Section 51509 - Hospital Outpatient Departments(a) Billing shall not exceed a provider's usual charge made to the general public. Reimbursement for hospital outpatient departments shall be the provider's usual charge to the general public not to exceed the maximum rates authorized by this section. (1) Maximum reimbursement rates, as shown in the following schedules, include overhead and professional components, except as otherwise indicated in (g) below. When these segments are billed separately, the total may not exceed the amounts listed.(2) Notwithstanding any other provisions of this section, the Director may negotiate with individual hospital facilities an all-inclusive per visit rate for hospital outpatient services, provided that such negotiated rates do not increase overall program costs.(b) Occupational therapy reimbursement shall be made in accordance with Section 51507.1, except that payment shall not be made for procedure codes X4114 or X4116.(c) Speech therapy and audiology reimbursement shall be made in accordance with Section 51507.2, except that payment shall not be made for procedure code X4306.(d) Psychology: Reimbursement for psychology shall be made in accordance with Section 51505.3, except no payment shall be made for procedure code X9548.(e) Laboratory: Reimbursement for laboratory services shall be made in accordance with Section 51529.(f) Physical therapy reimbursement shall be made in accordance with Section 51507, except that payment shall not be made for procedure codes X3932 or X3934.(g) Physician Services. (1) Hospital Outpatient Departments. (A) Services by interns, residents or hospital compensated physicians.1. Reimbursement for services shall be made directly to the hospital.2. Reimbursement shall not exceed the amounts payable in accordance with Section 51503(g) plus the amounts payable under (2).(B) Services by physicians not compensated by the hospital.1. Payment for services may be made separately to the physician and to the hospital for services provided by each provider.2. Reimbursement for hospital services shall not exceed the amounts payable in (2).3. Reimbursement for physician services shall be made in accordance with Section 51503(g), Title 22, California Code of Regulations.(2) Maximum reimbursement rates for hospital facilities shall be as follows: | Procedure Code | Maximum Allowance |
| Z7500 | Use of hospital examining or treatment room | $23.77 |
| Z7502 | Use of emergency room (Bill only when used for the treatment of emergency conditions; for nonemergency conditions the examining room fee is payable.) | 34.58 |
| Z7504 | Use of cast room | 34.58 |
| Z7506 | Use of operating room or cystoscopic room--first hour | 101.90 |
| Z7508 | first subsequent half hour | 40.76 |
| Z7510 | second subsequent half hour | 40.76 |
| maximum reimbursement | 224.19 |
| Z7512 | Use of recovery room | 18.22 |
| Z7514 | Payment for room and board and general nursing care for stays of less than 24 hours, including ordinary medication | 40.76 |
| Z7612 | Unlisted services | By Report |
(h) Pharmaceutical Services: Billings for drugs and medical supplies dispensed to outpatients shall be in accordance with sections 51513, and 51520.(i) Radiology Services: Reimbursement for radiology services will not exceed amounts payable by Medi-Cal for the same services when rendered by physicians in nonhospital settings. If the hospital and professional components are billed separately, the total payment will not exceed the amount otherwise payable.(j) Other Outpatient Services: Payment shall not exceed the maximum payment under the program for the same services by individual providers.(k) Reimbursement rates payable to hospital outpatient departments qualifying for outpatient disproportionate share reimbursement shall be the maximum reimbursement rates authorized in subsections (a) through (j) of this section augmented by the hospital's disproportionate reimbursement factor, as described below: (1) The Department shall develop annually a disproportionate provider factor for each hospital outpatient department located within the State and actively participating in the Medi-Cal program, using, to the extent available, the most recent annual financial disclosure data administered by the Office of Statewide Health Planning and Development.(2) The disproportionate provider factor shall be the ratio of total Medi-Cal outpatient gross revenue, including "other" outpatient deductions from revenues, and revenue-offsetting subsidies, including medically indigent services program funds, as those deductions are described in the Office of Statewide Health Planning and Development Quarterly and Financial Disclosure Report, to total outpatient revenue. For hospitals unable to report the outpatient component of their "other" deductions from revenue, the Department shall estimate this amount by multiplying the ratio of other outpatient gross revenues to other total gross revenues by the total of other deductions from revenue. The calculation of a hospital's outpatient disproportionate provider factor shall not take into account any funds received by the hospital pursuant to Part 4.7, commencing with Section 16900, of the Welfare and Institutions Code, and shall exclude Medicare and Medi-Cal contractual allowances.(3) Notwithstanding Section 51509(k)(2), the outpatient disproportionate provider factor for each qualifying children's hospital shall be no less than the amount that would have been established had the formula specified in Section 51509(k)(2) excluded revenue-offsetting subsidies, including medically indigent services program funds.(4) Hospital outpatient departments with disproportionate provider factors exceeding the mean factor for all hospital outpatient departments specified in Section 51509(k)(1) shall qualify for outpatient disproportionate share reimbursement. In calculating the mean disproportionate provider factor, equal weight will be given to each separately located outpatient department.