| Outpatient
Hospital Fee Schedule Frequently Asked Questions |
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Q |
How should OPFS bundling be applied for claims for multiple dates of service?
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A |
Bundle only those applicable services on the same date of
service as each bundling trigger.
For example:
- Claim dates of service 10/1 - 10/2 Bundling trigger procedure
(as defined on RF797) occurs on 1/1 and there is no bundling
trigger procedure on 1/2. Only those applicable services (as
defined on RF796) which occur on 1/1 should be subject to
bundling.
-
Claim dates of service 10/1 - 10/2 Bundling trigger procedure
(as defined on RF797) occurs on 1/1 and there is also an
additional bundling trigger procedure that occurs on 1/2. Those
applicable services (as defined on RF796) which occur on 1/1 and
1/2 should be subject to bundling.
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|
Q |
Are Hospital Based Dialysis services billed under the
facility NPI reimbursed under OPFS?
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A |
Any OP services (including Dialysis) billed under the hospitals
NPI, (in the absence of a contract specifying otherwise) should
be valued under OPFS. |
|
Q |
Why are AHCCCS service limits not published?
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A |
Except in rare instances, AHCCCS covers
medically necessary services. Limits in our system are not
benefit limits, but rather serve as triggers for internal review
of the services provided to members. AHCCCS, like most payors,
including Medicare, does not publish the limits used for
internal reviews of claims for services provided to our members.
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|
Q |
What are the values of the Action Codes listed on the RF723
extract?
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A |
Possible values are: 01-Override Multiple Surgery Discount,
02-Override Frequency Service Limit, 04-Override CCI Edits,
05-Override Bundled Revenue Codes. |
|
Q |
How will OPFS claims
which overlap (10/1) fee schedule changes be valued?
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A |
Valuation of OPFS claims will be based upon the beginning date
of service on the claim. This is consistent with historical OP
Cost to Charge and current IP methodologies. |
|
Q |
What
revenue codes trigger bundling?
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A |
Revenue
codes do not trigger bundling. Bundling triggers are HCPCS
procedure based and can be found on RF797. |
|
Q |
Are the 51X (clinic)
range of revenue codes covered under OPFS?
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A |
Yes. 51X (clinic) revenue codes are covered under OPFS for
all Providers (both I.H.S. and non-I.H.S.) and were also covered
services under the prior cost to charge methodology.
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|
Q |
Please provide a list of Surgeries which are not subject to
multiple surgery logic. |
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A |
This information will be posted to the Website as
an extract from table RF789.
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|
Q |
How often is the Fee Schedule updated?
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A |
Generally annually.
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Q |
When will the default Cost to Charge be updated?
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A |
Updates should be infrequent and normally tied
only to rebasing of rates. |
|
Q |
How do we know how many units will be allowed per
Rev Code.
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A |
Units that exceed table allowances will be
reviewed. There should not be
any problems as long as services are correctly billed as these
limits are consistent with industry standards. |
|
Q |
Why is 99217 not appropriate for hospital billing?
(Observation Services)
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A |
The internal AHCCCS Work group did not feel that
99217 was appropriate as this code is observation care discharge
day management, used by physician to report if discharge is not
on initial date of observation status, whereas codes we are
using are not discharge codes but are codes for observation care
and can be billed hourly by hospital. This code was considered
by the internal AHCCCS workgroup, but not selected as AHCCCS is
looking for hours of observation at levels of care. |
|
Q |
Please verify that “J” code rates are appropriate, they appear
to be much lower than Medicare. |
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A |
J codes rates are based on the physician fee
schedule rates, and pretty much matched Medicare when they were
updated in the spring. AHCCCS is aware that there are some
updates Medicare has posted for July and is in the process of
reviewing these. If there are particular examples of concern
please let us know via the Outpatient Workgroup email address.
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Q |
How do we find if we need a peer group modifier?
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A |
Peer Group modifiers are a term used to describe
the % of the Fee Schedule that AHCCCS will reimburse groupings
of Hospitals. This % is automatically applied and has no
reporting requirements. |
|
Q |
Will you be following the OCE updates?
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A |
AHCCCS will follow OCE edits, but may not
implement all or at the same time, as Medicaid coverage differs
from Medicare in some areas. |
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Q |
Are you following CMS Payment Status Indicators such
as S&T, N, K, etc.?
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A |
AHCCCS has not implemented status indicators at
this time. If and when these are implemented, AHCCCS will not
be implementing all values. However, AHCCCS is following the
logic for status indicators S&T through our internal tables.
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|
Q |
Should we use bill type 137 for the adjustment of
previously paid claims?
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A |
Yes. |
|
Q |
How are these changes going to effect getting
authorizations?
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A |
Will not impact AHCCCS FFS authorizations. Please
contact individual health plans for specific requirements. |
|
Q |
We are a CAH, AHCCCS is secondary to Medicare. What claim
form do you want submitted? |
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A |
All hospital claims
must be submitted on either a hardcopy UB92 claim form or via
the 837I electronic file format.
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|
Q |
If Hospital E/R admit date and discharge date does
not match (service spans midnight), will claim reject, pend or
deny?
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A |
Should not be an issue, no change to the allowance
of date spans for O/P. |
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Q |
Clarify admission dates from ER to inpatient. |
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A |
No change to current I/P requirements.
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