1. GENERAL: Reimbursement for hospital services is to be determined by peer group assignments. Unless otherwise specified in this section of the fee schedule. Peer 3 and Critical Access Hospitals are subject to a discount rate.
2. “IMPLANTABLES” means those services indicated by revenue codes 274 (prosthetic/orthotic devices), 275 (pace maker), 276 (intraocular lens), and 278 (other implants), which involve an item or device intended for permanent placement in the body. “Implantable items” include rods, pins, screws, plates, prosthetic joint replacements, and other items properly indicated by revenue code 278 which are plastic, metallic or of autogenous/non-autogenous graft material.
Generally, durable medical equipment and supplies provided or administered in an inpatient hospital setting are not separately reimbursed since they are included in the Medical Severity Diagnosis Related Groups (MS-DRG) payment rate. However, surgical implantables as defined above which are medically necessary are excepted from this rule. Inpatient hospitals shall be separately reimbursed for medically necessary implantables. The maximum allowable reimbursement for the implantable shall be the cost of the implantable to the hospital plus 25%. Tax, freight and handling are not reimbursable costs for the implantable. The invoice for the actual cost to the hospital of an implantable device shall be provided to the payor by the hospital as a condition of payment for the implantable.
3. “INPATIENT” means being confined to a hospital setting for twenty-four (24) hours or more. An inpatient stay requires documentation of official admission to the hospital pursuant to an order by a physician or other qualified practitioner and the order is present in the medical record.
4. REIMBURSEMENT AND BILLING: Except as otherwise provided in these Ground Rules, reimbursement for inpatient hospital services shall be limited to the maximum allowable reimbursement per inpatient stay as computed in Ground Rule 5 of these ground rules. Billing for inpatient hospital services shall reference the MS-DRG code, Version 31, state the actual charges billed and if applicable, include an invoice for implantables as provided in Ground Rule 6 of these ground rules. A hospital shall not knowingly charge a payor more for treatment under worker’s compensation than that normally charged for similar treatment outside the workers compensation system.
5. COMPUTATION OF MAXIMUM ALLOWABLE REIMBURSEMENT: The Kansas Workers Compensation Schedule of Medical Fees that is current on the date of an inpatient discharge from the hospital, will define the levels of payment applicable to computation of the maximum allowable reimbursement. The maximum allowable reimbursement per inpatient stay shall be computed as follows:
MAXIMUM ALLOWABLE REIMBURSEMENT= Medicare MS-DRG (Version 31) Relative Weight X
$7400 (for Peer Group I Hospitals) or $7200 (for Peer Group 2 hospitals).
CRITICAL ACCESS HOSPITALS AND PEER GROUP 3 HOSPITALS shall be reimbursed at billed charges less 15.0%.
All out- of-state hospitals except out-of-state critical access hospitals will be reimbursed at Peer Group 2 hospital level or Medicare MS-DRG Relative Weight X $7200. Out-of-state critical access hospitals shall be reimbursed at billed charges less 15%. Additionally, the rules that are contained within this fee schedule also apply to out-of-state hospitals.
6. STOP-LOSS METHOD:
a. PURPOSE AND APPLICATION: Stop-loss is an independent reimbursement methodology that will
reimburse the hospital for unusually costly services rendered during treatment to an injured worker. No charge attributable to implantables or trauma activation fees shall be considered for purposes of determining eligibility for, and reimbursement under, stop-loss.
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b. COMPUTATION OF THE MAXIMUM ALLOWABLE REIMBURSEMENT UNDER STOP-LOSS: To be eligible for the stop-loss payment, the total charges for the hospital inpatient stay, excluding charges
attributable to implantables and trauma activation fees, must be at least Sixty Thousand Dollars ($60,000.00), the minimum stop-loss threshold. If the total charges for the hospital inpatient stay equal or exceed the minimum stop-loss threshold, the total charges are then multiplied by seventy percent (70%) to determine the maximum allowable reimbursement excluding implantables (see Ground Rule 2 of these Ground Rules)and trauma activation fees (see Ground Rule 7 of these Ground Rules).
