Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-22 - Ambulatory Surgery Center Services › Section 5160-22-01 - Ambulatory surgery center (ASC) services: provider eligibility, coverage, and reimbursement

Current through all regulations passed and filed through July 1, 2024
Effective for dates of service on or after the effective date
				of this rule, eligible ambulatory surgery centers as defined in paragraphs
				(A)(1) and (B) of this rule are subject to the enhanced ambulatory patient
				grouping system (EAPG) and prospective payment methodology utilized by the Ohio
				department of medicaid (ODM) as described in this
				rule.
(A) Definitions, for the
			 purposes of this rule the following meanings apply.
(1) An "ambulatory surgery center (ASC)" is
			 any distinct entity that operates exclusively for the purpose of providing
			 surgical services to patients not requiring hospitalization.
(2)
									"ASC
			 claim" encompasses the ASC services rendered to one eligible medicaid
			 beneficiary on one date of service at an ASC facility.
(3)
									
									"ASC Cost-to-charge ratio" is ninety per cent of the
			 statewide average outpatient cost-to-charge ratio as calculated in rule
			 5160-2-22 of the Administrative
			 Code.
(4)
									
									"ASC facility services" are items and services
			 furnished by an ASC in connection with a covered ASC surgical
			 procedure(s).
(5)
									
									"ASC
			 invoice" is a bill submitted in accordance with Chapter 5160-1 of the
			 Administrative Code, to ODM for services rendered to one eligible medicaid
			 beneficiary 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.
(6)
									
									"Default EAPG settings" are
			 the default EAPG grouper options in 3M's core grouping software for each EAPG
			 grouper version.
(7)
									
									"Diagnosis code" is the
			 international classification of diseases (ICD) diagnosis code as identified in
			 rule 5160-1-19 of the Administrative
			 Code.
(8)
									
									"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.
(9)
									
									"EAPG base rate" is the dollar value
			 that is multiplied by the final EAPG relative weight for each EAPG on a claim
			 to determine the total allowable medicaid payment for a visit. The EAPG base
			 rate for ASCs is sixty-three and six tenths per cent of the statewide average
			 outpatient hospital EAPG base rate. Hospital EAPG base rates are calculated as
			 described in rule
			 5160-2-75 of the Administrative
			 Code.
(10)
									
									"EAPG grouper" is the software provided
			 by 3M health information systems to group outpatient claims based on services
			 performed and resource intensity.
(11)
									
									"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) procedural codes, and
			 healthcare common procedure coding system (HCPCS) procedure
			 codes.
(12)
									
									"Procedure code" is the CPT code or
			 HCPCS code as identified in rule
			 5160-1-19 of the Administrative
			 Code.
(13)
									"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 EAPGs are calculated as described in rule
			 5160-2-75 of the Administrative
			 Code.