053-9 Wyo. Code R. §§ 9-9 - Facility Fees
(a) Fees for
Inpatient Hospital Services.
(i) Inpatient
hospital services shall be reimbursed in accordance with the CMS IPPS
(Inpatient Prospective Payment System) payment methodology and the MS-DRG
(Medicare Severity-Diagnosis Related Group) weight according to the CMS Table 5
(for the corresponding year of service) at 150% of the Medicare Base Rate, as
updated on April 1st of each year. The MS-DRG CMS
Table 5 can be found at:
(ii) Medical services for which there is no
inpatient weight listed shall be reimbursed at eighty percent (80%) of the
reasonable charge.
(iii) If the
inpatient admission and discharge occur across different calendar years, the
Base Rate and MS-DRG weight of the discharge year shall be used for the
entirety of the inpatient stay.
(iv) Required documentation to support billed
charges are as follows:
(A) Detailed
itemization;
(B) Anesthesia
graphic;
(C) Operative
report;
(D) History and
physical;
(E) Discharge
summary;
(F) Implant Log and
itemization; and
(G) Supplier's
invoice for any supplies and/or implants charged at five thousand dollars
($5,000.00) or more, per episode of care, for device intensive procedures as
indicated by Medicare. Such items shall be reimbursed at one hundred fifteen
percent (115%) of invoice amount. Shipping and handling charges shall not be
reimbursed.
(v) Bills
shall be audited for unidentified and unrelated services and/or
items.
(vi) The Division shall
provide a copy of the audit upon request.
(b) Fees for Outpatient Facility Services.
(i) Outpatient Services shall be reimbursed
in accordance with Medicare Ambulatory Payment Classifications (APC) rates at
one hundred fifty percent (150%) of the allowed amount as they were in effect
on October 1, 2024, found at:
https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient/addendum-a-b-updates.
(ii) Required documentation to support billed
charges are as follows:
(A) Treatment notes to
support the billed services.
(B)
All test results.
(iii)
Bills shall be audited for unidentified and unrelated services and/or items.
(iv) The Division shall provide a copy of the audit upon request.
(c) Fees for Ambulatory Surgery
Services.
(i) Ambulatory Surgery Services
shall be reimbursed in accordance with Medicare Ambulatory Surgery Center (ASC)
rates at one hundred fifty percent (150%) of the allowed amount as they were in
effect on October 1, 2024, found at:
https://www.cms.gov/medicare/medicare-fee-for-service-payment/ascpayment/11_addenda_updates.
(ii) Medical services for which there is no
ASC weight listed shall be reimbursed at eighty percent (80%) of the reasonable
charge.
(iii) All payment status
indicators shall be followed as indicated by Medicare.
(iv) Required documentation to support billed
charges are as follows:
(A) Operative
report;
(B) Implant Log and
itemization; and
(C) Supplier's
invoice for any supplies and/or implants charged at one thousand dollars
($1,000.00) or more, per episode of care. Such items shall be reimbursed at one
hundred fifteen percent (115%) of invoice amount. Shipping and handling charges
shall not be reimbursed.
(v) Bills shall be audited for unidentified
and unrelated services and/or items.
(vi) The Division shall provide a copy of the
audit upon request.
(d)
Critical Access Hospitals (CAH) inpatient services will be paid at one hundred
fifty percent (150%) of Rural Cost-to-Charge Ratio (CCR) in accordance with the
Wyoming Medicare file CMS-1771-P Tables 8A and 8B for the fiscal year 2024.
More information can be found at:
https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2024-ipps-final-rule-home-page.
(i) Critical Access Hospital (CAH) outpatient
services will be paid in accordance with the conversion factors and
methodologies listed in Section 2(c).
(e) Fees for Inpatient Rehabilitation
Services.
(i) Inpatient Rehabilitation
Services shall be reimbursed at eighty percent (80%) of billed
charges.
(ii) Required documents to
support billed charges are as follows:
(A)
History and physical;
(B) Daily
notes including physician visits, therapy notes, nursing notes, etc.;
and
(C) Discharge summary, if
applicable.
(iii) Bills
shall be audited for unidentified and unrelated services and/or
items.
(iv) The Division shall
provide a copy of the audit upon request.
(f) Fees for Skilled Nursing Services.
(i) Inpatient Skilled Nursing Services shall
be reimbursed in accordance with the Annual Skilled Nursing Facility Per Diem
Room Rate Survey conducted by the Division.
(A) If the facility has not established a per
diem room rate with the Division for the calendar year corresponding to the
date of service, the average of the submitted rates will be used.
(ii) The per diem room rates for a
semi-private bed shall be the usual and customary rates charged to the general
public. Such rates shall be effective automatically on the first day of each
calendar year.
(A) The per diem room rates
will be all inclusive of the care for the claimant for the day. This includes
but is not limited to:
(I) Administration of
oxygen and related medication;
(II)
Hand feedings;
(III) Incontinence
Care;
(IV) Tray Service;
(V) Therapy Services, including physical
therapy, occupational therapy, speech and language therapy; and
(VI) Over the counter medications.
(B) Certain items are permitted to
be billed outside of the per diem rate, such as:
(I) Ambulance services when medically
necessary;
(II) Some durable
medical equipment (DME) items;
(III) Wheelchairs;
(IV) Braces;
(V) Medical services including laboratory,
radiology and surgical procedures;
(VI) Physician and other practitioner
services, excluding physical therapy, occupational therapy and speech and
language therapy; and
(VII)
Prosthetics.
Notes
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