Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.160 - Outpatient Hospital Services Reimbursement Methodology

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This proposed amendment updates all
				  documents incorporated by reference and used to create the outpatient
				  simplified fee schedule.
(1)
				Outpatient
Simplified Fee Schedule
(OSFS) Payment Methodology.
(A) Definitions. The following definitions
				will be used in administering section (1) of this rule:
1. Ambulatory Payment Classification (APC).
				Medicare's ambulatory payment classification assignment groups of Current
				Procedural Terminology (CPT) or Healthcare Common Procedures Coding System
				(HCPCS) codes. APCs classify and group clinically similar outpatient hospital
				services that can be expected to consume similar amounts of hospital resources.
				All services within an APC group have the same relative weight used to
				calculate the payment rates;
2. APC
				conversion factor. The unadjusted national conversion factor calculated by
				Medicare effective January 1 of each year, as published with the Medicare
				Outpatient Prospective Payment System (OPPS) Final Rule, and used to convert
				the APC relative weights into a dollar payment. The Medicare OPPS Final Rule is
				incorporated by reference and made a part of this rule as published by the
				Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
				Baltimore, MD 21244, and available at
https://www.govinfo.gov/content/pkg/FR-2022-11-23/pdf/2022-23918.pdf
,
				November 23, 2022. This rule does not incorporate any subsequent amendments or
				additions;
3. APC relative weight.
				The national relative weights calculated by Medicare for the Outpatient
				Prospective Payment System;
4.
				Current Procedural Terminology (CPT). A medical code set that is used to report
				medical, surgical, and diagnostic procedures and services to entities such as
				physicians, health insurance companies, and accreditation
				organizations;
5. Dental procedure
				codes. The procedure codes found in the Code on Dental Procedures and
				Nomenclature (CDT), a national uniform coding method for dental procedures
				maintained by the American Dental Association;
6. Federally Deemed Critical Access Hospital.
				Hospitals that meet the federal definition found in section 1820(c)(2)(B) of
				the Social Security Act;
7. HCPCS.
				The national uniform coding method maintained by the Centers for Medicare &
				Medicaid Services (CMS) that incorporates the American Medical Association
				(AMA) Physicians CPT and the three (3) HCPCS unique coding levels, I, II, and
				III;
8. Medicare Inpatient
				Prospective Payment System (IPPS) wage index. The wage area index values are
				calculated annually by Medicare, published as part of the Medicare IPPS Final
				Rule;
9. Missouri conversion
				factor. The single, statewide conversion factor used by the MO HealthNet
				Division (MHD) to determine the APC-based fees, uses a formula based on
				Medicare OPPS. The formula consists of sixty percent (60%) of the APC
				conversion factor, as defined in paragraph (1)(A)2. multiplied by the St.
				Louis, MO, Medicare IPPS wage index value, plus the remaining forty percent
				(40%) of the APC conversion factor, with no wage index adjustment;
10. Nominal charge provider. A nominal charge
				provider is determined from the third prior year audited Medicaid cost report.
				The hospital must meet the following criteria:
A. A public non-state governmental acute care
				hospital with a low-income utilization rate (LIUR) of at least forty percent
				(40%) and a Medicaid inpatient utilization rate (MIUR) greater than one (1)
				standard deviation from the mean, and is licensed for fifty (50) inpatient beds
				or more and has an occupancy rate of at least forty percent (40%). The hospital
				must meet one (1) of the federally mandated Disproportionate Share
				qualifications; or
B. The hospital
				is a public hospital operated by the Department of Mental Health primarily for
				the care and treatment of mental disorders; and
C. A hospital physically located in the state
				of Missouri;
11.
				Outpatient Prospective Payment System (OPPS). Medicare's hospital outpatient
				prospective payment system mandated by the Balanced Budget Refinement Act of
				1999 (BBRA) and the Medicare, Medicaid, and State Children's Health Insurance
				Program (SCHIP) Benefits Improvement and Protection Act of 2000 (BIPA);
				and
12. Payment level adjustment.
				The percentage applied to the Medicare fee to derive the OSFS
				fee.