90-351 C.M.R. ch. 5, § 4 - OUTPATIENT FACILITY FEES

4.01 BILLING

Bills for hospital outpatient and ambulatory surgical services must be submitted on a UB-04 form. Outpatient hospital facility services performed on the same day for the same patient must be reported on a single UB-04 form.

4.02 ACUTE CARE HOSPITALS

The base rate for outpatient services at acute care hospitals is $150.05.

4.03 CRITICAL ACCESS HOSPITALS

The base rate for outpatient services at critical access hospitals is $174.00.

4.04 AMBULATORY SURGICAL CENTERS

The base rate for surgical services at ambulatory surgical centers is $113.39.

4.05 PAYMENT CALCULATION

Pursuant to 39-A M.R.S.A. §209-A, the medical fee schedule for services rendered by health care facilities must reflect the methodology and categories set forth in the federal Centers for Medicare and Medicaid Services ambulatory payment classification system for outpatient services. Fees for procedure codes are calculated by multiplying the base rate times the APC weight. In the event of a dispute regarding the fee listed in Appendix IV, the listed relative weight times the base rate controls.

1. For procedure codes with no CPT^®/HCPCS code or for procedure codes with a status indicator of N, there is no separate payment.

2. If the ACH Fee, CAH Fee or ASC Fee listed in Appendix IV is $0.00 for a procedure code with a status indicator other than N, then payment must be calculated at 75% of the health care provider's usual and customary charge.

3. When two or more procedure codes with a status indicator of T are billed on the same date of service, the highest weighted code is paid at 100% of the fee listed in Appendix IV and additional T status code procedures are paid at 50% of the fee listed in Appendix IV. Add-on codes are not subject to discounting.

4. If application of this subsection results in a $0.00 fee, payment must be calculated at 75% of the provider's usual and customary charge.

4.06 OUTLIER PAYMENTS

The threshold for outlier payments is $2,500.00 per procedure code plus the fee listed in Appendix IV. If the outlier threshold is met, the outlier payment is the charges above the threshold multiplied by 75%. If a bill has more than one surgical procedure with a status indicator of J, S or T and one or more of those procedures has less than a $1.01 charge, charges for all status J, S and T lines are summed and the charges are then divided across the J, S and T lines in proportion to their APC payment rate. The new charge amount is used in place of the submitted charge amount in the outlier calculation.

4.07 IMPLANTABLES

Where an implantable exceeds $250.00 in cost, hospitals or ambulatory surgical centers may seek additional reimbursement (regardless of the status indicator) by submitting a copy of the invoice(s) along with the bill. Invoices need not be requested by the employer/insurer. Reimbursement is set at the actual amount paid plus 20% or the actual amount paid plus $500.00, whichever is less. Handling and freight charges must be included in the facility's invoiced cost and are not to be reimbursed separately. When a hospital seeks additional reimbursement for an implantable, the implantable charge is excluded from any payment calculation.

4.08 SERVICES INCLUDED

Outpatient services include observation in an outpatient status.

4.09 TRANSFERS

The following applies to facility transfers when a patient is transferred for continuation of medical treatment between two facilities:

1. A hospital or ambulatory surgical center transferring a patient is paid the maximum allowable payment established in this section.

2. A hospital discharging a patient is paid the full MS-DRG payment plus any appropriate outliers and add-ons per section 3.

3. Facility transfers do not include costs related to transportation of a patient to obtain medical care. Costs related to transportation are payable separately.

4.10 OTHER OUTPATIENT FACILITY FEES

Outpatient services provided by institutional health care providers other than acute care or critical access hospitals and ambulatory surgical centers (e.g., clinical medical laboratories, free standing outpatient facilities, etc.) must be paid at 75% of the provider's usual and customary charge.

4.11 PROFESSIONAL SERVICES

Individual health care providers who furnish professional services in an outpatient setting must be reimbursed using the maximum fees set forth in Appendix II. The individual health care provider's charges are excluded from any calculation of outpatient facility fees.

Notes

90-351 C.M.R. ch. 5, § 4