Adopted Regulation February 18, 2010

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69320	1,197.16	Reconstruction external auditory canal for congenital atresia, single stage
69400	85.04	Eustachian tube inflation, transnasal; with catheterization
69401	44.79	Eustachian tube inflation, transnasal; without catheterization
69405	117.50	Eustachian tube catheterization, transtympanic
69420	105.50	Myringotomy including aspiration and/or eustachian tube inflation
69421	536.92	Myringotomy including aspiration and/or eustachian tube inflation requiring general anesthesia
69424	74.01	Ventilating tube removal requiring general anesthesia
69433	105.17	Tympanostomy (requiring insertion of ventilating tube), local or topical anesthesia
69436	536.92	Tympanostomy (requiring insertion of ventilating tube), general anesthesia
69440	673.43	Middle ear exploration through postauricular or ear canal incision
69450	906.68	Tympanolysis, transcanal
69501	1,197.16	Transmastoid antrotomy (simple mastoidectomy)
69502	886.24	Mastoidectomy; complete
69505	1,197.16	Mastoidectomy; modified radical
69511	1,197.16	Mastoidectomy; radical
69530	1,197.16	Petrous apicectomy including radical mastoidectomy
69540	123.67	Excision aural polyp
69550	1,075.18	Excision aural glomus tumor; transcanal
69552	1,197.16	Excision aural glomus tumor; transmastoid
69601	1,197.16	Revision mastoidectomy; resulting in complete mastoidectomy
69602	1,197.16	Revision mastoidectomy; resulting in modified radical mastoidectomy
69603	1,197.16	Revision mastoidectomy; resulting in radical mastoidectomy
69604	1,197.16	Revision mastoidectomy; resulting in tympanoplasty
69605	1,197.16	Revision mastoidectomy; with apicectomy
69610	165.55	Tympanic membrane repair, with or without site preparation of perforation for closure, with or without patch
69620	645.34	Myringoplasty (surgery confined to drumhead and donor area)
69631	1,075.18	Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; without ossicular chain reconstruction
69632	1,075.18	Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction (e.g., postfenestration)
69633	1,075.18	Tympanoplasty without mastoidectomy (including canalplasty, atticotomy and/or middle ear surgery), initial or revision; with ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis (PORP), total ossicular replacement prosthesis (TORP))
69635	1,197.16	Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); without ossicular chain reconstruction
69636	1,197.16	Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction
69637	1,197.16	Tympanoplasty with antrotomy or mastoidotomy (including canalplasty, atticotomy, middle ear surgery, and/or tympanic membrane repair); with ossicular chain reconstruction and synthetic prosthesis (e.g., partial ossicular replacement prosthesis (PORP), total ossicular replacement prosthesis (TORP))
69641	1,197.16	Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); without ossicular chain reconstruction
69642	1,197.16	Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with ossicular chain reconstruction
69643	1,197.16	Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed wall, without ossicular chain reconstruction
69644	1,197.16	Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); with intact or reconstructed canal wall, with ossicular chain reconstruction
69645	1,197.16	Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, without ossicular chain reconstruction
69646	1,197.16	Tympanoplasty with mastoidectomy (including canalplasty, middle ear surgery, tympanic membrane repair); radical or complete, with ossicular chain reconstruction
69650	886.24	Stapes mobilization
69660	1,075.18	Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material;
69661	1,075.18	Stapedectomy or stapedotomy with reestablishment of ossicular continuity, with or without use of foreign material; with footplate drill out
69662	1,075.18	Revision of stapedectomy or stapedotomy
69666	1,037.00	Repair oval window fistula
69667	1,037.00	Repair round window fistula
69670	984.35	Mastoid obliteration (separate procedure)
69676	984.35	Tympanic neurectomy
69700	984.35	Closure postauricular fistula, mastoid (separate procedure)
69711	906.68	Removal or repair of electromagnetic bone conduction hearing device in temporal bone
69714	5,749.99	Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy
69715	5,749.99	Implantation, osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy
69717	5,749.99	Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; without mastoidectomy
69718	5,749.99	Replacement (including removal of existing device), osseointegrated implant, temporal bone, with percutaneous attachment to external speech processor/cochlear stimulator; with mastoidectomy
69720	1,075.18	Decompression facial nerve, intratemporal; lateral to geniculate ganglion
69740	1,075.18	Suture facial nerve, intratemporal, with or without graft or decompression; lateral to geniculate ganglion
69745	1,075.18	Suture facial nerve, intratemporal, with or without graft or decompression; including medial to geniculate ganglion
69801	1,075.18	Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or perfusion of vestibuloactive drugs (single or multiple perfusions); transcanal
69802	1,197.16	Labyrinthotomy, with or without cryosurgery including other nonexcisional destructive procedures or perfusion of vestibuloactive drugs (single or multiple perfusions); with mastoidectomy
69805	1,197.16	Endolymphatic sac operation; without shunt
69806	1,197.16	Endolymphatic sac operation; with shunt
69820	1,075.18	Fenestration semicircular canal
69840	1,075.18	Revision fenestration operation
69905	1,197.16	Labyrinthectomy; transcanal
69910	1,197.16	Labyrinthectomy; with mastoidectomy
69915	1,197.16	Vestibular nerve section, translabyrinthine approach
69930	21,643.06	Cochlear device implantation, with or without mastoidectomy
C9716	1,127.56	Creations of thermal anal lesions by radiofrequency energy
C9724	921.91	Endoscopic full-thickness plication in the gastric cardia using endoscopic plication system (EPS); includes endoscopy
C9725	212.59	Placement of endorectal intracavitary applicator for high intensity brachytherapy
C9726	780.47	Placement and removal (if performed) of applicator into breast for radiation therapy
C9727	273.65	Insertion of implants into the soft palate; minimum of 3 implants
C9728	491.00	Placement of interstitial device(s) for radiation therapy/surgery guidance (e.g., fiducial markers, dosimeter), other than prostate (any approach), single or multiple
G0104	78.88	Colorectal cancer screening; flexible sigmoidoscopy
G0105	340.90	Colorectal cancer screening; colonoscopy on individual at high risk
G0121	340.90	Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0127	11.03	Trimming of dystrophic nails, any number
G0186	211.70	Destruction of localized lesion of choroid (for example, choroidal neovascularization); photocoagulation, feeder vessel technique (one or more sessions)
G0247	20.12	Routine foot care by a physician of a diabetic patient with diabetic sensory neuropathy resulting in a loss of protective sensation (LOPS) to include the local care of superficial wounds (i.e., superficial to muscle and fascia) and at least the following, if present: (1) local
G0260	276.38	Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography
G0364	5.19	Bone marrow aspiration performed with bone marrow biopsy through the same incision on the same date of service
G0392	1,465.88	Transluminal balloon angioplasty, percutaneous; for maintenance of hemodialysis access, arteriovenous fistula or graft; arterial
G0393	1,465.88	Transluminal balloon angioplasty, percutaneous; for maintenance of hemodialysis access, arteriovenous fistula or graft; venous

