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 as described in this rule.
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.
"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
Classification of Diseases"
classification of diseases (ICD)
diagnosis codes, current procedural terminology (
and healthcare common procedure
coding system (HCPCS) procedure codes.
(3) "EAPG grouper" is the software provided
by 3M health information systems to group outpatient claims based on services
performed and resource intensity.
(4) "Default EAPG settings" are the default
EAPG grouper options in 3M's core grouping software for each EAPG grouper
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.
"Packaging factor" is a factor of zero per cent applicable for services
designated with a packaging flag by the EAPG grouper under default EAPG
invoice" is a bill submitted in accordance with Chapter 5160-1 of the
Administrative Code, to the department 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.
(7) "ASC claim" encompasses the ASC services
rendered to one eligible medicaid beneficiary on one date of service at an ASC
"Procedure code" is
current procedural terminology (CPT)
healthcare common procedure coding system
as identified in rule
code" is the
"International Classification of
as identified in
"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 paragraph (F) of rule
of the Administrative Code.
"EAPG base rate" is the dollar value that
multiplied by the final EAPG weight
for each EAPG on a claim to determine the total allowable medicaid payment for
a visit. The EAPG base rate for ASCs is
of the statewide average outpatient hospital EAPG base rate. Hospital EAPG base
rates are calculated as described in paragraph (D) of rule
of the Administrative Code.
"ASC facility services" are items and services furnished by an ASC in
connection with a covered ASC surgical procedure.
"ASC Cost-to-charge ratio" is eighty per
cent of the statewide average outpatient cost-to-charge ratio as calculated in
of the Administrative Code.
Eligible ASC providers.
(1) All ASCs that have a valid agreement with
the centers for medicare and medicaid services (CMS) to provide services in the
medicare program are eligible to become medicaid providers upon execution of
the "Ohio Medicaid Provider Agreement."
bill in accordance with rule
Administrative Code. The department will reimburse an ASC for properly
submitted claims for facility services furnished in connection with covered
surgical procedures when the services are provided by an eligible ASC provider
to an eligible medicaid recipient. Reimbursement for covered ASC facility
services will be paid in accordance with paragraph (D) of this rule.
Covered ASC services.
Services include but are not limited to:
(a) Nursing, technician, and related
(b) Use of the ASC
(c) Drugs, biologicals
(e.g., blood), surgical dressings, splints, casts and appliances, and equipment
directly related to the provision of the surgical procedure;
(d) Diagnostic or therapeutic services or
items directly related to the provisions of a surgical procedure;
(e) Administrative, record keeping, and
housekeeping items and services;
(f) Materials for anesthesia;
(g) Intraocular lenses; and
Supervision of the services of an
anesthetist by the operating surgeon.
(2) Services covered in an ASC are
listed on the department's web site http:// www.medicaid.ohio.gov/.
Prior authorization (PA)
will be required
for certain surgical CPT codes. The services
the department's web site, http://www.medicaid.ohio.gov/,
accordance with section
of the Revised Code.
(1) Total EAPG payment is the sum
across all paid line items on an ASC claim
The payment for a paid line on the claim
is calculated as follows, except as described in paragraph (E) or (F) of this
(a) The ASC EAPG base rate
(b) The EAPG relative weight
for which the service was assigned by the EAPG grouper, rounded to the nearest
EAPGs 00134 and 00149
, the result of paragraph (D)(2)(b) of this
rule multiplied by one hundred
per cent, rounded to the nearest whole
. For EAPG
00485, the result of paragraph (D)(2)(b) of this rule multiplied by two hundred
thirty three per cent, rounded to the nearest whole cent;
The result of paragraphs (D)(2)(a) and
(D)(2)(b) of this rule, or, for EAPGs
00233 and 00485
, (D)(2)(a) to
(D)(2)(c), times applicable discounting factor(s) as defined in paragraph
(A)(5) of this rule, rounded to the nearest whole cent.
Payment for laboratory
services, radiological services, and diagnostic and therapeutic procedures.
An ASC may be reimbursed in addition to the facility fee for
covered laboratory procedures, radiological procedures, and diagnostic and
therapeutic procedures provided in connection with a covered ASC surgical
Payment for laboratory
(a) An ASC may be reimbursed for
covered laboratory services
bill separately for the professional component of an anatomical pathology
(c) Laboratory services
will be reimbursed the lesser of billed charges or the result of paragraph
(D)(2)(d) of this rule.
Payment for radiological services.
(a) An ASC may be reimbursed for covered
bill the department for the professional component separately.
(c) Radiological services will be reimbursed
the lesser of billed charges or the result of paragraph (D)(2)(d) of this
diagnostic and therapeutic procedures.
ASC may be reimbursed for the provision of diagnostic and therapeutic services
bill separately for the professional component of a diagnostic and therapeutic
(c) Diagnostic and
therapeutic services will be reimbursed the result of paragraph (D)(2)(d) of
(4) An ASC
may also be reimbursed for laboratory, radiology and diagnostic and therapeutic
services actually performed in the ASC in conjunction with covered services not
eligible for an ASC facility payment.
Items which may be paid outside of EAPG.
(a) Payments for covered pharmaceuticals will
be made in accordance with the discounting factors as determined by the EAPG
grouper. If no consolidation or packaging factors are assigned then the
pharmaceutical line is separately payable and will pay according to paragraphs
(F)(1)(b) and (F)(1)(c) of this rule.
Reimbursement for separately payable
covered pharmaceuticals shall be the lesser of billed charges or the payment
amounts in the provider administered pharmaceutical fee schedule as published
on the department's web site, http://medicaid.ohio.gov/
, at the rate
in effect on the date of service.
(c) If a J-code or Q-Code, that is covered
for ASC facilities and separately payable, is listed as "by report" in the
provider-administered pharmaceutical fee schedule, the line will be multiplied
by sixty per cent of the ASC cost-to-charge ratio.
Durable medical equipment (DME).
made for all line items grouping to a DME
code 01001, 01002, 01003, 01004, 01005, 01006,
01007, 01008, 01009, 01010, 01011, 01012, 01013, 01014, 01015, 01016, 01017,
01018, 01019, or 01020
Reimbursement for DME
the lesser of billed charges or the payment amounts in the medicaid
non-institutional maximum payment schedule as published on the department's web
, at the
rate in effect on the date of service.
(c) Payments for DME will be made in
accordance with the discounting factors as determined by the EAPG
Reimbursement for claims assigned to a
dental service EAPG type will be paid as follows:
(a) Payments for covered dental
services may be made for all line items grouping to EAPG code 00350, 00351,
00352, 00353, 00354, 00355, 00356, 00357, 00358, 00359, 00360, 00361, 00362,
00363, 00364, 00365, 00366, 00367, 00368, 00369, 00370, 00371, or
(a) Reimbursement for dental services will be
nine-hundred fifty-three dollars and sixty cents.
(b) Payments for
dental services will be made in accordance with the discounting factors as
determined by the EAPG grouper.
Ohio Admin. Code
Five Year Review (FYR) Dates:
Effective Dates: 03/20/1984, 01/04/1988, 02/17/1991, 12/29/1995 (Emer.),
05/21/1996, 01/01/2004, 05/10/2007, 07/01/2009, 04/15/2015, 08/01/2016,