(5) Any reimbursement generated by the disproportionate provider factor of a qualifying hospital outpatient department shall be directly proportioned to that hospital's disproportionate provider factor, as defined in Section 51509(k)(2). The disproportionate provider factors for all qualifying hospital outpatient departments shall be set at levels which ensure that the estimated aggregate payments to be made under this Section to all qualifying hospitals do not exceed the funding available for this purpose.(6) The maximum reimbursement payable to each qualifying hospital outpatient department under this section, including any reimbursement attributable to a disproportionate provider factor developed pursuant to this Section, shall not exceed the charges billed by that hospital for any services or items provided to eligible Medi-Cal beneficiaries.(l) The maximum reimbursement rates payable to hospital outpatient departments qualifying for small and rural hospital outpatient rate increases shall be the reimbursement rates authorized in subsections (a) through (k) of this section, augmented by the hospital's rate increase factor as described below: (1) The Department shall establish and annually update two separate percentage rate increase factors for hospital outpatient department services provided by small and rural hospitals, as defined in Section 1188.855 of the Health and Safety Code, in order to allocate to each eligible hospital its share of the total funding appropriated for rate increases under this subsection. One rate increase factor shall be computed for all minimum floor hospitals, and one rate increase factor shall be computed for all nonminimum floor hospitals.(2) The percentage rate increase factors specified in Section 51509 (l)(1) shall be based on the ratio of Medi-Cal's outpatient expenditures for each small and rural hospital to the total of Medi-Cal's outpatient expenditures for all small and rural hospitals during the preceding calendar year, provided that:(A) The rate increase for minimum floor hospitals shall be 125 percent of the rate increase for nonminimum floor hospitals.(B) Estimated expenditures attributable to the combined rate increases for minimum floor and nonminimum floor hospitals shall not exceed the funds appropriated for this purpose in the annual Budget Act or in any other specific appropriation measure.(3) If any eligible hospital had less than a full year of operation upon which to determine the ratio of Medi-Cal expenditures as specified in Section 51509 (l)(2), the Department shall extrapolate the Medi-Cal paid claims expenditures for that hospital to estimate a full year's expenditures.(4) For purposes of this subsection, "minimum floor hospital" means a hospital for which: (A) Medi-Cal's expenditures for outpatient services during the preceding calendar year were less than one-half percent of Medi-Cal's expenditures for outpatient services rendered by all small and rural hospitals during that period; and,(B) Total gross patient revenue from all sources during the preceding calendar year was less than $2,500,000.(5) For purposes of this subsection, "nonminimum floor hospital" means a hospital for which: (A) Medi-Cal's expenditures for outpatient services during the preceding calendar year were equal to or greater than one-half percent of Medi-Cal's total expenditures for outpatient services rendered by all small and rural hospitals during that period, or;(B) Total gross patient revenue from all sources during the preceding calendar year was equal to or greater than $2,500,000.(6) The maximum reimbursement rates payable to each hospital outpatient department under this section, including rates attributable to small and rural hospital outpatient reimbursement, shall not exceed the charges billed by that hospital for the services and items rendered.(m) Except as provided in subsection (n), the maximum reimbursement rates paid to hospitals for hospital outpatient services under this section shall be the rates in effect on June 30, 2001, increased by the following percentages, when the hospital submits a bill in accordance with applicable requirements of section 51502 using a currently active hospital outpatient department provider number with respect to services in which the hospital uses Medi-Cal authorized billing codes: (1) 30 percent for services provided on or after July 1, 2001.(2) 34.33 percent for services provided on or after July 1, 2002.(3) 38.81 percent for services provided on or after July 1, 2003.(4) 43.44 percent for services provided on or after July 1, 2004.(n) The increases provided for in subsection (m) are subject to the following exceptions: (1) The increases shall not apply to reimbursement for drugs dispensed to outpatients and paid in accordance with section 51513.(2) The increases shall not apply to reimbursement for medical supplies dispensed to outpatients and paid in accordance with section 51520.(3) The increases shall not apply to reimbursement for services that are paid on a cost-basis, which for the purpose of this paragraph includes, but is not limited to, the following: (A) Federally qualified health center services,(B) Medical items and equipment that are paid a rate equal to or greater than the provider's acquisition cost,(C) Medical items and equipment that are paid a rate equal to or greater than the manufacturer's suggested retail price.(4) The increases for a clinical diagnostic laboratory test shall not exceed the difference between the rate payable on June 30, 2001 and the payment rate recognized under title 42 United States Code, section 1395l(h) for such test under Part B of the Medicare Program.Cal. Code Regs. Tit. 22, § 51509
1. New subsection (k) filed 5-24-89 as an emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14105.97; operative 5-24-89 (Register 89, No. 21). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 9-21-89. For prior history, see Register 85, No. 52.