7. TRAUMA ALERTS AND ACTIVATION FEES: Trauma Revenue Codes can only be used by trauma centers/hospitals as licensed or designated by state or local government authority authorized to do so, or as verified by the American College of Surgeons. Only patients for whom there has been pre-hospital notification based on triage information by pre-hospital care givers who meet either state, local, or American College of Surgeons field triage criteria, or are delivered by interhospital transfers, and are given the appropriate team response can be billed a trauma activation charge. Trauma Center fees are not paid for “Alerts”. “Activation Fees” mean that a Trauma Team has to be activated, not just alerted. These fees are in addition to ER and inpatient fees. Trauma Center Activation fees are as follows:
Level I $3,750.00 Level II $3,250.00 Level III $1,750.00 Level IV $0.00
8. PHYSICAL MEDICINE AND REHABILITATION: Generally, physical/occupational therapists services provided or administered in an inpatient hospital setting are not separately reimbursed since they are included in the Medical Severity Diagnosis Related Groups (MS-DRG) payment rate. However, for any hospitals having one or more affiliate clinics providing services on an outpatient basis, only one such clinic is allowed to submit billings using the hospital’s Federal Tax ID number. The services for all other clinics affiliated with the same hospital are limited to the Maximum Allowable Fee for the respective CPT code that is contained within the Physical Medicine and Rehabilitation Section of this Fee Schedule.
9. RADIOLOGY CHARGES: Generally, radiology services provided or administered in an inpatient hospital setting are not separately reimbursed since they are included in the Medical Severity Diagnosis Related Groups (MS-DRG) payment rate. Physicians that provide and bill separately for the professional component of radiology CPT codes submitted for payment must attach the -26 modifier for proper reimbursement.
10. PATHOLOGY OR LABORATORY CHARGES: Generally, pathology and laboratory services provided or administered in an inpatient hospital setting are not separately reimbursed since they are included in the Medical Severity Diagnosis Related Groups (MS-DRG) payment rate. Physicians that provide and bill separately for the professional component of pathology or laboratory CPT codes submitted for payment must attach the -26 modifier for proper reimbursement.
11. INPATIENT CARE: Charges for inpatient hospital care at critical access hospitals of more than one day shall be subject to review in cases where the patient is ambulatory. The attending health care provider will be required to submit sufficient information to substantiate why inpatient care was necessary. Once the patient's condition becomes such that further inpatient care is only a matter of personal convenience, the executive officer or administrator of the hospital or ambulatory surgical center should notify the employer (or insurance carrier) at once. Such notification should also be provided to the Director of Workers Compensation.
. 12. ROOM: Room charges are generally included in the MS-DRG, room charges at critical access hospitals for other than semiprivate or ward service shall be subject to review, and must be accompanied by a statement identifying the source of authorization and necessity for other types of accommodations.
13. REVIEWS AND AUDITS: The employer (or insurance carrier) has the right to conduct, or make arrangements for a bill audit of inpatient services to determine that such services were directly related to the compensable
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injury. The hospital should not make any additional charges on a given case under review during the course of the bill audit, unless it is for service which would not be covered under the Workers Compensation Act.
14. COST CONTAINMENT: Nothing in this section shall preclude an employer (or insurance carrier) from entering into payment agreements with hospitals in their community to promote the continuity of care and the reduction of health care costs. Such payment agreements, if less, will supersede the limitation amounts specified herein.
Please refer to K.S.A. 44-510i(e) for further clarification, if necessary.
15. NATIONAL CORRECT CODING INITIATIVE (NCCI) EDITS: In order to promote correct coding methodologies and to control improper coding leading to inappropriate payments, the Kansas Division of Workers Compensation Schedule of Medical Fees recognizes the 2014 National Correct Coding Initiatives (NCCI) Edits as established by the Centers for Medicare and Medicaid Services (CMS) as the primary standard of reference. The NCCI Edits are not requirements, nor are they mandates or standards; they simply provide advice for correct coding methodologies. Bills must be itemized by procedure code, date of service, and amount of charge.
16. WORKERS COMPENSATION PEER GROUPS AS OF APRIL 2014:
Reimbursement for impatient and outpatient medical services provided by hospitals and surgical centers will be made at a variable rate based on the facility’s Peer Group Classification.
Peer Group 1
Facilities in the following communities:
Derby
Facilities in the following communities:
Andover
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Liberal McPherson Manhattan Moundridge Newton Osawatomie Ottawa Paola Parsons Pittsburg Pratt Salina Ulysses Wellington
Including all out of state hospitals Peer Group 3
Critical Access Hospitals are considered Peer Group 3 and shall be reimbursed at billed charges less 15.0%. All other hospitals are to be reimbursed at their billed charges, less 15.0%. This is to include the following state institutions:
Rainbow Mental Health Facility at Kansas City, Kansas Larned State Hospital at Larned, Kansas
Osawatomie State Hospital at Osawatomie, Kansas
Parsons State Hospital & Training Center at Parsons, Kansas Kansas Neurological Institute at Topeka, Kansas