WSR 01-24-045

PERMANENT RULES

DEPARTMENT OF

LABOR AND INDUSTRIES

[ Filed November 29, 2001, 10:13 a.m. , effective January 1, 2002 ]

Date of Adoption: November 29, 2001.

Purpose: The purpose of the rule changes is to allow the department to implement an outpatient prospective payment system (OPPS) in order to better manage outpatient expenditures, improve consistency of payment policies, improve consistency between payment levels and actual costs of service, establish greater uniformity between state agencies regarding reimbursement methodologies, allow for greater analysis and prediction of utilization and costs, and allow for rate adjustments to be based on more consistent and applicable data.

Citation of Existing Rules Affected by this Order: New WAC 296-23A-0221, 296-23A-0700, 296-23A-0710, 296-23A-0720, 296-23A-0730, 296-23A-0740, 296-23A-0750, 296-23A-0770 and 296-23A-0780; and amending WAC 296-23A-0220.

Statutory Authority for Adoption: RCW 51.04.020, 51.04.030, 51.36.080, 51.36.085.

Adopted under notice filed as WSR 01-18-082 on September 5, 2001.

Changes Other than Editing from Proposed to Adopted Version: WAC 296-23A-0220, information added concerning critical access hospitals; WAC 296-23A-0221, added a word inadvertently left out of the WAC; WAC 296-23A-0700, added clarifying terminology that the Center for Medicare and Medicaid Services system had been modified; WAC 296-23A-0710, clarified the definition of "Blended rate"; WAC 296-23A-0750, clarified exclusionary language to give the department additional flexibility; and WAC 296-23A-0780, clarified the language concerning the printed guidelines.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 8, Amended 1, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 8, Amended 1, Repealed 0.
Effective Date of Rule: January 1, 2002.

November 29, 2001

Gary Moore

Director

OTS-5120.2


AMENDATORY SECTION(Amending WSR 00-06-027, filed 2/24/00, effective 3/26/00)

WAC 296-23A-0220   How does the department ((or self-insurer)) pay for hospital outpatient services?   The department ((or self-insurer)) will pay for hospital outpatient services according to the following table:


((Hospital Type or Location Do percent of allowed charges (POAC) payment methods apply? Does the department's Medical Aid Rules and Fee Schedules apply to hospital outpatient radiology, laboratory, pathology an physical therapy services?
Children's Hospitals Yes, paid 100% of allowed charges Yes
Chronic Pain Management Program Exempt, paid per department agreement Exempt, paid per department agreement
Health Maintenance Organizations Yes, paid 100% of allowed charges Yes
Military Yes, paid 100% of allowed charges No, paid 100% of allowed charges
Veterans Administration Yes, paid 100% of allowed charges No, paid 100% of allowed charges
State psychiatric facility Yes, paid 100% of allowed charges Yes
Washington rural (Peer Group A) Yes, applies to hospital outpatient services except radiology, laboratory, pathology and physical therapy Yes
All other Washington hospitals Yes, applies to hospital outpatient services except radiology, laboratory, pathology and physical therapy Yes))

Hospital Type or Service Location Does the Ambulatory Payment Classification System apply? Do percent of allowed charges (POAC) payment methods apply? Do the department's Medical Aid Rules and Fee Schedules apply to hospital outpatient radiology, laboratory, pathology, occupational therapy, and physical therapy services?
Children's hospitals No Yes, paid 100% of allowed charges Yes
Chronic Pain Management Program No Exempt, paid per department agreement Exempt, paid per department agreement
Health Maintenance Organizations Yes, paid statewide average per APC rate Yes, applies to certain hospital outpatient services excluded from OPPS except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes
Military No Yes, paid 100% of allowed charges No, paid 100% of allowed charges
Veterans Administration No Yes, paid 100% of allowed charges No, paid 100% of allowed charges
State psychiatric facility No Yes, paid 100% of allowed charges Yes
Other psychiatric hospitals No Yes, applies to hospital outpatient services except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes
Rehabilitation hospitals No Yes, applies to hospital outpatient services except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes
Cancer hospitals No Yes, applies to hospital outpatient services except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes
Washington rural (Peer Group 1) No Yes, applies to hospital outpatient services except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes
Critical access hospitals No Yes, applies to hospital outpatient services except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes
All other Washington hospitals Yes Yes, applies to certain hospital outpatient services excluded from OPPS except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes

Hospitals are reimbursed only for the technical component of rates listed in the fee schedules, for outpatient radiology, pathology and laboratory services.

