Oklahoma Administrative Code › Title 317 - Oklahoma Health Care Authority › Chapter 30 - Medical Providers-Fee for Service › Subchapter 5 - Individual Providers and Specialties › Part 3 - HOSPITALS › Section 317:30-5-42.14 - Surgery and diagnostic services

Current through Vol. 41, No. 20, July 1, 2024
(a)
Ambulatory Patient Classification
				  (APC) Groups.
All outpatient hospital services paid under the Medicare
				  Outpatient Prospective Payment System (OPPS) are classified into groups called
				  Ambulatory Payment Classifications or APCs. Group services identified by Health
				  Care Procedure Coding System (HCPCS) codes and descriptors within APC groups
				  are the basis for setting payment rates under OPPS. Services in each APC are
				  similar clinically and in terms of the resources they require. The payment rate
				  calculated for an APC applies to all of the services assigned to the APC.
				  Depending on the services provided, a hospital may receive a number of APC
				  payments for the services furnished to a member on a single day.
(b)
Reimbursement.
Reimbursement
				  is made for selected services performed in an outpatient hospital. Hospital
				  outpatient services are paid on a rate-per-service basis that varies according
				  to the Ambulatory Payment Classification (APC) group to which the services are
				  assigned.
(c)
Multiple
				  Surgeries.
Multiple procedures furnished during the same visit are
				  discounted. The full amount is paid for the procedure with the highest payment
				  group. Fifty percent is paid for any other surgical procedure(s) performed at
				  the same time if the procedure is subject to discounting based on the status
				  indicator established by Medicare.
(d)
Status indicators.
Status
				  indicators identify whether the service described by a HCPCS code is paid under
				  the OPPS and if so, whether payment is made separately or packaged and if
				  payment is subject to discounting. SoonerCare follows Medicare's guidelines for
				  packaged/bundled service costs.
(e)
Minor procedures.
Minor procedures that are normally performed in
				  a physician's office are not covered in the outpatient hospital unless
				  medically necessary.
(f)
Ambulatory Surgery.
When an ambulatory surgery is performed in the
				  inpatient hospital setting, the physician must provide exception rationale
				  justifying the need for an inpatient setting to OHCA medical staff for
				  review.
(g)
Dental
				  Procedures.
Routine dental procedures that are normally performed in a
				  dentist's office are not covered in an outpatient hospital setting unless
				  medically necessary as determined by OHCA. For OHCA payment purposes, the APC
				  list has been expanded to cover dental services for adults in an ICF/MR and all
				  children.
(1) Non-emergency routine dental
				  that is provided in an outpatient hospital setting is covered under the
				  following circumstances:
(A) The child has a
				  medical history of uncontrolled bleeding or other medical condition which
				  renders in-office treatment impossible.
(B) The child has uncontrollable behavior in
				  the dental office even with premedication.
(C) The child needs extensive dental
				  procedures or oral surgery procedures.