12 Va. Admin. Code § 30-80-190 - State agency fee schedule for RBRVS
A. Reimbursement of fee-for-service
providers. Effective for dates of service on or after July 1, 1995, the
Department of Medical Assistance Services (DMAS) shall reimburse
fee-for-service providers, with the exception of home health services (see
12VAC30-80-180
) and durable medical equipment services (see
12VAC30-80-30
), using a fee schedule that is based on a Resource Based Relative Value Scale
(RBRVS).
B. Fee schedule.
1. For those services or procedures that are
included in the RBRVS published by the Centers for Medicare and Medicaid
Services (CMS) as amended from time to time, the DMAS fee schedule shall employ
the Relative Value Units (RVUs) developed by CMS as periodically updated.
a. Effective for dates of service on or after
July 1, 2008, DMAS shall implement site of service differentials and employ
both nonfacility and facility RVUs. The implementation shall be budget neutral
using the methodology in subdivision 2 of this subsection.
b. The implementation of site of service
shall be transitioned over a four-year period.
(1) Effective for dates of service on or
after July 1, 2008, DMAS shall calculate the transitioned facility RVU by
adding 75% of the difference between the nonfacility RVU and nonfacility RVU to
the facility RVU.
(2) Effective for
dates of service on or after July 1, 2009, DMAS shall calculate the
transitioned facility RVU by adding 50% of the difference between the
nonfacility RVU and nonfacility RVU to the facility RVU.
(3) Effective for dates of service on or
after July 1, 2010, DMAS shall calculate the transitioned facility RVU by
adding 25% of the difference between the nonfacility RVU and nonfacility RVU to
the facility RVU.
(4) Effective for
dates of service on or after July 1, 2011, DMAS shall use the unadjusted
Medicare facility RVU.
2. DMAS shall calculate the RBRVS-based fees
using conversion factors (CFs) published from time to time by CMS. DMAS shall
adjust the CMS CFs by additional factors so that no change in expenditure will
result solely from the implementation of the RBRVS-based fee schedule. DMAS may
revise the additional factors when CMS updates its RVUs or CFs so that no
change in expenditure will result solely from such updates. Except for this
adjustment, the DMAS CFs shall be the same as those published from time to time
by CMS. The calculation of the additional factors shall be based on the
assumption that no change in services provided will occur as a result of these
changes to the fee schedule. The determination of the additional factors
required in this subdivision shall be accomplished by means of the following
calculation:
a. The estimated amount of DMAS
expenditures if DMAS were to use Medicare's RVUs and CFs without modification,
is equal to the sum, across all relevant procedure codes, of the RVU value
published by the CMS, multiplied by the applicable conversion factor published
by the CMS, multiplied by the number of occurrences of the procedure code in
DMAS patient claims in the most recent period of time (at least six
months).
b. The estimated amount of
DMAS expenditures, if DMAS were not to calculate new fees based on the new CMS
RVUs and CFs, is equal to the sum, across all relevant procedure codes, of the
existing DMAS fee multiplied by the number of occurrences of the procedures
code in DMAS patient claims in the period of time used in subdivision 2 a of
this subsection.
c. The relevant
additional factor is equal to the ratio of the expenditure estimate (based on
DMAS fees in subdivision 2 b of this subsection) to the expenditure estimate
based on unmodified CMS values in subdivision 2 a of this subsection.
