90-day Requirement for Submission of Prior Authorization Requests. The provider must submit the request for prior authorization to the MassHealth agency no later than 90 calendar days from the date of the prescription. Failure to submit the request within the 90-day period will result in a denial of the prior authorization request.

(C) Prior Authorization Requests for DME Units in Excess of the Maximum Allowable Units. MassHealth requires prior authorization for certain DME provided to the member if the number of units requested exceeds the maximum units described in the DME and Oxygen Payment and Coverage Guideline Tool. (1) The provider must include documentation that supports the medical necessity of the additional units, including requirements under 130 CMR 409.417 and 409.418. (2) If the PA request is authorized by the MassHealth agency, the provider must submit a separate claim for which PA is authorized.

(D) Prior Authorization Requests for Members Who Have Other Insurance. For members for whom MassHealth is not the primary insurer and for whom the provider is seeking payment from another insurer, the provider must also request a prior authorization from the MassHealth agency according to the timelines established in 130 CMR 409.418, if the provider intends to seek secondary payment from MassHealth.

(E) Repairs of Durable Medical Equipment. Providers must submit a prior authorization request for repairs of durable medical equipment that exceed $1000 per repair, unless otherwise indicated in the DME and Oxygen Payment and Coverage Guideline Tool. (1) MassHealth pays for repairs to medically necessary mobility systems, including back-up systems, when either the member's primary or back-up systems are customized, adapted, or modified to the extent that no rental equipment would be comparable, and the repair is not covered under the warranty. (2) The DME provider must submit the following documentation with the prior authorization request:

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409.418: continued

(a) a completed MassHealth Prior Authorization Request (PA-1) form (if request is submitted on paper); (b) a prescription and letter of medical necessity that meet the requirements of 130 CMR 409.416 if the MassHealth agency has not yet determined the medical necessity of the durable medical equipment requiring repair; (c) a description of the customization or modification of the member's mobility systems, if applicable; (d) an invoice or quote for the repaired or replaced item; (e) a work order log with the estimated number of hours the repair will take; (f) a detailed description of the circumstances that made the repair necessary; and (g) an explanation as to why the repaired or replaced item is not covered under any warranty. (3) DME providers must furnish the member with substitute equipment in accordance with 130 CMR 409.420 when a repair service requires removal of the equipment from the member's home. (4) Providers must submit a prior authorization request for repairs of a member's back-up mobility system if the repair exceeds $1,000.

(F) Notice of Approval, Denial, or Modification of a Prior-authorization Request. (1) If the MassHealth agency approves a prior authorization request for DME, the MassHealth agency will send notice of its decision to the member and the DME provider. (2) If the MassHealth agency denies or modifies a prior authorization request for DME, the MassHealth agency will send notice of its decision to the member and the DME provider. The notice will state the reason for the denial or modification, and will inform the member of the right to appeal and of the appeal procedure in accordance with 130 CMR 610.000. (3) If the MassHealth agency defers a prior authorization request due to an incomplete submission or lack of documentation to support medical necessity, the MassHealth agency will notify the member and the DME provider of the deferral, and will inform the DME provider of the reason for the deferral and provide an opportunity for the provider to submit the incomplete or missing documentation. (4) If the provider does not submit the required information within 21 calendar days of the date of deferral, the MassHealth agency will deny the prior authorization request and will send notice of its decision to the provider and the member in accordance with 130 CMR 409.418(F)(2). The provider may resubmit a new prior authorization request that includes all required documentation.

409.419: Delivery of Durable Medical Equipment

(A) Delivery of Durable Medical Equipment to a Member's Home. (1) The DME provider must maintain in the member's record a copy of its delivery slip signed by the member or the member's designee accepting delivery on behalf of the member, and dated at the time of delivery. The date of the signature on the delivery slip must be the same as the date of delivery. (2) The MassHealth agency accepts the member's mark or a signature stamp as proof of delivery on behalf of a member whose disability inhibits the member's ability to write. A signature stamp may be used only by the member or the member's designee. A signature stamp may not be used by anyone associated with either the provider or the delivery service.

(B) Delivery of Durable Medical Equipment to a Nursing Facility or ICF/MR. The provider must obtain and maintain in the member's record documentation as required in 130 CMR 409.430, including documentation from the facility that the equipment will be used only for the member to whom the equipment was delivered. The DME provider's delivery slip must be signed by the member, the member's designee or a designee from the nursing facility or ICF/MR, and otherwise meet the requirements of 130 CMR 409.430(D).

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409.419: continued

(C) Delivery of Durable Medical Equipment to a Hospital, a Nursing Facility, or an ICF/MR in Anticipation of Discharge. A provider may deliver durable medical equipment to a facility for a member who is being discharged from a hospital, a nursing facility, or ICF/MR for the purpose of fitting or training the member in its proper use up to ten business days prior to the member's discharge date. The DME provider's delivery slip must be signed by the member, or the member's designee or a designee from the facility, and otherwise meet the requirements of 130 CMR 409.430(D). The durable medical equipment must be solely for use in the member's home or community. The provider may not bill for durable medical equipment for the days that the member was receiving training or fitting in the facility. The provider must use the date of the member's discharge from the facility as the date of service on the claim.

(D) Delivery Service or Shipping Service. (1) For medical supplies delivered to a member by the DME provider or by a shipping service, the DME provider is responsible for maintaining in the member's record a copy of the delivery services tracking slip attached to the provider's shipping invoice. The shipping invoice must include: (a) the name of the member; (b) the quantity of the supply delivered; (c) a detailed description of the items delivered including the brand name and, if applicable, the serial number; and (d) the delivery service's package identification number. (2) The DME provider's or the shipping service's tracking slip must refer to each package delivered, the delivery address, and the corresponding package identification number assigned by the shipping service. The date of service on the claim must match the delivery date (if delivered by the DME provider), or shipping date, if delivered by a shipping service.

(E) Refills. For DME provided as refills to an original prescription, the provider must contact the member or the member's designee up to at least five business days before shipping or delivering the refill to ensure that the refill is necessary and to confirm any changes to the order. If the member or designee declines a delivery, the provider must not make the delivery and must not submit a claim to the MassHealth agency for the items.

(F) MassHealth does not allow automatic deliveries. DME that is delivered to a member on a recurring basis must meet 130 CMR 409.419(E).

(G) For items picked up by the member or delivered to the member's home by the DME provider, the date of service is the date the DME was picked up by or delivered to the member.

(H) The DME provider responsible for the delivery of the DME is also responsible for providing adjustments needed for proper fit and function and instructing the member on the use of the DME.

409.420: Repairs to Durable Medical Equipment

(A) Prescription Requirements. The MassHealth agency does not require a prescription or a letter of medical necessity for the repair of durable medical equipment that the MassHealth agency previously determined to be medically necessary for the member.

(B) Repairs of Purchased Durable Medical Equipment. When a repair service for purchased durable medical equipment requires removing the equipment from a member's home, the provider must supply, on a rental basis, properly working substitute equipment that is comparable in most respects to the equipment to be repaired. Rental of substitute equipment is covered by MassHealth in accordance with rates established by DHCFP until repair to the equipment is complete and the original equipment is returned to the member.

3/5/10 130 CMR - 200.5 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 130 CMR: DIVISION OF MEDICAL ASSISTANCE

409.420: continued

(C) Repairs of Rented Durable Medical Equipment. When a repair service for rented durable medical equipment requires removing the equipment from the member's home, the provider must supply the member with properly working substitute equipment that is comparable in most respects to the equipment to be repaired. Providers may continue to bill a rental fee in accordance with rates established by DHCFP, but no extra rental charge is allowed for this substitute equipment.

(D) Prior Authorization. MassHealth requires the DME provider obtain prior authorization for repairs that exceed $1,000 per repair. See 130 CMR 409.418(E).

(E) Provider Responsibility. The DME provider who submits a claim to the MassHealth agency for repair of durable medical equipment is responsible for (1) ensuring quality of workmanship and parts; (2) ensuring that the repaired equipment is free of defects and in proper working condition; (3) taking advantage of all manufacturer warranties; (4) complying with the requirements of the Wheelchair Lemon Law (M.G.L. c. 93, § 107) and any other applicable provisions of federal and state laws pertaining to the service provided; (5) providing the member with regular updates regarding the status of the repairs and the expected delivery date of the equipment being repaired; and (6) responding in a timely fashion to a member's complaint regarding the repair of the equipment.

409.427: Payment for Durable Medical Equipment

Providers of DME must accept MassHealth payment in full for DME according to the rates and regulations established by the Division of Health Care Finance and Policy at 114.3 CMR 22.00. Payments are subject to the conditions, exclusions, and limitations set forth in 130 CMR 409.000 and 450.000.

409.428: Augmentative and Alternative Communication Devices (AAC)

(A) Covered Services. AAC devices are defined in 130 CMR 409.402. An AAC device must be a dedicated speech device, used solely by the member who has a severe expressive communication impairment. Examples of AAC devices are (1) communication boards or books; (2) electro larynxes; (3) speech/voice amplifiers; and (4) electronic devices that produce speech or written output.

(B) Requirements for Coverage. MassHealth covers AAC devices when the following conditions are met. (1) The member must have a communication disability with a diagnosis of severe dysarthria, apraxia, and/or aphasia as evidenced by documentation from the member's physician; (2) The device must be prescribed by the member's physician and recommended by a licensed speech and language pathologist who is not affiliated with the AAC provider and who has conducted a thorough evaluation of, and has a treatment plan for, the member's condition that includes use of the recommended device. (a) The treatment plan must describe the specific components of the AAC services and the required amount, duration, and scope of the AAC services, and include documentation that demonstrates 1. the requested AAC device and the AAC services constitute the least costly form of treatment that will have the comparable effect of overcoming or ameliorating communication limitations that preclude or interfere with the member's meaningful participation in current and planned daily activities; 2. the impairment or disability has caused communication limitations that preclude or interfere with the member's meaningful participation in daily activities;

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409.428: continued

3. the member is unable to meet communication needs arising in the course of daily activities using other available communication techniques; 4. therapies or treatments, including speech, occupational and/or physical therapy that have been provided to the member in relation to the prescribed ACC; 5. the member has the cognitive, visual, auditory, language, and motor ability necessary to utilize the selected device; 6. expected functional communication goals; and 7. a plan of care for the use of the device, including anticipated training needs, programming needs, evaluations, etc. (3) The provider has obtained prior authorization from the MassHealth agency for the AAC device. The request for a prior authorization request must include documentation in accordance with 130 CMR 409.418 and documentation demonstrating that the conditions in 130 CMR 409.428(B) have been met, including a copy of the member's treatment plan.

(C) Trial Period. (1) A trial-use period of not more than two months may be authorized by the MassHealth agency to determine if the device requested is appropriate for the member. (2) The provider must submit the following documentation in order to receive a trial period with an AAC device: (a) a prescription pursuant to 130 CMR 409.416; (b) a prior-authorization request pursuant to 409.418; (c) an explanation of the type of AAC device to be used by the member, including all necessary components; (d) identification of the clinicians or therapists who will assess the trial period; and (e) the evaluation criteria specific to the member that will be used by the clinician or therapist to determine the success or failure of the trial period. (3) Success of the trial period will be determined by a current evaluation of the therapeutic benefit of the AAC device completed by a licensed speech/language pathologist experienced in the assessment of AAC services. (4) After evaluating all appropriate documentation, the MassHealth agency will decide whether to purchase the equipment or to continue renting up to the purchase price of the device.

(D) Reasons for Noncoverage. The MassHealth agency will deny coverage of an AAC device if it determines that (1) the criteria set forth in 130 CMR 409.428(B) have not been met; (2) after a trial period, the member has failed to demonstrate to the MassHealth agency's satisfaction that the device is medically necessary; or (3) the requested device is not a dedicated speech device.

409.429: Personal Emergency Response System (PERS)

(A) Requirements for Coverage. PERS is indicated for the personal use of a member with medical conditions that cause significant functional limitations or incapacitation and prevents the member from using other methods of summoning assistance in an emergency. The member must (1) have a functioning land line phone that can accommodate a PERS; (2) live alone or be routinely alone for extended periods of time such that the member's safety would be compromised without the availability of a PERS unit in the home; (3) be able to independently use the PERS to summon help; (4) understand when and how to appropriately use the PERS; and (5) be at risk of moving to a more structured residential setting, or be at significant risk for falls or other medical complications that may result in an emergency situation.

