Outpatient Hospital Fee Schedule Frequently Asked Questions (FAQs)



Q: Do same day admission/discharge or transfer claims submitted with an Inpatient bill type require HCPCS codes in order to be paid under OPFS?

A: HCPCS requirements should be based upon the published values on the RF774 table.  The RF774 table defines whether a HCPC code is required, optional or not required when billed with specific bill type and revenue code combinations. If this indicator is optional, a HCPC code is not required, but may be reported if applicable.
 

Q: The following list of procedures were historically not included on RF797 as bundling triggers, has this designation changed under the OPFS rebase on 10/1/2011? Procedures - 59000, 59001, 59012, 59015, 59020, 59025, 59030, 59070, 59074, 59076 and 59200

A: Yes. In October 2011, AHCCCS completed a rebase for outpatient fee schedule. Part of the goal of this rebase was to make the AHCCCS system more Medicare-like. In the Medicare OPPS these procedures as well as other maternity-related procedures are included as bundling triggers. So, in order to make the system more Medicare-like, AHCCCS made the decision to also treat them as bundling triggers.


Q: What procedures are applicable to multiple surgery evaluation under OPFS?

A: AHCCCS follows the guidelines as outlined in the Medicare Physicians Fee Schedule multiple procedure indicators to define those codes to which multiple procedure reductions apply. Procedures which are considered for multiple surgical evaluation are found on the RF724 extract.


Q: If a revenue code to HCPC/CPT relationship is present on RF773 does that mean that the listed revenue code requires HCPCS/CPT reporting under OPFS?

A: No, RF774 (not RF773) defines whether or not a HCPC code is required, optional or not required when billed with a specific revenue code. If this indicator is optional, a HCPC code should not be required, but may be reported if applicable.


Q: Are serviced under revenue code 68X reimbursable by AHCCCS?

A: No, AHCCCS does not pay separately for services billed with 68X revenue codes. The services provided are billable with the 45X Emergency Room Revenue Codes. If a patient becomes an inpatient, services billed with the 68X revenue code are not reimbursable, neither are they allowed for outlier consideration.


Q: How is the OPFS bundling of multiple dates of service applied to claims?

A: For dates of service prior to 10/1/2011
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 10/1 and there is no bundling trigger procedure on 10/2. Only those applicable services (as defined on RF796) which occur on 10/1 should be subject to bundling.

Claim dates of service 10/1 - 10/2 Bundling trigger procedure (as defined on RF797) occurs on 10/1 and there is also an additional bundling trigger procedure that occurs on 10/2. Those applicable services (as defined on RF796) which occur on 10/1 and 10/2 should be subject to bundling.

For dates of service on and after 10/1/2011
Bundle applies to those applicable services within a claim, regardless of the date of service of bundling triggers.

For example:
Claim dates of service 10/1 - 10/2 Bundling trigger procedure (as defined on RF797) occurs on 10/1 and there is no bundling trigger procedure on 10/2. All applicable services (as defined on RF796) which occur on either 10/1 or 10/2 should be subject to bundling.


Q: Are Hospital Based Dialysis services billed under the facility (NPI) reimbursed under OPFS?

A: Any Outpatient (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 the AHCCCS service limits not published?

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.


Q: What are the values of the Action Codes listed on the RF723 extract?

A: Possible Action Code values are:

  • 01-Override Multiple Surgery Discount
  • 02-Override Frequency Service Limit
  • 04-Override Correct Coding Initiative (CCI) Edits
  • 05-Override Bundled Revenue Codes
  • Values 07, 08 and 09 are not associated with OPFS and are utilized for internal AHCCCS processing only.

Q: How will OPFS claims which overlap (10/1) fee schedule changes be valued?

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 In-patient (IP) methodologies.


Q: What revenue codes trigger bundling?

A: Revenue codes do not trigger bundling. Bundling triggers are Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS/CPT) procedure based and can be found on RF797.
HCPCS/CPT procedures trigger bundling (RF797), actual bundled services are revenue code based (RF796).


Q: Are the 51X (clinic) range of revenue codes covered under OPFS?

A: Yes, 51X (clinic) revenue codes are covered under OPFS for all Providers (both Indian Health Service (IHS) and non-IHS) and were also covered services under the prior cost to charge methodology.


Q: Please provide a list of Surgeries which are not subject to multiple surgery logic.

A: All surgeries which are subject to multiple surgery logic are listed in the RF724 extract, if a service is not listed on this extract it is not subject to multiple surgery logic.


Q: How often is the Fee Schedule updated?

A: Fee schedules are generally updated annually.


Q: When will the default Cost to Charge be updated?

A: Fee schedules are generally updated annually.


Q: How do we know how many units will be allowed per Rev Code?

A: Units of service on OP claims are generally related to the HCPCS/CPT code reported rather than the revenue code. HCPCS/CPT 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: Please verify that "J" drug code rates are appropriate; they appear to be much lower than Medicare.

A: J code rates are based on the physician fee schedule rates, and closely matched Medicare when they were updated in the spring.


Q: How do we find if we need a peer group modifier?

A: Peer group modifiers are terms used to describe the percent (%) 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?

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.


Q: Are you following Centers for Medicare and Medicaid Services (CMS) Payment Status Indicators such as S&T, N, K, etc.?

A: AHCCCS has not fully implemented status indicators at this time. However, AHCCCS is following the logic for most status indicators through our internal tables.


Q: Should we use bill type 137 for the adjustment of previously paid claims?

A: Yes, use bill type 137.


Q: We are a Critical Access Hospital CAH, AHCCCS is secondary to Medicare. What claim form do you want submitted?

A: All hospital claims must be submitted on either a hardcopy UB92 claim form or via the 837I electronic file format.


Q: If Hospital the (ER) admit date and discharge date does not match (service spans midnight), will claim reject, pend, or deny?

A: Should not be an issue, no change to the allowance of date spans for OP.


Q: Clarify admission dates from ER to inpatient.

A: No change to current IP requirements.


Q: Why doesn't AHCCCS pay Trauma Revenue codes under OPFS?

A: AHCCCS doesn't allow the Trauma Revenue codes (681 682 683 684 and 685) because the hospitals receive supplemental payments each year to cover their incremental trauma expenses.


Q: If a revenue code to HCPC/CPT relationship is present on RF773 does that mean that the listed HCPCS/CPT procedure code is covered under OPFS?

A: No, RF773 defines whether or not a HCPC/CPT code is valid for reporting with a specific revenue code only; it does not indicate coverage of that service.


Q: Are services reported with 051X revenue codes eligible for PGM’s?

A: Yes, as appropriate for the hospital and the service associated with the revenue code.


Q: If a HCPCS/CPT is reported with a 051X revenue code and no rate is listed on RF133 will the service default to the CCR?

A: No, if no rate is found on RF133 the service will default to the rate on the OPFS fee schedule.


Q: When do Observation bundling triggers apply?

A: Observation bundling is only applied if the claim has not already applied either ER or surgical bundling triggers.


Q: Are there any special rules to observation bundling that differ from surgical or ER bundling?

A: No, rules are equal to ER. For example, some services are excluded from surgical bundling but not ER bundling.


Q: Would observation bundling be treated like surgical bundling rules, ER bundling rules, or a unique rule for observation itself different than ER or surgical bundling?

A: No, rules are equal to ER. Surgical bundling exceptions do not apply.


Q: Are lines which include bundling trigger procedures subject to bundling if the associated revenue code is found on RF796?

A: No, bundling trigger lines never bundle regardless of the associated revenue code billed.