Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-75 - Outpatient hospital reimbursement

Current through all regulations passed and filed through July 1, 2024
For purposes of
				this rule, eligible providers of hospital services as defined in rule
				5160-2-01 of the Administrative
				Code and assigned to prospective payment peer group as described in rule
				5160-2-05 of the Administrative
				Code are subject to the enhanced ambulatory patient grouping system (EAPG)
				prospective payment methodology utilized by the Ohio department of medicaid
				(ODM) as described in this rule.
(A) Definitions.
(1) "Enhanced ambulatory patient grouping
			 (EAPG)" is a group of outpatient procedures, encounters, or ancillary services,
			 which reflect similar patient characteristics and resource utilization, and which incorporate the use of international
			 classification of diseases (ICD) diagnosis codes, current procedural
			 terminology (CPT) code set and healthcare common procedure coding system
			 (HCPCS) procedure codes.
(2) "EAPG
			 grouper" is the software provided by 3M health information systems to group
			 outpatient claims based on services performed and resource intensity.
(3) "Default EAPG settings" are the default
			 EAPG grouper options in 3M's core grouping software for each EAPG grouper
			 version.
(4) "Discounting factor"
			 is a factor applicable for multiple significant procedures or repeated
			 ancillary services designated by default EAPG settings or both. The appropriate
			 percentage (fifty or one hundred per cent) will be applied to the highest
			 weighted of the multiple procedures or ancillary services payment group.
(a) "Full payment" is the EAPG payment with
			 no applicable discounting factor.
(b) "Consolidation factor" is a factor of
			 zero per cent applicable for services designated with a same procedure
			 consolidation flag or clinical procedure consolidation flag by the EAPG grouper
			 under default EAPG settings.
(c)
			 "Packaging factor" is a factor of zero per cent applicable for services
			 designated with a packaging flag by the EAPG grouper under default EAPG
			 settings.
(5) "EAPG base
			 rate" is the dollar value that will be multiplied by the final EAPG weight for each
			 EAPG on a claim to determine the total allowable medicaid payment for a
			 visit.
(6) "Hospital peer groups"
			 are for the purposes of setting rates and making payments under the EAPG or
			 prospective payment system. ODM classifies all hospitals
			 not excluded in rule
			 5160-2-05 of the Administrative
			 Code into one of the mutually exclusive peer groups defined in this paragraph.
(a) Critical access hospitals as defined in
			 rule 5160-2-05 of the Administrative
			 Code.
(b) Rural hospitals as
			 defined in rule
			 5160-2-05 of the Administrative
			 Code.
(c) Children's hospitals as
			 defined in rule
			 5160-2-05 of the Administrative
			 Code.
(d) Teaching hospitals as
			 defined in rule
			 5160-2-05 of the Administrative
			 Code.
(e) Urban hospitals as
			 defined in rule
			 5160-2-05 of the Administrative
			 Code.
(f) All other hospitals not
			 located in Ohio that are not classified in paragraphs (A)(6)(a) to (A)(6)(e) of
			 this rule.
(7) "Outpatient claim"
			 encompasses the outpatient services rendered to one eligible medicaid recipient
			 on one date of service.
(8) "Outpatient
			 invoice" is a bill submitted in accordance with Chapter 5160-1 of the
			 Administrative Code, to ODM for services rendered to one eligible medicaid
			 recipient on one or more date(s) of service. For an invoice encompassing more
			 than one date of service, each date will be processed separately as an
			 individual claim. An invoice should be limited to thirty calendar
			 days.
(9) "Procedure code"
			 is a CPT or HCPCS code as identified in rule
			 5160-1-19 of the Administrative
			 Code. A list of covered procedure codes is published on
			 ODM's website,
http://medicaid.ohio.gov/
.
(10)
			 "Relative weight" is a factor specific to each EAPG that represents that EAPG's
			 relative cost compared to an average case. The relative weights for all EAPGs
			 are calculated as described in paragraph (F) of this rule.
(11)
			 "Revenue center codes" are those in effect on the date of service and are
			 listed in ODM's hospital billing guidelines as published on
			 ODM's website,
http://medicaid.ohio.gov/
.