Oregon Administrative Rules
Chapter 836 - DEPARTMENT OF CONSUMER AND BUSINESS SERVICES, INSURANCE REGULATION
Division 53 - HEALTH BENEFIT PLANS
Section 836-053-1605 - Definitions for 836-053-1600 to 836-053-1615

(1) "Anesthesia Conversion factor" means the dollar value assigned to the following geographic rating area where the procedure is performed:

(2) "Base units" means the number of units assigned to the relevant CPT code for the anesthesia-related procedure published in the American Society of Anesthesiologists (ASA), Relative Value Guide 2018. To obtain a copy of the ASA Relative Value Guide 2018, contact the American Society of Anesthesiologists, 1061 American Lane, Schaumberg, IL 60173, 847-825-5586, or www.asahq.org.

(3) "Base Rate" means the dollar amount listed on the Non-Anesthesia Base Rate Fee Schedule under Appendix A.

(4) "CMS" means the Center for Medicare and Medicaid Services.

(5) "CPT"® means Current Procedural Terminology codes and terminology under the American Medical Association's (AMA) Current Procedural Terminology (CPT® 2018), Fourth Edition Revised, 2017, for billing by medical providers.

(6) "CPI adjustment" means the annual adjustment designated by the director calculated with the Consumer Price Index for All Urban Consumers U.S. city average series for all items, not seasonally adjusted. Prior to January 1 of each year the director shall publish the adjustment figure representing the Consumer Price Index adjustment from January 2015 to July of the prior year. For 2019, the designated CPI adjustment is 107.83%.

(7) "Director" means the Director of the Department of Consumer and Business Services.

(8) "Geographic rating area" means the rating area defined under OAR 836-053-0063(6).

(9) "Modifier adjustment" means the adjustment allowed under the CMS CY 2018 Physician Fee Schedule Final Rule as of January 1, 2018, for the following modifiers, if applicable: AS, FX, FY, SA, UE, 22, 23, 25, 47, 50, 51, 52, 53, 54, 55, 56, 62, 66, 73, 78, 80, 81, 82. The CY 2018 Physician Fee Schedule Final Rule is available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1676-F.html. The adjustment for any other modifier or no modifier is 100%.

(10) "Out-of-network reimbursement" means the allowable rate paid by the insurer to the out-of-network provider for emergency services or other covered inpatient or outpatient services provided at an in-network health care facility in Oregon in accordance with ORS 743B.287(3). The amount to be paid by the insurer may include applicable coinsurance, copayment, and deductible amounts paid by the enrollee as outlined in the insurance policy.

(11) "Physical status units" means the number of units assigned based on the provider's assessment of the medical condition of the patient. Physical status units are assigned as follows:

(12) "Q modifier adjustment" means the relevant percentage adjustment, if applicable, assigned for the following modifiers:

(13) "Time units" means the relevant amount of time for an anesthesia-related procedure expressed in 15-minute increments.