(d) Modifiers.

50	Bilateral procedure
51	Multiple procedures
73	Discontinued outpt hospital/ambulatory surgery center (ASC) procedure prior to administration of anesthesia
74	Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia

47.04: Reporting Requirements
(1) Required Reports. Upon request of the Division, each provider within 90 days following the end of its fiscal year, shall forward to the Division a complete and accurate cost report (FDSF-1) and certified financial statements. The provider shall also make available within 30 days all records and books relating to said operations, including such data, statistics, and records as the Division may from time to time request.
(2) Extension of Filing Date. The Division may grant an extension of time for the submission of cost reports or other information, data or statistics upon written request from the provider demonstrating that good cause exists for such an extension.
(3) Failure to File Timely Reports. Failure to submit accurate information within the time required by 114.3 CMR 47.04(1) and (2) or to submit within the stated time other acceptable data and statistics requested by the Division, may result in the delay, reduction or non-payment of the provider's rates, as well as application of other sanctions and penalties provided by law subject to the approval of the purchasing Governmental Unit.
47.05: Severability
The provisions of 114.3 CMR 47.00 are severable, and if any provision of 114.3 CMR 47.00 or application of such provision to any freestanding surgical facility or any circumstances shall be held to be invalid or unconstitutional, such invalidity shall not be construed to affect the validity or constitutionality of any remaining provisions to eligible freestanding surgical facilities or circumstances other than those held invalid.
REGULATORY AUTHORITY
114.3 CMR 47.00: M.G.L. c. 118G.

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