(B) PERS must meet the definition in 130 CMR 409.402 and must include all of the following: (1) an in-home communications transceiver; (2) a remote, portable activator; (3) the capacity to respond to all incoming emergency signals;

3/5/10 130 CMR - 200.7 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 130 CMR: DIVISION OF MEDICAL ASSISTANCE

409.429: continued

(4) the ability to receive multiple signals simultaneously and ensure that calls are not disconnected or put in a first come, first serve rotation; (5) the ability to routinely send a signal to the central monitoring system to test the device and ensure the unit is working properly; and (6) a central monitoring station with back-up systems, staffed by trained attendants 24 hours a day, seven days a week.

(C) The PERS Must M\eet Underwriter Laboratories (UL) Standards 1637—Home Health Care Signaling Equipment. Providers of PERS must provide documentation upon request to the MassHealth agency demonstrating compliance with these standards.

(D) In addition to the provider responsibilities described in 130 CMR 409.405 and the requirements of 130 CMR 409.429, a MassHealth provider of PERS must (1) include options such as TDD and TTY capability to meet the needs of those members who are hearing impaired; (2) provide PERS that can accommodate the needs of non-English speaking members; (3) provide PERS that can accommodate the needs of members who are physically disabled (for example, providing "Sip-n-Puff" systems); (4) maintain current data files at the central monitoring station and at each service facility that contain preestablished response protocols, and personal, medical, and emergency information for each member served; (5) assess the member's need for in-home installation of PERS at the time the provider receives a referral for PERS. The MassHealth agency will pay a DME PERS provider for installation of PERS only if the DME PERS provider's assessment determines that there is no one else available to install the PERS in the member's home, such as the member, the member's caregiver, or a family member. The DME PERS provider must maintain documentation of such assessment in the member's record. If other options exist for members to install PERS, providers may deliver the PERS to the member by mail. Return receipt is required. If PERS is delivered by mail, the provider must not submit a claim to the MassHealth agency for the PERS installation.

(E) Documentation of Medical Necessity. Providers must ensure that PERS is medically necessary. In addition to the applicable record requirements under 130 CMR 409.430, the provider must complete the MassHealth Personal Emergency Response System (PERS) General Prescription Form in accordance with the instructions on the form, including obtaining the member's prescribing provider's prescription and medical justification for PERS, and maintain such documentation in the member's record. (1) The PERS General Prescription form must be completed, dated, and signed by the member's prescribing provider before the installment of PERS. (2) The form must be renewed and signed by the member's prescribing provider in the event that the member's medical condition or living situation changes such that the member may no longer meet the requirements of coverage of PERS under 130 CMR 409.429(A). (3) The DME provider must maintain the PERS General Prescription Form in the member's record and make it available to the MassHealth agency upon request.

(F) Reasons for Noncoverage. MassHealth does not pay for PERS when the following conditions apply: (1) the PERS duplicates equipment already available to the member in an emergency (e.g., emergency call buttons, or other electronic means of calling for help); or (2) the member has access to help on a 24-hour-per-day, seven-day-per-week basis.

409.430: Recordkeeping Requirements

The DME provider must keep a record, either paper or electronic, at the service facility for each member. The record must include all purchases, rentals, and repairs of DME provided for each member in accordance with the recordkeeping requirements set forth in 130 CMR 450.205. The provider must make all records retained in accordance with 130 CMR 450.205 and 409.430 available to the MassHealth agency upon request. Payment for services is conditioned upon the complete documentation in the member's record. In addition to fulfilling the requirements of 130 CMR 450.205, the provider must ensure that each member's record includes the following:

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409.430: continued

(A) a completed, signed, and dated prescription and letter of medical necessity that meets the requirements set forth in 130 CMR 409.416;

(B) a copy of the prior-authorization request submitted to the MassHealth agency (if the request was submitted on paper), including a copy of the MassHealth agency decision;

(C) a copy of all documentation submitted with a member's prior authorization request, including any MassHealth agency correspondence and decisions related to such requests;

(D) written confirmation of receipt of the prescribed DME, including refills, signed by the member or the member's designee, that includes (1) the date the equipment or medical supplies were delivered to the member; (2) the manufacturer, brand name, model number, and, if applicable, the serial number of the equipment or medical supplies; and (3) if the delivery slip is signed by the member's designee, an explanation of the designee's relationship to the member. This individual cannot be associated with either the DME provider or the delivery service;

(E) a copy of the original invoice showing the cost to the DME provider of the materials (if the DME provider is not the manufacturer of the materials);

(F) for repair services, a complete description of all repair services, including the manufacturer, brand name, model number, and serial number of the repaired item;

(G) copies of written warranties and any discounts;

(H) documentation of member's other insurance and any documentation submitted to and received from other insurers;

(I) documentation of any oral or written complaints received by the member in accordance with 130 CMR 409.405(O). The documentation must include, at a minimum (1) the name, address, and telephone number of the member; (2) the name, address, and telephone number of the person filing the complaint (if not the member); (3) a summary of the complaint; (4) the date the complaint was received by the provider; (5) the name of the person receiving the complaint; (6) a summary of any investigation or actions taken by the DME provider to resolve the complaint; and (7) if the DME provider determined that an investigation of the complaint or further action was not necessary, the name of the person making this decision and the reason for the decision.

(J) a written description of any instruction or orientation provided to the member or the member's caregiver on the proper use of the equipment in accordance with 130 CMR 409.405(Q) and (R), signed and dated by the provider staff who provided the instruction or orientation;

(K) a written description or an electronically dated note of all contacts the provider has had with the member or the member's caregiver, signed and dated by the provider staff who had the contact; and

(L) a written description of any action taken by the provider in response to a recall notice, including any communication with members and repair/replacement of equipment, signed and dated by the technician or clinician responsible for implementing the instructions in the recall notice.

REGULATORY AUTHORITY

130 CMR 409.000: M.G.L. c. 118E, §§ 7 and 12.

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NON-TEXT PAGE

3/5/10 130 CMR - 200.10 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Docket # 631

THE COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth

Regulation Filing To be completed by filing agency

CHAPTER NUMBER: 211 CMR 130.00

CHAPTER TITLE: Credit for Reinsurance

AGENCY: Division of Insurance

SUMMARY OF REGULATION: State the general requirements and purposes of this regulation. 211 CMR 130.00 sets forth rules and procedural requirements that the Commissioner deems necessary to carry out the provisions of M. G. L. c. 175, section 20A relating to credit insurance.

REGULATORY AUTHORITY: M. G. L. c. 175, section 20A

AGENCY CONTACT: Elisabeth Ditomassi, Deputy Commissioner and PHONE: 617-521-7309 General Counsel ADDRESS: Division of Insurance, One South Station, Boston, MA 02110

Compliance with M.G.L. c. 30A

EMERGENCY ADOPTION - if this regulation is adopted as an emergency, state the nature of the emergency.

Date of public hearing or comment period: 2/17/2010

For the first five years:

No fiscal effect: None

None.

CODE OF MASSACHUSETTS REGULATIONS INDEX - List key subjects that are relevant to this regulation: Insurance, reinsurance, credit for reinsurance

ATTESTATION - The regulation described herein and attached hereto is a true copy of the regulation adopted by this agency. ATTEST:

SIGNATURE: SIGNATURE ON FILE DATE: Feb 19 2010

Publication - To be completed by the Regulations Division

MASSACHUSETTS REGISTER NUMBER: 1151 DATE: 03/05/2010

EFFECTIVE DATE: 03/05/2010

CODE OF MASSACHUSETTS REGULATIONS Remove these pages: Insert these pages: 809 - 816 809 - 816 817, 818 817, 818

02/19/2010 mrs

211 CMR 130.00: CREDIT FOR REINSURANCE

Section

130.01: Authority 130.02: Purpose 130.03: Severability 130.04: Credit for Reinsurance - Reinsurer Licensed in this State 130.05: Credit for Reinsurance - Accredited Reinsurers 130.06: Credit for Reinsurance - Reinsurer Domiciled in Another State 130.07: Credit for Reinsurance - Reinsurers Maintaining Trust Funds 130.08: Credit for Reinsurance Required by Law 130.09: Asset or Reduction from Liability for Reinsurance Ceded to Unauthorized Assuming Insurer not Meeting the Requirements of 211 CMR 130.04 through 130.08 130.10: Trust Agreements Qualified Under 211 CMR 130.09 130.11: Letters of Credit Qualified Under 211 CMR 130.09 130.12: Other Security 130.13: Reinsurance Contract 130.14: Contracts Affected 130.15: AR-1 Certificate of Assuming Insurer

130.01: Authority

211 CMR 130.00 is promulgated pursuant to the authority granted by M.G.L. c. 175, § 20A.

130.02: Purpose

The purpose of 211 CMR 130.00 is to set forth rules and procedural requirements that the commissioner deems necessary to carry out the provisions of M.G.L. c. 175, § 20A. The actions and information required by 211 CMR 130.00 are declared to be necessary and appropriate in the public interest and for the protection of the ceding insurers in this state.

130.03: Severability

If any provision of 211 CMR 130.00, or the application of the provision to any person or circumstance, is held invalid, the remainder of 211 CMR 130.00, and the application of the provision to persons or circumstances other than those to which it is held invalid, shall not be affected.

130.04: Credit for Reinsurance - Reinsurer Licensed in this State

Pursuant to M.G.L. c. 175, § 20A(1)(A) the commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer that was licensed in this state as of any date on which statutory financial statement credit for reinsurance is claimed.

130.05: Credit for Reinsurance - Accredited Reinsurers

(1) Pursuant to M.G.L. c. 175, § 20A(1)(B) the commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer that is accredited as a reinsurer in this state as of any date on which statutory financial statement credit for reinsurance is claimed. An accredited reinsurer: (a) Files a properly executed Form AR-1 (attached as an exhibit to 211 CMR 130.000) as evidence of its submission to this state’s jurisdiction and to this state’s authority to examine its books and records; (b) Files with the commissioner a certified copy of a certificate of authority or other acceptable evidence that it is licensed to transact insurance or reinsurance in at least one state, or, in the case of a U.S. branch of an alien assuming insurer, is entered through and licensed to transact insurance or reinsurance in at least one state; (c) Files annually with the commissioner a copy of its annual statement filed with the insurance department of its state of domicile or, in the case of an alien assuming insurer, with the state through which it is entered and in which it is licensed to transact insurance or reinsurance, and a copy of its most recent audited financial statement; and

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130.05: continued

1. Maintains a surplus as regards policyholders in an amount not less than $20,000,000 and whose accreditation has not been denied by the commissioner within 90 days of its submission; or 2. Maintains a surplus as regards policyholders of less than $20,000,000, and whose accreditation has been approved by the commissioner.

(2) If the commissioner determines that the assuming insurer has failed to meet or maintain any of these qualifications, the commissioner may upon written notice and hearing revoke the accreditation. Credit shall not be allowed a domestic ceding insurer if the assuming insurer’s accreditation has been revoked by the commissioner.

130.06: Credit for Reinsurance - Reinsurer Domiciled in Another State

(1) Pursuant to M.G.L. c. 175, § 20A(1)(C) the commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer that as of any date on which statutory financial statement credit for reinsurance is claimed: (a) Is domiciled in (or, in the case of a U.S. branch of an alien assuming insurer, is entered through) a state that employs standards regarding credit for reinsurance substantially similar to those applicable under M.G.L. c. 175, § 20A and 211 CMR 130.00; (b) Maintains a surplus as regards policyholders in an amount not less than $20,000,000; and (c) Files a properly executed Form AR-1 with the commissioner as evidence of its submission to this state’s authority to examine its books and records.

(2) The provisions of 211 CMR 130.06 relating to surplus as regards policyholders shall not apply to reinsurance ceded and assumed pursuant to pooling arrangements among insurers in the same holding company system. As used in 211 CMR 130.06, “substantially similar” standards means credit for reinsurance standards that the commissioner determines equal or exceed the standards of M.G.L. c. 175, § 20A and 211 CMR 130.00.

