101 CMR, § 306.03

Current through Register 1538, January 3, 2025

Section 306.03 - Rate Provisions

(1)Rates as Full Compensation. The rates under 101 CMR 306.00 shall constitute full compensation for mental health services provided by community health centers and mental health centers to publicly aided and industrial accident patients, including full compensation for necessary administration and professional supervision associated with patient care.

(2)Rates of Payment. Except as otherwise provided in 101 CMR 306.03(5)(c), payment rates under 101 CMR 306.00 shall be the lower of:

(a) the eligible provider's usual charge to the general public; or

(b) the schedule of allowable rates for services provided by mental health centers and community health centers as set forth in 101 CMR 306.03(5)(a).

(3)Child and Adolescent Needs and Strengths (CANS): Psychiatric Diagnostic Interview Examination for Children and Adolescents Younger than 21 Years Old. Eligible clinicians who complete the CANS for a MassHealth child or adolescent younger than 21 years old during a psychiatric diagnostic interview examination, must use procedure code 90791 accompanied by a modifier -HA to bill for the service.

(4)Modifiers.

(a) -25: Significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health professional on the same day of the procedure or other service. Modifier '-25' applies to two E/M services provided on the same day.

(b) -59: Distinct Procedure Service. To identify a procedure distinct or independent from other services performed on the same day add the modifier '-59' to the end of the appropriate service code. Modifier '-59' is used to identify services/procedures that are not normally reported together, but are appropriate under certain circumstances. However, when another already established modifier is appropriate, it should be used rather than modifier '-59'.

(c) -SA Nurse Practitioner rendering service in collaboration with a physician. (Modifier '- SA' is to be applied to service codes billed by the mental health center which were performed by a psychiatric clinical nurse specialist.)

(d) -EP: Group psychotherapy modifier for preventive behavioral health session (only used with 90853)

(e) -GJ: Opt-out physician or practitioner emergency or urgent service. (Urgent Care services. To identify services provided by Mental Health Centers that are designated as Behavioral Health Urgent Care provider sites.)

(f) -AF: Specialty physician (This modifier is to be applied to service codes billed by the mental health center which were performed by a psychiatrist)

(g) -AH: Clinical psychologist (This modifier is to be applied to service codes billed by the mental health center which were performed by doctoral level clinician, including PhD, PsyD, EdD)

(i) -HO: Master's degree level (This modifier is to be applied to service codes billed by the mental health center which were performed by Master's level clinician, including Licensed Clinical Social Workers (LCSWs), Licensed Independent Clinical Social Workers (LICSWs), Licensed Alcohol and Drug Counselor I, Licensed Mental Health Counselor, Licensed Marriage and Family Therapist)

(j) -HL: Intern (This modifier is to be applied to service codes billed by the mental health center which were performed by intern level clinicians, including Post-Doctoral Fellows and Psychology Interns, Post-Master's Mental Health Counselors and Mental Health Counselor Interns, Post-Master's Marriage and Family Therapist, Licensed Alcohol and Drug Counselor IIs (LADC II), Certified Addiction Counselor / Certified Alcohol & Drug Abuse Counselor) (k) -HE: Mental health program (Certified Peer Specialist Services)

(5)Fee Schedule.

(a) Allowable fee for community health centers and mental health centers.

Service Code	Payment Rate for service codes performed by a psychiatrist (Modifier -AF)	Payment Rate for service codes performed by a doctor level clinician (Modifier - AH)	Payment Rate for service codes performed by a Master level clinician (Modifier -HO)	Payment Rate for service codes performed by an intern (Modifier -HL)	Service Description
90791	$160.45	136.38	130.48	81.83	Psychiatric diagnostic evaluation
90791-HA	$175.45	151.38	145.48	90.83	Psychiatric diagnostic evaluation performed with a CANS (Children and Adolescent Needs and Strengths)
90832	$69.60	59.16	52.20	35.50	Psychotherapy, 30 minutes with patient
90833	$63.83	54.26	47.87	32.56	Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure.)
90834	$95.46	95.46	95.46	57.28	Psychotherapy, 45 minutes with patient
90836	$82.90	82.90	82.90	49.74	Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure.)
90837	$135.04	125.69	125.69	75.41	Psychotherapy, 60 minutes with patient
90839	$171.13	171.13	171.13	102.68	Psychotherapy for crisis, first 60 minutes
90840	$85.57	85.57	85.57	51.34	Psychotherapy for crisis, each additional 30 minutes (List separately in addition to the code for primary procedure)
90846	$101.43	101.43	101.43	60.86	Family psychotherapy (without the patient present), 50 minutes
90847	$101.43	101.43	101.43	60.86	Family psychotherapy (conjoint psychotherapy) (with patient present) 50 minutes
90849	$32.16	27.69	27.69	16.61	Multiple-family group psychotherapy (per person per session not to exceed 10 clients)
90853	$30.31	30.31	30.31	18.19	Group psychotherapy (other than multiple-family group) (per person per session not to exceed 12 clients)
90853-EP	$30.31	30.31	30.31	18.19	Group psychotherapy (other than of a multiple-family group) (per person not to exceed 12 clients) (preventive behavioral health session)
90882	$71.80	71.80	71.80	43.08	Environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies, employers, or institutions
90887	$79.19	67.31	59.40	40.39	Interpretation or explanation of results of psychiatric, or other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient
90840-GJ	$98.41	98.41	98.41	59.04	Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service)
90846-GJ	$116.64	116.64	116.64	69.99	Family psychotherapy (without the patient present), 50 minutes
90847-GJ	$116.64	116.64	116.64	69.99	Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes
90849-GJ	$36.98	31.84	31.84	19.10	Multiple-family group psychotherapy (per person session not to exceed 10 clients)
90853-GJ	$34.86	34.86	34.86	20.92	Group psychotherapy (other than multiple-family group) (per person per session not to exceed 12 clients)
90853-EP-GJ	$34.86	34.86	34.86	20.92	Group psychotherapy (other than of a multiple-family group)(per person not to exceed 12 clients) (preventive behavioral health session)
90882-GJ	$82.57	82.57	82.57	49.54	Environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies, employers, or institutions
90887-GJ	$91.07	77.41	68.31	46.45	Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient
90889-GJ	$49.66	49.66	49.66	29.80	Preparation of report of patient's psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other individuals, agencies, or insurance carriers

