Current through Register Vol. 47, No. 17, September 10, 2024
(A) INPATIENT
FACILITY FEES
(1) Billing:
(a) Inpatient facility fees shall be billed
on a UB-04 and require summary level billing by revenue code. The provider must
submit itemized bills along with the UB-04.
(b) Hospitals reimbursed based on MS-DRGs
shall indicate the MS-DRG code FL 71 of the UB-04 billing form and maintain
documentation on file showing how the MS-DRG was determined. The hospital shall
determine the MS-DRG using the MS-DRGs Definitions Manual in effect per section
18-2 at the time of discharge. The attending Physician shall not be required to
certify this documentation unless a dispute arises between the hospital and the
Payer regarding MS-DRG assignment. The Payer may deny payment for services
until the appropriate MS-DRG code is supplied.
(2) Reimbursement:
(a) The following types of inpatient
facilities, as defined in Rule 16, are allowed a reasonable charge as
negotiated by the Provider and Payer:
(i)
Children's Hospitals
(ii) Veterans
Administration Hospitals
(iii)
State-run Psychiatric Hospitals
(iv) Psychiatric Hospitals
The provider has the burden of proving reasonableness of
reimbursement sought. Veterans Administration Hospital payments must comply
with applicable rules promulgated by the United States Department of Veterans
Affairs.
(b) The
following inpatient facilities, as defined in Rule 16, are allowed a daily
rate:
(i) Skilled Nursing Facilities (SNFs)
are allowed $663 per day.
(ii)
Rehabilitation Hospitals are allowed $1,479 per day.
(iii) Long Term Acute Care Hospitals (LTACHs)
are allowed $3,417 per day.
Each of the daily rates listed above is all-inclusive for
services related to the injured worker's compensable conditions. Physician's
professional services, ambulance services, and chemotherapy drugs or
radioisotopes may be billed separately. In the rare case extraordinary medical
care is required, or for treatment of traumatic brain injuries or spinal cord
injuries, there shall be an additional payment of $306 on a per day
basis.
All charges shall be submitted on a final bill unless the
parties agree on interim billing. The rate in effect on the last date of
service covered by an interim or final bill shall determine payment.
The total length of stay includes the date of admission but
not the date of discharge. Typically, bed hold days or temporary leaves are not
subtracted from the total length of stay.
(c) All other inpatient facilities:
The maximum allowance is determined by the relative weights
for the assigned MS-DRG from Table 5 in effect per section 18-2 at the time of
discharge and the hospital's base rate in Exhibit #2, calculated as
follows:
(MS-DRG Relative Wt x Specific hospital base rate x 160%) +
(trauma center activation allowance) + (organ acquisition, when
appropriate)
(i) For trauma center
activation allowance, (revenue codes 680-684) see subsection
(B)(8)(c);
(ii) For organ
acquisition allowance, (revenue codes 810-819) see subsection (A)(2)(g).
Table 5 establishes the maximum length of stay (LOS) using
the "arithmetic mean LOS." However, there is no additional allowance for
exceeding this LOS, other than through the cost outlier criteria.
An admission requiring the use of both an acute care hospital
(admission/discharge) and its Rehabilitation Hospital (admission/discharge) is
considered as one admission and MS-DRG.
(d) Outliers for inpatient hospitals
identified in Exhibit #2:
Outliers are admissions with extraordinary cost warranting
additional reimbursement beyond the maximum allowance. To calculate the
additional reimbursement, if any:
(i)
Determine the hospital's cost by multiplying total billed charges (excluding
any trauma center activation or organ acquisition billed charges) by the
hospital's cost-to-charge ratio located in Exhibit #2;
(ii) The difference = hospital's cost -
maximum allowance excluding any trauma center activation or organ acquisition
allowance;
(iii) If the difference
is greater than $38,859, additional reimbursement is warranted. The additional
allowance is determined by multiplying the difference by .80.
(e) If an injured worker is
admitted to a hospital through the emergency department (ED), the ED fee is
included in the inpatient allowance.
