SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)
Preproposal statement of inquiry was filed as WSR 05-13-076.
Title of Rule and Other Identifying Information: Amending WAC 388-550-6000 Outpatient hospital services -- Conditions of payment and reimbursement, 388-550-6350 Outpatient sleep apnea/sleep study programs, 388-550-6500 Blood and blood products, 388-550-7000 Outpatient prospective payment system (OPPS) -- General, 388-550-7050 OPPS -- Definitions, 388-550-7100 OPPS -- Exempt hospitals, 388-550-7200 OPPS -- Payment method, 388-550-7300 OPPS -- Payment limitations, 388-550-7400 OPPS APC relative weights, 388-550-7500 OPPS APC conversion factor, and 388-550-7600 OPPS payment calculation.
Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on June 5, 2007, at 10:00 a.m.
Date of Intended Adoption: Not earlier than June 6, 2007.
Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail email@example.com, fax (360) 664-6185, by 5:00 p.m. on June 5, 2007.
Assistance for Persons with Disabilities: Contact Stephanie Schiller by June 1, 2007, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at firstname.lastname@example.org.
Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department is proposing to amend sections in chapter 388-550 WAC relating to outpatient prospective payment system (OPPS), outpatient sleep apnea/sleep study programs, blood and blood components, and conditions of payment and payment methods for outpatient hospital services. These amendments change verbiage from "medical assistance administration (MAA)" to "the department," replace "ambulatory payment classification (APC) conversion factor" with "OPPS conversion factor," add the definition for "national payment rate," and clarify and update existing language.
Reasons Supporting Proposal: See above.
Statutory Authority for Adoption: RCW 74.08.090 and 74.09.500.
Statute Being Implemented: RCW 74.08.090 and 74.09.500.
Rule is not necessitated by federal law, federal or state court decision.
Name of Proponent: Department of social and health services, governmental.
Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1342; Implementation and Enforcement: Cynthia Smith, P.O. Box 45502, Olympia, WA 98504-5510, (360) 725-1839.
No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has determined that the proposed rule will not create more than minor costs for affected small businesses.
A cost-benefit analysis is not required under RCW 34.05.328. The department has determined that the proposed rule does not meet the definition of "significant legislative rule" under RCW 34.05.328, and therefore a cost-benefit analysis is not required.
April 26, 2007
Stephanie E. Schiller
(2) To be paid for covered outpatient hospital services, a hospital provider must:
(a) Have a current core provider agreement with ((
(b) Bill ((
MAA)) the department according to the conditions
of payment under WAC 388-502-0100;
(c) Bill ((
MAA)) the department according to the time limits
under WAC 388-502-0150; and
(d) Meet program requirements in other applicable WAC and
MAA)) the department's published issuances.
MAA)) The department does not pay separately for any
(a) Included in a hospital's room charges;
(b) Included as covered under ((
MAA's)) the department's
definition of room and board (e.g., nursing services). See WAC 388-550-1050; or
(c) Related to an inpatient hospital admission and provided within one calendar day of a client's inpatient admission.
MAA)) The department does not pay:
(a) A hospital for outpatient hospital services when a
managed care plan is contracted with ((
MAA)) the department to
cover these services;
(b) More than the "acquisition cost" ("A.C.") for HCPCS
(Healthcare Common Procedure Coding System) codes noted in the
outpatient fee schedule ((
as paid "A.C.")); or
(c) For cast room, emergency room, labor room, observation room, treatment room, and other room charges in combination when billing periods for these charges overlap.
MAA)) The department uses the outpatient departmental
weighted costs-to-charges (ODWCC) rate to pay for covered
outpatient services provided in a critical access hospital (CAH).
See WAC 388-550-2598.
MAA)) The department uses the maximum allowable fee
schedule to pay non-OPPS hospitals and non-CAH hospitals for the
following types of covered outpatient hospital services listed in
(( MAA's)) the department's current published outpatient hospital
fee schedule and billing instructions:
Laboratory services)) EKG/ECG/EEG and other
(b) Imaging services;
EKG/ECG/EEG and other diagnostics)) Immunizations;
Physical therapy)) Laboratory services;
Speech/language)) Occupational therapy;
Synagis)) Physical therapy;
(g) Sleep studies; ((
(h) Speech/language therapy;
(i) Synagis; and
(j) Other hospital services identified and published by the department.
MAA)) The department uses the hospital outpatient rate
as described in WAC 388-550-4500 to pay for covered outpatient
hospital services when:
(a) A hospital provider is a non-OPPS or a non-CAH provider; and
(b) The services are not included in subsection (6) of this section.
(8) Hospitals must provide documentation as required and/or
requested by ((
MAA)) the department.
(9) All hospital providers must present final charges to the department within three hundred sixty-five days of the "statement covers period from date" shown on the claim. The state of Washington is not liable for payment based on billed charges received beyond three hundred sixty-five days from the "statement covers period from date" shown on the claim.