130.07: Credit for Reinsurance - Reinsurers Maintaining Trust Funds

(1) Pursuant to M.G.L. c.1 75, § 20A(1)(D) the commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer which, as of any date on which statutory financial statement credit for reinsurance is claimed, and thereafter for so long as credit for reinsurance is claimed, maintains a trust fund in an amount prescribed below in a qualified U.S. financial institution as defined in M.G.L. c. 175, § 20A(3)(B), for the payment of the valid claims of its U.S. domiciled ceding insurers, their assigns and successors in interest. The assuming insurer shall report annually to the commissioner substantially the same information as that required to be reported on the National Association of Insurance Commissioners (NAIC) annual statement form by licensed insurers, to enable the commissioner to determine the sufficiency of the trust fund.

(2) The following requirements apply to the following categories of assuming insurer: (a) The trust fund for a single assuming insurer shall consist of funds in trust in an amount not less than the assuming insurer’s liabilities attributable to reinsurance ceded by U.S. domiciled insurers, and in addition, the assuming insurer shall maintain a trusteed surplus of not less than $20,000,000. (b) 1. The trust fund for a group including incorporated and individual unincorporated underwriters shall consist of: a. For reinsurance ceded under reinsurance agreements with an inception, amendment or renewal date on or after August 1, 1995, funds in trust in an amount not less than the group’s several liabilities attributable to business ceded by U.S. domiciled ceding insurers to any member of the group; b. For reinsurance ceded under reinsurance agreements with an inception date on or before July 31, 1995, and not amended or renewed after that date, notwithstanding the other provisions of 211 CMR 130.00, funds in trust in an amount not less than the group’s several insurance and reinsurance liabilities attributable to business written in the United States; and

8/27/04 211 CMR - 810 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 211 CMR: DIVISION OF INSURANCE

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c. In addition to these trusts, the group shall maintain a trusteed surplus of which $100,000,000 shall be held jointly for the benefit of the U.S. domiciled ceding insurers of any member of the group for all the years of account. 2. The incorporated members of the group shall not be engaged in any business other than underwriting as a member of the group and shall be subject to the same level of regulation and solvency control by the group’s domiciliary regulator as are the unincorporated members. The group shall, within 90 days after its financial statements are due to be filed with the group’s domiciliary regulator, provide to the commissioner: a. An annual certification by the group’s domiciliary regulator of the solvency of each underwriter member of the group; or b. If a certification is unavailable, a financial statement, prepared by independent public accountants, of each underwriter member of the group. (c) 1. The trust fund for a group of incorporated insurers under common administration, whose members possess aggregate policyholders surplus of $10,000,000,000 (calculated and reported in substantially the same manner as prescribed by the annual statement instructions and Accounting Practices and Procedures Manual of the NAIC) and which has continuously transacted an insurance business outside the United States for at least three years immediately prior to making application for accreditation, shall: a. Consist of funds in trust in an amount not less than the assuming insurers’ several liabilities attributable to business ceded by U.S. domiciled ceding insurers to any members of the group pursuant to reinsurance contracts issued in the name of such group and; b. Maintain a joint trusteed surplus of which $100,000,000 shall be held jointly for the benefit of U.S. domiciled ceding insurers of any member of the group; and c. File a properly executed Form AR-1 as evidence of the submission to this state’s authority to examine the books and records of any of its members and shall certify that any member examined will bear the expense of any such examination. 2. Within 90 days after the statements are due to be filed with the group’s domiciliary regulator, the group shall file with the commissioner an annual certification of each underwriter member’s solvency by the member’s domiciliary regulators, and financial statements, prepared by independent public accountants, of each underwriter member of the group.

(3) (a) Credit for reinsurance shall not be granted unless the form of the trust and any amendments to the trust have been approved by either the commissioner of the state where the trust is domiciled or the commissioner of another state who, pursuant to the terms of the trust instrument, has accepted responsibility for regulatory oversight of the trust. The form of the trust and any trust amendments also shall be filed with the commissioner of every state in which the ceding insurer beneficiaries of the trust are domiciled. The trust instrument shall provide that: 1. Contested claims shall be valid and enforceable out of funds in trust to the extent remaining unsatisfied 30 days after entry of the final order of any court of competent jurisdiction in the United States; 2. Legal title to the assets of the trust shall be vested in the trustee for the benefit of the grantor’s U. S. ceding insurers, their assigns and successors in interest; 3. The trust shall be subject to examination as determined by the commissioner; 4. The trust shall remain in effect for as long as the assuming insurer, or any member or former member of a group of insurers, shall have outstanding obligations under reinsurance agreements subject to the trust; and 5. No later than February 28 of each year the trustee of the trust shall report to the commissioner in writing setting forth the balance in the trust and listing the trust’s investments at the preceding year-end, and shall certify the date of termination of the trust, if so planned, or certify that the trust shall not expire prior to the following December 31.

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(b) 1. Notwithstanding any other provisions in the trust instrument, if the trust fund is inadequate because it contains an amount less than the amount required by 211 CMR 130.07(3)(b)1., or if the grantor of the trust has been declared insolvent or placed into receivership, rehabilitation, liquidation or similar proceedings under the laws of its state or country of domicile, the trustee shall comply with an order of the commissioner with regulatory oversight over the trust or with an order of a court of competent jurisdiction directing the trustee to transfer to the commissioner with regulatory oversight over the trust or other designated receiver all of the assets of the trust fund. 2. The assets shall be distributed by and claims shall be filed with and valued by the commissioner with regulatory oversight over the trust in accordance with the laws of the state in which the trust is domiciled applicable to the liquidation of domestic insurance companies. 3. If the commissioner with regulatory oversight over the trust determines that the assets of the trust fund or any part thereof are not necessary to satisfy the claims of the U.S. beneficiaries of the trust, the commissioner with regulatory oversight over the trust shall return the assets, or any part thereof, to the trustee for distribution in accordance with the trust agreement. 4. The grantor shall waive any right otherwise available to it under U.S. law that is inconsistent with this provision.

(4) For purposes of 211 CMR 130.00, the term “liabilities” shall mean the assuming insurer’s gross liabilities attributable to reinsurance ceded by U.S. domiciled insurers that are not otherwise secured by acceptable means, and, shall include: (a) For business ceded by domestic insurers authorized to write accident and health, and property and casualty insurance: 1. Losses and allocated loss expenses paid by the ceding insurer, recoverable from the assuming insurer; 2. Reserves for losses reported and outstanding; 3. Reserves for losses incurred but not reported; 4. Reserves for allocated loss expenses; and 5. Unearned premiums. (b) For business ceded by domestic insurers authorized to write life, health and annuity insurance: 1. Aggregate reserves for life policies and contracts net of policy loans and net due and deferred premiums; 2. Aggregate reserves for accident and health policies; 3. Deposit funds and other liabilities without life or disability contingencies; and 4. Liabilities for policy and contract claims.

(5) Assets deposited in the trusts, established pursuant to M.G.L. c. 175, § 20A and 211 CMR 130.07(5) shall be valued according to their fair market value and shall consist only of cash in U.S. dollars, certificates of deposit issued by a U.S. financial institution as defined in M.G.L. c. 175, § 20A(3)(A), clean, irrevocable, unconditional and “evergreen” letters of credit issued or confirmed by a qualified U.S. financial institution, as defined in M.G.L. c. 175, § 20A(3)(A) and investments of the type specified in 211 CMR 130.07(5), but investments in or issued by an entity controlling, controlled by or under common control with either the grantor or beneficiary of the trust shall not exceed 5% of total investments. No more than 20% of the total of the investments in the trust may be foreign investments authorized under 211 CMR 130.07(5)(a)5., (b), (f)2. or (g) and no more than 10% of the total of the investments in the trust may be securities denominated in foreign currencies. For purposes of applying the preceding sentence, a depository receipt denominated in U. S. dollars and representing rights conferred by a foreign security shall be classified as a foreign investment denominated in a foreign currency. The assets of a trust established to satisfy the requirements of M.G.L. c.175, § 20A(1) shall be invested only as follows: (a) Government obligations that are not in default as to principal or interest, that are valid and legally authorized and that are issued, assumed or guaranteed by: 1. The United States or by any agency or instrumentality of the United States; 2. A state of the United States; 3. A territory, possession or other governmental unit of the United States;

3/5/10 211 CMR - 812 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 211 CMR: DIVISION OF INSURANCE

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4. An agency or instrumentality of a governmental unit referred to in 211 CMR 130.07(5)(a)2. and 3., if the obligations shall be by law (statutory of otherwise) payable, as to both principal and interest, from taxes levied or by law required to be levied or from adequate special revenues pledged or otherwise appropriated or by law required to be provided for making these payments, but shall not be obligations eligible for investment under 211 CMR 130.07(5)(a)4., if payable solely out of special assessments on properties benefited by local improvements; or 5. The government of any other country that is a member of the Organization for Economic Cooperation and Development and whose government obligations are rated A or higher, or the equivalent, by a rating agency recognized by the Securities Valuation Office of the NAIC; (b) Obligations that are issued in the United States, or that are dollar denominated and issued in a non-U.S. market, by a solvent U.S. institution (other than an insurance company) or that are assumed or guaranteed by a solvent U.S. institution (other than an insurance company) and that are not in default as to principal or interest if the obligations: 1. Are rated A or higher (or the equivalent) by a securities rating agency recognized by the Securities Valuation Office of the NAIC, or if not so rated, are similar in structure and other material respects to other obligations of the same institution that are so rated; 2. Are insured by at least one authorized insurer (other than the investing insurer or a parent, subsidiary or affiliate of the investing insurer) licensed to insure obligations in this state and, after considering the insurance, are rated AAA (or the equivalent) by a securities rating agency recognized by the Securities Valuation Office of the NAIC; or 3. Have been designated as Class One or Class Two by the Securities Valuation Office of the NAIC; (c) Obligations issued, assumed or guaranteed by a solvent non-U.S. institution chartered in a country that is a member of the Organization for Economic Cooperation and Development or obligations of U.S. corporations issued in a non-U.S. currency, provided that in either case the obligations are rated A or higher, or the equivalent, by a rating agency recognized by the Securities Valuation Office of the NAIC; (d) An investment made pursuant to the provisions of 211 CMR 130.07(5)(a), (b) or (c) shall be subject to the following additional limitations: 1. An investment in or loan upon the obligations of an institution other than an institution that issues mortgage-related securities shall not exceed 5% of the assets of the trust; 2. An investment in any one mortgage-related security shall not exceed 5% of the assets of the trust; 3. The aggregate total investment in mortgage-related securities shall not exceed 25% of the assets of the trust; and 4. Preferred or guaranteed shares issued or guaranteed by a solvent U.S. institution are permissible investments if all of the institution’s obligations are eligible as investments under 211 CMR 130.07(5)(b)1. and 3., but shall not exceed 2% of the assets of the trust. (e) As used in 211 CMR 130.00: 1. “Mortgage-related security” means an obligation that is rated AA or higher (or the equivalent) by a securities rating agency recognized by the Securities Valuation Office of the NAIC and that either: a. Represents ownership of one or more promissory notes or certificates of interest or participation in the notes (including any rights designed to assure servicing of, or the receipt or timeliness of receipt by the holders of the notes, certificates, or participation of amounts payable under, the notes, certificates or participation), that: i. Are directly secured by a first lien on a single parcel of real estate, including stock allocated to a dwelling unit in a residential cooperative housing corporation, upon which is located a dwelling or mixed residential and commercial structure, or on a residential manufactured home as defined in 42 U.S.C.A. Section 5402(6), whether the manufactured home is considered real or personal property under the laws of the state in which it is located; and

3/5/10 211 CMR - 813 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 211 CMR: DIVISION OF INSURANCE

