October 1, 2016
Control Log No.: DCO16032 1
District of Columbia Medicaid
A New Outpatient Hospital Payment
Method
Frequently Asked Questions
Version Date: October 1, 2016
UPDATE:
The District of Columbia (DC) Department of Health Care Finance (DHCF) submitted state plan
amendments (SPAs) for three new hospital payment methods that were effective October 1, 2014. The
outpatient SPA was approved by CMS on August 27, 2015. All claims with a first date of service on or
after October 1, 2014 have been reprocessed with payment adjustments as necessary under the new
payment method.
OVERVIEW
1. What change was made?
The DC Department of Health Care Finance (DHCF) has implemented a new payment method for all
outpatient hospital services. The previous payment method was a cost-based method with hospital-
specific visit rates. The new method uses Enhanced Ambulatory Patient Groups (EAPGs). EAPGs are a
visit-based patient classification system designed by 3M Health Information Systems to characterize the
amount and type of resources used in a hospital outpatient visit for patients with similar clinical
characteristics. The use of EAPGs results in higher payments for higher intensity services and lower
payments for lower intensity services.
2. Why change to a new payment method?
The previous outpatient payment method was based upon hospital-specific costs with an enhanced rate for
emergency services, while some services were paid by a fee based on the procedures billed. A flat visit
rate of $50 was also paid in certain instances, for example, for emergency room visits considered non-
emergent. Outpatient surgery services were paid by flat rates based on groups of HCPCS procedure
codes. Based upon this payment methodology, hospitals were reimbursed at 36% of their costs for
outpatient services. The previous payment methodology did not take into account the clinical complexity
of the patient and the resources needed to appropriately diagnose and treat that patient.
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October 1, 2016
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3. What are the goals that DHCF hopes to achieve by implementing a new outpatient payment
methodology?
Goals of the new outpatient hospital payment method include:
• Implement a sustainable payment method. The District needs an outpatient payment method that is
sustainable over time, promotes quality of care and is flexible enough to accommodate changes in
payment policy and federal regulatory requirements.
• Increase fairness. Under the previous payment method, different hospitals were often paid very
different amounts for the same or very similar care to similar patients based upon historic differences
in the cost of providing care. We believe it is fairer to have payment reflect resources currently
available and the reasonable costs of providing care based on patient needs rather than the individual
hospital’s historic experience in providing care.
• Reduce administrative burden. One component of the previous payment method relied on diagnosis
codes defined as emergent for an add-on ER payment. Maintaining this list of emergent diagnosis
codes presents an administrative burden after implementation of ICD-10 coding. The EAPG grouper
is compliant with ICD-10 coding.
• Improve purchasing clarity. Under the previous payment method, it was very difficult to understand
how much Medicaid was paying for specific types of outpatient services. The District aimed to align
its payment methodology with prevailing methodologies used by other Medicaid programs and
private payers that improve purchasing clarity and encourage hospital efficiency.
4. Does the implementation of ICD-10 impact the new payment method?
The EAPG grouper is fully compliant with both ICD-9 and ICD-10 codes.
5. What providers and services are affected?
The new payment method will apply to all outpatient hospital services provided by:
• In-District general acute care hospitals and specialty hospitals that offer outpatient hospital services
(psychiatric, rehabilitation, and children’s hospitals) and
• Out-of-District hospitals, except for Maryland hospitals.
ENHANCED AMBULATORY PATIENT GROUPS (EAPGS)
6. Why were EAPGs chosen? Why not the Ambulatory Payment Classification groups (APCs)
that Medicare uses?
The District conducted an assessment of various options available for payment of outpatient hospital
services, including Medicare’s APCs. EAPGs were chosen because they are more suitable for use with
the Medicaid population. Medicare APCs were designed for the Medicare population in support of
Medicare policies. EAPGs are designed for an all-patient population. EAPGs reflect the relative intensity
of the entire visit allowing providers and payers to more accurately account for resources and for
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October 1, 2016
Control Log No.: DCO16032 3
payment. EAPGs reward hospitals for providing efficient access to a wide variety of increasingly
clinically complex outpatient hospital services in a more appropriate manner.
