INSTRUCTIONS FOR OP FORMS - Colorado



SECRETARY OF STATE

RULES ACTION SUMMARY AND FILING INSTRUCTIONS

SUMMARY OF ACTION ON RULE(S)

|1. Department / Agency Name: |Health Care Policy and Financing / Medical Services Board |

|2. Title of Rule: |MSB 14-06-25-A, Revision to the Medical Assistance Health Program Services and Supports |

| |Rule Concerning Amount, Scope and Duration of Ambulatory Surgery Centers, Section |

| |8.570.3.D |

|3. This action is an adoption of: |an amendment |

|4. Rule sections affected in this action (if existing rule, also give Code of Regulations number and page numbers affected): |

|Sections(s) 8.570.3.D, Colorado Department of Health Care Policy and Financing, Staff Manual Volume 8, Medical Assistance (10 CCR 2505-10). |

|5. Does this action involve any temporary or emergency rule(s)? |No |

|If yes, state effective date: | |

|Is rule to be made permanent? (If yes, please attach notice of hearing). |Yes |

PUBLICATION INSTRUCTIONS*

Add new definitions text at §8.570.1, unnumbered paragraphs 1 – 4. Replace existing text at §8.570.2.A with new text provided. Remove current text at §8.570.3.B.1 and renumber paragraph 2. Add new text at §8.570.3.C.2 and remove current text beginning at 8.570.3.C.2 through the end of §8.570.3.D. Add new section §8.570.4.D and renumber the current sections at §8.570.4 and §8.570.4.A to §8.570.5 and §8.570.5.A. Add new section §8.570.6 and §8.570.7. Renumber current sections 8.570.6, §8.570.6.A, §8.570.6.B to §8.570.8 and §8.570.8.A and §8.570.8.B. Replace current text at §8.570.6.B.2 with new text provided. Renumber current section 8.570.5 to 8.570.9. All text indicated in blue is for reference only and should not be revised. This change is effective 11/30/2014.

|Title of Rule: |Revision to the Medical Assistance Health Program Services and Supports Rule Concerning Amount, |

| |Scope and Duration of Ambulatory Surgery Centers, Section 8.570.3.D |

|Rule Number: |MSB 14-06-25-A |

|Division / Contact / Phone: |HPSS / Max Salazar / x3289 |

STATEMENT OF BASIS AND PURPOSE

|1. Summary of the basis and purpose for the rule or rule change. (State what the rule says or does and explain why the rule or rule change|

|is necessary). |

|The Department is updating this rule to include content from the Ambulatory Surgery Center Benefit Coverage Standard. Specifically, the |

|rule will define the amount, scope and duration of the benefit. |

|2. An emergency rule-making is imperatively necessary |

| |to comply with state or federal law or federal regulation and/or |

| |for the preservation of public health, safety and welfare. |

|Explain: |

| |

|3. Federal authority for the Rule, if any: |

|§1905(a)(9) of the Social Security Act |

|4. State Authority for the Rule: |

|25.5-1-301 through 25.5-1-303, C.R.S. (2013); |

|§ 25.5-5-301(2)(d), C.R.S. (2013) |

|Title of Rule: |Revision to the Medical Assistance Health Program Services and Supports Rule Concerning Amount, |

| |Scope and Duration of Ambulatory Surgery Centers, Section 8.570.3.D |

|Rule Number: |MSB 14-06-25-A |

|Division / Contact / Phone: |HPSS / Max Salazar / x3289 |

REGULATORY ANALYSIS

1. Describe the classes of persons who will be affected by the proposed rule, including classes that will bear the costs of the proposed rule and classes that will benefit from the proposed rule.

This rule will impact the providers of ambulatory surgery center services.

2. To the extent practicable, describe the probable quantitative and qualitative impact of the proposed rule, economic or otherwise, upon affected classes of persons.

By clearly defining clinical criteria in the ambulatory surgery center services benefit, the Department hopes to achieve its goal to reduce inappropriate utilization and variations in care.

Clearly-defined rules will provide assurance for persons receiving benefits that services meet established criteria, will provide better guidance for service providers, will assure that public funds are more responsibly allocated and will reduce the administrative burden on the Department. Additionally, clearly-defined rules will reduce confusion and unnecessary adversarial situations among those receiving benefits, service providers and the Department and will simplify the appeal process for all participants.

3. Discuss the probable costs to the Department and to any other agency of the implementation and enforcement of the proposed rule and any anticipated effect on state revenues.

This rule does not have any costs to the Department or any other agency as a result of its implementation and enforcement.

4. Compare the probable costs and benefits of the proposed rule to the probable costs and benefits of inaction.

Enforceable policy rules will help the Department recover improper payments for inappropriate services rendered, uphold decisions based upon evidence-based criteria, and reduce the volume of appeals. By being able to enforce evidence-based criteria, this rule may generate cost-savings as inappropriate utilization and appeal volumes are reduced.

5. Determine whether there are less costly methods or less intrusive methods for achieving the purpose of the proposed rule.

