TX DWC Posts Ambulatory Surgical Center Fee Guideline FAQs

Dallas, TX (CompNewsNetwork) - The Texas Division of Workers' Compensation has posted a list of "frequently asked questions" regarding 2010 ambulatory surgical centers fee guidelines on its website.

Here are some FAQs:

Q. What are the steps in calculating reimbursement for a non-device intensive procedure when no implants were used in the procedure?

A. 1. Calculate the geographic adjusted ASC reimbursement for the procedure.

    2. Multiply the geographically adjusted ASC reimbursement by the TDI-DWC payment adjustment factor, currently 235% (2.35). 

Q. What is a device intensive procedure?

A. A device intensive procedure is a surgical procedure in which the cost of the implantables is greater than 50 percent of the CMS ambulatory payment classification's median cost. A device intensive procedure always involves implantables.

Q. Is the method for determining the facility reimbursement to a specific Ambulatory Surgical Center (ASC) for surgical procedures in CY 2009 and CY 2010 different than surgical procedures in CY 2008 when the fee guideline was adopted? 

A. The reimbursement methodology is the same for each year. However, since the TDI-DWC rules require the use of the most current CMS weights, values and measures the CMS tables for a specific calendar year should be the source for any data required to calculate Texas workers' compensation system reimbursement for services provided during that calendar year.

Additionally, it is important to note that in publishing its rules CMS sometimes finds it necessary to revise, rename or reformat data required to calculate reimbursement. 

Q. An ASC indicates separate reimbursement for implantables and agrees to allow the surgical implant provider to bill for the implantables. The surgical implant provider does not provide documentation. What options are available to the payer?

A. The options are:

1. Contact the surgical implant provider to request the information to complete the bill.

2. If the required documents are not provided, deny the bill due to the lack of documentation. 

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