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(a)Applicability of this rule is as follows: (1)This section applies to facility services provided by an ambulatory surgical center, other than professional medical services. (2)This section applies to facility services provided by an ambulatory surgical center on or after September 1, 2004. (3)Specific provisions contained in the Texas Workers' Compensation Act (Act) or Texas Workers' Compensation Commission (commission) rules, including this rule, shall take precedence over any conflicting provision adopted or utilized by the Centers for Medicare and Medicaid Services (CMS) in administering the Medicare program. Exceptions to Medicare payment policies for medical necessity may be provided by commission rule. Independent Review Organization (IRO) decisions regarding medical necessity are made on a case-by-case basis. The commission will monitor IRO decisions to determine whether commission rulemaking action would be appropriate. (4)Whenever a component of the Medicare program is revised and effective, use of the revised component shall be required for compliance with commission rules, decisions and orders for services rendered on or after the effective date of the revised component. (b)For coding, billing, reporting, and reimbursement of facility services covered in this rule, Texas workers' compensation system participants shall apply the Medicare program reimbursement methodologies, models, and values or weights including its coding, billing, and reporting payment policies in effect on the date a service is provided with any additions or exceptions in this section. (c)To determine the maximum allowable reimbursement (MAR) for a particular service, system participants shall apply the Medicare payment policies for these services and the Medicare ASC reimbursement amount multiplied by 213.3%. (d)In all cases, reimbursement shall be the lesser of the: (1)MAR amount established by this rule regardless of billed amount; or (2)facility's and payer's workers' compensation negotiated and/or contracted amount that applies to the billed service(s). (e)Notwithstanding Medicare payment policies, whenever Medicare requires a retroactive payment policy change, the change shall not apply to services already provided. (f)Where any terms or parts of this section or its application to any person or circumstance are determined by a court of competent jurisdiction to be invalid, the invalidity does not affect other provisions or applications of this section that can be given effect without the invalidated provision or application.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed with the Office of
the Secretary of State on April 19, 2004
TRD-200402581 Susan Cory
General Counsel
Texas Workers' Compensation Commission
Effective date: May 9, 2004
Proposal publication date: October 31, 2003
For further information, please call: (512) 804-4287
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