Current through Reg. 49, No. 38; September 20, 2024
(a) Applicability of this rule is as follows:
(1) This section applies to facility services
provided on or after September 1, 2008 by an ambulatory surgical center (ASC),
other than professional medical services.
(2) This section does not apply to:
(A) professional medical services billed by a
health care provider not employed by the ASC, except for a surgical implant
provider as described in this section; or
(B) medical services provided through a
workers' compensation health care network certified pursuant to Insurance Code
Chapter 1305, except as provided in Insurance Code Chapter 1305.
(b) Definitions for
words and terms, when used in this section, shall have the following meanings,
unless clearly indicated otherwise.
(1)
"Ambulatory Surgical Center" means a health care facility appropriately
licensed by the Texas Department of State Health Services.
(2) "ASC device portion" means the portion of
the ASC payment rate that represents the cost of the implantable device, and is
calculated by applying the Centers for Medicare and Medicaid Services (CMS)
Outpatient Prospective Payment System (OPPS) device offset percentage to the
OPPS payment rate.
(3) "ASC service
portion" means the Medicare ASC payment rate less the device portion.
(4) "Device intensive procedure" means an ASC
covered surgical procedure that has been designated by CMS as device intensive
in TABLE 56 - ASC COVERED SURGICAL PROCEDURES DESIGNATED AS DEVICE INTENSIVE
FOR CY 2008 or its successor.
(5)
"Implantable" means an object or device that is surgically:
(A) implanted,
(B) embedded,
(C) inserted,
(D) or otherwise applied, and
(E) related equipment necessary to operate,
program, and recharge the implantable.
(6) "Medicare payment policy" means
reimbursement methodologies, models, and values or weights including its
coding, billing, and reporting payment policies as set forth in the Centers for
Medicare and Medicaid Services (CMS) payment policies specific to
Medicare.
(7) "Surgical implant
provider" means a person that arranges for the provision of implantable devices
to a health care facility and that then seeks reimbursement for the implantable
devices provided directly from an insurance carrier.
(c) A surgical implant provider is subject to
Chapter 133 of this title and is considered a health care provider for purposes
of this section and the sections in Chapter 133.
(d) For coding, billing, and reporting, of
facility services covered in this rule, Texas workers' compensation system
participants shall apply the Medicare payment policies in effect on the date a
service is provided with any additions or exceptions specified in this section,
including the following paragraphs.
(1)
Specific provisions contained in the Labor Code or the Texas Department of
Insurance, Division of Workers' Compensation (Division) rules, including this
chapter, shall take precedence over any conflicting provision adopted or
utilized by the CMS in administering the Medicare program.
(2) Independent Review Organization decisions
regarding medical necessity made in accordance with Labor Code §
413.031
and § 133.308 of this title (relating to MDR by Independent Review
Organizations), which are made on a case-by-case basis, take precedence in that
case only, over any Division rules and Medicare payment policies.
(3) Whenever a component of the Medicare
program is revised and effective, use of the revised component shall be
required for compliance with Division rules, decisions, and orders for services
rendered on and after the effective date, or after the effective date or the
adoption date of the revised Medicare component, whichever is later.
(e) Regardless of billed amount,
reimbursement shall be:
(1) the amount for
the service that is included in a specific fee schedule set in a contract that
complies with the requirements of Labor Code §
413.011;
or
(2) if no contracted fee
schedule exists that complies with Labor Code §
413.011,
the maximum allowable reimbursement (MAR) amount under subsection (f) of this
section, including any reimbursement for implantables.
(3) If no contracted fee schedule exists that
complies with Labor Code §
413.011,
and an amount cannot be determined by application of the formula to calculate
the MAR as outlined in subsection (f) of this section, reimbursement shall be
determined in accordance with §
134.1 of
this title (relating to Medical Reimbursement).