See chapter 296-23 WAC for rules on radiology, pathology, laboratory, physical therapy, occupational therapy, and work hardening services.

See WAC 296-23A-700 for rules on prospective payment system for hospital outpatient services.

See WAC 296-20-132 and 296-20-135 for information on the conversion factor used for certain hospital outpatient services.

[Statutory Authority: RCW 51.04.020, 51.04.030, 51.36.080. 00-06-027, 296-23A-0220, filed 2/24/00, effective 3/26/00; 97-06-066, 296-23A-0220, filed 2/28/97, effective 4/1/97.]

OTS-5121.2


NEW SECTION
WAC 296-23A-0221   How does the self-insurer pay for hospital outpatient services?   The self-insurer will pay for hospital outpatient services according to the following table:

Hospital Type or Service Location Do percent of allowed charges (POAC) payment methods apply? Do the department's Medical Aid Rules and Fee Schedules apply to hospital outpatient radiology, laboratory, pathology, occupational therapy, and physical therapy services?
Children's hospitals Yes, paid 100% of allowed charges Yes
Chronic Pain Management Program Not Applicable Not Applicable
Health Maintenance Organizations Yes, paid 100% of allowed charges Yes
Military Yes, paid 100% of allowed charges No, paid 100% of allowed charges
Veterans Administration Yes, paid 100% of allowed charges No, paid 100% of allowed charges
State psychiatric facility Yes, paid 100% of allowed charges Yes
Other psychiatric hospitals Yes, applies to hospital outpatient services except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes
Rehabilitation hospitals Yes, applies to hospital outpatient services except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes
Cancer hospitals Yes, applies to hospital outpatient services except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes
Washington rural (Peer Group 1) Yes, applies to hospital outpatient services except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes
All other Washington hospitals Yes, applies to hospital outpatient services except radiology, laboratory, pathology, occupational therapy, and physical therapy Yes

Hospitals are reimbursed only for the technical component of rates listed in the fee schedules, for outpatient radiology, pathology and laboratory services.

See chapter 296-23 WAC for rules on radiology, pathology, laboratory, physical therapy, occupational therapy, and work hardening services.

See WAC 296-23A-700 for rules on the prospective payment system for hospital outpatient services.

See WAC 296-20-132 and 296-20-135 for information on the conversion factor used for certain hospital outpatient services.

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OTS-5122.2

PART 4 - AMBULATORY PAYMENT CLASSIFICATION PAYMENT METHODS AND POLICIES
NEW SECTION
WAC 296-23A-0700   What is the "ambulatory payment classification" (APC) payment system?   The APC outpatient prospective payment system (OPPS) is a reimbursement method that categorizes outpatient visits into groups according to the clinical characteristics, the typical resource use, and the costs associated with the diagnoses and the procedures performed. The groups are called Ambulatory Payment Classifications (APCs). The department uses a modified version of the Centers for Medicare and Medicaid Services' (CMS) Prospective Payment System for Hospital Outpatient Department Services to pay some hospitals for covered outpatient services provided to injured workers. The department will utilize CMS' current outpatient code editor to categorize outpatient visits.

The payment system methodology uses CMS' outpatient prospective payment system's relative weight factor for each APC group and a blend of statewide and hospital-specific rates for each APC.

For a complete description of CMS' Prospective Payment System for Hospital Outpatient Department Services see 42 CFR, Chapter IV, Part 419, et al.

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NEW SECTION
WAC 296-23A-0710   Definitions.   "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 CFR, 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 financing administration's 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 healthcare 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 healthcare 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 healthcare services and treatment ordinarily furnished by a hospital in which the injured worker is under the age of fourteen.

"Peer group." Categories of hospitals adopted by the department of health for rate setting purposes. The categories are:

Group 1 - Usually rural hospitals.

Group 2 - Usually urban hospitals without a medical education program.

Group 3 - Hospitals with a medical education program.

"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.

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NEW SECTION
WAC 296-23A-0720   How does the department calculate the hospital-specific per APC rate used for paying outpatient services under the outpatient prospective payment system (OPPS)?   (1) OPPS payment rates are calculated with a formula that blends a hospital-specific rate and a statewide rate. Each hospital's historic labor and industries' reimbursement level in combination with the department's statewide payments will determine payment rates.

(2) For the statewide rate, the department:

(a) Determines the total number of APC procedures that the department paid the covered hospitals. The relative weights for all of these APCs are summed.