As opposed to Medicare’s APC mixed fee schedule approach, EAPGs are an outpatient visit grouping
system, which places patients and services into clinically coherent groups. EAPGs do rely on the
CPT/HCPCS procedure code but also use diagnosis codes and other clinical and demographic factors to
determine appropriate EAPG assignment. And while APCs generate payment based on volume of codes
submitted, EAPGs are more clinically driven and are designed to generate payments that reflect the
relative resource intensity of the entire visit. Therefore the use of EAPGs will result in higher payments
for higher intensity services and lower payments for lower intensity services.
7. In general, how will the new payment method impact hospitals?
In general, the new payment method provides rational incentives for the provision of outpatient hospital
services:
• There is a more direct link between the level of payment and the complexity of the service provided.
Efficiency and cost containment are rewarded. Hospitals that provide similar services are paid
similarly.
• Complete and correct coding of claims is more important, and may have an effect on claim payment.
It should be noted that CPT/HCPCS codes are not required nor expected on every line of the claim.
Some claim lines may be bundled whether or not a procedure code is present. Hospitals should code
claims according to national coding guidelines.
8. What other payers use EAPGs?
Medicaid programs currently using EAPGs include: New York, Virginia, Wisconsin, Illinois and
Washington, DC for payment; and Massachusetts for service-mix adjustment. Medicaid programs with
planned EAPG implementations for outpatient hospital services are: Ohio, Nebraska, Florida, Colorado,
and Texas. Massachusetts will begin using EAPGs for payment beginning December 1, 2016.
Commercial payers currently using EAPGs include: Oklahoma BlueCross BlueShield, Minnesota
BlueCross BlueShield, and Wellmark in Iowa and South Dakota. BlueCross BlueShield of Alabama will
move to EAPGs effective October 1, 2016.
9. Is my hospital required to purchase EAPG software in order to receive payment under the new
method?
No. The EAPG grouper/pricer specific to DC Medicaid assigns the EAPGs to the claim lines and
calculates the payment. The DC Medicaid claims processing system then adjudicates the claim for final
pricing. Hospitals may choose to purchase grouping software allowing them to project revenue. For
Washington, DC, the 3M sales representative is Kelli Boswell, Client Relationship Executive, 770-725-
2090. Neither DHCF nor Xerox has a financial interest in any 3M product.
10. Does my hospital have to start collecting additional data to use 3M EAPGs?
No. The data elements needed for EAPG grouping include only those that hospitals already submit on the
paper and electronic standard institutional claim forms. For example, diagnosis codes, CPT/HCPCS
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October 1, 2016
Control Log No.: DCO16032 4
procedure codes, revenue codes, line item dates of service, age and gender. Hospitals do not need to add
the EAPG to the claim. The EAPG grouper in the DC claims processing system assigns the EAPG.
PAYMENT CALCULATIONS
11. How is EAPG payment calculated?
Each CPT/HCPCS procedure code on a claim line is assigned to the appropriate EAPG at the line level.
Each EAPG has an assigned relative weight. This relative weight is adjusted by the various payment
mechanisms as applicable such as discounting, packaging and consolidation. The adjusted relative weight
is multiplied by a conversion factor to yield the EAPG payment amount. DC Medicaid has also added a
50% pediatric policy adjustor for FY 17 (this is unchanged from FY16). This is applied as a percent
increase on claims for beneficiaries under the age of 21.
