5160-22-03 Reimbursement of facility services in an ambulatory surgery center (ASC).

(A) Payment for facility services.

(1) Payment for facility services is based on a reimbursement rate for each surgical group classification as determined by the department. The reimbursement rate will be called the surgical group rate.

(2) Covered ASC procedures will be classified into nine surgical groups numbered one, two, three, four, five, six, seven, eight or nine. The surgical group classification for each covered procedure is contained in appendix DD to rule 5101:3-1-60 to the Administrative Code.

(3) Maximum reimbursement for facility services furnished with a covered surgical procedure will be the provider's billed charges or one hundred per cent of the surgical group rate as specified in paragraph (J) of rule 5101:3-1-60 of the Administrative Code, whichever is less.

(4) When more than one covered procedure is performed in a single operative session, reimbursement for facility services will be one hundred per cent of the surgical group rate for the primary procedure and fifty per cent of the surgical group rate for the secondary procedure. Any subsequent procedures will be reimbursed zero per cent of the surgical group rate.

(B) Payment for laboratory services, radiological services, and diagnostic and therapeutic procedures.

An ASC may be reimbursed in addition to the facility fee for laboratory procedures, radiological procedures, and diagnostic and therapeutic procedures provided in connection with a covered ASC surgical procedure. To be reimbursed for these services, ASC providers must bill using the appropriate HCPCS codes.

(1) Payment for laboratory services.

(a) An ASC facility may be reimbursed in addition to the facility payment for covered laboratory services they actually performed as long as the services are provided in accordance with Chapter 5101:3-11 of the Administrative Code.

(b) An ASC may not bill separately for the professional component of an anatomical pathology procedure.

(2) Payment for radiological services.

(a) An ASC may be reimbursed in addition to the facility fee for radiological procedures they actually performed as long as the services are provided and billed in accordance with rule 5101:3-4-25 of the Administrative Code.

(b) An ASC may not bill the department for the professional component separately.

(3) Payment for diagnostic and therapeutic procedures.

(a) An ASC may be reimbursed in addition to the facility fee for the provision of diagnostic and therapeutic services when provided in accordance with rules 5101:3-4-11, 5101:3-4-16, 5101:3-4-17 and 5101:3-4-18 of the Administrative Code.

(b) An ASC may not bill separately for the professional component of a diagnostic and therapeutic procedure.

(c) An ASC may not bill for any service designated as a professional only service in the rules cited in paragraph (B)(3)(a) of this rule.

(C) An ASC may also be reimbursed for laboratory, radiology and diagnostic and therapeutic services actually performed in the ASC in conjunction with covered services not eligible for an ASC facility payment.

Effective: 07/01/2009
R.C. 119.032 review dates: 02/11/2009 and 07/01/2014
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 5111.021
Prior Effective Dates: 1/4/88, 2/17/91, 12/29/95 (Emer), 5/21/96, 1/1/04