(b) Determines the total dollar amount the department paid for those APCs.

(c) Determines the total dollar amount the department paid as outlier payments.

(d) Subtracts the total outlier payments in (c) of this subsection from the total dollar amount in (b) of this subsection and then divides the adjusted dollar amount by the APC relative weight total from (a) of this subsection.

(Sum of APC payments - Sum of outlier payments)/Sum of APC relative weights = Statewide rate
(3) For the hospital-specific rate, the department:

(a) Segregates all the APCs for each hospital and totals the relative weights for each hospital.

(b) Determines the total dollar amount the department historically paid each hospital for those APCs.

(c) Determines the total dollar amount the department historically paid each hospital as an outlier payment for those APCs.

(d) Subtracts the total hospital-specific outlier payments in (c) of this subsection from the total hospital-specific APC payments in (b) of this subsection and then divides the hospital's adjusted dollar amount by the hospital-specific APC relative weight total from (a) of this subsection.

(Sum of hospital-specific APC payment - Sum of hospital-specific outlier payments)/Sum of the hospital-specific APC relative weights = Hospital-specific rate
(4) The final per APC rate paid to a hospital is a blended combination of the hospital-specific and statewide rates.

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NEW SECTION
WAC 296-23A-0730   How does the department determine the APC relative weights?   The relative weight for each APC is the current relative weight listed by CMS for the corresponding APC.

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NEW SECTION
WAC 296-23A-0740   How does the department calculate payments for covered outpatient services through the outpatient prospective payment system (OPPS)?   (1) Billed services that are reimbursed by the OPPS are grouped into one or more APCs using the outpatient code editor software.

(2) Additional payment may be made for services classified by CMS as transitional pass-through.

(3) Incidental services are grouped within an APC and are not paid separately.

(4) The OPPS APC payment method uses an APC relative weight for each classification group (APC) and the current hospital-specific blended rate to determine the APC payment for an individual service.

(5) For each additional APC listed on a single claim for services, the payment is calculated with the same formula and then discounted. L&I follows all discounting policies used by CMS for the Medicare Prospective Payment System for Hospital Outpatient Department Services.

(6) APC payment for each APC = (APC relative weight x hospital-specific blended rate)* discount factor (if applicable) x units (if applicable).

(7) The total payment on an APC claim is determined mathematically as follows:

(a) Sum of APC payments for each APC +

(b) Additional payment for each transitional pass-through (if applicable) +

(c) Additional outlier payment (if applicable).

(8) L&I follows all billing policies used by CMS for the Medicare Prospective Payment System for Hospital Outpatient Department Services with respect to:

(a) Billing of units of service;

(b) Outlier claims;

(c) Use of modifiers;

(d) Distinguishing between single and multiple visits during a span of time and reporting a single visit on one claim, but multiple visits with unrelated medical conditions on multiple claims; and

(e) For paying terminated procedures based on services actually provided and documented in the medical record, and properly indicated by the hospital through the CPT codes and modifiers submitted on the claim.

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NEW SECTION
WAC 296-23A-0750   What exclusions and exceptions apply to ambulatory-payment-classification (APC) payments for hospital services?   (1) Peer Group 1 (rural) hospitals as identified by the Washington state department of health (DOH).

(2) Critical access hospitals as identified by the Washington state department of health (DOH).

(3) All out-of-state hospitals.

(4) Military/veterans hospitals.

(5) Psychiatric hospitals.

(6) Rehabilitation hospitals.

(7) Cancer hospitals.

(8) Children's hospitals.

(9) Ambulatory surgery centers.

(10) Any outpatient service or special program identified by the department or by CMS as being a non-APC service.

(11) Any inpatient-only procedures as identified by CMS.

(12) Any APCs identified by the department as a non-APC service.

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NEW SECTION
WAC 296-23A-0770   How will excluded outpatient services and hospitals be paid?   Services excluded from APC-payment, if deemed appropriate for reimbursement, will be reimbursed using an alternate outpatient payment method, such as a specific fee schedule and/or using the hospital-specific or the statewide average percent of allowed charges (POAC).

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NEW SECTION
WAC 296-23A-0780   What information needs to be submitted for the hospital to be paid for outpatient services?   Each claim for services must include the required elements as described within the current L&I hospital billing and administrative guidelines.

Note: Includes Provider General Billing Manual; Billing Instructions for Hospital Services; Provider Bulletins; and Provider Updates.

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Washington State Code Reviser's Office