Table 1
EAPG Payment
EAPG payment = (Adjusted EAPG relative weight * pediatric policy adjustor) * conversion factor
Adjusted EAPG relative weight = EAPG relative weight *multiple significant procedure discount * bilateral
procedure discount * terminated procedure discount * repeat ancillary procedure discount * other discounts
12. What EAPG relative weights are used to calculate EAPG payment?
DC Medicaid currently uses version 3.8 of the national relative weights available from 3M Health
Information Systems. The EAPG national relative weights are calculated by 3M based on Medicare
claims data, comprising approximately 55 million claims from FY 2014. Effective October 1, 2016, DC
Medicaid will move to version 3.11 of the 3M EAPG national relative weights.
During the design of the new outpatient payment method, DHCF did examine other options for relative
weights. After review, the District opted to use the national relative weights because statistically valid
District-specific relative weights are not feasible due to the District’s small volume of Medicaid claims.
The national relative weights are updated annually by 3M and use EAPG default settings which align
more closely with the District’s overall approach and goals. Other Medicaid programs also use or plan to
use the national relative weights for their EAPG-based payment method.
13. What conversion factors are used in EAPG payment?
For both FY 2016 and FY 2017, DHCF uses three conversion factors: one for in-District and out-of-
District hospitals and one that is 2% higher for United Medical Center (based on its geographic location
in an economic disadvantage zone). National Rehabilitation Hospital also has a separate conversion
factor because of their significantly different cost structure and more limited array of outpatient services
than that of the other hospitals. The values for the final conversion factors effective for Fiscal Year 2016
(October 1, 2015 through September 30, 2016) and Fiscal Year 2017 (October 1, 2016 through September
30, 2017) are shown in the table below.
DC Medicaid EAPG FAQ
October 1, 2016
Control Log No.: DCO16032 5
Conversion Factors
FY 2017
FY 2016
National Rehab Hospital
$150.80
$205.32
United Medical Center
$664.18
$692.34
All Other Hospitals
$651.16
$678.76
14. How were conversion factors calculated?
For both FY 2016 and FY 2017, the conversion factors were configured to achieve overall payments
equal to 77% of inflated costs. FY16 costs were estimated using cost-to-charge ratios (CCRs) from the
District’s FY 2014 (October 1, 2013-September 30, 2014) hospital cost reports which were inflated
forward to FY15 by a 2.52% inflation factor. FY17 costs were estimated using CCRs from the District’s
FY 2015 (October 1, 2014 through September 30, 2015) hospital cost reports which were inflated forward
to FY16 by a 3.3% inflation factor. For FY16, the budget target was reduced by 5% with the expectation
that hospitals will improve coding above 77% of inflated costs. No coding improvement factor was
applied to FY17 simulations.
While conversion factors for FY17 are lower than the FY16 conversion factors, this change does not
represent a decrease in overall payment rates. The District is moving from version 3.8 of the EAPG
national weights to version 3.11. The overall impact of that change on DC claims was an increase in
average claim service mix. In other words, the relative weights of the EAPGs used in DC increased by
about 17% from version 3.8 to version 3.11. In order to maintain the District’s budget target of a 77%
pay-to-cost ratio, conversion factors had to be lowered.
15. How often will conversion factors be updated?
DHCF will evaluate rates on an annual basis to consider any changes necessary to conversion factors
based on budgetary constraints and other factors. DHCF will monitor payment levels closely, especially
during the first year of EAPG payment to ensure that payments do not grossly differ from budgeted
amounts.
16. What version of the EAPG grouper was implemented?
Effective October 1, 2014, DHCF implemented version 3.8 of the EAPG grouper, which was released in
January 2013. For October 1, 2016, DHCF will implement version 3.11 which was released in January
2016.
17. Will there be regular updates to the EAPG Grouper/Pricer software?
Yes. DHCF performs EAPG quarterly updates, which generally involve staying current with
CPT/HCPCS coding updates. The grouper version will be updated at a minimum every two years, which
may involve changes in grouper logic, enhancements and updates to EAPG settings.
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18. Will any outpatient hospital services be paid based on a fee schedule under EAPGs?
No. All outpatient hospital services are paid based on EAPGs. No services have been identified for
payment by fee schedule at this time.