(f) If an injured worker is admitted to one
hospital and is subsequently transferred to another hospital, the payment to
each hospital will be based upon a per diem value of the MS-DRG maximum
allowance. The per diem value is calculated based upon the individual
hospital's MS-DRG relative weight multiplied by the hospital's specific base
rate divided by the MS-DRG geometric mean LOS established in Table 5. This per
diem amount is multiplied by the actual LOS. If the patient is admitted and
transferred on the same day, or transferred and discharged on the same day, the
actual LOS equals one. If the LOS is greater than or equal to the geometric
mean LOS for the MS-DRG, then the maximum MS-DRG is allowed for that
hospital.
(g) The Payer shall
compare each billed charge type:
(i) The
MS-DRG adjusted billed charges to the MS-DRG allowance (including any outlier
allowance);
(ii) The trauma center
activation billed charge to the trauma center activation allowance;
and
(iii) The organ acquisition
billed charges to the organ acquisition allowance.
The MS-DRG adjusted billed charges are determined by
subtracting the trauma center activation billed charge and the organ
acquisition billed charges from the total billed charges. The final payment is
the sum of the lesser of each of these comparisons.
The organ acquisition allowance is calculated using the most
recent filed computation of organ acquisition costs and charges for hospitals
that are certified transplant centers (CMS Worksheet D-4 or subsequent form)
plus 20%.
(B) OUTPATIENT FACILITY FEES
(1) Provider Restrictions:
(a) All non-emergency outpatient surgeries
require prior authorization unless the MTGs recommend a surgery for the
particular condition. All outpatient surgical procedures performed in an ASC
shall warrant performance at an ASC level.
(b) A facility fee is payable only if the
facility is licensed as a hospital or an ASC by the Colorado Department of
Public Health and Environment (CDPHE) or applicable out of state governing
agency or statute.
(2)
Types of Bills for Service:
(a) Outpatient
facility fees shall be billed on a UB-04 and require summary level billing by
revenue code. The provider must submit itemized bills along with the
UB-04.
(b) All professional charges
(professional services including, but not limited to, PT, OT, CCC-SLP,
anesthesia, etc.) are subject to the RBRVS and Dental Fee Schedules as
incorporated by this Rule. These fee schedules apply to professional services
performed in all facilities.
(c)
Outpatient hospital facility bills include all outpatient surgery, ED, clinics,
Urgent Care, and diagnostic testing in the Radiology, Pathology or Medicine
Section of CPT®/RBRVS.
(3) General Reimbursement Instructions:
(a) The following outpatient facilities, as
defined in Rule 16, are allowed a reasonable charge, as negotiated by the
Provider and Payer, except for any associated professional fees that are
reimbursed per section 18-4:
(i) Children's
Hospitals
(ii) Veterans
Administration Hospitals
(iii)
State-run Psychiatric Hospitals
The Provider has the burden of proving reasonableness of
reimbursement sought. Veterans Administration Hospital payments must comply
with applicable rules promulgated by the United States Department of Veterans
Affairs.
(b) The
maximum allowance for Ambulatory Payment Classifications (APC) is calculated at
the following percentages of the payment rates listed in Medicare's OPPS
Addendum A, as incorporated by 18-2:
(i)
Outpatient hospital is 160%
(ii)
CAH is 200%
(iii) ASC is 150%
To identify which APC grouper is aligned with a CPT® code
and dollar value, use Medicare's Addendum B, as incorporated by 18-2. For
comprehensive APCs (C-APCs), see 18-5(B)(6).
(c) CPT® codes listed with a "C" status
indicator in Medicare's Addendum B shall align to the APC codes as listed in
Exhibit #4. The status indicator assigned to the Exhibit #4 APC code, as
identified in Medicare's Addendum A, shall apply. These codes are not eligible
for complexity-adjusted APC payments.
(d) Facilities receive the lesser of the
actual charge or the fee schedule allowance. A line-by-line comparison of
charges is not appropriate.
(4) APC values include the services and
revenue codes listed in Table 2 of the 2022 NFRM OPPS Claims Accounting, as
incorporated by Rule 18-2; therefore, these are generally not separately
payable. Drugs and devices having a status indicator of G and H receive a
pass-through payment. In some instances, the procedure code may have an APC
code assigned. These are separately payable based on APC values, if given, or
at cost to the facility.