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ii. Were originated by a savings and loan association, savings bank, commercial bank, credit union, insurance company, or similar institution that is supervised and examined by a federal or state housing authority, or by a mortgagee approved by the Secretary of Housing and Urban Development pursuant to 12 U.S.C.A. Sections 1709 and 1715-b, or, where the notes involve a lien on the manufactured home, by an institution or by a financial institution approved for insurance by the Secretary of Housing and Urban Development pursuant to 12 U.S.C.A. Section 1703; or b. Is secured by one or more promissory notes or certificates of deposit or participations in the notes (with or without recourse to the insurer of the notes) and, by its terms, provides for payments of principal in relation to payments, or reasonable projections of payments, or notes meeting the requirements of 211 CMR 130.07(5)(e)1.a.i. and ii.; 2. “Promissory note,” when used in connection with a manufactured home, shall also include a loan, advance or credit sale as evidenced by a retail installment sales contract or other instrument. (f) Equity interests. 1. Investments in common shares or partnership interests of a solvent U.S. institution are permissible if: a. Its obligations and preferred shares, if any, are eligible as investments under 211 CMR 130.07(5); and b. The equity interests of the institution (except an insurance company) are registered on a national securities exchange as provided in the Securities Exchange Act of 1934, 15 U.S.C. §§ 78a to 78kk or otherwise registered pursuant to that Act, and if otherwise registered, price quotations for them are furnished through a nationwide automated quotations system approved by the National Association of Securities Dealers, Inc. A trust shall not invest in equity interests under 211 CMR 130.07(5)(f)1.b. an amount exceeding 1% of the assets of the trust even though the equity interests are not so registered and are not issued by an insurance company; 2. Investments in common shares of a solvent institution organized under the laws of a country that is a member of the Organization for Economic Cooperation and Development, if: a. All its obligations are rated A or higher, or the equivalent, by a rating agency recognized by the Securities Valuation Office of the NAIC; and b. The equity interests of the institution are registered on a securities exchange regulated by the government of a country that is a member of the Organization for Economic Cooperation and Development; 3. An investment in or loan upon any one institution’s outstanding equity interests shall not exceed 1% of the assets of the trust. The cost of an investment in equity interests made pursuant to 211 CMR 130.07(5)(f)3., when added to the aggregate cost of other investments in equity interests then held pursuant to 211 CMR 130.07(5)(f)3., shall not exceed 10% of the assets in the trust; (g) Obligations issued, assumed or guaranteed by a multinational development bank, provided the obligations are rated A or higher, or the equivalent, by a rating agency recognized by the Securities Valuation Office of the NAIC. (h) Investment companies. 1. Securities of an investment company registered pursuant to the Investment Company Act of 1940, 15 U.S.C. § 802, are permissible investments if the investment company: a. Invests at least 90% of its assets in the types of securities that qualify as an investment under 211 CMR 130.07(5)(a), (b) or (c) or invests in securities that are determined by the commissioner to be substantively similar to the types of securities set forth in 211 CMR 130.07(5)(a), (b) or (c); or b. Invests at least 90% of its assets in the types of equity interests that qualify as an investment under 211 CMR 130.07(5)(f)1.; 2. Investments made by a trust in investment companies under 211 CMR 130.07(5)(f)1.b. shall not exceed the following limitations: a. An investment in an investment company qualifying under 211 CMR 130.07(5)(f)1.a. shall not exceed 10% of the assets in the trust and the aggregate amount of investment in qualifying investment companies shall not exceed 25% of the assets in the trust; and

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b. Investments in an investment company qualifying under 211 CMR 130.07(5)(f)1.b. shall not exceed 5% of the assets in the trust and the aggregate amount of investment in qualifying investment companies shall be included when calculating the permissible aggregate value of equity interests pursuant to 211 CMR 130.07(5)(f)1. (i) Letters of Credit. 1. In order for a letter of credit to qualify as an asset of the trust, the trustee shall have the right and the obligation pursuant to the deed of trust or some other binding agreement (as duly approved by the commissioner), to immediately draw down the full amount of the letter of credit and hold the proceeds in trust for the beneficiaries of the trust if the letter of credit will otherwise expire without being renewed or replaced. 2. The trust agreement shall provide that the trustee shall be liable for its negligence, willful misconduct or lack of good faith. The failure of the trustee to draw against the letter of credit in circumstances where such draw would be required shall be deemed to be negligence and/or willful misconduct.

(6) A specific security provided to a ceding insurer by an assuming insurer pursuant to 211 CMR 130.09 shall be applied, until exhausted, to the payment of liabilities of the assuming insurer to the ceding insurer holding the specific security prior to, and as a condition precedent for, presentation of a claim by the ceding insurer for payment by a trustee of a trust established by the assuming insurer pursuant to 211 CMR 130.07.

130.08: Credit for Reinsurance Required by Law

Pursuant to M.G.L. c. 175, § 20A(1)(E), the Commissioner shall allow credit for reinsurance ceded by a domestic insurer to an assuming insurer not meeting the requirements of M.G.L. c. 172, § 20A(1)(A), (B), (C), (D) or other appropriate section of M.G.L. c. 172, but only as to the insurance of risks located in jurisdictions where the reinsurance is required by the applicable law or regulation of that jurisdiction. As used in 211 CMR 130.08, “jurisdiction” means a state, district or territory of the United States and any lawful national government.

130.09: Asset or Reduction from Liability for Reinsurance Ceded to an Unauthorized Assuming Insurer not Meeting the Requirements of 211 CMR 130.04 through 130.08

(1) Pursuant to M.G.L. c. 175, § 20A(2), the Commissioner shall allow a reduction from liability for reinsurance ceded by a domestic insurer to an assuming insurer not meeting the requirements of M.G.L. c. 175, § 20A(1) in an amount not exceeding the liabilities carried by the ceding insurer. The reduction shall be in the amount of funds held by or on behalf of the ceding insurer, including funds held in trust for the exclusive benefit of the ceding insurer, under a reinsurance contract with such assuming insurer as security for the payment of obligations under the reinsurance contract. The security shall be held in the United States subject to withdrawal solely by, and under the exclusive control of, the ceding insurer or, in the case of a trust, held in a qualified United States financial institution as defined in M.G.L. c. 175, § 20A(3)(B). This security may be in the form of any of the following: (a) Cash; (b) Securities listed by the Securities Valuation Office of the NAIC and qualifying as admitted assets; or (c) Clean, irrevocable, unconditional and “evergreen” letters of credit issued or confirmed by a qualified United States institution, as defined in M.G.L. c. 175, § 20A(3)(A), effective no later than December 31st of the year for which filing is being made, and in the possession of, or in trust for, the ceding company on or before the filing date of its annual statement. Letters of credit meeting applicable standards of issuer acceptability as of the dates of their issuance (or confirmation) shall, notwithstanding the issuing (or confirming) institution’s subsequent failure to meet applicable standards of issuer acceptability, continue to be acceptable as security until their expiration, extension, renewal, modification or amendment, whichever first occurs.

3/5/10 211 CMR - 815 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 211 CMR: DIVISION OF INSURANCE

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(2) An admitted asset or a reduction from liability for reinsurance ceded to an unauthorized assuming insurer pursuant to 211 CMR 130.09 shall be allowed only when the requirements of 211 CMR 130.13 and the applicable portions of 211 CMR 130.10, 130.11 and 130.12 have been satisfied.

130.10: Trust Agreements Qualified under 211 CMR 130.09

(1) As used in 211 CMR 130.10: (a) “Beneficiary” means the entity for whose sole benefit the trust has been established and any successor of the beneficiary by operation of law. If a court of law appoints a successor in interest to the named beneficiary, then the named beneficiary includes and is limited to the court appointed domiciliary receiver (including conservator, rehabilitator or liquidator). (b) “Grantor” means the entity that has established a trust for the sole benefit of the beneficiary. When established in conjunction with a reinsurance agreement, the grantor is the unlicensed, unaccredited assuming insurer. (c) “Obligations,” as used in 211 CMR 130.10(2)(k) means: 1. Reinsured losses and allocated loss expenses paid by the ceding company, but not recovered from the assuming insurer; 2. Reserves for reinsured losses reported and outstanding; 3. Reserves for reinsured losses incurred but not reported; and 4. Reserves for allocated reinsured loss expenses and unearned premiums.

(2) Required conditions. (a) The trust agreement shall be entered into between the beneficiary, the grantor and a trustee, which shall be a qualified United States financial institution as defined in M.G.L. c. 175, § 20A(3)(B). (b) The trust agreement shall create a trust account into which assets shall be deposited. (c) All assets in the trust account shall be held by the trustee at the trustee’s office in the United States. (d) The trust agreement shall provide that: 1. The beneficiary shall have the right to withdraw assets from the trust account at any time, without notice to the grantor, subject only to written notice from the beneficiary to the trustee; 2. No other statement or document is required to be presented to withdraw assets, except that the beneficiary may be required to acknowledge receipt of withdrawn assets; 3. It is not subject to any conditions or qualifications outside of the trust agreement; and 4. It shall not contain references to any other agreements or documents except as provided for in 211 CMR 130.10(2)(k). (e) The trust agreement shall be established for the sole benefit of the beneficiary. (f) The trust agreement shall require the trustee to: 1. Receive assets and hold all assets in a safe place; 2. Determine that all assets are in such form that the beneficiary, or the trustee upon direction by the beneficiary, may whenever necessary negotiate any such assets, without consent or signature from the grantor or any other person or entity; 3. Furnish to the grantor and the beneficiary a statement of all assets in the trust account upon its inception and at intervals no less frequent than the end of each calendar quarter; 4. Notify the grantor and the beneficiary within ten days, of any deposits to or withdrawals from the trust account; 5. Upon written demand of the beneficiary, immediately take any and all steps necessary to transfer absolutely and unequivocally all right, title and interest in the assets held in the trust account to the beneficiary and deliver physical custody of the assets to the beneficiary; and 6. Allow no substitutions or withdrawals of assets from the trust account, except on written instructions from the beneficiary, except that the trustee may, without the consent of but with notice to the beneficiary, upon call or maturity of any trust asset, withdraw such asset upon condition that the proceeds are paid into the trust account. (g) The trust agreement shall provide that at least 30 days, but not more than 45 days, prior to termination of the trust account, written notification of termination shall be delivered by the trustee to the beneficiary.

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1. To pay or reimburse the ceding insurer for the assuming insurer’s share under the specific reinsurance agreement regarding any losses and allocated loss expenses paid by the ceding insurer, but not recovered from the assuming insurer, or for unearned premiums due to the ceding insurer if not otherwise paid by the assuming insurer; 2. To make payment to the assuming insurer of any amounts held in the trust account that exceed 102% of the actual amount required to fund the assuming insurer’s obligations under the specific reinsurance agreement; or 3. Where the ceding insurer has received notification of termination of the trust account and where the assuming insurer’s entire obligations under the specific reinsurance agreement remain unliquidated and undischarged ten days prior to the termination date, to withdraw amounts equal to the obligations and deposit those amounts in a separate account, in the name of the ceding insurer in any qualified U.S. financial institution as defined in M.G.L. c. 175, § (3)(B) apart from its general assets, in trust for such uses and purposes specified in 211 CMR 130.10(2)(k)1. and 2. as may remain executory after such withdrawal and for any period after the termination date. (l) Notwithstanding other provisions of 211 CMR 130.00, when a trust agreement is established to meet the requirements of 211 CMR 130.09 in conjunction with a reinsurance agreement covering life, annuities or accident and health risks, where it is customary to provide a trust agreement for a specific purpose, the trust agreement may provide that the ceding insurer shall undertake to use and apply amounts drawn upon the trust account, without diminution because of the insolvency of the ceding insurer or the assuming insurer, only for the following purposes: 1. To pay or reimburse the ceding insurer for: a. The assuming insurer’s share under the specific reinsurance agreement of premiums returned, but not yet recovered from the assuming insurer, to the owners of policies reinsured under the reinsurance agreement on account of cancellations of the policies; and b. The assuming insurer’s share under the specific reinsurance agreement of surrenders and benefits or losses paid by the ceding insurer, but not yet recovered from the assuming insurer, under the terms and provisions of the policies reinsured under the reinsurance agreement; 2. To pay to the assuming insurer amounts held in the trust account in excess of the amount necessary to secure the credit or reduction from liability for reinsurance taken by the ceding insurer; or 3. Where the ceding insurer has received notification of termination of the trust and where the assuming insurer’s entire obligations under the specific reinsurance agreement remain unliquidated and undischarged ten days prior to the termination date, to withdraw amounts equal to the assuming insurer’s share of liabilities, to the extent that the liabilities have not yet been funded by the assuming insurer, and deposit those amounts in a separate account, in the name of the ceding insurer in any qualified U.S. financial institution apart from its general assets, in trust for the uses and purposes specified in 211 CMR 130.10(2)(l)1.a. and b. as may remain executory after withdrawal and for any period after the termination date. (m) The reinsurance agreement may, but need not, contain the provisions required in 211 CMR 130.10(4)(a)2., so long as these required conditions are included in the trust agreement. (n) Notwithstanding any other provisions in the trust instrument, if the grantor of the trust has been declared insolvent or placed into receivership, rehabilitation, liquidation or similar proceedings under the laws of its state or country of domicile, the trustee shall comply with an order of the commissioner with regulatory oversight over the trust or court of competent jurisdiction directing the trustee to transfer to the commissioner with regulatory oversight or other designated receiver all of the assets of the trust fund. The assets shall be applied in accordance with the priority statutes and laws of the state in which the trust is domiciled applicable to the assets of insurance companies in liquidation. If the commissioner with regulatory oversight determines that the assets of the trust fund or any part thereof are not necessary to satisfy claims of the U.S. beneficiaries of the trust, the assets or any part of them shall be returned to the trustee for distribution in accordance with the trust agreement.