19. Will outlier payments be included in the new payment method?
Outlier payment provisions are typically made for cases that are unpredictably expensive. The District’s
analysis of claims data performed to date does not indicate extreme variation in claim charges or cost,
typically associated with outlier cases. An outpatient cost outlier payment policy is not used unless a need
is identified in future claims data analyses.
20. Is EAPG payment capped to the lower of the EAPG payment or billed charges?
The previous outpatient hospital payment method limited payment for some services to the lesser of the
calculated amount or billed charges. Limiting payment to billed charges is typically used to control costs,
particularly when the payment method is based on a percent of charges. EAPGs are a visit-based patient
classification system designed to link the level of payment with the complexity of the service provided.
When a sophisticated grouping algorithm is used to price claims, such as EAPGs, the result is that a
hospital may be paid more than its charge on a specific claim or line and significantly less than its charge
for others due to payment bundling techniques (packaged services and discounting). However, on balance
the payment method is expected to be fair. A charge cap to limit payment to billed charges is not
imposed.
21. Does this change affect payments from Medicaid managed care plans?
While payments to hospitals from Medicaid managed care plans are outside the scope of this project, the
DC Medicaid managed care organizations may opt to move to Medicaid’s new fee-for-service payment
methods.
22. Does the change affect how Medicare crossover claims are paid?
No. The payment logic for Medicare crossover claims is not affected by EAPGs. DC Medicaid continues
to pay the lesser of these two amounts on an outpatient crossover claim:
a. The Medicaid allowed amount minus the Medicare paid amount
b. The Medicare co-insurance amount plus Medicare deductible amount
COVERAGE AND PAYMENT FOR SPECIFIC SERVICES
23. What changes, if any, were made to prior authorization policy?
The Department uses prior authorization to help control inappropriate utilization of services. While there
were no changes specifically related to the implementation of EAPGs, changes in the Department’s prior
authorization policy are made from time to time to address new coverage policies, new technologies or to
address areas of potential fraud, waste and abuse.
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October 1, 2016
Control Log No.: DCO16032 7
24. How are laboratory and radiology services paid?
Laboratory and radiology services are processed and paid by EAPG, subject to consolidation, packaging
or discounting as applicable.
25. How are physical, occupational, and speech therapy services paid?
Physical therapy, occupational therapy and speech therapy procedures are processed and paid by EAPGs,
subject to consolidation, discounting and packaging as applicable.
26. How are dental services provided in an outpatient hospital setting paid?
Outpatient hospital dental services are processed and paid by EAPGs. The procedure codes and payment
are for the facility services, not for the professional services provided by the dentist. Professional services
provided by dentists (e.g., pediodentist) are not included in the EAPG payment method and will continue
to be billed separately and paid by fee schedule.
27. How are payments for pediatric services affected under EAPGs?
For FY 2016, a 50% pediatric policy adjustor applies to claims for beneficiaries under the age of 21. This
means that payments for these claims will be 50% higher than the otherwise calculated EAPG payment.
For FY 2017, the pediatric policy adjustor will remain at 50%. See FAQ #11 for an illustration of the
calculation formula.
28. Are payments for vaccines and vaccine administration codes affected?
DHCF continues its existing policy and makes no payment for vaccines available through the Vaccines
for Children (VFC) Program. VFC vaccines are not payable under Medicaid because these vaccines are
federally funded and available at no charge to providers for Medicaid eligible children.
Other vaccine and vaccine administration procedure codes currently covered for adults and children are
processed through the EAPG grouper. The payment for vaccine administration codes for adults and
children are bundled when a significant procedure is billed on the claim.
29. What changes were made to observation room services policy?
DHCF changed its previous policy and now pays separately for observation room services under certain
specific conditions. Observation room services begin at the time that the physician writes the order to
evaluate the patient.
The new DHCF policy states that observation services must be at least 8 hours and not more than 48
hours.