[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-20-060, § 388-550-6000, filed 10/1/04, effective 11/1/04. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, and Public Law 104-191. 03-19-044, § 388-550-6000, filed 9/10/03, effective 10/11/03. Statutory Authority: RCW 74.08.090, 74.09.500, 74.09.035(1), and 43.88.290. 02-21-019, § 388-550-6000, filed 10/8/02, effective 11/8/02. Statutory Authority: RCW 74.09.090, 42 U.S.C. 1395x(v), 42 C.F.R. 447.271 and 42 C.F.R. 11303. 99-14-028, § 388-550-6000, filed 6/28/99, effective 7/1/99. Statutory Authority: RCW 74.08.090, 42 USC 1395 x(v), 42 CFR 447.271, 447.11303, and 447.2652. 99-06-046, § 388-550-6000, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-6000, filed 12/18/97, effective 1/18/98.]
(2) The department ((
shall)) pays for polysomnograms or
multiple sleep latency tests only when performed in outpatient
hospitals approved by the (( medical assistance administration
(MAA))) the department as centers of excellence for sleep
apnea/sleep study programs.
(3) The department ((
shall)) does not require prior
authorization for sleep studies as outlined in WAC 388-550-1800.
(4) Hospitals ((
shall)) must bill the department for sleep
studies using current procedural terminology codes. The
department (( shall)) does not (( reimburse)) pay hospitals for
these services when billed under revenue codes alone.
[Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-6350, filed 12/18/97, effective 1/18/98.]
(a) Blood bank service charges for processing ((
storage of blood and blood (( products)) components; and
(b) Blood administration charges.
Other than payment of blood bank service charges,))
The department (( shall)) does not pay for blood and blood
(( derivatives)) components.
(3) The department ((
shall)) does not pay a hospital
separately (( reimburse blood bank service charges for handling
and processing blood and blood derivatives provided to an
individual who is hospitalized when the hospital is reimbursed
under)) for the services identified in subsection (1) when these
services are included and paid using the diagnosis-related group
(DRG) (( system)), per diem, or per case rate payment rates. (( The department shall bundle these service charges into the
total DRG payment.))
(4) The department ((
shall reimburse a hospital, which is))
pays a hospital no more than the hospital's cost, as determined
by the department, for the services identified in subsection (1)
when the hospital is paid (( under)) using the ratio of
costs-to-charges (RCC) or departmental weighted costs-to-charges
(DWCC) payment method(( , separately for processing blood and
[Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-6500, filed 12/18/97, effective 1/18/98.]
(2) For a complete description of the CMS outpatient hospital prospective payment system, including the assignment of status indicators (SIs), see 42 CFR, Chapter IV, Part 419. The Code of Federal Regulations (CFR) is available from the CFR web site and the Government Printing Office, Seattle office. The document is also available for public inspection at the Washington state library (a copy of the document may be obtained upon request, subject to any pertinent charge).
[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-20-061, § 388-550-7000, filed 10/1/04, effective 11/1/04.]
"Alternative outpatient payment" means a payment
calculated using a method other than the ambulatory payment
classification (APC) method, such as the outpatient hospital rate
or the fee schedule.))
"Ambulatory payment classification (APC)" means a grouping that categorizes outpatient visits according to the clinical characteristics, the typical resource use, and the costs associated with the diagnoses and the procedures performed.
"Ambulatory payment classification (APC) weight" means the
relative value assigned to each APC.
"Ambulatory payment classification (APC) conversion factor" means a dollar amount that is one of the components of the APC payment calculation.))
"Budget target" means the amount of money appropriated by
the legislature or through ((
MAA's)) the department's budget
process to pay for a specific group of services, including
anticipated caseload changes or vendor rate increases.
"Budget target adjustor" means the ((
specific multiplier applied to all payable ambulatory payment
classifications (APCs) to allow (( MAA)) the department to reach
and not exceed the established budget target.
"Discount factor" means the percentage applied to additional significant procedures when a claim has multiple significant procedures or when the same procedure is performed multiple times on the same day. Not all significant procedures are subject to a discount factor.
"Medical visit" means diagnostic, therapeutic, or consultative services provided to a client by a healthcare professional in an outpatient setting.
"Modifier" means a two-digit alphabetic and/or numeric identifier that is added to the procedure code to indicate the type of service performed. The modifier provides the means by which the reporting hospital can describe or indicate that a performed service or procedure has been altered by some specific circumstance but not changed in its definition or code. The modifier can affect payment or be used for information only. Modifiers are listed in fee schedules.
"National payment rate" means a rate for a given procedure code, published by the centers for medicare and medicaid (CMS), that does not include a state or location specific adjustment.
"Observation services" means services furnished by a hospital on the hospital's premises, including use of a bed and periodic monitoring by hospital staff, which are reasonable and necessary to evaluate an outpatient's condition or determine the need for possible admission to the hospital as an inpatient.
"Outpatient code editor (OCE)" means a software program
published by 3M Health Information Systems that ((
department uses for classifying and editing claims in ambulatory
payment classification (APC) based OPPS.
"Outpatient prospective payment system (OPPS)" means the
payment system used by ((
MAA)) the department to calculate
reimbursement to hospitals for the facility component of
outpatient services. This system uses ambulatory payment
classifications (APCs) as the primary basis of payment.