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130.10: continued

(3) Permitted conditions. (a) The trust agreement may provide that the trustee may resign upon delivery of a written notice of resignation, effective not less than 90 days after the beneficiary and grantor receive the notice and that the trustee may be removed by the grantor by delivery to the trustee and the beneficiary of a written notice of removal, effective not less than 90 days after the trustee and the beneficiary receive the notice, provided that no such resignation or removal shall be effective until a successor trustee has been duly appointed and approved by the beneficiary and the grantor and all assets in the trust have been duly transferred to the new trustee. (b) The grantor may have the full and unqualified right to vote any shares of stock in the trust account and to receive from time to time payments of any dividends or interest upon any shares of stock or obligations included in the trust account. Any interest or dividends shall be either forwarded promptly upon receipt to the grantor or deposited in a separate account established in the grantor’s name. (c) The trustee may be given authority to invest, and accept substitutions of, any funds in the account, provided that no investment or substitution shall be made without prior approval of the beneficiary, unless the trust agreement specifies categories of investments acceptable to the beneficiary and authorizes the trustee to invest funds and to accept substitutions that the trustee determines are at least equal in market value to the assets withdrawn and that are consistent with the restrictions in 211 CMR 130.10(4)(a)2. (d) The trust agreement may provide that the beneficiary may at any time designate a party to which all or part of the trust assets are to be transferred. Transfer may be conditioned upon the trustee receiving, prior to or simultaneously, other specified assets. (e) The trust agreement may provide that, upon termination of the trust account, all assets not previously withdrawn by the beneficiary shall, with written approval by the beneficiary, be delivered over to the grantor.

(4) Additional conditions applicable to reinsurance agreements: (a) A reinsurance agreement may contain provisions that: 1. Require the assuming insurer to enter into a trust agreement and to establish a trust account for the benefit of the ceding insurer, and specifying what the agreement is to cover; 2. Stipulate that assets deposited in the trust account shall be valued according to their current fair market value and shall consist only of cash in United States dollars, certificates of deposit issued by a United States bank and payable in United States dollars, and investments permitted by M.G.L. c. 175 or any combination of the above, provided investments in or issued by an entity controlling, controlled by or under common control with either the grantor or the beneficiary of the trust shall not exceed 5% of total investments. The reinsurance agreement may further specify the types of investments to be deposited. Where a trust agreement is entered into in conjunction with a reinsurance agreement covering risks other than life, annuities and accident and health, then the trust agreement may contain the provisions required by 211 CMR 130.10(4)(a)2. in lieu of including such provisions in the reinsurance agreement; 3. Require the assuming insurer, prior to depositing assets with the trustee, to execute assignments or endorsements in blank, or to transfer legal title to the trustee of all shares, obligations or any other assets requiring assignments, in order that the ceding insurer, or the trustee upon the direction of the ceding insurer, may whenever necessary negotiate these assets without consent or signature from the assuming insurer or any other entity; 4. Require that all settlements of account between the ceding insurer and the assuming insurer be made in cash or its equivalent; and 5. Stipulate that the assuming insurer and the ceding insurer agree that the assets in the trust account, established pursuant to the provisions of the reinsurance agreement, may be withdrawn by the ceding insurer at any time, notwithstanding any other provisions in the reinsurance agreement, and shall be utilized and applied by the ceding insurer or its successors in interest by operation of law, including without limitation any liquidator, rehabilitator, receiver or conservator of such company, without diminution because of insolvency on the part of the ceding insurer or the assuming insurer, only for the following purposes:

6/27/97 211 CMR - 818 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Docket # 152

THE COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Secretary of the Commonwealth

Regulation Filing To be completed by filing agency

CHAPTER NUMBER: 430 CMR 4.00

CHAPTER TITLE: Benefit Series

AGENCY: Division of Unemployment Assistance

SUMMARY OF REGULATION: State the general requirements and purposes of this regulation. The new Section 4.13(4) provides that a claimant whose preferred language is listed in G.L. c. 151A, § 62A (Spanish, Chinese, Haitian Creole, Italian, Portuguese, Vietnamese, Laotian, Khmer, and Russian) and who did not receive a determination in that language shall have an extended time period in which to request a hearing.

REGULATORY AUTHORITY: M.G.L. c. 23, Sec. 1

AGENCY CONTACT: Robert Ganong, Esq. PHONE: 617 626-5600

ADDRESS: Legal Department, 1st Floor, 19 Staniford Street, Boston, MA 02114

Compliance with M.G.L. c. 30A

EMERGENCY ADOPTION - if this regulation is adopted as an emergency, state the nature of the emergency.

PRIOR NOTIFICATION AND/OR APPROVAL - If prior notification to and/or approval of the Governor, Legislature or others was required, list each notification, and/or approval and date, including notice to the Local Government Advisory Commission. Advisory Council 10-14-09; A&F 11-6-09; Local Government Advisory Committee 12-4-09; interested parties 12-18-09; newspaper notices by 12-30-09; public hearing 1-20-10

Date of public hearing or comment period: 1-20-10

For the first five years: None

No fiscal effect: Yes

None

CODE OF MASSACHUSETTS REGULATIONS INDEX - List key subjects that are relevant to this regulation: Notice; Languages; Filing

ATTESTATION - The regulation described herein and attached hereto is a true copy of the regulation adopted by this agency. ATTEST:

SIGNATURE: SIGNATURE ON FILE DATE: Feb 19 2010

Publication - To be completed by the Regulations Division

MASSACHUSETTS REGISTER NUMBER: 1151 DATE: 03/05/2010

EFFECTIVE DATE: 03/05/2010

CODE OF MASSACHUSETTS REGULATIONS Remove these pages: Insert these pages: 1, 2 1, 2 21, 22 21 - 22.2

02/19/2010 mrs

Table of Contents Page

(430 CMR 1.00: RESERVED) 5

430 CMR 2.00: RULES 7

Section 2.02: Lost Time 7

( 430 CMR 3.00: RESERVED) 9

430 CMR 4.00: BENEFIT SERIES 11

Section 4.01: Registration and Claims in General 12 Section 4.03: Replacement of Benefit Checks 14 Section 4.04: Disqualification for Benefits 14 Section 4.05: Interstate Claims 16.1 Section 4.07: Mass Layoff 18 Section 4.09: Combined Wage Claims 20 Section 4.10: Solicitation by Non-commercial Legal Training Programs 21 Section 4.11: Notice of Hearing 21

Good Cause for Filing a Request for Hearing Beyond the Ten Day Limit as Provided for in M.G.L. c. 151A, § 39(b)

Section 4.12: Purpose 21 Section 4.13: Filing a Request for a Hearing 21 Section 4.14: Good Cause for a Late Appeal 22 Section 4.15: Late Appeals Filed Beyond 30 Days 22.1

Use of Interpreters

Section 4.16: Purpose 23 Section 4.17: Scope and Applicability 23 Section 4.18: Statement of Policy 23 Section 4.20: Matters Relating to Hearings 23

Interest on Overpaid Benefits

Section 4.21: Purpose 24 Section 4.22: Scope and Applicability 24 Section 4.23: Definitions 24 Section 4.24: Assessment of Interest 24 Section 4.25: Application of Payments 25 Section 4.26: Cancellation of Interest 25

Reconsideration of a Decision

Section 4.30: Purpose 25 Section 4.31: Scope and Applicability 25 Section 4.32: Definitions 25 Section 4.33: Request for Reconsideration 25 Section 4.34: Conditions for Reconsideration 26 Section 4.35: Effect of Reconsideration 26

Remuneration

Section 4.36: Purpose 26.1 Section 4.37: Scope and Applicability 26.1 Section 4.38: Definitions 26.1 Section 4.39: Certification 26.1 Section 4.40: Receipt of Remuneration 26.2 Section 4.41: Exceptions to Receipt of Remuneration 26.2

3/5/10 430 CMR - 1 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 430 CMR: DIVISION OF UNEMPLOYMENT ASSISTANCE

Table of Contents (continued) Page

Part-time Availability

Section 4.42: Purpose 26.2 Section 4.43: Scope and Applicability 26.3 Section 4.44: Definitions 26.3 Section 4.45: Conditions for Limiting Availability 26.3

Reduction of Job Insurance Benefits Relating to Part-time Employment

Section 4.71: Purpose 27 Section 4.72: Scope and Applicability 27 Section 4.73: Definitions 27 Section 4.74: Criteria for Determining Full-time Work 27 Section 4.75: Application for Criteria for Determining Full-time Work 27 Section 4.76: Reduction of Benefits 28 Section 4.77: The Effect of Subsequent Part-time Work 28 Section 4.78: Constructive Deduction Calculation 28

Base Period Section 4.81: Purpose 28 Section 4.82: Scope and Applicability 28 Section 4.83: Definitions 28.1 Section 4.84: Procedures with Respect to Benefit Years Beginning After October 1, 1994 but Before April 2, 1995 28.1 Section 4.85: Procedures with Respect to Benefit Years Beginning on or After April 2, 1995 28.2 Section 4.86: General Procedures 28.2

Payment of Retroactive Unemployment Benefits for Non- professional Employees who Performed Services for Educational Institutions (M.G.L. c. 151A § 28A(b))

Section 4.91: Purpose 29 Section 4.92: Scope and Applicability 29 Section 4.93: Definitions 29 Section 4.94: Filing a Claim 29 Section 4.95: Determination of Reasonable Assurance 30 Section 4.96: Opportunity to Perform Service 30 Section 4.97: Request for Retroactive Payment of Benefits 30 Section 4.98: Payments of Retroactive Benefits 31

430 CMR 5.00: EMPLOYER REQUIREMENT SERIES 33

Section 5.01: Work Records 33 Section 5.02: Reporting Requirements, General 33 Section 5.03: Contribution Reports 35 Section 5.04: Wage Reports 36.1 Section 5.05: Experience Rating 37 Section 5.06: Non-profit Organizations and Governmental Employers, Payment in Lieu of Contributions 38

4/3/09 430 CMR - 2 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 430 CMR: DIVISION OF UNEMPLOYMENT ASSISTANCE

4.09: continued

(5) A combined wage claimant may withdraw his/her combined wage claim within the period prescribed by M.G.L. c. 151A for filing an appeal, protest, or request for redetermination from the monetary determination of the combined wage provided: (a) He/she repays in full any benefits paid to him/her thereunder, or (b) He/she authorizes the State(s) against which he/she files a substitute claim(s) for benefits to withhold and forward to the paying State a sum sufficient to repay such benefits.

(6) Employment and wages which have been used under this arrangement for a determination of benefits which establish a benefit year shall not thereafter be used by another State as the basis for another monetary determination of benefits.

(7) If an individual requests to file a combined wage claim that does not have any wages and employment in Massachusetts, the Division of Unemployment Assistance shall inform the claimant of the option to file in another State in which the claimant has wages and employment during that State’s base period(s).

4.10: Solicitation by Non-commercial Legal Training Programs

The Division interprets the anti-solicitation provision of the last sentence of M.G.L. c. 151A, § 37 (and in particular its element of "business"), not to prohibit solicitation which is devoid of any commercial or commercially-motivated element. Non-profit, non- commercial entities, which seek to further the objectives of the employment security law by providing assistance to unemployed workers in representing them at Division hearings, and which charge no fee for their services (or which request, but do not require, a nominal gratuity, pursuant to Division authorization under M.G.L. c. 151A, § 37), and their representatives are not, in the Division's view, prohibited by M.G.L. c. 151A, § 37 from soliciting claimants for unemployment benefits for purposes of representing said claimants at such hearings and advocating for unemployment insurance benefits at such hearings. Any such solicitation is subject to reasonable restrictions of time, place and manner, e.g. 430 CMR 4.08, to protect the rights of those unemployed persons being solicited and to assure that the smooth functioning of the business of the Division and the orderly administration of the employment security Law are not impaired.