(f) The reimbursement calculation used for
establishing the MAR shall be the Medicare ASC reimbursement amount determined
by applying the most recently adopted and effective Medicare Payment System
Policies for Services Furnished in Ambulatory Surgical Centers and Outpatient
Prospective Payment System reimbursement formula and factors as published
annually in the Federal Register. Reimbursement shall be based on the fully
implemented payment amount as in ADDENDUM AA, ASC COVERED SURGICAL PROCEDURES
FOR CY 2008, published in the November 27, 2007 publication of the Federal
Register, or its successor. The following minimal modifications apply:
(1) Reimbursement for non-device intensive
procedures shall be:
(A) The Medicare ASC
facility reimbursement amount multiplied by 235 percent; or
(B) if an ASC facility or surgical implant
provider requests separate reimbursement for an implantable, reimbursement for
the non-device intensive procedure shall be the sum of:
(i) the lesser of the manufacturer's invoice
amount or the net amount (exclusive of rebates and discounts) plus 10 percent
or $1,000 per billed item add-on, whichever is less, but not to exceed $2,000
in add-on's per admission; and
(ii)
the Medicare ASC facility reimbursement amount multiplied by 153
percent.
(2)
Reimbursement for device intensive procedures shall be:
(A) the sum of:
(i) the ASC device portion; and
(ii) the ASC service portion multiplied by
235 percent; or
(B) If
an ASC facility or surgical implant provider requests separate reimbursement
for an implantable, reimbursement for the device intensive procedure shall be
the sum of:
(i) the lesser of the
manufacturer's invoice amount or the net amount (exclusive of rebates and
discounts) plus 10 percent or $1,000 per billed item add-on, whichever is less,
but not to exceed $2,000 in add-on's per admission; and
(ii) the ASC service portion multiplied by
235 percent.
(g) A facility, or surgical implant provider
with written agreement of the facility, may request separate reimbursement for
an implantable.
(1) The facility or surgical
implant provider requesting reimbursement for the implantable shall:
(A) bill for the implantable on the
Medicare-specific billing form for ASCs;
(B) include with the billing a certification
that the amount billed represents the actual cost (net amount, exclusive of
rebates and discounts) for the implantable. The certification shall include the
following sentence: "I hereby certify under penalty of law that the following
is the true and correct actual cost to the best of my knowledge," and shall be
signed by an authorized representative of the facility or surgical implant
provider who has personal knowledge of the cost of the implantable and any
rebates or discounts to which the facility or surgical implant provider may be
entitled.
(2) An
insurance carrier may use the audit process under §
133.230
of this title (relating to Insurance Carrier Audit of a Medical Bill) to seek
verification that the amount certified under paragraph (1) of this subsection
properly reflects the requirements of this subsection. Such verification may
also take place in the Medical Dispute Resolution process under §
133.307 of
this title (relating to MDR of Fee Dispute), if that process is properly
requested, notwithstanding §
133.307(d)(2)(B)
of this title.
(3) Nothing in this
rule precludes an ASC or insurance carrier from utilizing a surgical implant
provider to arrange for the provision of implantable devices. Implantables
provided by a surgical implant provider shall be reimbursed according to this
subsection.
(h) For
medical services provided in an ASC, but not addressed in the Medicare payment
policies as outlined in subsection (f) of this section, and for which Medicare
reimburses using other Medicare fee schedules, reimbursement shall be made
using the applicable Division Fee Guideline in effect for that service on the
date the service was provided.
(i)
If Medicare prohibits a service from being performed in an ASC setting, the
insurance carrier, health care provider, and ASC may agree, on a voluntary
basis, to an ASC setting as follows:
(1) The
agreement may occur before, or during, preauthorization.
(2) A preauthorization request may be
submitted for an ASC facility setting only if an agreement has already been
reached and a copy of the signed agreement is filed as a part of the
preauthorization request.
(3) The
agreement between the insurance carrier and the ASC must be in writing, in
clearly stated terms, and include:
(A) the
reimbursement amount;
(B) any other
provisions of the agreement; and
(C) names, titles and signatures of both
parties with dates.
(4)
Copies of the agreement are to be kept by both parties. This agreement does not
constitute a voluntary network established in accordance with Labor Code §
413.011(d-1).
(5) Upon request of the Division, the
agreement information shall be submitted in the form and manner prescribed by
the Division.
(j) Where
any terms or parts of this section or its application to any person or
circumstance are determined by a court of competent jurisdiction to be invalid,
the invalidity does not affect other provisions or applications of this section
that can be given effect without the invalidated provision or
application.
