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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 (ASC), other than professional medical services. (2)This section applies to facility services provided by an ASC on or after September 1, 2004. The provisions of subsection (e)(2), (3), and (4), and subsection (f) of this section apply to facility services provided by an ASC on or after April 1, 2005. (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 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)Exceptions and modifications to the Medicare payment policies are as follows: (1)Whenever Medicare requires a payment policy change to be retroactive, that change shall only apply to services provided on or after the date of that change. (2)In addition to the ASC List of Medicare Approved Procedures, the following procedures will be reimbursed when provided in an ASC at the reimbursement rate provided by this section as if they were on that list (using the same Medicare group assignment values): (A)11750 - Group 1 (B)11760 - Group 1 (C)20552 - Group 1 (D)20526 - Group 1 (E)27599 - Group 1 (F)29873 - Group 3 (G)29999 - Group 4 (H)63030 - Group 6 (I)64405 - Group 1 (J)64999 - Group 1 (3)If a service is not included on the ASC List of Medicare Approved Procedures or listed in subsection (e)(2) of this section, the insurance carrier (carrier), health care provider, and ASC may agree to an ASC setting as follows: (A)The agreement may occur before, during, or after preauthorization. (i)A preauthorization request may be submitted for an ASC setting only if an agreement has already been reached and a copy of the signed agreement is filed as a part of the preauthorization request. (ii)A preauthorization request or approval for a non-ASC facility setting may be revised to an ASC setting by written agreement of the carrier and the health care provider during or after preauthorization. (B)The agreement between the carrier and the ASC must be in writing, in clearly stated terms, and include: (i)the reimbursement amount; (ii)any other provisions of the agreement; and (iii)names, titles and signatures of both parties with dates. (C)Copies of the agreement are to be kept by both parties. (D)Upon request of the Commission, the agreement information shall be submitted in the form and manner prescribed by the Commission. (4)The carrier shall reimburse all surgically implanted, inserted, or otherwise applied devices at the lesser of the manufacturer's invoice amount or the net amount (exclusive of rebates and discounts) actually paid for such device to the manufacturer by the ASC. Provider billing shall include a certification that the amount sought represents its actual cost (net amount, exclusive of rebates and discounts). That certification shall include the following sentence: "I hereby certify under penalty of law that the following is the true and correct actual cost to the best of my knowledge." (f)A carrier may use the audit process under §133.302 and §133.303 of this title (relating to Preparation for an Onsite Audit and Onsite Audits) to seek verification that the amount certified under subsection (e)(4) of this section properly reflects the actual cost standard contained in that subsection. Such verification may also take place in the Medical Dispute Resolution process under §133.307 of this title (relating to Medical Dispute Resolution of a Medical Fee Dispute), if that process is properly requested. (g)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 February 18, 2005
TRD-200500769 Susan Cory
General Counsel
Texas Workers' Compensation Commission
Effective date: March 10, 2005
Proposal publication date: December 3, 2004
For further information, please call: (512) 804-4287
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