Payment for observation services is based on the EAPG, regardless of the number of units (hours)
billed as long as units billed are at least 8. If units are not at least 8, the line will group to EAPG 999
and pay zero.
Observation room services are always packaged when a significant procedure is also billed.
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Under the new payment method, observation room services may be identified by HCPCS code G0378
which groups to EAPG 450. The relative weight for this EAPG reflects the national average units (hours)
greater than 8. (For details on the observation logic, please see EAPG Information handout question #11)
30. What changes were made to partial hospitalization program (PHP) services policy?
No change in current policy for partial hospitalization program (PHP) services was made due to the new
payment method. Consistent with the District Medicaid State Plan, PHP services are not a covered
outpatient hospital service, except as part of waiver services. PHP services are not paid under the new
payment method based on EAPGs.
BILLING AND EDITING
31. What billing practices are important for hospitals to follow under EAPGs?
The EAPG grouper relies on procedure and diagnosis codes and patient demographic information to
accurately group and price claims. Hospitals are asked to ensure that these fields are coded completely,
accurately and defensibly on their outpatient claims based on national coding guidelines.
32. Do hospitals have to submit claim lines in any particular order under EAPGs?
No. After EAPGs were activated in the claims processing system, the order in which claim lines or
HCPCS procedures are billed on the claim is not relevant for accurate payment. Under certain
circumstances, such as when multiple unrelated significant procedures are billed in the same visit, the
grouper ranks those procedures by weight for discounting purposes. This occurs regardless of the order in
which lines are billed on the claim.
33. Do hospitals need to continue using the DC Medicaid visit codes?
Under the previous payment method, hospitals were required to bill outpatient hospital services using one
of the District-designated ‘visit codes’ which included mostly evaluation and management CPT codes.
The presence of the visit codes did not interfere with accurate payment of the claims when they were
reprocessed under EAPGs. Now that EAPGs are activated in the DC Medicaid system, hospitals no
longer have to use the visit codes in order to receive claim payment.
34. When should outpatient services be billed as part of an inpatient claim?
Hospital outpatient diagnostic services provided one to three days prior to an inpatient admission at the
same hospital are not separately payable and should be billed as part of the inpatient stay. Diagnostic
services are defined by revenue code, see table below. All hospital outpatient services (regardless of
revenue code) that occur on the same day as an inpatient admission at the same hospital are also
considered part of the inpatient stay and as such are not separately payable.
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Diagnostic
Revenue Codes
for 3-Day
Window
Revenue Code Desc
0254 - 0255
Pharmacy
0341, 0343
Nuclear medicine
0371 - 0372
Anesthesia
0471
Diagnostic audiology
0482 - 0483
Cardiology
0918
Behavioral health svcs
0300 - 0319
Laboratory
0320 - 0329
Diagnostic radiology
0350 - 0359
CT Scan
0400 - 0409
Other imaging
0460 - 0469
Pulmonary function
0530 - 0539
Osteopathic svcs
0610 - 0619
Magnetic resonance tech
0621 - 0624
Med/surg supplies
0730 - 0739
EKG/ECG
0740
EEG
0920 - 0929
Other dx services
35. Is there any limit to the number of diagnosis codes, modifiers, CPT or procedures codes that
can be submitted per claim?
The DC claims processing system can accept up to 26 diagnosis codes; however the EAPG grouper only
looks at the principal diagnosis and does so only under certain circumstances. The limit on the number of
lines per claim that can be accepted by the EAPG grouper is 450. Up to four modifiers may be accepted
per line but only certain modifiers impact payment under EAPGs, please see FAQ #44.
36. Should HCPCS/CPT procedure codes be billed on every line of the outpatient claim?
No. HCPCS/CPT codes are not expected on some claim lines, such as certain drugs and supplies. While
lines without procedure codes are assigned to EAPG 999 with zero payment, the payment for these items
is included in the payment for the significant procedure or medical visit. Some claim lines are packaged
or consolidated even if a procedure code is present. Hospitals should note that there is a list of specific
revenue codes for which DC Medicaid requires a procedure code. This list is not new nor does it change
under EAPGs.
