Effective for dates of service on or after the effective date
of this rule, eligible ambulatory surgery centers as defined in paragraphs
(A)(1) and (B) of this rule are subject to the enhanced ambulatory patient
grouping system (EAPG) and prospective payment methodology utilized by the Ohio
department of medicaid (ODM) as described in this
rule.
(A) Definitions, for the
purposes of this rule the following meanings apply.
(1) An "ambulatory surgery center (ASC)" is
any distinct entity that operates exclusively for the purpose of providing
surgical services to patients not requiring hospitalization.
(2)
"Enhanced
ambulatory patient grouping (EAPG)" is a group of outpatient procedures,
encounters, or ancillary services, which reflect similar patient
characteristics and resource utilization and which incorporate the use of
international classification of diseases (ICD) diagnosis codes, current
procedural terminology (CPT) procedural codes, and healthcare common procedure
coding system (HCPCS) procedure codes.
"ASC
claim" encompasses the ASC services rendered to one eligible medicaid
beneficiary on one date of service at an ASC facility.
(3)
"EAPG grouper"
is the software provided by 3M health information systems to group outpatient
claims based on services performed and resource intensity.
"ASC Cost-to-charge ratio" is ninety per cent of the
statewide average outpatient cost-to-charge ratio as calculated in rule
5160-2-22 of the Administrative
Code.
(4)
"Default EAPG settings" are the default EAPG grouper
options in 3M's core grouping software for each EAPG grouper version.
"ASC facility services" are items and services
furnished by an ASC in connection with a covered ASC surgical
procedure(s).
(5)
"Discounting factor" is a factor applicable for
multiple significant procedures or repeated ancillary services designated by
default EAPG settings or both. The appropriate percentage (fifty or one hundred
per cent) will be applied to the highest weighted of the multiple procedures or
ancillary services payment group.
"ASC
invoice" is a bill submitted in accordance with Chapter 5160-1 of the
Administrative Code, to ODM for services rendered to one eligible medicaid
beneficiary on one or more date(s) of service. For an invoice encompassing more
than one date of service, each date will be processed separately as an
individual claim.
(a) "Full payment" is the EAPG
payment with no applicable discounting factor.
(b) "Consolidation factor" is a
factor of zero per cent applicable for services designated with a same
procedure consolidation flag or clinical procedure consolidation flag by the
EAPG grouper under default EAPG settings.
(c) "Packaging factor" is a factor
of zero per cent applicable for services designated with a packaging flag by
the EAPG grouper under default EAPG settings.
(6)
"ASC invoice"
is a bill submitted in accordance with Chapter 5160-1 of the Administrative
Code, to the department for services rendered to one eligible medicaid
beneficiary on one or more date(s) of service. For an invoice encompassing more
than one date of service, each date will be processed separately as an
individual claim.
"Default EAPG settings" are
the default EAPG grouper options in 3M's core grouping software for each EAPG
grouper version.
(7)
"ASC claim" encompasses the ASC services rendered to
one eligible medicaid beneficiary on one date of service at an ASC
facility.
"Diagnosis code" is the
international classification of diseases (ICD) diagnosis code as identified in
rule 5160-1-19 of the Administrative
Code.
(8)
"Procedure code" is the CPT code or HCPCS code as
identified in rule
5160-1-19 of the Administrative
Code.
"Discounting factor" is a factor
applicable for multiple significant procedures or repeated ancillary services
designated by default EAPG settings or both. The appropriate percentage (fifty
or one hundred per cent) will be applied to the highest weighted of the
multiple procedures or ancillary services payment group.
(a)
"Full payment" is
the EAPG payment with no applicable discounting factor.
(b)
"Consolidation
factor" is a factor of zero per cent applicable for services designated with a
same procedure consolidation flag or clinical procedure consolidation flag by
the EAPG grouper under default EAPG settings.
(c)
"Packaging
factor" is a factor of zero per cent applicable for services designated with a
packaging flag by the EAPG grouper under default EAPG settings.
(9)
"Diagnosis code" is the ICD code as identified in rule
5160-1-19 of the Administrative
code.
