Rates for Restorative Services

Final Adoption Date Published in Mass Register: June 6, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 339.00: RATES FOR RESTORATIVE SERVICES

Section

339.01: General Provisions 339.02: General Definitions 339.03: General Rate Provisions 339.04: Allowable Fees 339.05: Filing and Reporting Requirements 339.06: Severability

339.01: General Provisions

(1) Scope, Purpose, and Effective Date. .00 governs the rates of payment to be used by all governmental units for rehabilitation center services and restorative services provided to publicly aided individuals by eligible providers. Rates for services rendered to individuals covered by M.G.L. c. 152 (the Workers’ Compensation Act) are set forth at 114.3 CMR 40.06(12): Restorative Services Description.

(2) Applicable Dates of Service. Rates contained in .00 apply for dates of service provided on or after June 6, 2025.

(3) Coverage. Except as provided otherwise, .00 and the rates of payment contained in .00 apply to services rendered by eligible providers of rehabilitation center services and eligible providers of restorative services to publicly aided individuals. The rates of payment specified in .00 are full compensation for professional services rendered, as well as for any administrative or supervisory duties.

(4) Exceptions. Rates of payment contained in .00 do not apply to indirect services, such as case conferences or in-service education programs provided by eligible providers in long-term-care facilities.

(5) 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 only the code number has changed, with the corresponding cross-reference between new and existing codes; (b) codes for which the code remains the same, but the description has changed; (c) deleted codes for which there are no corresponding new codes; and (d) entirely new codes that require new pricing. EOHHS may list these codes and price them at a percentage of the prevailing Medicare fees, when Medicare fees are available. When Medicare fees are not available or when otherwise designated by EOHHS, EOHHS may apply individual consideration in reimbursing for these new codes until appropriate rates can be developed.

(6) Administrative Bulletins. EOHHS may issue administrative bulletins to clarify its policy on and understanding of substantive provisions of .00.

(7) Disclaimer of Authorization of Services. .00 is not authorization for or approval of the procedures for which rates are determined pursuant to .00. Governmental units that purchase care are responsible for the definition, authorization, and approval of care and services extended to publicly aided individuals.

339.02: General Definitions

As used in .00, unless the context requires otherwise, terms have the meanings in .02.

Center. The Center for Health Information and Analysis established under M.G.L. c. 12C.

Comprehensive Restorative and Rehabilitation Center Evaluation. An all-inclusive, in-depth assessment of medical condition and level of functioning and limitations, to determine the need for treatment and, if necessary, to develop a plan of treatment. The comprehensive evaluation includes a written report.

Eligible Provider of Rehabilitation Center Services. Freestanding centers providing rehabilitation services that are licensed by the Massachusetts Department of Public Health, that are accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), and that meet such

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Final Adoption Date Published in Mass Register: June 6, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR RESTORATIVE SERVICES

conditions of participation as may be required by a governmental unit purchasing rehabilitation services, or by a purchaser under M.G.L. c. 152 (the Workers’ Compensation Act).

Eligible Provider of Restorative Services. A provider who meets the conditions of participation adopted by a governmental unit purchasing restorative services or by purchasers under M.G.L. c. 152 (the Workers' Compensation Act), and who is (a) a physical therapist — a person who is currently licensed by and in good standing with the Massachusetts Division of Professional Licensure, Board of Allied Health Professionals; (b) a physical therapy assistant — a person who is currently licensed by and in good standing with the Massachusetts Division of Professional Licensure, Board of Allied Health Professional and works under the supervision of a physical therapist; (c) an occupational therapist — a person who is currently licensed by and in good standing with the Massachusetts Division of Professional Licensure, Board of Allied Health Professionals; (d) an occupational therapy assistant — a person who is licensed by and in good standing with the Massachusetts Division of Professional Licensure, Board of Allied Health Professionals and works under the supervision of an occupational therapist; (e) a speech/language therapist (speech/language pathologist) — a person who is currently licensed by and in good standing with the Massachusetts Board of Registration in Speech- Language Pathology and Audiology; (f) a speech/language therapist assistant (speech/language pathologist assistant) — a person who is currently licensed by and in good standing with the Massachusetts Board of Registration in Speech-Language Pathology and Audiology and works under the supervision of a speech/language therapist; or (g) any speech and hearing center (proprietorship, partnership, or corporation) that provides authorized speech or language services rendered by a qualified speech pathologist who does not bill separately from such facility for professional services rendered.

EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A.