Service Code	Payment Rate	Service Description
S9480-GJ	$65.11	Intensive outpatient psychiatric services, per diem
H0015-GJ	$71.59	Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education (Structured Outpatient Addiction Program)
H0015-TF-GJ	$113.82	Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education (Enhanced Structured Outpatient Addiction Program)
H0046-HE-GJ	$16.92	Mental health services, not otherwise specified (Certified Peer Specialist)

(b) Allowable fee for mental health service provided by a behavioral health urgent care provider:

Service Code	Payment Rate for service codes performed by a psychiatrist (Modifier -AF)	Payment Rate for service codes performed by a doctoral level clinician (Modifier -AH)	Payment Rate for service codes performed by a Master level clinician (Modifier -HO)	Payment Rate for service codes performed by an intern (Modifier -HL)	Service Description
90791-GJ	$184.52	156.84	150.05	94.10	Psychiatric diagnostic evaluation
90791-HA-GJ	$201.77	174.09	167.30	104.45	Psychiatric diagnostic evaluation performed with a CANS (Children and Adolescent Needs and Strengths)
90832-GJ	$80.04	68.03	60.03	40.83	Psychotherapy, 30 minutes with patient
90833-GJ	$73.40	62.40	55.05	37.44	Psychotherapy, 30 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90834-GJ	$109.78	109.78	109.78	65.87	Psychotherapy, 45 minutes with patient
90836-GJ	$95.34	95.34	95.34	57.20	Psychotherapy, 45 minutes with patient when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90837-GJ	$155.30	144.54	144.54	86.72	Psychotherapy, 60 minutes with patient
90839-GJ	$196.80	196.80	196.80	118.08	Psychotherapy for crisis; first 60 minutes
90840-GJ	$98.41	98.41	98.41	59.04	Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service)
90846-GJ	$116.64	116.64	116.64	69.99	Family psychotherapy (without the patient present), 50 minutes
90847-GJ	$116.64	116.64	116.64	69.99	Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes
90849-GJ	$36.98	31.84	31.84	19.10	Multiple-family group psychotherapy (per person session not to exceed 10 clients)
90853-GJ	$34.86	34.86	34.86	20.92	Group psychotherapy (other than multiple-family group) (per person per session not to exceed 12 clients)
90853-EP-GJ	$34.86	34.86	34.86	20.92	Group psychotherapy (other than of a multiple-family group)(per person not to exceed 12 clients) (preventive behavioral health session)
90882-GJ	$82.57	82.57	82.57	49.54	Environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies, employers, or institutions
90887-GJ	$91.07	77.41	68.31	46.45	Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient
90889-GJ	$49.66	49.66	49.66	29.80	Preparation of report of patient's psychiatric status, history, treatment, or progress (other than for legal or consultative purposes) for other individuals, agencies, or insurance carriers

Service Code	Payment Rate	Service Description
S9480-GJ	$65.11	Intensive outpatient psychiatric services, per diem
H0015-GJ	$71.59	Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education (Structured Outpatient Addiction Program)
H0015-TF-GJ	$113.82	Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education (Enhanced Structured Outpatient Addiction Program)
H0046-HE-GJ	$16.92	Mental health services, not otherwise specified (Certified Peer Specialist)

(c) Allowable fee for mental health services provided by a mental health center in a nursing facility are as follows:

