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(a) Except as provided otherwise in (d) - (h) of this section, and in this chapter for certain provider types or services, the department will establish fees for use in payment for each provider type and service subject to this chapter. The fees will be established using the methodology described in this section, and will be paid as provided in 7 AAC 43.040.
(b) The methodology set out in this section is for procedures that have a relative value unit (RVU) established for Medicare, adopted by reference in (h) of this section. The resource-based relative value scale (RBRVS) payment for these procedures consists of
(1) an RVU that contains
(A) a work component (RVUw) that is measured by the time and intensity of effort required to provide a service;
(B) a practice expense component (RVUp) that includes costs related to the provision of services such as rent, salaries, equipment, and supplies; and
(C) a malpractice expense component (RVUm) that is measured by professional liability insurance premium costs;
(2) a geographic practice cost index (GPCI) that is set by the department as an adjustment factor that modifies each RVU to reflect the cost of practice in the state; each GPCI contains
(A) a work component set at 1.064;
(B) a practice expense component set at 1.172; and
(C) a malpractice expense component set at 1.126; and
(3) a conversion factor that is a dollar amount set by the department and used to convert each RVU into a fee amount; this conversion factor is $49.90.
(c) The fee for each procedure subject to RBRVS-based payment is determined using the following calculation: [(RVUw X 1.064) + (RVUp X 1.172) + (RVUm X 1.126)] X $49.90.
(d) The department will pay for anesthesiology services in accordance with the following calculation: ($42.90 X the number of base units for anesthesiology services + $36.00 X the number of time units), where the number of base units is determined according to the Relative Value Guide adopted by reference in (h) of this section, and the value of one time unit is 10 minutes. The department will not make an additional payment for a physical status modifier as set out in Current Procedural Terminology, adopted by reference in (h) of this section.
(e) Except as provided in (f) of this section, and subject to 7 AAC 43.040(b) , if a procedure does not have an RVU established for Medicare, and is not subject to another payment methodology or fee under this chapter, the department will pay for a covered procedure at 80 percent of billed charges for the first nine billings that reflect a charge for the service that complies with the applicable standards in 7 AAC 43.040. Thereafter, the fee will be established based on the 90th percentile of the first ten billings. To be paid under this subsection, a billing must reflect a charge for the procedure that complies with the applicable standards in 7 AAC 43.040.
(f) An item or service described as an "unlisted procedure,""not otherwise classified (NOC)," or "not otherwise specified" will be paid at 50 percent of billed charges if the department agrees that the item or service cannot be billed under another code, and if the billing reflects a charge for the item or service that complies with the applicable standards in 7 AAC 43.040.
(g) The department will not make an additional payment for an unusual procedural service identified as modifier 22 in the list of modifiers set out in Current Procedural Terminology, adopted by reference in (h) of this section.
(h) For purposes of this section, the department will use the following documents or other materials to establish fees or to verify procedural and diagnosis codes and classifications. The following documents and materials, as amended from time to time, are adopted by reference:
(1) the nonfacility individual RVUs for the Medicare program for each medical procedure, as published in 68 Fed. Reg. 63261 - 63389 (November 7, 2003);
(2) Relative Value Guide 2004, published by the American Society of Anesthesiologists;
(3) International Classification of Diseases - 9th Revision, Clinical Modification (ICD-9-CM), 2004 revision, based on information compiled by the United States Department of Health and Human Services, and published by the American Medical Association;
(4) Healthcare Common Procedure Coding System (HCPCS 2004), based on information compiled by the Centers for Medicare and Medicaid Services (CMS), and published by the American Medical Association; and
(5) Current Procedural Terminology, CPT 2004, published by the American Medical Association.
History: Eff. 2/1/97, Register 141; am 6/26/98, Register 146; am 11/8/98, Register 148; am 5/5/99, Register 150; am 8/19/2004, Register 171
Authority: AS 47.05.010
Editor's note: The Relative Value Guide is on file in the Office of the Lieutenant Governor and may be obtained by contacting the American Society of Anesthesiologists at 520 N. Northwest Highway, Park Ridge, Illinois 60068-2573. A copy is also available for review at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Building L, Anchorage, Alaska 99503-7167.
The International Classification of Diseases - 9th Revision, Clinical Modification (ICD9-CM), 2004 revision, is on file in the Office of the Lieutenant Governor and may be obtained by contacting the American Medical Association at P.O. Box 930876, Atlanta, GA 31193 or visiting its web site at www.amapress.com. A copy is also available for review at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Building L, Anchorage, Alaska 99503-7167.
The Healthcare Common Procedure Coding System (HCPCS 2004) and the Current Procedural Terminology, CPT 2004 are on file in the Office of the Lieutenant Governor and may be obtained by contacting the American Medical Association at P.O. Box 930876, Atlanta, GA 31193 or visiting its web site at www.amapress.com. A copy of each document is also available for review at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Building L, Anchorage, Alaska 99503-7167.
On November 2, 2004, as required by AS 44.62.245 and AS 47.05.012 , the department gave notice that the following amended version of material, previously adopted by reference in 7 AAC 43.108, would be in effect on October 1, 2004: the 2005 version of the American Medical Association's International Classification of Diseases - 9th Revision, Clinical Modification (ICD-9-CM) . The amended version may be reviewed at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska, 99503-7167.
On December 1, 2004, as required by AS 44.62.245 and AS 47.05.012 , the department gave notice that the following amended version of material, previously adopted by reference in 7 AAC 43.108, would be in effect on January 1, 2005: the Physicians' Current Procedural Terminology, 4th edition, as revised for 2005 ( "CPT 2005" ) and the United States Department of Health and Human Services, Centers for Medicare and Medicaid Service's (CMS) HealthCare Common Procedure Coding System (HCPCS) 2005 . The amended versions may be reviewed at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage Alaska, 99503-7167.
On December 1, 2004, as required by AS 44.62.245 and AS 47.05.012 , the department gave notice that the following amended versions of material, previously adopted by reference in 7 AAC 43.108, would be in effect on January 1, 2005: the non-facility individual relative value units (RVUs) for the Medicare program, as published in 69 Federal Register 66428 - 66688 (Addenda B and C) (November 15, 2004). The amended version may be reviewed at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska, 99503-7167.
On September 8, 2005, as required by AS 44.62.245 and AS 47.05.012 , the department gave notice that the following amended version of material, previously adopted by reference in 7 AAC 43.108, would be in effect on October 1, 2005: the 2006 version of the American Medical Association's International Classification of Diseases - 9th Revision, Clinical Modification, (ICD-9-CM) . The amended version may be reviewed at the Department of Health and Social Services, Division of Health Care Services, 4501 Business Park Boulevard, Suite 24, Anchorage, Alaska, 99503-7167.
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Last modified 7/05/2006