101 Cmr: Executive Office of Health and Human Services
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101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 101 CMR 347.00: FREESTANDING AMBULATORY SURGERY CENTERS Section 347.01: General Provisions 347.02: Definitions 347.03: General Rate Provisions and Payment 347.04: Filing and Reporting Requirements 347.05: Severability 347.01: General Provisions (1) Scope and Purpose. 101 CMR 347.00 governs the rates of payment to eligible freestanding ambulatory surgery centers (FASCs) to be used by all governmental units for services provided to publicly aided individuals. Rates for services provided to individuals covered by M.G.L. c. 152 (the Worker's Compensation Act), are not set forth in 101 CMR 347.00, but are at 114.3 CMR 40.00: Rates for Services under M.G.L. c. 152, Workers’ Compensation Act. (2) Effective Date. Rates contained in 101 CMR 347.00 are effective for dates of service provided on or after November 30, 2018, unless otherwise indicated. (3) Coverage. 101 CMR 347.00 and the rates of payment contained in 101 CMR 347.00 are full compensation for facility services furnished in connection with surgical procedures that can be performed safely on an ambulatory basis in an FASC, are within the scope of covered services, and meet the purchasing governmental unit's conditions of payment for such facility services. Payment from any other sources will be used to offset the amount of the purchasing governmental unit's obligation for such services rendered to the publicly aided individuals. 101 CMR 347.00 does not cover professional services that are billed by a physician, dentist, or podiatrist separately from the surgery center and who receives no other compensation for the professional services rendered. Covered freestanding ambulatory surgery center 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. (4) Disclaimer of Authorization of Services. 101 CMR 347.00 is not authorization for or approval of the procedures for which rates are determined pursuant to 101 CMR 347.00. Governmental units that purchase care are responsible for the definition, authorization, coverage policies, and approval of the care and services extended to publicly aided individuals. (5) Coding Updates and Corrections. EOHHS may publish service 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 the code numbers change, with the corresponding cross references between new codes and the codes being replaced. Rates for such new codes are set at the rate of the code that is being replaced; (b) deleted codes for which there are no corresponding new codes; (c) codes for entirely new services that require pricing. EOHHS will list these codes and apply individual consideration (I.C.) reimbursement for these codes until appropriate rates can be developed, unless 101 CMR 347.01(5)(d) is applied; and (d) for entirely new codes that require new pricing and that have Medicare rates, EOHHS may list these codes and price them according to the rate methodology used in setting FASC facility component rates. (6) Administrative Bulletins. EOHHS may issue administrative bulletins to add, delete, or otherwise update codes or modifiers, to clarify its policy on and understanding of substantive provisions of 101 CMR 347.00, and otherwise as specified in 101 CMR 347.00. (MA REG. # 1379, Dated 11-30-18) 101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 347.02: Definitions Meaning of Terms. (a) The descriptions and five-digit codes included in 101 CMR 347.00 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' 2018 Current Procedural Terminology, copyright 2017 by the American Medical Association, unless otherwise specified. Level II codes are obtained from the 2018 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 two-digit modifiers for reporting medical services and procedures performed by physicians and other healthcare professionals, as well as associated non-physician services. 101 CMR 347.00 includes only HCPCS numeric and alphanumeric identifying codes and modifiers for reporting medical services and procedures that were selected by EOHHS. Any use of CPT outside the fee schedule should refer to the 2018 Physicians' Current Procedural Terminology, copyright 2017. (b) In addition, terms used in 101 CMR 347.00 have the meanings set forth in 101 CMR 347.02, unless the context requires otherwise. Center. The Center for Health Information and Analysis established under M.G.L. c. 12C. Eligible Provider. A licensed FASC that meets the conditions of participation adopted by a governmental unit, and to the extent specified by such governemental unit. Facility Component. Rate of payment for an FASC's facility costs. The facility component does not include payment for a physician's, dentist's, or podiatrist's services in performing a surgical procedure. Freestanding Ambulatory Surgery 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 (or, if out-of-state, the applicable licensing authority of that state), and meets the conditions for payment by the governmental unit 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 ambulatory surgery center services that are authorized but not listed in 101 CMR 347.00, 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 analyzes the eligible provider's operative report, which must contain a diagnosis, a pertinent medical history, a description of the services rendered, and the length of time spent with the patient. In making the determination of whether the service is appropriately classified as an individually considered item, and in determining appropriate payment for services designated as I.C., the governmental unit considers standards and criteria including the following, subject to any documentation requirements of the governmental unit: (a) policies, procedures, and practices of other third-party purchasers of care, both governmental and private; (b) the severity and complexity of the patient's disorder or disability; (c) prevailing provider ethics and accepted practice; and (d) time, degree of skill, and cost including equipment cost required to perform the procedure(s). Modifiers. Listed services may be modified under certain circumstances. When applicable, the modifying circumstances must be identified by the addition of the appropriate two-digit number or letters to the service code. 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. 101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES 347.02: continued 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 service 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. 347.03: General Rate Provisions and Payment (1) Rate Determination. Rates of payment for authorized FASC services to which 101 CMR 347.00 applies are the lowest of (a) the eligible provider's usual fee to the general public; (b) the eligible provider's actual charge submitted; and (c) the schedule of allowable rates set forth in 101 CMR 347.03(6). (2) Maximum Allowable Rates. Rates of payment are for the facility component only. The maximum allowable payment rate for each FASC service is listed next to the HCPCS code and its description in the fee schedule set forth in 101 CMR 347.03(6). Service codes listed in 101 CMR 347.03(6) with $0 rates are packaged services for which no separate payment is made. (3) Individual Consideration and Non-listed Services. Rates of payment to eligible providers for FASC services that are authorized but not listed in 101 CMR 347.00, services performed in unusual circumstances, and services whose fees are designated by the letters "I.C." are determined on an individual consideration basis. (4) Terminated Procedures. The purchasing governmental unit determines payment on an individual consideration (I.C.) basis for any procedure that has been terminated after the procedure has been initiated. (5) Modifiers. (a) -50: Bilateral Procedure. Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding the modifier 50 to the appropriate five-digit code. (Only one claim line is billed for both procedures. If a reimbursable surgical procedure provided in a single operative session is performed bilaterally, the full maximum fee is 150% of the payment group contained in 101 CMR 347.00 for the operative procedure.) (b) -51: Multiple Procedures. When multiple procedures, other than E/M services, physical medicine and rehabilitation services or provision of supplies (e.g., vaccines), are performed at the same session by the same individual the primaryprocedure or services may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).