Governmental Unit. The Commonwealth, any department, agency, board, division, or commission of the Commonwealth, or any political subdivision of the Commonwealth.

Group Therapy. Simultaneous therapy services provided to two to six patients who may or may not be doing the same activities.

HCPCS. The Healthcare Common Procedure Coding System.

Individual Consideration (IC). A designation indicating that there is no specified rate for a given service. Payment amounts for services designated “IC” are determined by the governmental unit purchasing such services. The governmental unit determines the appropriate payment based on the provider’s report of services provided, and documentation as requested by the governmental unit. The report must include a pertinent history and diagnosis, a description of the service rendered, and the length of time spent with the patient. In making the determination of the appropriate payment amount, the governmental unit uses the following criteria: (a) the 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) the time, degree of skill, and cost including equipment cost required to perform the procedure(s).

Occupational Therapy. Therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct, rehabilitate, or prevent the worsening of functions that affect the activities of daily living that have been lost, impaired, or reduced because of acute or chronic medical conditions, congenital anomalies, or injuries. Occupational therapy programs are designed to improve quality of life by recovering competence, preventing further injury or disability, and to improve the individual’s ability to perform tasks required for independent functioning, so that the individual can engage in activities of daily living.

Office Visit. Patient treatments rendered in a speech and hearing center, a licensed clinic or center, or in a practitioner's office (whether an individual practice, a group practice, or an association of practitioners). If a practitioner has an office in their home that is used for patient treatment, then services rendered there must be billed as office visits.

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Final Adoption Date Published in Mass Register: June 6, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR RESTORATIVE SERVICES

Out-of-Office Visit. Patient treatments rendered in a nursing home, school, a patient's home, or in any other setting where the practitioner travels from their usual place of business to render patient treatment.

Physical Therapy. Therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct, rehabilitate, or prevent the worsening of physical functions that have been lost, impaired, or reduced because of acute or chronic medical conditions, congenital anomalies, or injuries. Physical therapy emphasizes a form of rehabilitation focused on treatment of dysfunctions involving neuromuscular, musculoskeletal, cardiovascular/pulmonary, or integumentary systems through the use of therapeutic interventions to optimize functioning levels.

Physician's Comprehensive Rehabilitation Evaluation. A cardiopulmonary, neuromuscular, orthopedic, and functional assessment performed at a rehabilitation center by a physician.

Publicly Aided Individual. A person who receives health care and services for which a governmental unit is in whole or part liable under a statutory program of public assistance.

Rehabilitation. The process of providing, in a coordinated manner, those comprehensive services deemed appropriate to the needs of the physically disabled individual, in a program designed to achieve objectives of improved health and welfare with realization of their maximum physical, social, psychological, and vocational potential.

Restorative Services. Services provided by a physical therapist, an occupational therapist, or a speech pathologist at the referral of a prescribing provider as defined by the governmental entity for the purpose of maximum reduction of physical and speech disability and restoration of the patient to a maximum functional level.

Speech/Language Therapy. Therapy services, including diagnostic evaluation and therapeutic intervention, that are designed to improve, develop, correct, rehabilitate, or prevent the worsening of speech/language communication and swallowing disorders that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Speech and language disorders are those that affect articulation of speech, sounds, fluency, voice, swallowing (regardless of presence of a communication disability), and those that impair comprehension, spoken, written, or other symbol systems used for communication.

339.03: General Rate Provisions

(1) Rate Determination. Rates of payment for authorized services to which .00 applies are the lower of (a) the usual fee of the eligible provider of rehabilitation center services or the eligible provider of restorative services to patients other than publicly aided individuals; or (b) the schedule of allowable fees set forth in .04.

(2) Out-of-office Rates. With the exception of services provided by rehabilitation centers and speech and hearing centers, the fee for any service provided out of the office will be 115% of the respective in-office fee.

(3) Multiple Procedures in Physical Therapy. When more than one type of physical therapy treatment is provided in a single visit, the provider receives 100% of the applicable fee for each procedure, with a maximum of four procedures (or a total of one hour) allowed in a given visit.

(4) Special Contracts. In certain circumstances, purchasing agencies may pay for services on an hourly basis, rather than a per visit basis as described in .00. A special contract would be appropriate where a large number of patients are treated by an individual practitioner on a regular basis for a particular purchaser at one site and/or where the treatment times described in the service codes in .00 do not define the treatment times authorized by the purchaser.

339.04: Allowable Fees

(1) Fee Schedule.