Services and items included in the APC value:
(a) nursing, technician, and related
services;
(b) use of the facility
where the surgical procedure(s) was performed;
(c) drugs and biologicals for which separate
payment is not allowed;
(d) medical
and surgical supplies, durable medical equipment and orthotics not listed as a
"pass through";
(e) surgical
dressings;
(f) equipment;
(g) splints, casts and related
devices;
(h) radiology services for
which separate payment is not allowed;
(i) administrative, record keeping, and
housekeeping items and services;
(j) materials, including supplies and
equipment for the administration and monitoring of anesthesia;
(k) supervision of tiie services of an
anestiietist by tiie operating surgeon;
(I) post-operative pain bloci^s;
and
(m) implanted items.
(5) Status Indicators from
Medicare's Addendum B apply as follows:
|
Indicator
|
Meaning
|
|
A
|
Use another fee schedule instead of Addendum B,
such as conversion factors listed in section 18-4, RBRVS RVUs, Ambulance Fee
Schedule, or section 18-4(F)(2).
|
|
B
|
Is not recognized for Outpatient Hospital Services
bill type (12x and 13x) and therefore is not separately payable unless separate
fees are applicable under another section of this Rule.
|
|
C
|
The Division recognizes these procedures on an
outpatient basis with prior authorization.
|
|
E
|
Not generally reimbursable when submitted on any
outpatient bill type. However, services could still be reasonable and
necessary, thus requiring hospital or ASC level of care. The billing party
shall submit documentation to substantiate the billed service codes and any
similar established codes with fees in Addendum A, as incorporated by
18-2.
|
|
F
|
Corneal tissue acquisition, certain CRNA services,
and Hepatitis B vaccines are allowed at a reasonable cost to the facility. The
facility must provide a separate invoice identifying its cost.
|
|
G
|
"Pass-Through Drugs and Biologicals"; separate APC
payment.
|
|
H
|
"Pass-Through Device"; separate APC payment based
on cost to the facility.
|
|
J1 or J2
|
The services are paid through a comprehensive
APC.
|
|
K
|
"Nonpass-Through Drug or Biological or Device" for
therapeutic radiopharmaceuticals, brachytherapy sources, blood and blood
products; separate APC payment.
|
|
L
|
Influenza Vaccine/Pneumococcal Pneumonia Vaccine
and therefore is generally considered to be unrelated to work injuries.
|
|
M
|
Not separately payable.
|
|
N
|
Items and services packaged into APC rates; not
separately payable.
|
|
P
|
Partial hospitalization paid based on observation
fees outlined in this section.
|
|
Q1-Q4
|
Packaged services subject to separate payment
criteria.
|
|
R
|
Blood and blood products; separate APC
payment.
|
|
S
|
Significant procedure, not discounted when
multiple.
|
|
T
|
Significant procedure, multiple procedure reduction
applies.
|
|
U
|
Brachytherapy source; separate APC payment.
|
|
V
|
Clinic or an ED visit; separate APC payment.
|
|
Y
|
Non-implantable Durable Medical Equipment paid
pursuant to Medicare's Durable Medical Equipment Regional Carrier fee schedule
for Colorado.
|
(6)
Multiple Procedures
(a) A comprehensive APC
treats all individually reported codes as representing components of the
comprehensive service, resulting in a single prospective payment.
As defined by status indicator J1, all covered outpatient
services on the claim are packaged with the primary J1 service for payment,
except services with a status indicator of F, G, H, L, or U; ambulance
services; diagnostic and screening mammography; rehabilitation therapy services
reported on a separate claim; new technology services; and self-administered
drugs.
When multiple codes with J1 status indicators are included on
the claim, services are packaged with the primary (highest APC value) J1 code.
Certain J1 codes, when billed together, may be eligible for a complexity
adjusted APC payment listed on Medicare's Addendum J, as incorporated by
18-2.
Services with a status indicator J2 are assigned to a
comprehensive APC (8011) when specific combinations of services are reported on
the claim. All levels of emergency department (ED) and clinic visits, if billed
in combination with observation time, can trigger this comprehensive composite
rate. Payment of APC 8011 requires a minimum of eight units of G0378
hospital observation service, per liour, no status T procedure
on the claim; and either an E&M visit on the same day or day before the
G0378 date of service; or G0379 direct admit to
observation.