d. DMAS shall calculate a separate additional
factor for:
(1) Emergency room services
(defined as the American Medical Association's (AMA) publication of the Current
Procedural Terminology (CPT) codes 99281, 99282, 99283, 99284, and 992851 in
effect at the time the service is provided);
(2) Obstetrical/gynecological services
(defined as maternity care and delivery procedures, female genital system
procedures, obstetrical/gynecological-related radiological procedures, and
mammography procedures, as defined by the American Medical Association's (AMA)
publication of the Current Procedural Terminology (CPT) manual in effect at the
time the service is provided);
(3)
Pediatric preventive services (defined as preventive E&M procedures,
excluding those listed in subdivision 2 d (1) of this subsection, as defined by
the AMA's publication of the CPT manual, in effect at the time the service is
provided, for recipients younger than 21 years of age);
(4) Pediatric primary services (defined as
evaluation and management (E&M) procedures, excluding those listed in
subdivisions 2 d (1) and 2 d (3) of this subsection, as defined by the AMA's
publication of the CPT manual, in effect at the time the service is provided,
for recipients younger than 21 years of age);
(5) Adult primary and preventive services
(defined as E&M procedures, excluding those listed in subdivision 2 d (1)
of this subsection, as defined by the AMA's publication of the CPT manual, in
effect at the time the service is provided, for recipients 21 years of age and
older);
(6) Effective July 1, 2019,
psychiatric services as defined by the AMA's publication of the CPT manual, in
effect at the time the service is provided; and
(7) All other procedures set through the
RBRVS process combined.
3. For those services or procedures for which
there are no established RVUs, DMAS shall approximate a reasonable relative
value payment level by looking to similar existing relative value fees. If DMAS
is unable to establish a relative value payment level for any service or
procedure, the fee shall not be based on a RBRVS, but shall instead be based on
the previous fee-for-service methodology.
4. Fees shall not vary by geographic
locality.
5. Effective for dates of
service on or after July 1, 2007, fees for emergency room services (defined in
subdivision 2 d (1) of this subsection) shall be increased by 5.0% relative to
the fees that would otherwise be in effect.
C. Effective for dates of service on or after
May 1, 2006, fees for obstetrical/gynecological services (defined in
subdivision B 2 d (2) of this section) shall be increased by 2.5% relative to
the fees in effect on July 1, 2005.
D. Effective for dates of service on or after
May 1, 2006, fees for pediatric services (defined in subdivisions B 2 d (3) and
(4) of this section) shall be increased by 5.0% relative to the fees in effect
on July 1, 2005. Effective for dates of service on or after July 1, 2006, fees
for pediatric services (defined in subdivisions B 2 d (3) and (4) of this
section) shall be increased by 5.0% relative to the fees in effect on May 1,
2006. Effective for dates of service on or after July 1, 2007, fees for
pediatric primary services (defined in subdivision B 2 d (4) of this section)
shall be increased by 10% relative to the fees that would otherwise be in
effect.
E. Effective for dates of
service on or after July 1, 2007, fees for pediatric preventive services
(defined in subdivision B 2 d (3) of this section) shall be increased by 10%
relative to the fees that would otherwise be in effect.
F. Effective for dates of service on or after
May 1, 2006, fees for adult primary and preventive services (defined in
subdivision B 2 d (4) of this section) shall be increased by 5.0% relative to
the fees in effect on July 1, 2005. Effective for dates of service on or after
July 1, 2007, fees for adult primary and preventive services (defined in
subdivision B 2 d (5) of this section) shall be increased by 5.0% relative to
the fees that would otherwise be in effect.
G. Effective for dates of service on or after
July 1, 2007, fees for all other procedures set through the RBRVS process
combined (defined in subdivision B 2 d (6) of this section) shall be increased
by 5.0% relative to the fees that would otherwise be in effect.
H. Effective for dates of service on or after
July 1, 2010, fees for all procedures set through the RBRVS process shall be
decreased by 3.0% relative to the fees that would otherwise be in
effect.
I. Effective for dates of
service on or after October 1, 2010, through June 30, 2011, the 3.0% fee
decrease in subsection H of this section shall no longer be in
effect.
J. Effective for dates of
service on or after July 1, 2019, rates for adult primary care services shall
be increased by 5.0% and rates for emergency department services shall be
increased by 1.0%.
K. Effective for
dates of service on or after July 1, 2019, rates for psychiatric services shall
be increased by 21%.
Notes
Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
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