"EAPG base rate" is the dollar value
that is multiplied by the final EAPG relative weight for each EAPG on a claim
to determine the total allowable medicaid payment for a visit. The EAPG base
rate for ASCs is sixty-three and six tenths per cent of the statewide average
outpatient hospital EAPG base rate. Hospital EAPG base rates are calculated as
described in rule
5160-2-75 of the Administrative
Code.
(10)
"Relative weight" is a factor specific to each EAPG
that represents that EAPG's relative cost compared to an average case. The
relative weights for EAPGs are calculated as described in paragraph (F) of rule
5160-2-75 of the Administrative
Code.
"EAPG grouper" is the software provided
by 3M health information systems to group outpatient claims based on services
performed and resource intensity.
(11)
"EAPG base
rate" is the dollar value that is multiplied by the final EAPG weight for each
EAPG on a claim to determine the total allowable medicaid payment for a visit.
The EAPG base rate for ASCs is ninety per cent of the statewide average
outpatient hospital EAPG base rate. Hospital EAPG base rates are calculated as
described in paragraph (D) of rule
5160-2-75 of the Administrative
Code.
"Enhanced ambulatory patient grouping
(EAPG)" is a group of outpatient procedures, encounters, or ancillary services,
which reflect similar patient characteristics and resource utilization, and
which incorporate the use of international classification of diseases (ICD)
diagnosis codes, current procedural terminology (CPT) procedural codes, and
healthcare common procedure coding system (HCPCS) procedure
codes.
(12)
"ASC facility services" are items and services
furnished by an ASC in connection with a covered ASC surgical
procedure.
"Procedure code" is the CPT code or
HCPCS code as identified in rule
5160-1-19 of the Administrative
Code.
(13)
"ASC Cost-to-charge ratio" is eighty per cent of the
statewide average outpatient cost-to-charge ratio as calculated in rule
5160-2-22 of the Administrative
Code.
"Relative weight" is a factor specific
to each EAPG that represents that EAPG's relative cost compared to an average
case. The relative weights for EAPGs are calculated as described in rule
5160-2-75 of the Administrative
Code.
(B) Eligible
ASC providers.
(1) All ASCs that have a valid
agreement with the centers for medicare and medicaid services (CMS) to provide
services in the medicare program are eligible to become medicaid providers upon
execution of the "Ohio Medicaid Provider Agreement."
(2) ASC providers bill in accordance with
rule
5160-1-19 of the Administrative
Code.
The department
ODM will reimburse an ASC for properly submitted
claims for facility services furnished in connection with covered surgical
procedures when the services are provided by an eligible ASC provider to an
eligible medicaid recipient. Reimbursement for covered ASC facility services
will be paid in accordance with paragraph (D) of this rule.
(C) Covered ASC services.
(1) Services include but are not limited to:
(a) Nursing, technician, and related
services;
(b) Use of the ASC
facilities;
(c) Drugs, biologicals
(e.g., blood), surgical dressings, splints, casts and appliances, and equipment
directly related to the provision of the surgical procedure;
(d) Diagnostic or therapeutic services or
items directly related to the provisions of a surgical procedure;
(e) Administrative, record keeping, and
housekeeping items and services;
(f) Materials for anesthesia;
(g) Intraocular lenses; and
(h) Supervision of the services of an
anesthetist by the operating surgeon.
(2) Prior authorization (PA) is necessary for
certain surgical CPT codes. The services needing PA are published in accordance
with section 5160.34 of the Revised
Code.
(D) EAPG payment
formula.
(1) Total EAPG payment is the sum
across all paid line items on an ASC claim
(2) The payment for a paid line on the claim
is calculated as follows, except as described in paragraph (E) or (F) of this
rule:
(a) The ASC EAPG base rate
times;
(b) The
ASC EAPG relative weight for which the service
was assigned by the EAPG grouper, rounded to the nearest whole cent;
(c) For EAPG 00233, the result of
paragraph (D)(2)(b) of this rule multiplied by one hundred forty-five per cent,
rounded to the nearest whole cent. For EAPG 00485, the result of paragraph
(D)(2)(b) of this rule multiplied by two hundred thirty three per cent, rounded
to the nearest whole cent;
(d)(c) The result of
paragraphs (D)(2)(a) and (D)(2)(b) of this rule
, or,
for EAPGs 00233 and 00485, (D)(2)(a) to (D)(2)(c), times applicable
discounting factor(s) as defined in paragraph
(A)
(5)
(A)(8) of this rule, rounded to the nearest whole
cent.
