Washington Administrative Code › Title 296 - Labor and Industries, Department of › Chapter 296-23A - Hospitals › Part 4 - AMBULATORY PAYMENT CLASSIFICATION PAYMENT METHODS AND POLICIES › Section 296-23A-0710 - Definitions

Current through Register Vol. 24-14, July 15, 2024
"Alternate outpatient payment."
A payment for
				  proper and necessary services calculated using a method other than the APC
				  method, such as the outpatient hospital rate or fee schedule.
"Ambulatory payment classification (APC) bill."
An outpatient bill for hospital services that are grouped and paid using
				  APCs.
"Ambulatory payment classification (APC)
				  weight."
The relative value assigned to each APC by CMS. For information
				  on calculating the APC weights, please see 42 C.F.R., Chapter IV, Part 419, et
				  al. Medicare Program; Prospective Payment System for Hospital Outpatient
				  Services.
"Ambulatory payment classification (APC)."
A
				  grouping for outpatient visits which are similar both clinically and in the
				  resources used.
"Ambulatory surgery centers (ASCs)."
Ambulatory
				  surgery centers as defined by the department. ASCs are excluded from the APC
				  payment system.
"Blended rate."
The dollar amount used to
				  determine APC payments.
"Bundling."
Including the costs of supplies and
				  certain other items with the costs of APCs. Bundled services will not be paid
				  separately.
"Cancer hospitals."
Freestanding hospitals
				  specializing in the treatment of individuals who have a neoplasm
				  diagnosis.
"Children's hospitals."
Freestanding hospitals
				  specializing in the treatment of individuals less than fourteen years of
				  age.
"CMS."
Centers for Medicare and Medicaid
				  Services, formerly the Health Care Financing Administration (HCFA).
"Correct coding initiative."
A process to
				  encourage hospitals to code the most appropriate diagnosis and procedure for
				  the services rendered.
"Critical access hospitals."
Critical access
				  hospitals as defined by the department of health.
"Current procedural terminology (CPT)."
A
				  systematic listing of descriptive terms and identifying codes for reporting
				  medical services, procedures, interventions performed by physicians; the
				  American Medical Association (AMA) publishes it annually.
"Discount factor."
The percentage applied to
				  additional significant procedures when a claim has multiple significant
				  procedures or when the same procedure is performed multiple times.
"Exempt services."
Services and hospitals that
				  have been identified by CMS and/or L&I as exempt from the APC-based payment
				  system.
"Health care common procedure coding system
				  (HCPCS)."
Medicare's procedure coding system, which consists of Level 1
				  CPT Codes, Level 2 National Codes, and Level 3 Local Codes.
"Incidental services."
Proper and necessary
				  services that are integral to the delivery of the significant procedure or
				  medical visit and are not separately reimbursable.
"Inpatient only procedures."
Certain procedures
				  designated by CMS as being of sufficient resource intensity that an inpatient
				  setting is always required.
"Modifier."
A two-digit alphabetic and/or
				  numeric identifier that is added to the procedure code to indicate the type of
				  service performed. Modifiers add clarification to procedures and can affect
				  payment. Modifiers are listed in the current CPT and HCPCS manuals.
"Non-APC services."
Services specifically
				  excluded by CMS or by L&I from APC payment.
"Out-of-state hospitals."
Any hospital not
				  physically located within the state of Washington.
"Outpatient code editor."
A prepayment analysis
				  program designed to exclude certain diagnostic and procedure codes from being
				  classified within the APC payment system.
"Outpatient prospective payment system (OPPS)."
A payment system that groups hospital outpatient visits into APCs and
				  multiplies the relative weight factor by the OPPS conversion rate to determine
				  the appropriate payment.
"Outpatient services."
Proper and necessary
				  health care services and treatment ordinarily furnished by a hospital in which
				  the injured worker is not admitted as an inpatient.
"Outpatient."
A patient who receives proper and
				  necessary health care services or supplies in a hospital-type setting but is
				  not admitted as an inpatient.
"Partial hospitalization."
Mental health
				  services provided in an inpatient setting without the traditional inpatient
				  overnight stay.
"Pediatric services."
Proper and necessary
				  health care services and treatment ordinarily furnished by a hospital in which
				  the injured worker is under the age of fourteen.
"Psychiatric hospitals."
Freestanding hospitals
				  specializing in the treatment of individuals with a mental health
				  disease.
"Rehabilitation hospitals."
Freestanding
				  hospitals specializing in the treatment of individuals in need of
				  rehabilitative services.
"Related encounters or related services."
Multiple encounters which are:
Provided within the same window of service; and
By the same provider (hospital).
"Single visit."
A single visit includes all
				  related services that are combined for reimbursement when they occur with the
				  same hospital during the window of service.
"Special programs."
Programs specifically
				  designated by the department.
"Transitional pass-through."
Certain drugs,
				  devices and biologicals, as identified by CMS that are entitled to a specified
				  payment until CMS assigns and reimburses them under their own APC.
"Window of service."
A single date of service.
				  All services associated with the visit for that date constitute a single visit,
				  even when those services are provided on different days.
Statutory Authority:
					 RCW
					 51.04.030 and 51.12.330. 06-12-073, §
					 296-23A-0710, filed 6/6/06, effective 7/7/06. Statutory Authority:
					 RCW
					  51.04.020. 03-21-069, § 296-23A-0710,
					 filed 10/14/03, effective 12/1/03. Statutory Authority:
					 RCW
					  51.04.020,
					 51.04.030,
					 51.36.080,
					 51.36.085. 01-24-045, §
					 296-23A-0710, filed 11/29/01, effective
					 1/1/02.