All covered services on the claim shall be considered adjunct
to APC 8011 and packaged into a single payment, except those items excluded by
rule. Other excluded services include covered screening procedures,
preventative services, pass-through drugs and devices (status indicator G or
H), PT, OT, and SLP services reported on a separate claim, certain vaccines
(status indicator L or F), cornea tissue acquisition, and new technology APCs
with status indicator S. If the claim contains a J1 primary service, the J1
C-APC will be the composite under which the services will be paid. There is no
complexity adjustment for J2 occurring on the same claim as J1.
If services with a J2 status indicator are provided during an
extended assessment and management encounter, including observation care, and
do not meet all the requirements for APC 8011 listed above, the usual APC logic
will apply.
(b) Codes with
a status Q1 indicator are packaged with the APC payment if billed on the same
claim as a HCPCS code assigned status indicator S, T, or V. Otherwise, payment
is made through a separate APC.
Codes with a Q2 indicator are packaged with the APC payment
if billed on the same claim as a HCPCS code assigned status indicator T.
Otherwise, payment is made through a separate APC. When multiple codes with
status Q1 or Q2 are billed together, only one unit of the highest-valued Q1 or
Q2 code is payable.
Codes with a status Q3 indicator may be paid through a
composite APC if billed with another code in the same family listed in Table 3
of the OPPS Imaging Families and Multiple Procedure Composite APCs, of the 2023
OPPS Final Rule. The five multiple imaging composite APCs are:
* APC 8004 (Ultrasound Composite);
* APC 8005 (CT and CTA without Contrast Composite);
* APC 8006 (CT and CTA with Contrast Composite);
* APC 8007 (MRI and MRA without Contrast Composite);
and
* APC 8008 (MRI and MRA with Contrast Composite).
Each imaging composite APC is defined as having two or more
imaging procedures from the same family performed on the same date of service.
If a "without contrast" procedure is performed during the same session as a
"with contrast" procedure from the same family, payment would be based on the
"with contrast" composite APC. Standard APC assignments apply for single
imaging procedures and multiple imaging procedures performed across
families.
Codes with a status Q4 indicator are packaged with the APC
payment if billed on the same claim as a HCPCS code assigned status indicator
S, T, V, Q1, Q2, or Q3. Otherwise, payment is made through a separate
APC.
(c) The maximum
allowance for multiple procedures with a T status indicator is limited to four
procedure codes per episode. The highest valued APC code is allowed at 100% of
the maximum allowance, plus 50% of the maximum allowance for the following
three highest valued codes.
(i) The use of
modifier 51 is not a factor in determining which codes are subject to multiple
procedure reductions.
(ii)
Bilateral procedures require each procedure to be billed on separate lines
using RT and LT modifier(s).
(iii)
When a code is billed with multiple units, multiple procedure reductions apply
to the second through fourth units as appropriate. Units may also be subject to
other maximum frequency per day policies.
(7) Other surgical payment policies:
(a) All surgical procedures performed in one
operating room, regardless the number of surgeons, are considered one
outpatient surgical episode of care for payment purposes.
(b) Discontinued surgeries require the use of
modifier 73 (discontinued prior to the administration of anesthesia) or
modifier 74 (discontinued after administration of anesthesia). Modifier 73
results in an allowance of 50% of the APC value for the primary procedure only.
Modifier 74 allows 100% of the primary procedure value only. If a comprehensive
APC procedure is discontinued or reduced and modifier 52, 73 or 74 is reported,
complexity adjustment will not apply to the claim.
(c) Facilities shall report G0260 when
billing for sacroiliac joint injections, not CPT® 27096.
(8) Emergency Department (ED)
Visits:
(a) Types of ED Visits:
(i) Hospitals billing type "A" ED visits must
be physically located within a hospital licensed by the CDPHE as a general
hospital or meet the out-of-state facility's state's licensure requirements,
and be open 24 hours a day, seven days a week. These EDs bill using revenue
code 450 and applicable CPT® codes;
(ii) A freestanding type "B" ED must have
operations and staffing equivalent to a licensed ED, be physically located
inside a hospital, and meet Emergency Medical Treatment and Active Labor Act
(EMTALA) regulations. All type "B" outpatient ED visits must be billed using
revenue code 456 with level of care HCPCS codes G0380-G0384, even though the
facility may not be open 24 hours a day, seven days a week.
