Md. Code Regs. 14.09.08.01

Current through Register Vol. 51, No. 24, December 2, 2024

Section 14.09.08.01 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) Ambulatory surgical center (ASC) means any center, service, office facility, or other entity that:

(a) Operates primarily for the purpose of providing surgical services to patients requiring a period of postoperative observation but not requiring overnight hospitalization; and

(b) Seeks reimbursement from payors as an ambulatory surgery center.

(2) "Authorized provider" means:

(a) A licensed physician's assistant (P.A.), providing services on or after March 24, 2008;

(b) A licensed acupuncturist;

(c) A medical doctor (M.D.);

(d) A doctor of osteopathy (D.O.);

(e) A doctor of chiropractic (D.C.), for services provided within the scope of Health Occupations Article, Title 3, Annotated Code of Maryland;

(f) Podiatrist (D.P.M.);

(g) An optometrist (O.D.);

(h) A certified registered nurse anesthetist (C.R.N.A.);

(i) An occupational therapist (O.T.);

(j) A pharmacist (R. Ph.);

(k) A licensed physical therapist (P.T.);

(l) A psychologist (Ph.D.);

(m) A licensed clinical social worker (L.C.S.W.);

(n) A licensed audiologist;

(o) A licensed speech-language pathologist;

(p) A dentist (D.D.S./D.M.D.); and

(q) Any other health care provider as defined under Health-General Article, § 4-301(h)(1)(i), Annotated Code of Maryland.

(3) "Base Unit/Basic Value" means the value assigned by CMS to each anesthesia procedure code based on the difficulty of the anesthesia service and is used to determine a portion of the reimbursement amount of the anesthesia procedure.

(4) "CMS" means the Centers for Medicare and Medicaid Services, the federal agency that administers the nation's Medicare program and partners with the states to administer the Medicaid program.

(5) "CMS-1500" means the standard claim form, maintained by the National Uniform Claim Committee (NUCC), used by a non-institutional provider or supplier to bill Medicare carriers, Medicare administrative contractors, and Medicaid State agencies.

(6) "CPT" means the Physician's Current Procedural Terminology, copyrighted and maintained by the American Medical Association.

(7) "CPT code" means the five digit numerical code obtained from the CPT in effect when a medical service or treatment is provided.

(8) "CPT modifier" means the numerical code used to indicate that a service or procedure was altered in some way from the stated CPT description.

(9) "Geographic Price Cost Index (GPCI)" means the resource cost difference of providing a service, by geographic region, reflected in the relative work (work), practice expense (PE), and malpractice costs (MP) of the service.

(10) "Healthcare Common Procedure Coding System (HCPCS) " means one of two coding systems used by CMS: level I, consisting of CPT codes, and level II, used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies.

(11) "Maryland specific conversion factor (MSCF)" means a fixed dollar amount used as a multiplier in calculating the MRA for medical services and treatment, orthopedic and neurological surgical procedures, and anesthesiology services.

(12) "Maximum reimbursement allowable (MRA)" means the amount payable to an authorized provider, unless subject to a private agreement to the contrary, calculated pursuant to this chapter for the provision of medical services and treatment rendered to an individual whose injury or disease falls within the scope of Labor and Employment Article, Title 9, Annotated Code of Maryland.

(13) "Medicare economic index (MEI)" means a measure of the inflation faced by physicians with respect to their practice costs and wage levels as calculated by CMS.

(14) "Medicare Physician Fee Schedule" means the Medicare database, based on the RBRVS, from which the Medicare reimbursement rate is obtained.

(15) "Medicare reimbursement rate (MRR)" means the rate at which Medicare reimburses a services provider based on certain inputs including the CPT/HCPCS code, jurisdiction, year, any applicable CPT modifiers, any federal budget neutrality adjuster, and any Medicare conversion factor.

(16) "Resource based relative value scale (RBRVS)" means the system by which medical providers are reimbursed based on the resource costs needed to provide a given service. Under the RBRVS, CMS assigns each medical procedure a relative value quantifying the relative work (work), practice expense (PE), and malpractice costs (MP) for each service.

(17) "RBRVS relative value unit (RVU)" means the uniform value assigned by CMS to each medical procedure and service identified by CPT/HCPCS code quantifying the work (work), practice expense (PE), and malpractice costs (MP) for each service.

(18) "Time Unit" means a measure of each 15-minute interval, or fraction thereof, during which anesthesiology services are performed.

Md. Code Regs. 14.09.08.01

Regulation .01 adopted as an emergency provision effective August 1, 1987 (14:17 Md. R. 1869); emergency status expired July 31, 1988
Regulation .01 adopted effective August 1, 1988 (15:14 Md. R. 1655)
Regulation .01 amended effective August 1, 1991 (18:13 Md. R. 1484)
Regulations .01 and new Regulation .01 adopted effective July 1, 1996 (23:12 Md. R. 872)
Regulation .01 amended effective September 1, 2004 (31:13 Md. R. 995)
Regulation .01 amended as an emergency provision effective February 1, 2006 (33:5 Md. R. 517); amended permanently effective June 5, 2006 (33:11 Md. R. 951)
Regulations .01 adopted effective March 24, 2008 (35:6 Md. R. 699); amended effective 47:4 Md. R. 263, eff. 2/24/2020