California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.30 - Hospital Outpatient Departments and Ambulatory Surgical Centers - Definitions

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) "Adjusted Conversion Factor" is
					 determined as follows: unadjusted conversion factor x (1-labor-related share +
					 (labor-related share x wage index)). For each update, the unadjusted conversion
					 factor for the preceding period is adjusted by the rate of change in the market
					 basket inflation factor. The market basket inflation factor and labor-related
					 share are specified in the Federal Register notices announcing revisions in the
					 Medicare payment rates. See Section
					 9789.39(b) for the
					 unadjusted conversion factor, market basket inflation factor, and labor-related
					 share by date of service.
For services rendered on or after February 15, 2006, in
						accordance with Section
						411 of
						Pub. L.
						108-173 and the final rule published in the
						Federal Register of November 10, 2005 (CMS-1501-FC, 70 FR 68516) at page 68556,
						the "Adjusted Conversion Factor" for a rural Sole Community Hospital (SCH)
						includes an adjustment factor of 1.071, which document is incorporated by
						reference and will be made available upon request to the Administrative
						Director.
(b) "Ambulatory
					 Payment Classifications (APC)" means the Centers for Medicare & Medicaid
					 Services' (CMS) list of ambulatory payment classifications of hospital
					 outpatient services.
(c)
					 "Ambulatory Surgical Center (ASC)" means any surgical clinic as defined in the
					 California Health and Safety Code Section
					 1204,
					 subdivision (b)(1), any ambulatory surgical center that is certified to
					 participate in the Medicare program under Title XVIII (42 U.S.C. SEC.
					 1395 et seq.) of the federal Social Security
					 Act, or any surgical clinic accredited by an accrediting agency as approved by
					 the Licensing Division of the Medical Board of California pursuant to Health
					 and Safety Code Sections
					 1248.15
					 and
					 1248.4
					 to use anesthesia, except local anesthesia or peripheral nerve blocks, or both,
					 in compliance with the community standard of practice, in doses that, when
					 administered have the probability of placing a patient at risk for loss of the
					 patient's life-preserving protective reflexes.
(d) "Ambulatory Surgical Center Payment
					 System" means Medicare's payment system for specific ambulatory surgical center
					 covered surgical procedures published in the Hospital Outpatient Prospective
					 Payment and Ambulatory Surgical Center Payment Systems final rule for the
					 relevant payment year.
(e) "Annual
					 Utilization Report of Specialty Clinics" means the Annual Utilization Report of
					 Clinics that is filed by February 15 of each year with the Office of Statewide
					 Health Planning and Development by the ASCs as required by Section
					 127285 and Section
					 1216
					 of the Health and Safety Code.
(f)
					 "APC Payment Rate" means CMS' hospital outpatient prospective payment system
					 rate. The APC payment rate is specified in the Federal Register notices
					 announcing revisions in the Medicare payment rates. See Section
					 9789.39(b) for the
					 Federal Register reference to the APC payment rate by date of
					 service.
(g) "APC Relative Weight"
					 means CMS' APC relative weight as set forth in CMS' hospital outpatient
					 prospective payment system. The APC relative weight is specified in the Federal
					 Register notices announcing revisions in the Medicare payment rates. See
					 Section 9789.39(b) for the
					 Federal Register reference to the APC relative weight by date of
					 service.
(h) "CMS" means the
					 Centers for Medicare & Medicaid Services of the United States Department of
					 Health and Human Services.
(i)
					 "Cost-to-Charge Ratio for ASC" means the ratio of the facility's total
					 operating costs to total gross charges during the preceding calendar
					 year.
(j) "Cost-to-Charge Ratio for
					 Hospital Outpatient Department" means the hospital cost-to-charge used by the
					 Medicare fiscal intermediary to determine high cost outlier payments.
(k) "Facility Only Services" means services,
					 defined by Medicare, that rarely or are never performed in the non-facility
					 setting, and are not:
1. emergency room
					 visits;
2. Surgical procedures;
					 or
3. An integral part of the
					 emergency room visit or surgical procedure, in accordance with section
					 9789.32. See section
					 9789.39(b) for the
					 CMS Physician Fee Schedule Relative Value File which contains the description
					 of the Facility Only Services by date of service.