Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.30 - Outpatient Hospital Services › Rule 37.86.3020 - OUTPATIENT HOSPITAL SERVICES, OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) METHODOLOGY, AMBULATORY PAYMENT CLASSIFICATION

Current through Register Vol. 13, July 5, 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.