Service Code	Payment Rate for service codes performed by a psychiatrist (Modifier -AF)	Payment Rate for service codes performed by a doctor level clinician (Modifier -AH)	Payment Rate for service codes performed by a Master level clinician (Modifier -HO)	Payment Rate for service codes performed by an intern (Modifier -HL)	Service Description
90791	$160.45	136.38	130.48	81.83	Psychiatric diagnostic evaluation
90832	$69.60	59.16	52.20	35.50	Psychotherapy, 30 minutes with patient
90833	$63.83	54.26	47.87	32.56	Psychotherapy, 30 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure)
90834	$95.46	95.46	95.46	57.28	Psychotherapy, 45 minutes with patient
90836	$82.90	82.90	82.90	49.74	Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service (List separately in addition to the code for primary procedure.)
90839	$171.13	171.13	171.13	102.68	Psychotherapy for crisis first 60 minutes
90840	$85.57	85.57	85.57	51.34	Psychotherapy for crisis, each additional 30 minutes (List separately in addition to the code for primary procedure)
90847	$101.43	101.43	101.43	60.86	Family psychotherapy (conjoint psychotherapy) (with patient present), 50 minutes
90849	$32.16	27.69	27.69	16.61	Multiple family group psychotherapy
90853	$30.31	30.31	30.31	18.19	Group psychotherapy (other than multiple-family group) (per person per session not to exceed 12 clients)
90853-EP	$30.31	30.31	30.31	18.19	Group psychotherapy (other than of a multiple-family group) (per person not to exceed 12 clients) (preventive behavioral health session)
90882	$71.80	71.80	71.80	43.08	Environmental intervention for medical management purposes on a psychiatric patient's behalf with agencies, employers, or institutions
90887	$79.19	67.31	59.40	40.39	Interpretation or explanation of results of psychiatric, or other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient

(d)Rates for Medication Visit. Services for Medication Visit shall be billed using the appropriate E/M code: 99201-99205, 99211-99215, 99304-99310, 99324-99328, 99334-99337, 99341-99345, and 99347-99350. Definitions, payment rules, and rates for these services are contained in 101 CMR 317.00: Medicine.

(e) The allowable fee for payment for covered E/M services provided by a practitioner other than a psychiatrist is 85% of the fees described in 101 CMR 306.03(5)(e).

(f) Rates for state-operated community mental health centers. A state-operated community mental health center will be paid at rates based on that center's reasonable cost of providing covered services to eligible MassHealth members.

1. The methodology set forth below governs rates for non-ESP services provided by a state-operated community mental health center between June 1, 2008, and June 30, 2009.

a.Initial Payments. Initial payments will be made at the rates in effect on the date of service.

b.Preliminary Reconciliation. There will be a preliminary reconciliation for each state-operated community mental health center based on the difference between the initial payments and payments based on rates calculated using the center's preliminary projected FY2009 reasonable costs. In order to determine the preliminary projected FY2009 reasonable costs, EOHHS will review costs reported in the FY2008 UFR by each state-operated community mental health center, and apply a cost adjustment factor based on the Massachusetts Consumer Price Index.

c.Final Reconciliation. There will be a final reconciliation for each state-operated community mental health center based on the difference between total payments pursuant to the preliminary reconciliation and payments based rates calculated using the center's reported reasonable costs for the rate period. In order to determine the reported reasonable costs, EOHHS will review costs reported in the FY2009 UFR by each state-operated community mental health center.

2.Rates Effective July 1, 2009. Payments for services provided effective July 1, 2009, will be determined as follows:

a.Initial Payments. Initial payments will be based on rates calculated by applying a cost adjustment factor to the reasonable costs reported by each center in its most recently submitted UFR.

b.Final Reconciliation. For each fiscal year beginning July 1, 2009, there will be a final reconciliation for each state-operated community mental health center based on the difference between the initial payments and payments based on rates calculated using the center's final reasonable costs for that fiscal year. In order to determine the final reasonable costs, EOHHS will review the costs reported in each center's UFR submitted for that fiscal year.

(6)Coding Updates and Corrections. EOHHS may publish procedure code updates and corrections in the form of an administrative bulletin. The publication of such updates and corrections will list:

(a) codes for which the code numbers only changed, with the corresponding cross-walk;

(b) codes for which the code remains the same but the description has changed; and

(c) deleted codes for which there is no cross-walk. In addition, for entirely new codes which require new pricing, EOHHS will list these codes and apply Individual Consideration in reimbursing these new codes until rates are established.

(7)Billing. Each clinic shall bill the governmental unit according to the appropriate fee schedule on a prescribed form. Each specific service must be separately enumerated on the bill.

101 CMR, § 306.03

Amended by Mass Register Issue 1485, eff. 1/1/2023.

Amended by Mass Register Issue 1496, eff. 1/1/2023.