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October 1, 2016
Control Log No.: DCO16032 10
37. How do the National Correct Coding Initiative edits apply under the new payment method?
DHCF continues to identify and edit claims where coding methods do not adhere to these federal
guidelines under the new EAPG payment method. The National Correct Coding Initiative is a federal
requirement for all Medicaid programs under the Affordable Healthcare Act.
38. How are payments for professional revenue codes affected?
Effective October 1, 2014, professional fees revenue codes are not eligible for payment under the EAPG
payment method when billed on outpatient hospital claims (UB-04). These professional services should
continue to be billed on professional claims (CMS-1500).
39. What type of bill (TOB) should be used for billing outpatient hospital surgery services?
Under the previous payment method, hospitals were required to use bill types 0830-0838 to bill for
outpatient hospital surgery services and some chemotherapy services. Now that EAPGs are activated in
the DC Medicaid claims processing system, outpatient surgical services should no longer be billed with
bill types 0830-0838 because these bill types are designated for ambulatory surgery centers. Outpatient
hospital services should be billed with bill types 0130-0138.
40. How is an outpatient hospital visit defined under EAPGs?
Under EAPGs, an outpatient hospital visit is defined as services on a single claim billed with the same
date of service. A given claim may contain multiple visits if the dates of service are different. However,
a single visit cannot cross different claims.
The ability to recognize multiple visits for payment on a single claim is a functionality that is built into
the EAPG grouper software. Under the previous payment method, multiple dates of service on a single
claim were not recognized for separate payment. Under EAPGs, each date of service on a claim is
processed and paid as a separate visit.
41. How are medical visits paid under EAPGs?
Lines billed with HCPCS/CPT codes that are designated by the EAPG grouper as a medical visit indicator
EAPGs are packaged in the presence of a significant procedure. If a claim is billed with a medical visit
HCPCS/CPT code and no significant procedure is present, then the EAPG for that line is assigned based
on the principal diagnosis. Most of the HCPCS/CPT codes designated as medical visit indicator codes are
evaluation and management codes.
42. Has DC Medicaid implemented an inpatient-only list? Is the list the same as that maintained by
Medicare for APCs?
Yes. The EAPG list of inpatient-only services applies under the new payment method. The list of
procedures is similar but less restrictive than the Medicare list.
43. What bundling or packaging methods did DHCF implement with EAPGs?
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Bundling or packaging refers to grouping different services provided into a single payment unit. A
bundled or packaged service receives no separate payment. DHCF will implement the following bundling
methods with EAPG payment:
Packaging/Bundling
Packaged Services
Significant Procedure Consolidation
Discounting Multiple Significant
Procedures
Discounting Repeat Ancillary/Drug/DME
Procedures
Notes:
1.
There are six EAPG significant procedure types subject to consolidation and discounting: significant procedure, physical
therapy and rehabilitation, mental health and counseling, dental procedure, radiologic procedure, and other diagnostic
procedure.
2.
3M Health Information Systems, Definitions Manual, Version 3.11.16.1, January 2016
44. What modifiers impact payment under EAPGs?
The EAPG grouper recognizes a number of modifiers which may potentially impact payment. Some
modifiers are used to increase or decrease the payment amount. Some modifiers are informational and
will not affect payment. Hospitals should continue to use standard coding conventions in the assignment
of modifiers.
DC Medicaid EAPG FAQ
October 1, 2016
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Modifier
Description
Effect on EAPG Payment
Therapy modifiers GN (speech and
language), GO (occupational), GP
(physical)
Identify whether the therapy services were
for speech, occupational or physical therapy
services.
•
Claim lines billed with therapy
modifiers will not be exempt
from significant procedure
consolidation.
