Library: Policy

317:30-5-42.14. Surgery and diagnostic services

Revised 1-2-09

(a) Ambulatory Patient Classification (APC) Groups.  All outpatient hospital services paid under the Medicare Outpatient Prospective Payment System (OPPS) are classified into groups called Ambulatory Payment Classifications or APCs.  Group services identified by Health Care Procedure Coding System (HCPCS) codes and descriptors within APC groups are the basis for setting payment rates under OPPS.  Services in each APC are similar clinically and in terms of the resources they require.  The payment rate calculated for an APC applies to all of the services assigned to the APC.  Depending on the services provided, a hospital may receive a number of APC payments for the services furnished to a member on a single day.

(b) Reimbursement.  Reimbursement is made for selected services performed in an outpatient hospital. Hospital outpatient services are paid on a rate-per-service basis that varies according to the Ambulatory Payment Classification (APC) group to which the services are assigned.

(c) Multiple Surgeries.  Multiple procedures furnished during the same visit are discounted.  The full amount is paid for the  procedure with the highest payment group.  Fifty percent is paid for any other surgical procedure(s) performed at the same time if the procedure is subject to discounting based on the status indicator established by Medicare.

(d) Status indicators.  Status indicators identify whether the service described by a HCPCS code is paid under the OPPS and if so, whether payment is made separately or packaged and if payment is subject to discounting.  SoonerCare follows Medicare's guidelines for packaged/bundled service costs.

(e) Minor procedures.  Minor procedures that are normally performed in a physician's office are not covered in the outpatient hospital unless medically necessary.

(f) Ambulatory Surgery.  When an ambulatory surgery is performed in the inpatient hospital setting, the physician must provide exception rationale justifying the need for an inpatient setting to OHCA medical staff for review.

(g) Dental Procedures.  Routine dental procedures that are normally performed in a dentist's office are not covered in an outpatient hospital setting unless medically necessary as determined by OHCA.  For OHCA payment purposes, the APC list has been expanded to cover dental services for adults in an ICF/MR and all children.

• (1) Non-emergency routine dental that is provided in an outpatient hospital setting is covered under the following circumstances:

  • (A) The child has a medical history of uncontrolled bleeding or other medical condition which renders in-office treatment impossible.

  • (B) The child has uncontrollable behavior in the dental office even with premedication.

  • (C) The child needs extensive dental procedures or oral surgery procedures.

• (2) Non-emergency routine dental that is provided in an outpatient hospital setting is covered for children and/or adults who are residents in ICFs/MR only under the following circumstances:

  • (A) A concurrent hazardous medical condition exists;

  • (B) The nature of the procedure requires hospitalization or;

  • (C) Other factors (e.g. behavioral problems due to mental impairment) necessitate hospitalization.