(b) ED level of care is identified
based upon one of five levels of care for either a type "A" or type "B" ED
visit. The level of care is defined by CPT® E&M code descriptions and
internal level of care guidelines developed by the hospital in compliance with
Medicare regulations. The hospital's guidelines should establish an appropriate
gradation of hospital resources (ED staff and other resources) as the level of
service increases. Upon request, the provider shall supply a copy of its level
of care guidelines to the Payer. (Only the higher one of any ED levels or
critical care codes shall be paid).
(c) Trauma activation means a trauma team has
been activated, not just alerted. Trauma activation is billed with 068X revenue
codes. The level of trauma activation shall be determined by CDPHE's assigned
hospital trauma level designation. Trauma activation fees are in addition to ED
and inpatient fees and are not paid for alerts. APC 5045, Trauma Response with
Critical Care, is not recognized for separate payment.
Trauma activation allowances are as follows:
|
Revenue Code 681
|
$5,534.00
|
|
Revenue Code 682
|
$2,298.00
|
|
Revenue Code 683
|
$1,289.00
|
|
Revenue Code 684
|
$954.00
|
(9) Ancillary Services:
(a) Any diagnostic testing, clinical labs, or
therapies with a status indicator of "A" shall be reimbursed using section
18-4(F)(2) or the appropriate CF to the unit values for the specific CPT®
code as listed in the RBRVS. Hospital bill types 13x are allowed payment for
any clinical laboratory services (even if the SI is "N" for the specific
clinical laboratory CPT® code) when these laboratory services are unrelated
to any other outpatient services performed that day. Off-campus freestanding
imaging centers are reimbursed using the RBRVS TC value(s).
(b) Professional fees are reimbursed in
accordance with section 18-4 regardless of the facility type. Additional
reimbursement is payable for the following services not included in the APC
values, as incorporated by 18-2:
(i) ambulance
services (revenue code 540), see section 18-6(E)
(ii) blood, blood plasma, platelets (revenue
codes 380X)
(iii) physician or
physician assistant services
(iv)
nurse practitioner services
(v)
licensed clinical psychologist
(vi)
licensed social workers
(vii)
rehabilitation services (PT, OT, respiratory or CCC-SLP, revenue codes 420,
430, 440)
(c) Any
prescription for a drug supply to be used for longer than 24 hours, filled at
any clinic, shall be reimbursed in accordance with section 18-6(C).
(d) Clinic facility fees are not separately
payable unless otherwise specified in this Rule.
(e) IV infusion therapy performed in an
outpatient hospital facility is separately payable in accordance with this
section.
(10) Rural
Health Clinics:
Rural Health Clinics are allowed a single separate clinic
facility fee at 80% of billed charges per date of service.
Allowed revenue codes for clinic fees are 521 for physical
health services and 900 for behavioral health services.
(C) URGENT CARE
FACILITIES
(1) Provider Restrictions:
Facility fees are only payable if the facility qualifies as
an Urgent Care facility. All Urgent Care facilities shall be accredited or
certified by the Urgent Care Association (UCA) or accredited by the Joint
Commission to be recognized for a separate facility payment for the initial
visit.
(2) Billing and
Maximum Allowances:
(a) Facility Fees:
(i) No separate facility fees are allowed for
follow-up care. To receive a separate facility fee, a subsequent diagnosis
shall be based on a new acute care situation and not the initial
diagnosis.
(ii) No facility fee is
appropriate when the injured worker is sent to the employer's designated
provider for a non-urgent episode of care during regular business hours of 8 am
to 5 pm, Monday through Friday.
(iii) Hospitals may bill on a UB-04 using
revenue code 516 or 526 and the facility HCPCS code S9088, $76.50, with one
unit. All maximum allowances for other services billed on the UB-04 shall be in
accordance with CPT® relative weights from RBRVS, multiplied by the
appropriate CF.
(iv) Hospital and
non-hospital based urgent care facilities may bill for the facility fee, HCPCS
code S9088, $76.50, on the CMS-1500 with professional services. All other
services and procedures provided in an urgent care facility, including a
freestanding facility, are allowed according to the appropriate CPT® code
relative weight from RBRVS multiplied by the appropriate CF.
(b) All professional fees shall be
billed on a CMS-1500 with a Place of Service Code 20 and reimbursed in
accordance with section 18-4.
(c)
All supplies are included in the facility fee.
(d) Any prescription for a drug to be used
for longer than 24 hours, filled at any clinic, shall be reimbursed in
accordance with section 18-6(C).
