907 KAR 1:008. Ambulatory surgical center services and reimbursement.

 

      RELATES TO: KRS 205.520(3), 205.560(2), 42 C.F.R. 447.271

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), EO 2004-726

      NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services. The Cabinet for Health and Family Services has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with a requirement that may be imposed or opportunity presented by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes the coverage provisions and method for establishing payment for an ambulatory surgical center.

 

      Section 1. Scope of Coverage. The Medicaid Program shall cover medically necessary, medically appropriate services rendered by a participating ambulatory surgical center licensed by its respective state and certified for Medicare participation.

 

      Section 2. Basis for Reimbursement. (1) The Department for Medicaid Services shall utilize the 1996 Medicare ambulatory surgical center group rates for the federal Cincinnati, Ohio - Kentucky region to reimburse for an ambulatory surgical center service. The following chart establishes the ambulatory surgical center reimbursement rate for each corresponding surgical group:

 

Ambulatory Surgical Center Group

Reimbursement Rate

Group 1

$307.38

Group 2

$412.79

Group 3

$471.90

Group 4

$582.25

Group 5

$664.02

Group 6

$775.59

Group 7

$921.15

Group 8

$911.55

 

      (2) Reimbursement for a procedure shall be the surgical group rate specific to that procedure as assigned by the Centers for Medicare and Medicaid Services.

      (3) Reimbursement for a procedure which does not have a surgical group rate shall be forty-five (45) percent of charges.

      (4) Ambulatory surgical center group surgical and covered provisions are established in the Ambulatory Surgical Centers Manual.

 

      Section 3. Incorporation by Reference. (1) "The Ambulatory Surgical Centers Manual", October 2002 edition, Department for Medicaid Services, is incorporated by reference.

      (2) It may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Medicaid Services, Cabinet for Health and Family Services, 275 East Main Street, Frankfort, Kentucky, 40621, Monday through Friday, 8 a.m. to 4:30 p.m. (Recodified from 904 KAR 1:008, 5-6-86; Am. 15 Ky.R. 670; eff. 9-21-88; 23 Ky.R. 3440; 3839; 4162; eff. 6-16-97; 29 Ky.R. 2146; eff. 4-11-03.)