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Final Adoption Date Published in Mass Register: June 6, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR RESTORATIVE SERVICES

Service Allowable Fee Service Description Code Special Otorhinolaryngologic Services 92507 $73.64 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual (maximum one unit per visit) 92508 $31.53 Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, two or more individuals (maximum one unit per visit) 92521 $102.21 Evaluation of speech fluency (e.g., stuttering, cluttering) 92521 HA $102.21 Evaluation of speech fluency (e.g., stuttering, cluttering) (for patients aged 21 or younger) 92521 TF $102.21 Evaluation of speech fluency (e.g., stuttering, cluttering) (for developmentally disabled adults aged 22 or older) 92522 $85.32 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) 92522 HA $85.32 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) (for patients aged 21 or younger) 92522 TF $85.32 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria) (for developmentally disabled adults aged 22 or older) 92523 $175.24 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language) 92523 HA $175.24 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language) (for patients aged 21 or younger) 92523 TF $175.24 Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language) (for developmentally disabled adults aged 22 or older) 92524 $83.97 Behavioral and qualitative analysis of voice and resonance 92524 HA $83.97 Behavioral and qualitative analysis of voice and resonance (for patients aged 21 or younger) 92524 TF $83.97 Behavioral and qualitative analysis of voice and resonance (for developmentally disabled adults aged 22 or older) 92526 $65.33 Treatment of swallowing dysfunction and/or oral function for feeding (maximum one unit per visit) Evaluative and Therapeutic Services 92605 $79.26 Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face- to-face with the patient; first hour 92606 $19.82 Therapeutic service(s) for the use of non-speech- generating device, including programming and modification 92607 $95.90 Evaluation for prescription for speech-generating augmentative and alternative communication device, face- to-face with the patient; first hour 92608 $37.70 Evaluation for prescription for speech-generating augmentative and alternative communication device, face- to-face with the patient; each additional 30 minutes (list separately in addition to code for primary procedure) 92609 $80.04 Therapeutic services for the use of speech-generating device, including programming and modification 92610 $65.90 Evaluation of oral and pharyngeal swallowing function (per hour, maximum of one hour) 92630 $18.06 Auditory rehabilitation; prelingual hearing loss 92633 $18.06 Auditory rehabilitation; postlingual hearing loss Physical Medicine and Rehabilitation

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Final Adoption Date Published in Mass Register: June 6, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR RESTORATIVE SERVICES

Service Allowable Fee Service Description Code 97161 $77.50 Physical therapy evaluation – Low complex – 20 min 97162 $77.50 Physical therapy evaluation- Mod complex – 30 min 97163 $77.50 Physical therapy evaluation High complex – 45 min 97164 $64.41 Physical therapy re-evaluation Est Plan Care – 20 min 97165 $78.31 Occupational therapy evaluation Low complex – 30 min 97166 $78.31 Occupational therapy evaluation Mod complex – 45 min 97167 $78.31 Occupational therapy evaluation High complex – 60 min 97168 $64.41 Occupational therapy re-evaluation Est Plan Care – 30 min Modalities—Supervised 97010 $5.25 Application of a modality to one or more areas; hot or cold packs 97012 $12.63 Application of a modality to one or more areas; traction, mechanical 97014 $15.62 Application of a modality to one or more areas; electrical stimulation (unattended) 97016 $13.04 Application of a modality to one or more areas; vasopneumatic devices 97018 $6.47 Application of a modality to one or more areas; paraffin bath 97022 $13.32 Application of a modality to one or more areas; whirlpool 97024 $5.74 Application of a modality to one or more areas; diathermy (e.g., microwave) 97026 $5.24 Application of a modality to one or more areas; infrared 97028 $6.51 Application of a modality to one or more areas; ultraviolet Modalities—Constant Attendance 97032 $14.68 Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes 97033 $15.01 Application of a modality to one or more areas; iontophoresis, each 15 minutes 97034 $14.68 Application of a modality to one or more areas; contrast baths, each 15 minutes 97035 $14.68 Application of a modality to one or more areas; ultrasound, each 15 minutes 97036 $27.68 Application of a modality to one or more areas; Hubbard tank, each 15 minutes 97039 $18.06 Unlisted modality (specify type and time if constant attendance) Therapeutic Procedures 97110 $22.67 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility 97112 $26.07 Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities 97113 $28.55 Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises 97116 $22.67 Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing) 97124 $23.72 Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) 97139 $19.82 Unlisted therapeutic procedure (specify) (each 15 minutes) 97140 $20.83 Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes 97150 $25.56 Therapeutic procedure(s), group (two or more individuals) (services delivered under an outpatient plan of care) (maximum one unit per visit )