4.11: Notice of Hearing

The notice of hearing on an appeal of a determination or a redetermination by the Commissioner shall be mailed to all interested parties and their authorized representatives and shall specify the time, date, place of hearing and the issues to be considered at the hearing. The Commissioner shall mail the notice of hearing at least ten days before the hearing, unless all interested parties have, with the approval of the Commissioner, waived the notice or agreed to a shorter period of time. It shall be good cause for postponement of the scheduled hearing when an interested party or their attorney or authorized representative was not provided with adequate time to prepare for the hearing because the notice of hearing was mailed to such party, attorney or authorized representative less than ten days prior to the scheduled hearing.

GOOD CAUSE FOR FILING A REQUEST FOR HEARING BEYOND THE TEN DAY LIMIT AS PROVIDED FOR IN M.G. L. C. 151A, § 39(B)

4.12: Purpose

The purpose of 430 CMR 4.12 through 430 CMR 4.15 is to set forth standards under which the Commissioner of the Division may extend the ten day time limit for filing a request for a hearing under M.G.L. c. 151A, § 39(b).

4.13: Filing a Request for a Hearing

(1) An interested party shall request a hearing within ten calendar days after delivery, in hand, or mailing of the Commissioner's determination. This ten day filing period may be extended by the Commissioner, for good cause shown as set forth in 430 CMR 4.14, provided a party files his or her request for a hearing within 30 calendar days after delivery or mailing of the Commissioner's determination.

4/3/09 430 CMR - 21 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 430 CMR: DIVISION OF UNEMPLOYMENT ASSISTANCE

4.13: continued

(2) The Commissioner shall not find good cause if a party fails to request a hearing within 30 calendar days after delivery or mailing of the Commissioner's determination.

(3) A request for a hearing shall be deemed filed on the date it is received, if delivered in hand to a Division employee designated to receive such request, or on the date postmarked, if mailed. A request is timely if it is delivered to the Division or postmarked on or before the tenth calendar day after the date of mailing or date of delivery, in hand, of the Commissioner's determination.

(4) Notwithstanding 430 CMR 4.13(1) through (3), where the party is an individual whose preferred language is listed under M.G.L. c.151A, § 62A and who did not receive the Com- missioner's determination in his or her preferred language, the request for hearing shall be deemed timely if filed within 60 calendar days from the date of mailing of the determination or if filed after the 60 day period and the reason for the delay in filing is caused by the Commissioner's determination having not been in his/her preferred language.

4.14: Good Cause for a Late Appeal

The Commissioner may extend the ten day filing period where a party establishes to the satisfaction of the Commissioner or authorized representative that circumstances beyond his or her control prevented the filing of a request for a hearing within the prescribed ten day filing period. Examples of good cause for a failure to file a timely request for a hearing include, but are not limited to, the following:

(1) A delay by the United States Postal Service in delivering the Commissioner's determination;

(2) Death of a household member or an immediate family member (including a spouse, child, parent, brother, sister, grandparent, stepchild or parent of a spouse);

(3) A documented serious illness or hospitalization of a party household member an immediate family member during the entire ten day filing period or a portion of the appeal period if the party's ability to timely appeal is thereby affected;

(4) An emergency family crisis which requires a party's immediate attention during the entire ten day filing period or a portion of the appeal period if the party's ability to timely appeal is thereby affected;

(5) An inability to effectively communicate or comprehend English and the party is unable to find a suitable translator to explain the notice of determination within the ten day filing period;

(6) The Commissioner's determination is not received and the party promptly files a request for a hearing after he or she knows or should have known that a determination was issued;

(7) A continuing absence from the Commonwealth, while seeking employment, during all or most of the ten day filing period;

(8) Intimidation, coercion or harassment by an employer resulting in a party failing to timely request a hearing;

(9) A Division employee directly discourages a party from timely requesting a hearing and such discouragement results in a party believing that a hearing is futile or that no further steps are necessary to file a request for a hearing.

(10) An inability because of illiteracy or a psychological disability to understand that a request for a hearing must be filed within the ten day filing period;

(11) The individual’s need to address the physical, psychological and legal effects of domestic violence as defined in M.G.L. c. 151A, § 1(g½);

(12) Any other circumstances beyond a party's control which prevented the filing of a timely appeal.

3/5/10 430 CMR - 22 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 430 CMR: DIVISION OF UNEMPLOYMENT ASSISTANCE

4.15: Late Appeals Filed Beyond 30 Days

The 30 day limitation on filing a request for a hearing shall not apply where the party establishes that:

3/5/10 430 CMR - 22.1 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 430 CMR: DIVISION OF UNEMPLOYMENT ASSISTANCE

NON-TEXT PAGE

3/5/10 430 CMR - 22.2 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Docket # 151

THE COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Notice of Compliance Secretary of the Commonwealth Regulation Filing To be completed by filing agency

CHAPTER NUMBER: 430 CMR 7.00

CHAPTER TITLE: Medical Security Plan for the Unemployed

AGENCY: Division of Unemployment Assistance

THIS REGULATION WAS ORIGINALLY ADOPTED AS AN EMERGENCY: Published in Massachusetts Register Number: 1146 Date: 12/25/2009 PRIOR NOTIFICATION AND/OR APPROVAL - If prior notification to and/or approval of the Governor, Legislature or others was required, list each notification, and/or approval and date, including notice to the Local Government Advisory Commission. A&F 11-16-09; Advisory Council 11-19-09; Local Government Advisory committee 12-4-09; notice to interested parties 12-18-09; newspaper notices published no later than 1-11-10; public hearing 1-20-10

AGENCY CONTACT: Robert Ganong, Esq. PHONE: 617 626-5600

ADDRESS: Legal Department, 1st Floor, 19 Staniford Street, Boston, MA 02114

ATTESTATION - The regulation described herein and attached hereto is a true copy of the regulation adopted by this agency. ATTEST: SIGNATURE ON FILE Feb 19 2010 SIGNATURE: DATE: Publication - To be completed by the Regulations Division MASSACHUSETTS REGISTER NUMBER: 1151 DATE: 03/05/2010 EFFECTIVE DATE: 12/01/2009 CODE OF MASSACHUSETTS REGULATIONS Remove these pages: Insert these pages: 47 - 50 47 - 50

02/19/2010 mrs

430 CMR 7.00: MEDICAL SECURITY PLAN FOR THE UNEMPLOYED

Section

7.01: General Provisions 7.02: Definitions 7.03: Eligibility Requirements 7.04: Initial Application Procedure 7.05: Other Application Procedures 7.06: Determination of Eligibility 7.07: Benefits 7.08: Third Party Payments; Repayment; Assignment; Subrogation 7.09: Termination of Benefits 7.10: Grievance 7.11: Fair Hearing 7.12: Severability

7.01: General Provisions

(1) Name, Scope, Purpose, and Effective Date. (a) The health care for the unemployed program described in 430 CMR 7.00 shall be known as the "Medical Security Plan for the Unemployed" (MSP). (b) 430 CMR 7.00 implements the provisions of M.G.L. c. 151A, § 14G, as most recently amended by St. 1996, c. 203, § 21, regarding health insurance benefits for the unemployed. (c) The purpose of 430 CMR 7.00 is to provide basic medical security for those eligible residents of the Commonwealth of Massachusetts who are receiving benefits or are eligible to receive benefits under M.G.L. c. 151A, and their dependents.

(2) Authority. 430 CMR 7.00 is adopted pursuant to M.G.L. c. 151A, § 14G, as most recently amended by St. 1996, c. 203, § 21.

7.02: Definitions

The following words and phrases as used in 430 CMR 7.00 have the following meanings unless otherwise clearly indicated by their context:

Appellant is a Medical Security Plan recipient who has initiated a proceeding under 430 CMR 7.11(3)(a).

Applicant is a person submitting an application for benefits provided under 430 CMR 7.00.

Base Period and Benefit Year are as defined in M.G.L. c. 151A, §§ 1(a) and (c), respectively.

Benefits are either of the following MSP programs: Direct Coverage or Premium Assistance.

Commissioner is the Commissioner of the Department of Workforce Development acting by and through the Director of the Division of Unemployment Assistance and/or his/her designee.

Continued Health Insurance Plan is a health insurance plan or self-insurance health plan except the Medicare and Medicaid program: (a) for which the primary enrollee is legally obligated to pay and pays the full cost of his or her premium, and (b) in which the primary enrollee participated at the time of, or prior to, applying for unemployment compensation benefits, including persons whose continued eligibility is based on federal COBRA law.

Contract Unit is an individual or family which submits a single application and receives benefits under 430 CMR 7.00.

Dependent is the spouse or child of any primary enrollee if such person(s) would qualify for dependent status under the Internal Revenue Code, or for whom a support order could be granted under M.G.L. chs. 208, 209, or 209C.

2/9/07 430 CMR - 47 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 430 CMR: DIVISION OF UNEMPLOYMENT ASSISTANCE

7.02: continued

Direct Coverage is a health benefit program in which the Division provides health care coverage to those who qualify.

Division is the Division of Unemployment Assistance.

Enrollee is a person who, either individually or as a member of a family, is receiving benefits under 430 CMR 7.00.

Family Income is the sum of all money, earned or unearned, such as salaries, wages, rents, tips, bonuses and annuities, received by the applicant and his or her spouse residing within the applicant's household.

Family Size is the sum of the number one (representing the applicant), and the number of people who meet the definition of dependent with respect to the applicant.

Good Cause exists if the circumstances which prevented the applicant or enrollee from complying with the requirements of 430 CMR 7.00 are beyond the control of the applicant or enrollee.

Hardship exists if the financial resources of the applicant as primary enrollee have been depleted or can reasonably be expected to be depleted to the extent that the applicant or primary enrollee will be unable to pay for goods and services (e.g. housing, heat, food, clothing, medicine, health care, transportation) necessary to support himself or herself and other members of the contract unit. The existence of a hardship shall be determined by the Division.

Health Care Services are supplies, care and services of medical, surgical, optometric, dental, podiatric, chiropractic, psychiatric, therapeutic, diagnostic, preventative, rehabilitative, supportive or geriatric nature including, but not limited to, inpatient and outpatient acute hospital care and services, services provided by a community health center, by a sanitarium, as included in the definition of "hospital" in Title XVIII of the Social Security Act, and treatment and care compatible with such services or by a health maintenance organization.

Health Insurance Plan is the Medicare program or an individual or group contract or other plan providing coverage of health care services which is issued by a health insurance company, a hospital service corporation, a medical service corporation or a health maintenance organization.

Health Plan is a health insurance plan, medical assistance program, a self-insurance health plan, or any other plan or program which provides for payment by a third-party payor or governmental payor for health care services used by the applicant or his or her dependents.

Medical Assistance Program is as defined in M.G.L. c. 151A, § 14G.

Premium Assistance is a program in which the Division makes payments directly to the enrollee in order to subsidize the enrollee's continued health insurance plan.

Presumptive Hardship -- Hardship shall be presumed if: (a) an applicant is receiving unemployment benefits and his or her actual, available total gross family income is at or under 150% of the current federal poverty income guidelines; or (b) an applicant is receiving unemployment benefits and the net monthly cost for him or her to maintain his or her existing health insurance under Premium Assistance is greater than 7% of his or her actual available monthly total gross family income; or (c) an applicant has not maintained his or her federal COBRA coverage and the deadline established for his/her election of COBRA continuation options has passed.

Primary Enrollee is an enrollee who has applied and been approved for benefits under 430 CMR 7.00 on behalf of himself or herself and/or his or her family.

Resident of the Commonwealth is a person who lives in the Commonwealth of Massachusetts with the intent to remain permanently or for an indefinite period.

3/5/10 (Effective 12/1/09) 430 CMR - 48 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 430 CMR: DIVISION OF UNEMPLOYMENT ASSISTANCE

7.02: continued

Self-Insurance Health Plan is a plan which provides health benefits to the employees of a business, which is not a health insurance plan, and in which the business is liable for the actual costs of the health care services provided by the plan as well as any administrative costs.

