Title: Section 86-4.40 - Computation of case-based rates of payment for licensed free-standing ambulatory surgery centers and hospital based ambulatory surgery services
86-4.40 Computation of case-based rates of payment for licensed free-standing ambulatory surgery centers and hospital-based ambulatory surgery services.
(a) Medicaid reimbursement for medically necessary ambulatory surgery services provided by licensed free-standing ambulatory surgical centers and hospital-based ambulatory surgery services shall be based upon a single payment schedule with a discrete price for each of the separate groupings of surgical procedures set forth in this section.
(b) Reimbursement for ambulatory surgery services shall be based upon the Products of Ambulatory Surgery (PAS) classification system as defined in subdivision (o) of this section. A base price shall be established for each of the payment groups defined in the PAS classification. All procedures within the same payment group shall be reimbursed at a single discrete price.
(c) Each base price shall be adjusted by a wage equalization factor and a space occupancy factor to reflect regional differences in the price of labor and space. The wage equalization factor shall be applied to the operating room and pre-operative and post-operative nursing personnel salary components of each base price.
(d) Prices established pursuant to subdivision (b) of this section shall provide full reimbursement for applicable:
(1) nursing services, technician services, and other related professional expenses directly incurred by the licensed facility;
(2) drugs, biologicals, surgical dressings, supplies, splints, appliances and equipment directly related to the provision of the surgical procedures;
(3) diagnostic or therapeutic items and services directly related to the provision of surgical procedures;
(4) materials for anesthesia;
(5) prosthetic and orthotic appliances provided during or integral to an ambulatory surgery procedure;
(6) administrative personnel, business office, data processing, recordkeeping, housekeeping and other related facility overhead expenses;
(7) space occupancy and plant overhead costs;
(8) costs associated with graduate medical education programs involved in the provision of ambulatory surgery services; and
(9) costs associated with hospital-based physicians, defined as salaried physicians, excluding interns and residents, engaged in direct provision of ambulatory surgical services can be included in a facility's payment rates upon appeal to the Department of Health. Such adjustments will be limited to the current schedule of surgical fees, as set forth in section 7.0 of the Medicaid Management Information System Provider Manual, Physicians (revised January, 1985). Copies of the Physicians Manual schedules may be obtained from the Department of Social Services, and are available for inspection and copying at the Department of Health Records Access Office, as indicated in subdivision (h) of this section.
(e) The commissioner shall establish trend factors to project increases in the base year prices during the effective period of the reimbursement rate. To determine trend factors, cost elements shall be weighted based upon data for salaries, employee health and welfare expenses, nonpayroll administrative and general expense, nonpayroll household and maintenance expense, and nonpayroll professional care expense. Each weight shall be adjusted by one or more price indices. Included among these indices are elements of the United States Department of Labor consumer and producer price indices and special indices developed by the commissioner for this purpose.
(f) The projected trend factors shall be updated on an annual basis, based upon then current and available data. The commissioner shall adjust annually subsequent trend factors based upon such update.
(g) Dental procedures included in subdivision (o) of this section performed at facilities for patients requiring the use of an operating room with anesthesia will continue to be paid at current cost-based rates.
(h) Reimbursement for physician services rendered in connection with the provision of ambulatory surgical services shall be in accordance with the Medicaid fee schedule set forth in Title 18 (Social Services) of the Official Compilation of Codes, Rules and Regulations of the State of New York at section 533.4 (18 NYCRR 533.4), as amended pursuant to chapter 904 of the Laws of 1984. Copies of the current schedule of fees, as set forth in section 7.0 of the Medicaid Management Information System Provider Manual, Physicians (revised January 1985), may be obtained from the Bureau of Program, Policy and Operations of the Division of Medical Assistance of the New York State Department of Social Services, 40 North Pearl Street, Albany, NY 12243. The current physicians' fee schedule is available for inspection and copying at the Department of Health, Records Access Office, 22nd Floor, Corning Tower Building, Governor Nelson A. Rockefeller Empire State Plaza, Albany, New York 12237-0042.
(i) Reimbursement for durable medical equipment subsequently required as a result of the provision of ambulatory surgical services shall be in accordance with section 4.2 of the Medicaid Management Information System (MMIS) Provider Manual, Durable Medical Equipment, Medical and Surgical Supplies, Prosthetic and Orthotic Appliances (revised March 1984). Copies of the current durable medical equipment schedules may be obtained from the New York State Department of Social Services, and are available for inspection and copying at the Department of Health, Records Access Office, as indicated in subdivision (h) of this section.