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Final Adoption Date Published in Mass Register: June 6, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR RESTORATIVE SERVICES

Service Allowable Fee Service Description Code 97530 $28.65 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes 97532 $18.06 Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes 97533 $49.38 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes 97535 $25.38 Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes 97537 $24.49 Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment) direct one-on-one contact, each 15 minutes 97542 $24.49 Wheelchair management (e.g., assessment, fitting, training), each 15 minutes 97545 $117.41 Work hardening/conditioning; initial two hours 97546 $58.70 Work hardening/conditioning; each additional hour (list separately in addition to code for primary procedure) (use in conjunction with 97545) Active Wound Care Management 97597 $79.74 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less 97598 $58.90 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure) 97602 IC Removal of devitalized tissue from wound(s), non- selective debridement, without anesthesia (e.g., wet-to- moist dressings, enzymatic, abrasion), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session 97605 $33.53 Negative pressure wound therapy (e.g., vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters 97606 $39.90 Negative pressure wound therapy (e.g., vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per

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Final Adoption Date Published in Mass Register: June 6, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR RESTORATIVE SERVICES

Service Allowable Fee Service Description Code session; total wound(s) surface area greater than 50 square centimeters Tests and Measurements 97750 $26.46 Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes 97755 $29.50 Assistive technology assessment (e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes Orthotic Management and Prosthetic Management 97760 $37.43 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes 97761 $32.57 Prosthetic training, upper and/or lower extremity(s), each 15 minutes 97762 $18.06 Checkout for orthotic/prosthetic use, established patient, each 15 minutes Other Procedures 97799 $19.82 Unlisted physical medicine/rehabilitation service or procedure (each 15 minutes, maximum six units per visit) Evaluation and Management—Office or Other Outpatient Services 99203 $85.74 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: - a detailed history; - a detailed examination; and - medical decision making of low complexity 99205 $168.54 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components (written report required): - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity 99212 $43.92 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: - a problem focused history; - a problem focused examination; and - straightforward medical decision making 99214 $98.65 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components (written report required): - a detailed history; - a detailed examination; and - medical decision making of moderate complexity 99215 $138.48 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components (written report required): - a comprehensive history; - a comprehensive examination; and - medical decision making of high complexity Caregiver Training Codes Caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or 97550 $40.44 community (e.g., activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving,

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Final Adoption Date Published in Mass Register: June 6, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: RATES FOR RESTORATIVE SERVICES

Service Allowable Fee Service Description Code safety practices) (without the patient present), face to face; initial 30 minutes Caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, 97551 $20.02 communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face; each additional 15 minutes

(Use 97551 in conjunction with 97550) Group caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (e.g., activities of daily living [ADLs], 97552 $17.51 instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face with multiple sets of caregivers

(2) Hourly Rates for IC Designated Services, Special Contracts, and Unlisted Procedures. As a guideline, rates for restorative and rehabilitation center services for aquatic therapy, nautilus training, work evaluations/job site analysis, work hardening programs, and other unlisted services are determined by applying the appropriate portion of the hourly rate specified in 101 CMR 339.04(2). Diagnostic procedures that require specialized machinery, such as muscle testing during isometric and isokinetic exercises (e.g., use of cybex machine), should be reimbursed with consideration for additional equipment costs and technical assistance, in addition to the prorated hourly fee for therapists' services and routine overhead expenses.

Rehabilitation Center Physical Therapist $64.41hr. Rehabilitation Center Occupational Therapist $64.41hr. Rehabilitation Center Speech Therapist $64.41hr. Restorative Physical Therapy office visit $64.41hr. Restorative Occupational Therapy office visit $64.41hr. Restorative Speech Therapy office visit $64.41hr. Restorative Physical Therapy out-of-office visit $74.07hr. Restorative Occupational Therapy out-of-office visit $74.07hr. Restorative Speech Therapy out-of-office visit $74.07hr.

339.05: Filing and Reporting Requirements

(1) Required Reports. Reporting requirements are governed by 957 CMR 6.00: Cost Reporting Requirements.

(2) Penalty for Noncompliance. The purchasing governmental unit may impose a penalty in the amount of up to 15% of its payments to any provider that fails to submit required information. The purchasing governmental unit will notify the provider in advance of its intention to impose a penalty under .05(2).

339.06: Severability

The provisions of .00 are severable. If any provision of .00 or application of any provision to an applicable individual, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of .00 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

.00: M.G.L. c. 118E.

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