101 CMR, § 312.03

Current through Register 1538, January 3, 2025

Section 312.03 - General Rate Provisions

(1)Reimbursement as Full Payment. Each eligible provider must, as a condition of payment made by the purchasing governmental unit for services rendered, accept the approved program rate as full payment and discharge of all obligations for the services rendered. Any third-party payments or sliding fees received on behalf of a publicly aided individual reduces, by that amount, the purchasing governmental unit's payment for services rendered to the publicly aided individual.

(2)Rates. Subject to the conditions listed herein, rates of payment for authorized family planning services for which 101 CMR 312.00 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 fees listed below in 101 CMR 312.03(4).

(3)Modifiers.

(a) 24 - Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period.

(b) 25 - Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.

(c) 59 - Distinct procedural service.

(d) LT - Left side (used to identify procedures performed on the left side of the body).

(e) RT - Right side (used to identify procedures performed on the right side of the body).

(f)Modifiers for Provider Preventable Conditions. Below are modifiers for reporting "provider preventable conditions" that are National Coverage Determinations, in accordance with 42 CFR 447.26.

Modifier Name	Description
PA	Surgical or other invasive procedure on wrong body part
PB	Surgical or other invasive procedure on wrong patient
PC	Wrong surgery or other invasive procedure on patient

(4)Schedule of Allowable Fees.

Code	Allowable Fee	Description
90651	I.C.	Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use.
New Patient
99202	$93.03	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.)
99203	$141.34	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 30-44 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.)
99204	$205.54	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.)
99205	$259.24	Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.)
Established Patient
99211	$36.90	Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.)
99212	$66.55	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.)
99213	$101.92	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.)
99214	$147.47	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.)
99215	$197.30	Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.)
Preventive Medicine Services
99384	$108.01	Initial comprehensive preventive medicine evaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years)
99385	$108.01	Initial comprehensive preventive medicine evaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years
99386	$121.00	Initial comprehensive preventive medicine evaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years
99394	$93.73	Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years)
99395	$94.20	Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years
99396	$100.28	Periodic comprehensive preventive medicine reevaluation and management of an individual, including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years
99402	$69.57	Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individual (separate procedure); approximately 30 minutes.
Allowable Medical and Related Supplies
S4993	$11.08	Contraceptives pills for birth control
All Other Medical and Related Supplies
S4989	I.C.	Contraceptive intrauterine device (e.g., Progestacert IUD), including implants and supplies.
A4261	I.C.	Cervical cap for contraceptive use
A4266	$9.55	Diaphragm for contraceptive use (includes applicator and contraceptive cream or jelly)
A4267	$0.19	Contraceptive supply, condom, male, each
A4268	$2.09	Contraceptive supply, condom, female, each
A4269	$4.01	Contraceptive supply, spermicide (e.g., foam, gel), each (per tube or package) (includes contraceptive sponges)
J1050	I.C.	Injection, medroxyprogesterone acetate, 1 mg
J7296	I.C.	Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg
J7297	I.C.	Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg
J7298	I.C.	Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg
J3490- FP	I.C.	Unclassified Drugs (service provided as part of a Medicaid family planning program) (may be used by other governmental purchasers of family planning services)
J7300	I.C.	Intrauterine copper contraceptive
J7301	I.C.	Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg
J7303	I.C.	Contraceptive supply, hormone containing vaginal ring, each
J7304	I.C.	Contraceptive supply, hormone containing patch, each
J7307	I.C.	Etonogestrel (contraceptive) implant system, including implant and supplies
Medical and Surgical Procedures
11976	$154.65	Removal, implantable contraceptive capsules.
11981	$255.74	Insertion, non-biodegradable drug delivery implant

(5)Other Family Planning Services. The rates of payment for other family planning services not listed in 101 CMR 312.03(4) that are authorized by the purchasing governmental unit, will be based on the applicable EOHHS regulations such as 101 CMR 313.00: Rates for Freestanding Clinics Providing Abortion and Sterilization Services; 101 CMR 316.00: Rates for Surgery and Anesthesia Services; 101 CMR 317.00: Rates for Medicine Services; 101 CMR 318.00: Rates for Radiology Services; and 101 CMR 320.00: Rates for Clinical Laboratory Services.