Third-Party Payor is an entity including, but not limited to the Medicaid program, the Medicare program, a health insurance company, a health maintenance organization, a hospital service corporation, a medical service corporation, provided, however that "third-party payor" shall not include a consumer responsible for payment to a provider for health care services rendered by such provider.

Unemployment Compensation is the program authorized by M.G.L. c. 151A. A person receives Unemployment Compensation if he or she actually receives a check for any amount of benefits under M.G.L. c. 151A. A person receives unemployment compensation benefits if he or she does not receive a check, but would have received a check if he or she were not having an amount deducted from his or her payments due to: (a) recovery of erroneous payments, in accordance with M.G.L. c. 151A, § 69; or (b) withholding of child support obligations, in accordance with M.G.L. c. 151A, § 29B; or (c) other withholdings as authorized by M.G.L. c. 151A.

Week is seven consecutive days beginning on Sunday.

7.03: Eligibility Requirements

(1) Applicant. In order to be eligible for benefits under 430 CMR 7.03 an applicant must meet all of the following requirements: (a) Receive or be Eligible to Receive Unemployment Compensation Benefits. An applicant must receive unemployment compensation benefits under the provisions of M.G.L. c. 151A, including extended benefits under M.G.L. c. 151A, § 30A or extended benefits under any federal act, to which he or she is entitled within the benefit period defined in 430 CMR 7.07(2), or be eligible to receive unemployment benefits pursuant to the provisions of M.G.L. c. 151A, § 24. (b) Employment in Massachusetts. An applicant must receive unemployment compensation in whole or in part for employment by an employer subject to the provisions of M.G.L. c. 151A, §§ 8, 8A, 8B, or 8C. (c) Residence. An applicant must be a resident of the Commonwealth of Massachusetts. (d) Maximum Family Income. 1. An applicant must not have gross family income greater than 400% of the federal non-farm poverty level as published in the Federal Register for a family of that family size. The poverty level shall be the level in effect for the calendar year in which the last day of the applicant becomes unemployed. If the poverty level for that year has not been published in the Federal Register on that date the poverty level shall be the poverty level of the prior year. 2. Gross family income is calculated as the gross income of the applicant and the applicant's spouse, if any, in the six months prior to application, and a projection of the gross income of the applicant and the applicant's spouse, if any, including a calculation of the maximum benefits payable to the applicant and the applicant's spouse, if any, from unemployment benefits, extended benefits or EUC benefits, for the six months after application. 3. For purposes of determining total family income under the hardship provisions as defined in 430 CMR 7.02, total family income shall be calculated as the gross income of the applicant and the applicant's spouse, if any, in the six months prior to the request for a hardship determination, plus the projected gross income of the applicant and the applicant's spouse, if any, for the six months following the request for a hardship determination. a. The applicant's projected gross income shall be calculated by determining the applicant's potential unemployment insurance compensation, including dependency allowances, entitlement for the six month period.

12/12/97 430 CMR - 49 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 430 CMR: DIVISION OF UNEMPLOYMENT ASSISTANCE

7.03: continued

b. The applicant's spouse's, if any, projected gross income shall be calculated by determining the spouse's average weekly wage for the 26 weeks prior to the request for a hardship determination and multiplying that figure by 26. 4. For purposes of determining monthly family income under the hardship and presumptive hardship provisions as defined in 430 CMR 7.02, monthly family income shall be calculated by projecting the applicants weekly UI benefits entitlement for the next four weeks, adding a projection of spousal, if any, monthly earnings by calculating the spouse's average weekly earnings in the previous six months (from the income eligibility determination) and multiplying by four. Any dependency allowance as defined in M.G.L. c. 151A, § 29(c) must be included in the calculations. (e) Alternative Health Plan. An applicant must not be enrolled in a health plan unless such a plan is a continued health insurance plan. (f) Release. An applicant must execute in writing a release of information from the provider of health care services or other party to the Division as is necessary for the proper administration of 430 CMR 7.03. The applicant must execute the release in the manner prescribed by the Division. (g) Spousal Health Plan. An applicant must not be eligible for health insurance under his or her spouse's health plan.

(2) Other Members of the Contract Unit. In order to be and remain eligible for membership in the contract unit, a person other than the applicant must: (a) be a dependent of the applicant; (b) be a resident of the Commonwealth of Massachusetts; (c) not be enrolled in a health plan unless such a plan is a continued health insurance plan; and (d) be a person who has the legal capacity to execute an assignment referred to in 430 CMR 7.08(3) and the release referred to in 430 CMR 7.03(1)(f).

(3) Primary Enrollee. In order for a contract unit to remain eligible for benefits under 430 CMR 7.03, the primary enrollee must continue to meet all of the following requirements: (a) Receive or be Eligible to Receive Unemployment Compensation Benefits. The primary enrollee satisfies this requirement for a given week if the primary enrollee receives or is eligible to receive unemployment compensation benefits for that week. (b) Residence. The primary enrollee must be a resident of the Commonwealth of Massachusetts. (c) Alternative Health Plan. The primary enrollee must not be enrolled in a health plan unless such a plan is a continued health insurance plan. (d) Notification of Changed Circumstances. The primary enrollee must notify the Division within seven days after any change of information which was reported or required to be reported on the application. This requirement of notification shall include, but not be limited to, termination of dependency status, change of residence, and change of employment status. (e) Spousal Health Plan. The primary enrollee must not be eligible for health insurance under his or her spouse's health plan.

7.04: Initial Application Procedure

(1) Written Application. All applicants must submit a signed, written application for benefits in a manner determined by the Division.

(2) Election of Plan. All applicants who are enrolled in a continued health plan at the time of application for benefits, must maintain continued enrollment in the health insurance plan in which they were enrolled prior to applying for unemployment compensation benefits, or as permitted by federal COBRA law. Such applicants shall be ineligible for enrollment into Direct Coverage and must elect Premium Assistance on their application. The Division may require applicants to submit proof demonstrating their ineligibility for Premium Assistance. Exceptions. (a) Applicants who do not qualify for COBRA benefits through their former employer or their spouse's employer shall be eligible for Direct Coverage pursuant to the eligibility requirements of 430 CMR 7.00. (b) Applicants unable to maintain continued enrollment in the health insurance plan in which they were enrolled prior to applying for unemployment compensation benefits may be eligible for Direct Coverage if:

3/5/10 (Effective 12/1/09) 430 CMR - 50 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. Docket # 563

THE COMMONWEALTH OF MASSACHUSETTS William Francis Galvin Notice of Compliance Secretary of the Commonwealth Regulation Filing To be completed by filing agency

CHAPTER NUMBER: 527 CMR 10.00

CHAPTER TITLE: Fire Prevention, General Provisions

AGENCY: Board of Fire Prevention Regulations

THIS REGULATION WAS ORIGINALLY ADOPTED AS AN EMERGENCY: Published in Massachusetts Register Number: 1151 Date: 03/05/2010 PRIOR NOTIFICATION AND/OR APPROVAL - If prior notification to and/or approval of the Governor, Legislature or others was required, list each notification, and/or approval and date, including notice to the Local Government Advisory Commission. Building Code Coordinating Council - November 19, 2009 E.O. 485 Approval sent on December 9, 2009 - approved on December 21, 2009 E.O. 145 Notice - December 22, 2009

AGENCY CONTACT: Peter A. Senopoulos, Esq. PHONE: 978-567-3181

ADDRESS: Board of Fire Prevention Regulations, P.O. Box 1025, State Road, Stow, MA 01775 ATTESTATION - The regulation described herein and attached hereto is a true copy of the regulation adopted by this agency. ATTEST: SIGNATURE ON FILE Feb 18 2010 SIGNATURE: DATE: Publication - To be completed by the Regulations Division MASSACHUSETTS REGISTER NUMBER: 1151 DATE: 03/05/2010 EFFECTIVE DATE: 02/19/2010 CODE OF MASSACHUSETTS REGULATIONS Remove these pages: Insert these pages: 3, 4 3, 4 128.1, 128.2 128.1 - 128.4

02/19/2010 mrs

Table of Contents Page

527 CMR 10.00: FIRE PREVENTION, GENERAL PROVISIONS 117

Section 10.01: Definitions 117 Section 10.02: Fire Extinguishers 118 Section 10.03: General Provisions 119 Section 10.04: Safety Cans 122 Section 10.05: General Storage 122 Section 10.06: Fumigation and Thermal Insecticidal Fogging 122.1 Section 10.07: Smoking 123 Section 10.08: Hospitals 124 Section 10.09: Schools 124 Section 10.10: Theatres 125 Section 10.11: Housing for the Elderly 126 Section 10.12: General Use Buildings 126 Section 10.13: Emergency Planning and Preparedness 126 Section 10.14: Hazard Abatement in Existing Buildings 128.2 Section 10.15: Floor Finishing or Refinishing 128.3 Section 10.16: Dust Explosions Hazards 129 Section 10.17: Places of Assembly 129 Section 10.18: Matches 130 Section 10.19: Ovens and Furnaces 131 Section 10.20: Open Air Parking Spaces 131 Section 10.21: Tire Rebuilding Plants 131 Section 10.22: Open Air Fires 131 Section 10.23: Bonfires and the Burning of Christmas Trees 132 Section 10.24: Miscellaneous Provisions 133 Section 10.25: Bulk Merchandising Retail Buildings 133 Section 10.26: Covered Mall Buildings 134 Section 10 27: Cellulose Nitrate Film 134 Section 10.28: Referenced Publications 134

527 CMR 11.00: COMMERCIAL COOKING OPERATIONS 135

Section 11.01: Scope and Purpose 135 Section 11.02: Adoption by Reference 135 Section 11.03: Modifications of Provisions of NFPA 96 135 Section 11.04: Issuance of Certificates of Competency to Conduct Inspections and Cleaning of Commercial Cooking Operations 136.1

527 CMR 12.00: 2005 MASSACHUSETTS ELECTRICAL CODE (Amendments) 137

527 CMR 13.00: EXPLOSIVES 153

Section 13.01: Scope and Application 153 Section 13.02: Appeals and Penalties 153 Section 13.03: Definitions 154 Section 13.04: Licenses, Permits and Certificates 160 Section 13.05: Storage 163 Section 13.06: Transportation 172.6 Section 13.07: Explosive Material Mixing 172.9 Section 13.08: Plosophoric Materials (Binary Explosive Material) 172.12 Section 13.09: Use of Explosive Materials (Blasting) 172.12 Section 13.10: Explosive Manufacturing 172.24 Section 13.11: Small Arms Ammunition and Primers, Smokeless Propellents and Black Powder 172.25 Section 13.12: General Provisions 172.27 Section 13.13: References 172.29 Section 13.14: Pre/Post Blast Inspection Waiver 172.30 Section 13.15: Blasting Damage Complaint Form 172.31

3/5/10 527 CMR - 3 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 527 CMR: BOARD OF FIRE PREVENTION REGULATIONS

Table of Contents Page

527 CMR 14.00: FLAMMABLE AND COMBUSTIBLE LIQUIDS, FLAMMABLE SOLIDS OR FLAMMABLE GASES 173

Section 14.01: Scope 173 Section 14.02: Definitions 173 Section 14.03: Storage 174 Section 14.04: Handling of Flammable Fluids 178 Section 14.05: Handling of Flammable Gases 179 Section 14.06: Handling of Flammable Solids 179 Section 14.07: Fire Control 179 Section 14.08: Referenced Publications 180

527 CMR 15.00: KEEPING, HANDLING AND TRANSPORTATION OF FLAMMABLE AND COMBUSTIBLE LIQUIDS, AND THE DISPOSITION OF CRUDE PETROLEUM OR ANY OF ITS PRODUCTS IN HARBORS OR OTHER WATERS OF THE COMMONWEALTH 183

Section 15.01: Application 183 Section 15.02: Definitions 183 Section 15.03: Storage 185 Section 15.04: Handling, Transporting or Disposing 186 Section 15.05: Piping, Valves, and Fittings for Marine Wharfs 188 Section 15.06: Mobile Fuel Facility 189 Section 15.07: Fuel Vessels and Barges 189 Section 15.08: Vapor Recovery System 190 Section 15.09: General Provisions 190 Section 15.10: Referenced Publications 192

527 CMR 16.00: MODEL ROCKETS 193

Section 16.01: Adoption by Reference 193 Section 16.02: Modification of Provisions of NFPA 1122 193 Section 16.03: Modification of Provisions of NFPA 1127 193 Section 16.04: Referenced Publications 193

527 CMR 17.00: LUMBER AND OTHER FOREST PRODUCTS 199

Section 17.01: Adoption by Reference 199 Section 17.02: Referenced Publications 199

527 CMR 18.00: FLAMMABLE LIQUIDS IN BULK PLANT LOADING AND UNLOADING FACILITIES 203

Section 18.01: Definitions 203 Section 18.02: Bottom Loading Facilities 205 Section 18.03: Referenced Materials 206

527 CMR 19.00: TENTAGE 207

Section 19.01: Definitions 207 Section 19.02: Scope 207 Section 19.03: General Requirements 207 Section 19.04: Referenced Publications 208

11/4/05 527 CMR - 4 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 527 CMR: BOARD OF FIRE PREVENTION REGULATIONS

10.13: continued

(6) High Rise Buildings. (a) General. The owner or other person having charge of buildings identified as high-rise buildings in 780 CMR shall be required to prepare and submit to the head of the fire department for review and approval a fire safety plan and evacuation procedure as set forth in 527 CMR 10.13(6). (b) Fire Safety Plan. The fire safety plan shall be distributed to the tenants and building service employees by the owner or agent. Tenants shall distribute to their employees applicable parts of the fire safety plan which affect their action in the event of a fire or emergency. (c) Responsibility to Update Fire Safe Plan. It shall be the responsibility of the owner or agent to promptly update the fire safety and evacuation procedures upon changes in occupancy, use or physical arrangement.

