Outpatient Hospital Reimbursement

Emergency Room Services

OHCA recently transitioned some codes currently paid under a different methodology to the APC payment methodology and the first codes to be transitioned were the emergency department facility fees. In the past, hospitals were paid using an all-inclusive bundled rate that included laboratory, radiology, and all other ancillary services.

The Centers for Medicare and Medicaid Services does not consider bundling facility and professional services efficient and economical for outpatient hospital services. Moreover, Federal law under Section 1903 (i) of the Social Security Act limits Medicaid reimbursement for clinical diagnostic laboratory services to the amount of the Medicare fee schedule for the services on a per test basis.

Therefore, OHCA modified the emergency department reimbursement methodology facility fee effective January 1, 2009 to more closely follow Medicare’s APC payment methodology. Providers will bill the revenue code 45X with the appropriate CPT code and the claim will price off the APC table. 

Payment for laboratory will be made at the Medicaid laboratory fee schedule and x-ray will be paid at the professional fee schedule. After January 1, 2009 claims filed with revenue code 45X without an appropriate CPT will no longer pay an emergency department facility fee.

Outpatient Surgery

Payment for facility services will be made to hospital-based and independent ambulatory surgery centers for certain outpatient surgical procedures. The surgical procedures are classified in eight payment groups, taking into consideration the Medicare methodology for payment of Ambulatory Surgical Centers. All procedures within the same payment group are paid at a single payment rate.