Current through Register Vol. 18, September 20, 2024
(1) Outpatient hospital or birthing center
services that are not provided by critical access hospitals will be reimbursed
on a rate-per-service basis using the Outpatient Prospective Payment System
(OPPS) schedules. The provider reimbursement rates for outpatient hospital
services is stated in the department's Outpatient Prospective Payment System
(OPPS) Fee Schedule as provided in ARM
37.85.105(3).
Under this system, Medicaid payment for outpatient services included in the
OPPS is made at a predetermined, specific rate. These outpatient services are
classified according to a list of APCs published annually in the Code of
Federal Regulations (CFR). The rates for OPPS are determined as follows:
(a) The department uses a conversion factor
for each APC group as defined in ARM
37.86.3001(5).
The conversion factor is as provided in ARM
37.85.105(3). The
APC-based fee equals the Medicare specific relative weight for the APC times
the conversion factor that is the same for all APCs with the exceptions of
services in ARM
37.86.3025. APCs are based on
classification assignment of CPT/HCPCS codes.
(b) At the claim level, payment will be the
lower of the provider's charge or the payment as calculated using OPPS. There
will be no charge cap at the line level.
(c) APCs are an all-inclusive bundled payment
per visit which covers all outpatient services provided to the patient,
including but not limited to nursing, pharmacy, laboratory, imaging services,
other diagnostic services, supplies and equipment, and other outpatient
services. For purposes of OPPS, a visit includes all outpatient hospital or
birthing center services related or incident to the outpatient visit that are
provided the day before or the day of the outpatient visit.
(d) If two or more surgical procedures are
performed at the same hospital on the same patient on the same day, payment for
the most expensive procedure will be made at 100% of the APC for that service
and payment for all other procedures will be made at 50% of the APC for those
services.
(e) If the OPPS does not
assign a Medicare fee or APC for a particular procedure code, a Medicaid fee
will be assigned in accordance with the resource based relative value scale
(RBRVS) methodology found at ARM
37.85.212. If there is not a
Medicaid fee, the service will be reimbursed at hospital-specific outpatient
cost-to-charge ratio as in ARM
37.86.2803. Birthing centers and
out-of-state hospitals will be reimbursed the statewide outpatient
cost-to-charge ratio:
(i) The Medicaid
statewide average outpatient cost-to-charge ratio is as provided at ARM
37.85.105(3).
(f) The department will make
separate payment for observation care procedure codes for Medicare qualifying
conditions or obstetric complications. If an observation service does not meet
these criteria for these services, payment for observation care will be
considered bundled into the APC for other services.
(i) The diagnosis used to define a potential
obstetric qualification will be taken from diagnosis-related groups 565 (false
labor) and 566 (other antepartum diagnosis with medical
complications).
(ii) The department
will make separate payment for observation care procedure codes when billed as
a direct admit or have a high level clinic visit, high level critical care, or
high level emergency room visit.
(iii) The department will make separate
payment for observation care procedure codes if billed using a qualifying
diagnosis as per the CMS Claims Processing Manual.
(g) The department follows Medicare
guidelines for procedures defined as "inpatient only". When these procedures
are performed in the outpatient hospital or birthing center setting, the claim
will be denied.
(h) Procedures
started on patients but discontinued before completion will be reimbursed at
50% of the APC for those services.
(2) The department adopts and incorporates by
reference the OPPS Schedules published by the Centers for Medicare and Medicaid
Services (CMS) as provided in ARM
37.85.105(3).
(3) All outpatient hospitals including
birthing centers are subject to the requirements in ARM
37.86.2801(9).
53-2-201,
53-6-113,
MCA; IMP,
53-2-201,
53-6-101,
53-6-111,
53-6-113,
MCA;