(j) Reimbursement for prosthetic and orthotic appliances subsequently required as a result of and necessitated by the provision of ambulatory surgical services shall be in accordance with Part 522 of Title 18 (Social Services) of the Official Compilation of Codes Rules and Regulations (18 NYCRR Part 522). Copies of current fee schedules for prosthetic and orthotic appliances, as contained in sections 4.6, 4.3 and 4.4, respectively, of the MMIS Provider Manual referenced in subdivision (g) of this section, may be obtained from the New York State Department of Social Services, and are available for inspection and copying at the Department of Health, Records Access Office, as indicated in subdivision (h) of this section.
(k) For any procedure which is not an ambulatory surgical procedure:
(1) facilities with a cost-based all-inclusive Medicaid clinic rate established pursuant to this Part or Subpart 86-1, shall be reimbursed at such rate; provided, however, that the provisions of subdivisions (h) through (j) of this section shall not apply and that the cost for services referred to in these subdivisions shall be considered fully reimbursed through payment of such clinic rate; and
(2) for facilities without a cost-based all-inclusive Medicaid clinic rate established pursuant to this Part or Subpart 86-1, facility costs shall be reimbursed in accordance with section 6.2.5 of the Medicaid Management Information System (MMIS) Clinic Provider Manual, Fees for Hospital-Based Referred Ambulatory Use of the Operating Room (revised December 1984). Copies of the schedule may be obtained from the New York State Department of Social Services, and are available for inspection and copying at the Department of Health, Records Access Office, as indicated in subdivision (h) of this section.
(l) Where multiple procedures are performed and they appear in more than one PAS group, payment pursuant to this section shall be based upon 100 percent of the group price for the highest priced procedure and 50 percent of the applicable group price for each additional procedure furnished in the same operative session.
(o) The following table represents the Products of Ambulatory Surgery (PAS) classification system for which reimbursement is available according to group and group price as established in this section. The Products of Ambulatory Surgery classification system, developed by the New York State Department of Health, classifies ambulatory surgery procedures based upon similarities in patient and resource use characteristics. The table includes the PAS classification and PAS name as follows:
|PAS GROUP||GROUP NAME|
|PAS GROUP 1||Nerve Repair|
|PAS GROUP 2||Eye Therapeutic|
|PAS GROUP 3||Eye Repair|
|PAS GROUP 4||Lens Remove/Replace|
|PAS GROUP 5||Eye Laser Therapeutic|
|PAS GROUP 6||Eye Muscle Repair|
|PAS GROUP 7||Ear Repair|
|PAS GROUP 8||Ear Therapeutic|
|PAS GROUP 9||Nasal/Paranasal Therapeutic|
|PAS GROUP 10||Rhino/Septo Plasty|
|PAS GROUP 11||Tonsil/Adenoid Therapeutic|
|PAS GROUP 12||Nasal/Tracheal Endoscope|
|PAS GROUP 13||Thoracic Diagnostic/Therapeutic|
|PAS GROUP 14||Vascular Diagnostic II|
|PAS GROUP 15||Vascular Repair|
|PAS GROUP 16||Vascular Diagnostic/Therapeutic|
|PAS GROUP 17||UpperGI Diagnostic/Therapeutic|
|PAS GROUP 18||LowerGI Diagnostic/Therapeutic|
|PAS GROUP 19||Rectal Diagnostic/Therapeutic|
|PAS GROUP 20||Hepatic Diagnostic/Therapeutic|
|PAS GROUP 21||Hepatic Endoscopy|
|PAS GROUP 22||Hernia Repair|
|PAS GROUP 23||Cystoscope|
|PAS GROUP 24||Urological Therapeutic|
|PAS GROUP 25||Lithotripsy|
|PAS GROUP 26||Male Genital Diagnostic|
|PAS GROUP 27||Genito-Urinary Repair|
|PAS GROUP 28||Male Genital Therapeutic|
|PAS GROUP 29||Laparoscopy|
|PAS GROUP 30||Oviduct Diagnostic/Therapeutic|
|PAS GROUP 31||Gyn Diagnostic/Therapeutic|
|PAS GROUP 32||Dilation and Curettage|
|PAS GROUP 33||Soft Tissue Repair|
|PAS GROUP 34||Bone Therapeutic|
|PAS GROUP 35||Arthroscopy|
|PAS GROUP 36||Bone Repair|
|PAS GROUP 37||Soft Tissue Therapy|
|PAS GROUP 38||Breast Diagnostic/Therapeutic|
|PAS GROUP 39||Breast Repair|
|PAS GROUP 40||Skin Diagnostic/Therapeutic|
|PAS GROUP 41||Skin Repair|
|PAS GROUP 42||Urological Diagnostic|
|PAS GROUP 43||Oral Surgery|
|PAS GROUP 44||STRB|
|PAS GROUP 45||Eye Implant/Therapeutic (HIV)|
VOLUME A-2 (Title 10)