Questions regarding 28 Texas Administrative Code (TAC) §134.402, Ambulatory Surgical Center Fee Guideline:
Services provided in an ambulatory surgical center apply on or after September 1, 2008.
The Texas Department of Insurance, Division of Workers’ Compensation (DWC) conducted seminars to facilitate the implementation of these rules. The seminar education materials are on the TDI website, and additional educational materials may be developed as needed. DWC will continue to answer questions or clarify issues through CompConnection@tdi.texas.gov, and will summarize appropriate topics in frequently asked questions and post updates on the TDI website. You can also call CompConnection for Health Care Providers at 800-252-7031, option 3.
Yes, the adopted ASC fee guideline uses the fully implemented reimbursement rates.
28 TAC §134.402, Ambulatory Surgical Center Fee Guideline, is based on Medicare ASC reimbursement and applies a specific Texas workers’ compensation payment adjustment factor. The rule also has provisions that allow an ASC to choose separate reimbursement for implantables on a case-by-case basis. The ASC reimbursement is calculated as shown in Table 1:
Surgical Procedure with Non-device Intensive Procedure | Surgical Procedure with Device Intensive Procedure |
---|---|
When no implants were used or when reimbursement for implantables is inclusive, reimbursement is 235% of Medicare’s geographically adjusted fully implemented rate. | When reimbursement for implantables is not requested, reimbursement is 235% of service portion of Medicare’s geographically adjusted fully implemented rate, plus the Medicare device portion. |
When implants were used and separate reimbursement for implantables is requested, reimbursement is 153% of Medicare’s geographically adjusted fully implemented rate, plus separately calculated reimbursement for implantables. | When separate reimbursement for implantable is requested, reimbursement is 235% of service portion of Medicare’s geographically adjusted fully implemented rate, plus separately calculated reimbursement for implantables. |
When the ASC chooses to have implantables reimbursed separately, the ASC or surgical implant provider is reimbursed at the lesser of:
- Manufacturer's invoice amount; or
- Net amount (exclusive of rebates and discounts); plus
- 10% or $1,000 per billed item add-on, whichever is less, but not to exceed $2,000 in add-ons per admission.
In this example, an injured employee received surgical services in an ambulatory surgical center. The surgical services included three implantable devices. Each device had an invoice amount of $20,000 and a rebate of $2,500.
Table 2 shows an Implantable Reimbursement Example
In this example, an injured employee received surgical services in an ambulatory surgical center. The surgical services included three implantable devices. Each device had an invoice amount of $20,000 and a rebate of $2,500.
Category | Item #1 | Item #2 | Item #3 | Total |
---|---|---|---|---|
Net amount for implantable item |
$20,000 |
$20,000 |
$20,000 |
$60,000 |
Rebates or discounts |
-$2,500 |
-$2,500 |
-$2,500 |
-$7,500 |
Adjusted net amount for implantable item |
$17,500 |
$17,500 |
$17,500 |
$52,500 |
Add-on of 10% or $1,000, whichever is less |
$1,000* |
$1,000* |
$0** |
$2,000 |
Total computed reimbursement for implanted items |
$18,500 |
$18,500 |
$17,500 |
$54,500
|
*$1,000 is less than 10% of $17,500
**The $2,000 “cap” for this admission was met by implants #1 and #2
To get a separate reimbursement for implantables, a provider must make the request using the shaded portion of CMS-1500/fields 24d - 24h as indicated in 28 TAC §133.10. The insurance carrier should review those fields to determine if the ASC or surgical implant provider is requesting separate reimbursement for implantables.
The following are examples of language that may facilitate communications:
- Separate reimbursement for implantables not requested.
- Separate reimbursement to ASC for implantables requested.
- Separate reimbursement to Company X for implantables requested.
- Separate reimbursement to ASC & Company X for implantables requested.
An ASC is responsible for communicating its choice regarding separate reimbursement for implantables and for providing documentation.
If the bill does not include information requesting separate reimbursement, the insurance carrier should use the appropriate multiplier in question #5.
Because separate reimbursement is the ASC’s choice, the insurance carrier would pay the ASC the appropriate multiplier that includes reimbursement for the implantable, but would deny the bill from the surgical implant provider.
- Contact the ASC to request the information to complete the bill.
- Deny the bill due to lack of documentation.
- Pay the ASC bill with the reimbursement calculated at the higher multiplier. The higher multiplier includes reimbursement for the implantable. The ASC may request reconsideration and provide documentation for the implantables.
- Contact the surgical implant provider to request the information to complete the bill.
- Deny the bill due to lack of documentation.
