101 CMR 347.02 - Definitions
The terms used in 101 CMR 347.00 have the meanings set forth in 101 CMR 347.02, unless the context requires otherwise. The five-digit codes included in 101 CMR 347.00 utilize the Healthcare Common Procedural Coding System (HCPCS) for Level I and Level II coding. Level 1 CPT-4 codes are obtained from the Physicians' 2021 Current Procedural Terminology, copyright 2020 by the American Medical Association, unless otherwise specified. Level II codes are obtained from the 2021 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 perforrmed by physicians and other healthcare professionals, as well as associated non-physician services. 101 CMR 347.00 includes only HCPCS numeric and alpha-numeric identifying codes and modifiers for reporting medical services and procedures that were selected by EOHHS. Any use of CPT outside the fee schedule should refer to the Physicians' 2021 Current Procedural Terminology, copyright 2020. For code descriptions, see the FASC service code spreadsheet at www.mass.gov/regulations/101-CMR-34700-rates-for-freestanding-ambulatory-surgery-center-services .
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 governmental 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 perforrmed 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.
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 perforrmed 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 perforrmed alone for a specific purpose, it may be considered to be a separate procedure.
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