"Outpatient prospective payment system conversion factor" means a hospital-specific multiplier assigned by the department that is one of the components of the APC payment calculation.
"Pass-throughs" means certain drugs, devices, and biologicals, as identified by centers for medicare and medicaid services (CMS), for which providers are entitled to additional separate payment until the drugs, devices, or biologicals are assigned their own ambulatory payment classification (APC).
"Significant procedure" means a procedure, therapy, or service provided to a client that constitutes the primary reason for the visit to the healthcare professional.
"Status indicator (SI)" means a one-digit identifier assigned to each service by the outpatient code editor (OCE) software.
"SI" see "status indicator."
[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-20-061, § 388-550-7050, filed 10/1/04, effective 11/1/04.]
(1) Cancer hospitals;
(2) Critical access hospitals;
(3) Free-standing psychiatric hospitals;
Out-of-state hospitals (Bordering-city hospitals are
considered in-state hospitals. See WAC 388-550-1050.);
(5))) Pediatric hospitals;
(6))) (5) Peer group A hospitals;
(7))) (6) Rehabilitation hospitals; and
(8))) (7) Veterans' and military hospitals.
[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-20-061, § 388-550-7100, filed 10/1/04, effective 11/1/04.]
AMBULATORY PAYMENT CLASSIFICATION (APC) METHOD
MAA)) The department uses the APC method when the
centers for medicare and medicaid services (CMS) has established
(( either an APC weight or)) a national payment rate to pay for
covered services. The APC method is the primary payment
methodology for OPPS. Examples of services paid by the APC
methodology include, but are not limited to:
(a) Ancillary services;
(b) Medical visits;
(b))) (c) Nonpass-through drugs or devices;
(d) Observation services;
(e) Packaged services subject to separate payment when criteria are met;
(f) Pass-through drugs;
(g) Significant procedures that are not subject to multiple procedure discounting (except for dental-related services);
(c))) (h) Significant procedures that are subject to
multiple procedure discounting; and
(d) Nonpass-through drugs or devices;
(e) Observation services; and
(f) Ancillary services)) (i) Other services as identified by the department.
OPPS MAXIMUM ALLOWABLE FEE SCHEDULE
MAA)) The department uses the (( OPPS)) outpatient fee
schedule published in the (( OPPS section of MAA's)) the
department's billing instructions to pay for covered:
(a) Services that are exempted from the APC payment methodology or services for which there are no established weight(s);
(b) Procedures that are on the CMS inpatient only list;
(c) Items, codes, and services that are not covered by medicare;
(d) Corneal tissue acquisition;
Drugs or biologicals that are pass-throughs; and
(f))) Devices that are pass-throughs (see WAC 388-550-7050 for definition of pass-throughs); and
(f) Dental clinic services.
HOSPITAL OUTPATIENT RATE
MAA)) The department uses the hospital outpatient rate
described in WAC 388-550-3900 and 388-550-4500 to pay for the
services listed in subsection (3) of this section for which
(( MAA)) the department has not established a maximum allowable
[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-20-061, § 388-550-7200, filed 10/1/04, effective 11/1/04.]
(a) When a unit limit for services is not stated in the
OPPS)) outpatient fee schedule, (( MAA)) department pays for
services according to the program's unit limits stated in
applicable WAC and published issuances.
(b) Because multiple units for services may be factored into
the ambulatory payment classification (APC) weight, ((
department pays for services according to the unit limit stated
in the (( OPPS)) outpatient fee schedule when the limit is not the
same as the program's unit limit stated in applicable WAC and
MAA)) The department does not pay separately for
covered services that are packaged into the APC rates. These
services are paid through the APC rates.
(3) The department:
(a) Limits surgical dental services payment to the ambulatory surgical services fee schedule and pays:
(i) The first surgical procedure at the applicable ambulatory surgery center group rate; and
(ii) The second surgical procedure at fifty percent of the ambulatory surgery center group rate.
(b) Considers all surgical procedures not identified in subsection (a) to be bundled.
(4) The department limits outpatient services billing to one claim per episode of care. If there are late charges, or if any line of the claim is denied, the department requires the entire claim to be adjusted.
[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-20-061, § 388-550-7300, filed 10/1/04, effective 11/1/04.]
[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-20-061, § 388-550-7400, filed 10/1/04, effective 11/1/04.]
[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-20-061, § 388-550-7500, filed 10/1/04, effective 11/1/04.]
APC payment =
APC relative weight x APC conversion factor x)) National
payment rate x Hospital OPPS conversion factor x
Discount factor (if applicable) x Units of service (if applicable) x
Budget target adjustor
(2) The total OPPS claim payment is the sum of the APC payments plus the sum of the lesser of the billed charge or allowed charge for each non-APC service.
(3) The department pays hospitals for claims that involve clients who have third-party liability (TPL) insurance, the lesser of either the:
(a) Billed amount minus the third-party payment amount; or
(b) Allowed amount minus the third-party payment amount.
[Statutory Authority: RCW 74.08.090 and 74.09.500. 04-20-061, § 388-550-7600, filed 10/1/04, effective 11/1/04.]