No, the $2,000 add-on cap for implantables is per admission, not the source of the implantables.
For surgical procedures with a date of service in CY 2017 the ADDENDUM AA, Final ASC Covered Surgical Procedures for CY 2017, can be found at:
The reimbursement methodology is the same for each year. However, because DWC rules require the use of the most current CMS weights, values, and measures, the CMS tables for a specific calendar year should be the source for data required to calculate reimbursement for services provided during that calendar year.
It is important to note that CMS sometimes finds it necessary to revise, rename, or reformat data required to calculate reimbursement.
Starting in 2017, the “device intensive” status is assigned to all surgical procedures with an individual HCPCS code-level device offset of greater than 40%.
Device-intensive procedures are identified in ADDENDUM AA with a payment indicator of J8 (device-intensive procedure paid at adjusted rate).
DWC rules require use of the most current CMS weights, values, and measures, and the CMS tables for a specific calendar year should be the source for any data required to calculate reimbursements for services provided during that calendar year.
It is important to note that CMS sometimes finds it necessary to revise, rename, or reformat data required to calculate reimbursement.
For dates of service on or after January 1, 2017, the list of the device-intensive procedures for CY 2017 are listed in the ASC policy file labeled
“CY 2017 ASC Procedures to which the No Cost/Full Credit and Partial Credit Device Adjustment Policy Applies” (referred to as “ASC device adjustment file” below), available at:
www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/ASC-Policy-Files.html.
For dates of service on or after January 1, 2017, the device-intensive procedures for CY 2017 are listed in the ASC policy file labeled “CY 2017 ASC Procedures to which the No Cost/Full Credit and Partial Credit Device Adjustment Policy Applies” (referred to as “ASC device adjustment file” below), which is available via the Internet on the CMS Web site at:
https://www.cms.gov/medicare/payment/prospective-payment-systems/ambulatory-surgical-center-asc/annual-policy-files.
A. Gather the information to calculate the geographical adjustment to the national ASC reimbursement amount:
- National reimbursement for procedure (Addendum AA).
- Statistical area number (White House/OMB Document).
- Use the statistical area number to determine wage index (CMS-1392 pre-class wage index for
ASC).
B. Perform geographical adjustment calculations
- Divide the national reimbursement by 2.
- Multiply half of the national reimbursement the wage index from Step 3.
- Add half of the national reimbursement and wage adjusted half of the national reimbursement calculated in step 5. The sum of these two numbers is the geographic adjusted ASC reimbursement.
- Calculate the geographic adjusted ASC reimbursement for the procedure.
- Multiply the geographically adjusted ASC reimbursement by the DWC payment adjustment factor, currently 235% (2.35).
- Calculate the geographic adjusted ASC reimbursement for the procedure.
- Multiply the geographically adjusted ASC reimbursement by the DWC payment adjustment factor, currently 235% (2.35).
- Calculate the geographic adjusted ASC reimbursement for the procedure.
- Multiply the geographically adjusted ASC reimbursement by the DWC payment adjustment factor, currently 153% (1.53).
- Calculate the separate reimbursement for the implantables (see FAQ #7).
- Add B and C for the reimbursement of a non-device intensive procedure when implantables were used in the procedure and separate reimbursement for the implant is requested.
- Calculate the geographic adjusted ASC reimbursement for the procedure.
- See the table referenced in FAQ #16 to determine the “device offset” amount (percentage).
- Multiply the hospital outpatient prospective payment system amount by the device offset percentage to determine the device portion of the reimbursement calculation.
- Subtract the device portion from the geographically adjusted reimbursement to determine the service portion of the reimbursement calculation.
- Multiply the service portion by the DWC payment adjustment factor, currently 235% (2.35), to determine the DWC reimbursement for the service portion.
- Add the reimbursement for the device portion to the DWC reimbursement for the service portion. The sum is the total reimbursement for the procedure.
- Calculate the geographic-adjusted ASC reimbursement for the procedure.
- See the table referenced in FAQ #16 to determine the “device offset” amount (percentage).
- Multiply the hospital outpatient prospective payment system amount by the device offset percentage to determine the device portion of the reimbursement calculation.
- Subtract the device portion from the geographically adjusted reimbursement to determine the service portion of the reimbursement calculation.
- Multiply the service portion by the DWC payment adjustment factor, currently 235% (2.35), to determine the DWC reimbursement for the service portion.
- Calculate the separate reimbursement for the implantable(s) (see FAQ #7).
- Add the separated reimbursement for the implantables to the DWC reimbursement for the service portion. The sum is the total reimbursement for the procedure.