Texas Register

TITLE 28 INSURANCE
PART 2TEXAS WORKERS' COMPENSATION COMMISSION
CHAPTER 134BENEFITS--GUIDELINES FOR MEDICAL SERVICES, CHARGES, AND PAYMENTS
SUBCHAPTER EHEALTH FACILITY FEES
RULE §134.402Ambulatory Surgical Center Fee Guideline
ISSUE 10/31/2003
ACTION Proposed
Preamble Texas Admin Code Rule

(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 June 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, with the following minimal modifications:

  (1)the Medicare facility specific reimbursement amount shall be multiplied by 230%; or,

  (2)for services for which neither Medicare nor the commission establishes a payment amount, the carrier shall reimburse a fair and reasonable amount, which may be based on nationally recognized published studies, published commission medical dispute decisions, and/or reimbursements for facility services involving similar work and resource commitments which are consistent with both the facts and the standards of §134.1 of this title (relating to Use of the Fee Guidelines).

(d)In all cases, reimbursement shall be the lesser of the:

  (1)MAR amount established by this rule regardless of billed amount;

  (2)facility's and payer's workers' compensation negotiated and/or contracted amount that applies to the billed service(s); or

  (3)the amount established by the commission in a fee guideline for the same or similar service provided in either an inpatient or outpatient hospital setting.

(e)Notwithstanding Medicare payment policies, exceptions and minimal modifications are as follows:

  (1)whenever Medicare requires a retroactive payment policy change, the change shall not apply to services already provided; and

  (2)whenever Medicare requires a specific setting for a service, that restriction shall apply, unless an alternative setting and payment has been approved through preauthorization, concurrent review, or voluntary certification.

(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 proposal has been reviewed by legal counsel and found to be within the agency's legal authority to adopt.

Filed with the Office of the Secretary of State on October 17, 2003

TRD-200306902

Susan Cory

General Counsel

Texas Workers' Compensation Commission

Earliest possible date of adoption: November 30, 2003

For further information, please call: (512) 804-4287



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