Tenn. Comp. R. & Regs. 0800-02-18-.07 - AMBULATORY SURGICAL CENTERS AND OUTPATIENT HOSPITAL CARE (INCLUDING EMERGENCY ROOM FACILITY CHARGES)
(1) Medically
appropriate surgical procedures may be performed on an outpatient basis.
(a) For the purpose of the Medical Fee
Schedule Rules, "ambulatory surgical center" means an establishment with an
organized medical staff of physicians; with permanent facilities that are
equipped and operated primarily for the purpose of performing surgical
procedures, with continuous physicians and registered nurses on site or on
call; which provides services and accommodations for patients to recover for a
period not to exceed twenty-three (23) hours after surgery. An ambulatory
surgical center may be a free-standing facility or may be attached to a
hospital facility. For purposes of workers' compensation reimbursement to ASCs,
the facility shall be a Medicare approved ASC.
(b) CMS has implemented the Outpatient
Prospective Payment System ("OPPS") under Medicare for reimbursement for
hospital outpatient services. All outpatient facility services paid under the
OPPS are classified into Ambulatory Payment Classifications ("APC") groups.
Services in each APC are similar clinically and in terms of the resources they
require. CMS has established a payment rate for each APC. The payment rate for
each APC group is the basis for determining the maximum total payment to which
an ASC or hospital outpatient center will be entitled, including addons,
hospital outpatient procedures, multiple procedure discounts and status
indicators, according to current CMS guidelines.
(c) Under the Medical Fee Schedule Rules, the
OPPS reimbursement system shall be used for reimbursement for all outpatient
services, wherever they are performed, in a free-standing ASC or hospital
setting. Medicare APC rates shall be used as the basis for facility fees
charged for outpatient services and shall be reimbursed at a maximum of 150% of
Medicare APC rates. APC groups and maximum allowable reimbursement amounts for
facility services performed in an outpatient hospital or ASC setting are
included in the rate tables on the same line as the professional fees.
Depending on the services provided, ASCs and hospitals may be paid for more
than one APC for an encounter. When multiple surgical procedures are performed
during the same surgical session, Medicare OPPS guidelines shall be used in
determining separate and distinct surgical procedures and the order of payment.
Medicare status indicators which govern payment of facility bills are included
in the rate tables.
(d) If a claim
contains services that result in an APC payment but also contains packaged
services, separate payment of the packaged services is not made since the
payment is included in the APC. However, charges related to the packaged
services are used in setting outher calculations.
(e) The maximum allowable reimbursement rates
for outpatient hospitals and ASCs included in the rate tables apply to Acute
Care and Critical Access Hospitals ("CAH").
(f) Services for which no outpatient rates
are included in the rate tables may be covered when preauthorized by the payer.
The maximum allowable facility reimbursement is the usual & customary
amount, which is 80% of the billed charges, as defined in the Bureau's Rules
for Medical Payments.
(g) All of
the following services are to be reimbursed in accordance with the Medicare
status indicators effective on the date of service. Maximum allowable
reimbursement amounts are included in the fee schedule:
1. Radiology services (technical components
may only be separately reimbursed when not included in APC);
2. Diagnostic procedures not related to the
surgical procedure;
3. Prosthetic
devices;
4. Orthotics;
5. Implantables;
6. DME for use in the patient's
home;
7. Take home medications;
and
8. Take home
supplies.
(h)
1. For cases involving implantation of
medical devices (implantables), regardless of the current Medicare status
indicators, payment shall be made only to the facility.
2. For DME, orthotics and prosthetics used in
the patient's home that is supplied by the facility, payment shall be made only
to the facility (at the rates specified in
0800-02-18-.10 and
0800-02-18-.11), and not to any
other separate entity for these services. No extra payment shall be made for
these services if according to CMS regulations and status indicators when those
particular services are included in the APC payment.
(i) Pre-admission lab and x-ray may be billed
separately from the Ambulatory Surgery bill when performed 24 hours or more
prior to admission, and will be reimbursed the lesser of billed charges or the
fee listed in the rate tables. Pre-admission lab and radiology are not included
in the facility fee.
(j) There may
be emergency cases or other occasions in which the patient was scheduled for
outpatient surgery and it becomes necessary to admit the patient. All hospitals
with ambulatory patients who stay longer than 23 hours past ambulatory surgery
or other diagnostic procedures and are formally admitted to the hospital as an
inpatient will be paid in accordance with the Inpatient Hospital Fee Schedule
Rules, 0800-02-19. Medicare hospital criteria shall apply to these
cases.
Notes
Authority: T.C.A. ยงยง 50-6-204, 50-6-205, and 50-6-233 (Repl. 2005).
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