Anatomical modifiers and other select
modifiers (E1–E4, F1–F9, FA, LT, RT T1–
T9, TA, 76, 77, RC, LC, LD, LM and RI)
Used to report procedures performed on
paired organs or specific sides of the body,
(e.g., eyelids, fingers, toes, arteries, kidneys,
lungs, right, left) or to report the same
procedure was performed more than once
by the same or different physicians.
•
Claim lines billed with these
modifiers will not be exempt
from significant procedure
consolidation.
Modifier 25 Distinct service
Used to report significant, separately
identifiable evaluation and management
(E/M) service by the same physician on the
same day as a significant procedure or other
service.
•
Medical visits are payable with a
significant procedure in the
presence of this modifier.
Modifier 27 Multiple outpatient hospital
E/M encounters
Used to report multiple outpatient hospital
E/M and emergency room visits on the
same day to indicate that the E/M service is
a separate and distinct E/M encounter.
•
Lines billed with this modifier
may be payable unless a
significant procedure is present
on the visit.
Modifier 59 Distinct procedural service
Used to report procedures not normally
reported together and are distinct or
independent from other services performed
on the same day.
•
Lines billed with this modifier
will not be subject to same
significant procedure
consolidation.
Distinct Procedure Modifier
Option
Used to report procedures not normally
reported together and are distinct or
independent from other services performed
on the same day.
Distinct procedure modifiers are:
XE: Separate encounter
XP: Separate practitioner
XS: Separate structure
XU: Unusual non-overlapping service
•
Lines billed with these modifiers
will not be subject to same
significant procedure
consolidation
Modifiers 73 and 52 Terminated procedures
Used to report that the procedures or
services were not completed so that the
service provided was less than usually
required for the procedure as defined by the
CPT/HCPCS code.
•
Lines billed with these modifiers
will be discounted by 50%
•
If the line is subject to both
multiple significant procedures
discounts and modifiers 73/52
discount, the modifier discount
will be based on the adjusted
weight that results after the
significant procedure discount is
applied.
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Modifier
Description
Effect on EAPG Payment
Modifier 50 Bilateral procedure
Used to report any bilateral procedures that
are performed on both sides at the same
operative session as a single line item
(except when ‘unilateral’ or ‘bilateral’ is in
the CPT/HCPCS description).
•
Lines appropriately billed with
this modifier will be paid at
150%. Certain procedures that
are identified as independent
bilateral procedures and will be
paid at 200%.
•
If the line is subject to both
multiple significant procedure
discounts and a modifier 50
discount, the modifier discount
will be based on the adjusted
weight that results after the
significant procedure discount is
applied.
Modifier 57 Option
Determines if the option to use modifier -57
is applied to allow the separate assignment
of a medical visit reported with modifier -57
when present with a significant procedure.
Claim lines billed with these
modifiers will not be separately
payable in the presence of a
significant procedure
Never Events modifiers PA (wrong body
part), PB (wrong patient) or PC (wrong
surgery)
Used to report erroneous surgical or
invasive procedures.
•
DC current policy continues for
non-payment of never event
procedures and related services,
as required by federal law.
Note
The list of bilateral procedure codes subject to discounting are identified in the Medicare Physician Fee Schedule.
OTHER
45. How will hospitals be kept informed and involved as changes occur to the prospective payment
system?
FAQ
This FAQ document which provides DC Medicaid policy, payment and billing
information about the new outpatient hospital payment method. FAQs are
periodically updated and distributed to hospitals.
EAPG Information
A separate document which provides general information about EAPGs.
Provider information sessions
Held periodically to keep providers informed of data, decisions and the progress
of the project.
Training sessions
Outpatient trainings are held periodically to communicate changes as needed.
46. Who can I contact for more information?
Sharon Augenbaum, Reimbursement Analyst, Office of Rates, Reimbursement and Financial Analysis
Department of Health Care Finance
Tel: 202-442-6082 ● Email: Sharon.augenbaum@dc.gov