(7) Marking or Identifying Certain Buildings that are Especially Unsafe in the Case of Fire. (a) Any building determined to be especially unsafe in case of fire, under the provisions of 780 CMR 121.2 shall be identified and caused to be marked by the building official, with the cooperation of the head of the fire department, to indicate the degree of hazard. (b) In marking such buildings, the following symbols shall be used: This symbol shall mean that interior hazard exists to such a degree that interior operations shall be conducted with extreme caution. This symbol shall not in any way limit the discretion of the on scene Incident Commander in directing operations that the Incident Commander deems necessary. This symbol shall mean that exterior or interior hazards exists to such a degree that consideration should be given to conduct operations from the exterior only. This symbol shall not in any way limit the discretion of the on scene Incident Commander in directing operations that the Incident Commander deems necessary. (c) Markings shall be applied on the front of the building at or above the second floor level, where practical, between openings such that they are visible from the street. Markings may be applied to the sides or the rear of a building if the head of the fire department deems such placement necessary. Markings shall also be applied in a conspicuous place near every entrance and on penthouses. Markings shall not be applied over doors, windows, or other openings where they may be obscured by smoke or fire. (d) Markings shall be a minimum of 24 inches by 24 inches. Markings shall either be on a placard with a reflective background or painted with a reflective paint of contrasting color directly on the surface of the building. Stripes and borders outside of the marking shall be a minimum of two inches wide. (e) All markings shall bear a date as to when applied or the date of the most recent inspection. (f) Prior to receiving a mark, all buildings shall be inspected thoroughly by the head of the fire department.

(8) Special Provisions for Certain Places of Worship Which have been Issued a Valid Certificate of Occupancy for Use as a Temporary Overnight Shelter from the Cold Pursuant to 780 CMR: The Massachusetts State Building Code. A place of worship which has been issued a valid Certificate of Occupancy for use as a temporary overnight shelter from the cold in accordance with the provisions of 780 CMR: The Massachusetts State Building Code, shall not be deemed in violation of the provision of 527 CMR, as a result of such temporary use, as long as the facility meets the following conditions: (a) The temporary shelter is in possession of a valid Certificate of Occupancy for such temporary use which has been reviewed and approved by the head of the fire department in accordance with 780 CMR. (b) The approved temporary shelter is used, occupied and operated in accordance with the terms and conditions specified in said Certificate of Occupancy and said certificate of occupancy is posted in a conspicuous location. (c) In addition to the terms and conditions specified in the Certificate of Occupancy, the following fire safety requirements shall be applicable: 1. The building which houses the approved temporary shelter shall have no known existing or outstanding violations of 527 CMR or M.G.L. c. 148.

3/5/10 (Effective 2/19/10) 527 CMR - 128.1 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 527 CMR: BOARD OF FIRE PREVENTION REGULATIONS

10.13: continued

2. The approved temporary shelter possess a written document which has been approved by the head of the fire department which states the allowable occupant load, bedding diagram, location of all exits and of aisles leading thereto and the designated evacuation meeting point or points. A copy of such plan shall be kept on the premises and posted near the main entrance. The responsible persons identified in the application of the temporary certificate of occupancy shall maintain the condition of the shelter in accordance with the approved layout. 3. The employees, volunteers or attendants of the temporary shelter shall be trained and drilled in the duties that they are to perform in case of fire, panic or other emergency in accordance with the provisions of 527 CMR 10.13(3)(a). During all hours of overnight activation of an approved temporary shelter, employees, volunteers and attendants shall be awake and alert. 4. No person shall be permitted to smoke within the temporary shelter. Smoking may be allowed outside in an area approved by the Head of the Fire Department. 5. A document shall be posted, in a location approved by the Head of the Fire Department, containing an accurate number of sheltered occupants on a nightly basis. Such document shall also contain the names of all workers and volunteers who are overseeing or assisting in the shelter usage on a nightly basis. In the event of an evacuation, a copy of the document shall be in the possession of the person in charge at a designated meeting point. 6. The temporary shelter shall maintain a working landline phone that must be accessible to initiate a call for assistance in the event of an emergency. A cell phone is not acceptable for compliance with this requirement. 7. Carbon monoxide alarms shall be installed in accordance with 527 CMR 31.04(1). For purpose of compliance with 527 CMR 31.04, the dwelling unit of an approved temporary shelter shall be considered that portion of the building used for sleeping purposes. 8. An approved temporary shelter shall feature working and approved smoke detectors in accordance with the requirements of the State Building Code, 780 CMR, if applicable. If smoke detectors are not currently required under 780 CMR, the shelter shall, at a minimum, feature approved working smoke detectors in accordance with the provisions of 527 CMR 32.00. Such smoke detectors shall be installed in any room or area used for sleeping purposes and in any room or area directly adjacent to said sleeping area. (d) The head of the Fire Department shall be notified, in writing, at least 48 hours prior to the actual activation of an approved temporary shelter and shall be notified, in writing, upon the termination of such activation. (e) As a condition to use and occupation of an approved temporary shelter pursuant to 527 CMR 10.13(8), The operator of any such shelter shall allow the head of the fire department or any person to whom the head of the fire department may delegate, the authority to enter the shelter during any hour of operation to determine compliance with the provisions of 527 CMR or M.G.L. c. 148. (f) The provisions of 527 CMR 10.13(8) shall not impede the ability of the head of the fire department to take any reasonable action to protect persons or property under the authority of any provision of M.G.L. c. 148 or 527 CMR. (g) The use of a temporary overnight shelter from the cold under the provisions of 527 CMR 10.13(8) shall not be allowed after June 15, 2010.

10.14: Hazard Abatement in Existing Buildings

(1) General. (a) Scope. The provisions of 527 CMR 10.14 are to provide a reasonable degree of safety to persons occupying existing buildings that do not conform with the minimum requirements of 780 CMR by requiring the following alterations to such existing buildings. (b) Application of Other Codes. All alterations to an existing building which are caused directly or indirectly by the enforcement of 527 CMR 10.00 shall be done in accordance with the applicable procedures and provisions of 780 CMR, 248 CMR, the BOCA Mechanical Code and 527 CMR 12.00.

3/5/10 (Effective 2/19/10) 527 CMR - 128.2 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 527 CMR: BOARD OF FIRE PREVENTION REGULATIONS

10.14: continued

(c) Continued Maintenance. All service equipment, means of egress devices and safeguards which are required by 527 CMR 10.00 or which were required by a previous statute or another regulation in a building or structure when erected, altered or repaired shall be maintained in good working order. The requirements of 527 CMR 10.14 are not to provide the basis for removal or abrogation of fire protection and safety systems and devices in existing buildings. These requirements are intended to require that existing buildings which do not comply with 527 CMR 10.00 be altered to provide a minimum level of safety as required herein.

(2) Elevator Recall. Required. Elevator recall shall conform to the requirements of 524 CMR.

(3) Mechanical Equipment Control. Smoke and Heat Detection. Each recirculating air system which serves more than one floor in buildings which exceed six stories in height shall be equipped with approved smoke and heat detection devices in accordance with the BOCA Mechanical Code. The devices shall stop the fan(s) automatically and shall be of the manual reset type. Automatic fan shutdown is not required when the system is part of an approved smoke removal or control system, or hazardous exhaust system.

10.15: Floor Finishing or Refinishing

(1) Specific Conditions. (a) Scope. 527 CMR 10.15 shall apply to persons, or other entities that engage in sanding, finishing, or refinishing wood floors with or without compensation in any building or structure. The equipment, processes and operation of floor finishing or refinishing operations shall comply with the applicable requirements of 527 CMR 10.00, 527 CMR 14.00 and 527 CMR 34.00. (b) Permit Required. Effective June 1, 2010, any person or entity that performs wood floor finishing or refinishing operations involving the use and application of flammable liquids, as defined by 527 CMR 14.00, shall obtain a permit from the head of the fire department. Said permit shall indicate the name and address of the person performing the work and the address, date and time where such work is going to be performed. Exception: For work in buildings classified as R-2 and containing less than four units or R-3, as defined in 780 CMR: The Massachusetts State Building Code, no permit shall be required provided that, a letter indicating the person who is going to perform the work, address, date and time where such work will be performed is forwarded to the head of the fire department at least 48 hours in advance of the proposed work, including changes to that date. The head of the fire department may waive or reduce the time of the written notice.

(2) Fire Safety Requirements. Effective June 1, 2010, every person applying any finishing or refinishing product to the floors in any building or structure must comply with the following fire/explosion safety requirements: (a) Sources of Ignition. All fires, open flames or other sources of ignition, including smoking materials, shall be eliminated from the area or unit under the control of the finisher/refinisher prior to the application of any flammable finish or refinish material and until the product has sufficiently dried as determined by the manufacturer's specifications. If any flammable liquids are used, all electric lights to be used during the work must be turned on before the liquids are brought onto the property and not turned off until the applied flammable liquids are dry to the touch and any remaining unused liquids have been removed from the property. If any flammable liquids are used, no spotlights, halogen lights, drop lighting, or other lamps that create more heat than standard incandescent lighting may be used during floor finishing until the applied finish is dry to the touch. (b) Electricity. Electrical equipment shall be designed and installed in accordance with 527 CMR 12.00: Massachusetts Electric Code. All power tools on the jobsite shall be properly grounded. Electrical Permit Required. An electrical permit is required when connecting any floor refinishing machine directly to the electrical panel in accordance with 527 CMR 12.00.

3/5/10 (Effective 2/19/10) 527 CMR - 128.3 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. 527 CMR: BOARD OF FIRE PREVENTION REGULATIONS

10.15: continued

(c) Appliances. If any flammable products are used, all appliances in the home or building unit that are under the control of the owner or tenant which have a standing pilot light or which can produce sparks must be turned off or disconnected before the flammable products are brought onto the property and for at least 24 hours after application. These appliances include, but are not limited to, the following: 1. All water heaters in the unit, including those in the basement 2. All pilot lights in the unit, including those in the stove and basement 3. All heaters, furnaces, and air conditioners in the unit 4. All refrigerators in the unit 5. All other appliances in the unit that might produce sparks

3/5/10 (Effective 2/19/10) 527 CMR - 128.4 The text of the regulations published in the electronic version of the Massachusetts Register is unofficial and for informational purposes only. The official version is the printed copy which is available from the State Bookstore at http://www.sec.state.ma.us/spr/sprcat/catidx.htm. William Francis Galvin PERIODICALS Secretary of the Commonwealth State Bookstore U.S. POSTAGE PAID State House, Room 116 Boston, MA 02133 Boston, MA

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