N/A. All benefits must be adequately described in rule.

6. Describe any alternative methods for achieving the purpose for the proposed rule that were seriously considered by the Department and the reasons why they were rejected in favor of the proposed rule.

N/A. Because the Department's previous method of defining amount, scope, and duration in rule though Incorporation by Reference was repealed by the Committee on Legal Services, the Department must include this content within the rule.

8.570 AMBULATORY SURGERY CENTERS

8.570.1 DEFINITIONS

Ambulatory Surgery Center (ASC) means an entity that operates exclusively for the purpose of furnishing surgical services for its clients that do not require hospitalization. An ASC may be independent or part of a hospital, but only if the building space utilized by the ASC is physically, administratively, and financially independent and distinct from other operations of the hospital.

CMS means the Centers for Medicare and Medicaid Services.

The Department refers to the Colorado Department of Health Care Policy and Financing.

Inpatient Basis in Hospitals means preventive, therapeutic, surgical, diagnostic, medical and rehabilitative services that are furnished by the Hospital for the care and treatment of inpatients and are provided in the Hospital by or under the direction of the physician.

8.570.2 REQUIREMENTS FOR PARTICIPATION

8.570.2.A. An ASC shall be certified by CMS to participate in the Medicare program as an ASC and be licensed by the Colorado Department of Public Health and Environment as an ASC.

8.570.3 COVERED SERVICES AND LIMITATIONS

8.570.3.A. Covered services are those surgical and other medical procedures that:

1. Are ASC procedures that are grouped into categories corresponding to the CMS defined groups.

2. Are commonly performed on an inpatient basis in hospitals, but may be safely performed in an ASC.

3. Are limited to those requiring a dedicated operating room (or suite), and generally requiring a post-operative recovery room or short-term (not overnight) convalescent room.

8.570.3.B. Covered surgical procedures are limited to those that do not generally exceed:

1. A total of 4 hours recovery or convalescent time.

8.570.3.C. If the covered surgical procedures require anesthesia, the anesthesia must be:

1. Local or regional anesthesia; or

2. General anesthesia.

8.570.4.D. DENTAL PROCEDURES

1. Qualifying clients may receive covered and medically necessary dental services in an ASC when those services cannot be delivered safely and effectively in a private office.

8.570.5 NON-COVERED SERVICES

8.570.5.A Non-covered services are those services that:

1. Are not commonly performed or may safely be performed in a physician’s office;

2. Generally result in extensive blood loss;

3. Require major or prolonged invasion of body cavities;

3. Directly involve major blood vessels; or

4. Are generally emergency or life-threatening in nature.

5. Pose a significant safety risk to clients or are expected to require active medical monitoring at midnight of the day on which the surgical procedure is performed (overnight stay) when furnished in an ASC.

6. Are not listed in the annual ASC billing manual.

8.570.6. CLIENT ELIGIBILITY

Eligible Clients include any Client enrolled in Colorado Medicaid for whom a covered ASC service is a medical necessity as defined at 10 CCR 2505-10 Section 8.076.1.8.

8.570.7. PRIOR AUTHORIZATION

The physician performing the surgery shall be responsible for obtaining all necessary Prior Authorizations for those procedures requiring pre-procedure approval by the Department.

8.570.8 REIMBURSEMENT

8.570.8.A For payment purposes, ASC surgical procedures are placed into groupers. The Health Care Procedural Coding System (HCPCS) is used to identify surgical services.

8.570.8.B Reimbursement for approved surgical procedures shall be allowed only for the primary or most complex procedure. No reimbursement is allowed for multiple or subsequent procedures. No reimbursement shall be allowed for services not included on the Department approved list for covered services. Approved surgical procedures identified in the ASC groupers shall be reimbursed a facility fee at the lower of the following:

1. Submitted charges; or

2. Department approved list for covered services.

8.570.9 ALLOWABLE COSTS

The services payable under this rule are facility services furnished to clients in connection with covered surgical procedures specified in Section 8.570.3.

1. Services and items reimbursed as part of the facility fee include, at a minimum, the following:

a) Use of the facilities where the surgical procedures are performed.

b). Nursing, technician, and related services.

c). Drugs, biologicals, surgical dressings, supplies, splints, casts, and appliances and equipment directly related to the provision of surgical procedures.

d). Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure.

e). Administrative, record keeping and housekeeping items and services.

f). Materials for anesthesia.

g). Intra-ocular lenses (IOLs).

h). Supervision of the services of an anesthetist by the operating surgeon.

2. Services and items that are not reimbursed as part of the facility fee, but that may be reimbursed separately include the following:

a). Physician services.

b). Anesthetist services.

c). Laboratory, X-ray or diagnostic procedures (other than those directly related to performance of the surgical procedure.)

d). Prosthetic devices excluding IOLs.

e). Ambulance services.

f). Leg, arm, back and neck braces.

g). Artificial limbs.

h). Durable medical equipment for use in the client's home.

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