(E)
Payment for laboratory services, radiological services, and diagnostic and
therapeutic procedures.
An ASC may be reimbursed in addition to the facility fee for
covered laboratory procedures, radiological procedures, and diagnostic and
therapeutic procedures provided in connection with a covered ASC surgical
procedure.
(1) Payment for laboratory
services.
(a) An ASC may be reimbursed for
covered laboratory services actually performed.
(b) An ASC should not bill separately for the
professional component of an anatomical pathology procedure.
(c) Laboratory services will be reimbursed
the lesser of billed charges or the result of paragraph (D)(2)(c) of this
rule.
(2) Payment for
radiological services.
(a) An ASC may be
reimbursed for covered radiological services actually performed.
(b) An ASC should not bill
the department
ODM for the professional component
separately.
(c) Radiological
services will be reimbursed the lesser of billed charges or the result of
paragraph (D)(2)(c) of this rule.
(3) Payment for diagnostic and therapeutic
procedures.
(a) An ASC may be reimbursed for
the provision of diagnostic and therapeutic services when provided.
(b) An ASC should not bill separately for the
professional component of a diagnostic and therapeutic procedure.
(c) Diagnostic and therapeutic services will
be reimbursed the result of paragraph (D)(2)(c) of this
rule.
(4) An ASC may also
be reimbursed for laboratory, radiology and diagnostic and therapeutic services
actually performed in the ASC in conjunction with covered services not eligible
for an ASC facility payment.
(F) Items which may be paid outside of EAPG.
(1) Pharmaceuticals.
(a) Payments for covered pharmaceuticals will
be made in accordance with the discounting factors as determined by the EAPG
grouper. If no consolidation or packaging factors are assigned
, then the pharmaceutical line is separately payable
and will pay according to paragraphs (F)(1)(b) and (F)(1)(c) of this
rule.
(b) Reimbursement for
separately payable covered pharmaceuticals
shall
will be the
lesser of billed charges or the payment amounts in the provider administered
pharmaceutical fee schedule as published on
the
department's
ODM's web site,
http://medicaid.ohio.gov/, at
the rate in effect on the date of service.
(c) If a J-code or Q-Code, that is covered
for ASC facilities and separately payable, is listed as "by report" in the
provider-administered pharmaceutical fee schedule, the line will be multiplied
by sixty per cent of the ASC cost-to-charge ratio.
(2) Durable medical equipment (DME).
(a) Additional payments may be made for all
line items grouping to a DME EAPG type.
(b) Reimbursement for DME will be the lesser
of billed charges or the payment amounts in the medicaid non-institutional
maximum payment schedule as published on
the
department's
ODM's web site,
http://medicaid.ohio.gov/, at
the rate in effect on the date of service.
(c) Payments for DME will be made in
accordance with the discounting factors as determined by the EAPG
grouper.
(3) Dental
services
Reimbursement for claims assigned to a dental service EAPG type
will be paid as follows:
(a)
Reimbursement for dental services will be
nine-hundred fifty-three dollars and sixty cents
one thousand three hundred twenty-eight
dollars.
(b) Payments for
dental services will be made in accordance with the discounting factors as
determined by the EAPG grouper.
(G)
Risk
corridors.
Effective for dates of services on or
after the effective date of this rule, ODM will apply the following to ASC EAPG
relative weights as described in paragraph (A)(13) of this rule:
(1)
The EAPG relative
weights were calculated to result in an increase of at least five per cent in
payments compared to the prior prospective payment system; or
(2)
The EAPG relative
weights were calculated to result in no more than a fifteen per cent increase
in payments compared to the prior prospective payment
system.
Notes
Ohio Admin. Code
5160-22-01
Effective:
1/1/2024
Five Year Review (FYR) Dates:
10/17/2023 and
01/01/2029
Promulgated
Under: 119.03
Statutory Authority: 5164.02
Rule
Amplifies: 5162.03, 5164.02
Prior Effective Dates: 03/20/1984,
01/04/1988, 02/17/1991, 12/29/1995 (Emer.), 05/21/1996, 01/01/2004, 05/10/2007,
07/01/2009, 04/15/2015, 08/01/2016, 08/01/2017, 01/01/2019,
09/01/2020