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PDFWAC 296-23A-0740

How does the department calculate payments for covered outpatient services through the outpatient prospective payment system (OPPS)?

(1) Billed services that are reimbursed by the OPPS are grouped into one or more APCs using the outpatient code editor software.
(2) Additional payment may be made for services classified by CMS as transitional pass-through.
(3) Incidental services are grouped within an APC and are not paid separately.
(4) The OPPS APC payment method uses an APC relative weight for each classification group (APC) and the current hospital-specific blended rate to determine the APC payment for an individual service.
(5) For each additional APC listed on a single claim for services, the payment is calculated with the same formula and then discounted. L&I follows all discounting policies used by CMS for the Medicare Prospective Payment System for Hospital Outpatient Department Services.
(6) APC payment for each APC = (APC relative weight x hospital-specific blended rate)* discount factor (if applicable) x units (if applicable).
(7) The total payment on an APC claim is determined mathematically as follows:
(a) Sum of APC payments for each APC +
(b) Additional payment for each transitional pass-through (if applicable) +
(c) Additional outlier payment (if applicable).
(8) Unless otherwise indicated in departmental payment policies, the department follows billing policies used by the Centers for Medicare and Medicaid Services (CMS) for the hospital outpatient prospective pricing system with respect to:
(a) Billing of units of service;
(b) Outlier claims;
(c) Use of modifiers;
(d) Distinguishing between single and multiple visits during a span of time and reporting a single visit on one claim, but multiple visits with unrelated medical conditions on multiple claims; and
(e) For paying terminated procedures based on services actually provided and documented in the medical record, and properly indicated by the hospital through the CPT codes and modifiers submitted on the claim.
[Statutory Authority: RCW 51.04.020(1) and 51.04.030. WSR 21-18-097, § 296-23A-0740, filed 8/31/21, effective 10/1/21. Statutory Authority: RCW 51.04.020, 51.04.030, 51.36.080, 51.36.085. WSR 01-24-045, § 296-23A-0740, filed 11/29/01, effective 1/1/02.]
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