20-77-129. Ambulatory surgery centers — Medicaid reimbursement — Definitions.

20-77-129. Ambulatory surgery centers — Medicaid reimbursement — Definitions. (a) As used in this section: (1) “Ambulatory surgery center” means an entity certified by Medicare as an ambulatory surgical center that operates for the purpose of providing surgical services to patients and that is eligible to receive reimbursement from Medicaid for ambulatory surgery services; (2) “Ambulatory Surgery Center Medicaid Procedure Code” means appropriate: (A) Current Procedural Terminology codes representing procedures that do not appear on the Medicare hospital inpatient-only list or Medicaid hospital inpatient-only list and that are medically necessary and not solely for cosmetic treatment or surgery; or (B) Comparable Current Procedural Terminology codes adopted and assigned under this section, representing procedures that do not appear on the Medicaid hospital inpatient-only list, are medically necessary, and are not solely for cosmetic treatment or surgery; (3) “Ambulatory Surgical Center Medicaid reimbursement rate for appropriate procedures” means ninety-five percent (95%) of ambulatory surgical center Medicare reimbursement that is currently effective for applicable Ambulatory Surgical Center Medicaid Procedure Codes; (4) “Appropriate procedure” means a surgical procedure or other procedure commonly performed in an ambulatory surgery center setting that is not on: (A) The Medicaid hospital inpatient-only list or Medicare hospital inpatient-only list; or (B) The Medicaid hospital inpatient-only list for which a comparable Current Procedural Terminology code has been adopted and assigned under this section; (5) “Current Procedural Terminology code” means the codes that are commonly used in the healthcare industry to identify services that are provided; (6) “Hospital inpatient-only list” means a listing kept by the Centers for Medicare & Medicaid Services of procedures that should be performed on an inpatient basis only with separately recorded lists for Medicare and Medicaid; (7) “Hospital outpatient procedure department” means a hospital-based ambulatory surgery center that bills in accordance with the Outpatient Hospital Services Medicaid Provider Guide; and (8) “Relative Value Unit” means a service unit value measured in relation to the values of other services and involving a Current Procedural Terminology code that, when multiplied by the conversion factor and a geographical adjustment, creates the compensation level for a particular service. (b) The purpose of this act is to decrease costs to Medicaid while increasing access to care by Arkansas's Medicaid population. (c)(1) An appropriate procedure may be performed at an ambulatory surgery center or a hospital outpatient procedure department. (2) If an appropriate procedure is performed at an ambulatory surgery center, the appropriate procedure and any appropriate implantable devices shall be billed using the Ambulatory Surgery Center Medicaid Procedure Codes and reimbursed pursuant to the Ambulatory Surgery Center Medicaid reimbursement rate for appropriate procedures. (d)(1) Upon request by, and in consultation with, the Arkansas Ambulatory Surgery Association, its successor, or an ambulatory surgery center, the Department of Human Services may adopt and assign an appropriate Current Procedural Terminology code for an appropriate procedure based on a Relative Value Unit for a comparable procedure not on the Medicaid hospital inpatient-only list, if the appropriate procedure: (A) Is not on the Medicaid hospital inpatient-only list but is on the Medicare hospital inpatient-only list; or (B) Is a medically necessary surgical service that is not on the Medicaid hospital inpatient-only list, for which there is no corresponding reimbursement value recited in the current Medicare ambulatory surgery center fee schedule. (2) A comparable Current Procedural Terminology code adopted and assigned under this section shall be reimbursed at ninety-five percent (95%) of the Medicare ambulatory surgical center reimbursement rate for the comparable procedure. (3) A request for the adoption and assignment of a comparable Current Procedural Terminology code shall be submitted and approved before the appropriate procedure is performed. (e) A reimbursement payment made under this section may not exceed the Medicaid upper payment limit as established by the Centers for Medicare & Medicaid Services.