2. Certificate of Compliance as to 5-24-89 order disapproved and new subsection (k) filed 9-29-89 as an emergency; operative 9-29-89 (Register 89, No. 41). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 1-2-90.
3. Certificate of Compliance as to 9-29-89 order including amendment of subsection (k)(2) filed 10-30-89 (Register 89, No. 45).
4. New subsection (l) filed 6-18-90 as an emergency; operative 6-18-90 (Register 90, No. 32). A Certificate of Compliance must be transmitted to OAL by 10-16-90 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 6-18-90 order transmitted to OAL 10-3-90 and filed 10-23-90 (Register 90, No. 49).
6. Amendment of subsections (k) and (k)(2)-(6) and NOTE filed 7-16-92 as an emergency; operative 7-16-92 (Register 92, No. 29). A Certificate of Compliance must be transmitted to OAL 11-13-92 or emergency language will be repealed by operation of law on the following day.
7. Amendment filed 9-25-92 as an emergency; operative 10-1-92 (Register 92, No. 40). A Certificate of Compliance must be transmitted to OAL 1-25-93 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 7-16-92 order transmitted to OAL 11-10-92 and filed 12-22-92 (Register 92, No. 52).
9. Certificate of Compliance as to 9-25-92 order transmitted to OAL 1-22-93 and filed 3-9-93 (Register 93, No. 11).
10. Editorial correction adding HISTORY 9 (Register 95, No. 25).
11. Amendment of subsections (g)(1)(A)2. and (g)(1)(B)3. filed 7-21-98 as an emergency; operative 7-27-98 (Register 98, No. 30). A Certificate of Compliance must be transmitted to OAL by 11-24-98 or emergency language will be repealed by operation of law on the following day.
12. Editorial correction of HISTORY 11 (Register 99, No. 2).
13. Certificate of Compliance as to 7-21-98 order transmitted to OAL 11-23-98 and filed 1-7-99 (Register 99, No. 2).
14. Amendment of subsection (g)(2) and amendment of NOTE filed 3-1-99 as an emergency; operative 3-1-99 (Register 99, No. 10). A Certificate of Compliance must be transmitted to OAL by 6-29-99 or emergency language will be repealed by operation of law on the following day.
15. Reinstatement of section as it existed prior to 3-1-99 emergency amendment by operation of Government Code section 11346.1(f) (Register 99, No. 33).
16. Amendment of subsection (g)(2) and amendment of NOTE filed 8-10-99 as an emergency; operative 8-10-99 (Register 99, No. 33). A Certificate of Compliance must be transmitted to OAL by 12-8-99 or emergency language will be repealed by operation of law on the following day.
17. Certificate of Compliance as to 8-10-99 order transmitted to OAL 12-2-99 and filed 1-13-2000 (Register 2000, No. 2).
18. Amendment of subsections (g)(1)(A)2. and (g)(1)(B)3., new subsection (m) and amendment of NOTE filed 7-16-2002; operative rates for services provided on or after 8-1-2000 pursuant to Stats. 2000, c. 52, Items 4260-101-0001 and 0890 (Register 2002, No. 29).
19. Certificate of Compliance as to 7-16-2002 order, including repealer of subsection (m), transmitted to OAL 11-12-2002 and filed 12-24-2002 (Register 2002, No. 52).
20. Amendment of subsection (a) and new subsections (m)-(n)(4) filed 4-10-2003 as an emergency; operative 4-10-2003 (Register 2003, No. 15). A Certificate of Compliance must be transmitted to OAL by 8-8-2003 or emergency language will be repealed by operation of law on the following day.
21. Certificate of Compliance as to 4-10-2003 order transmitted to OAL 8-7-2003 and filed 9-15-2003 (Register 2003, No. 38). Note: Authority cited: Section 1188.877, Health and Safety Code; and Sections 10725, 14105, 14105.97 and 14124.5, Welfare and Institutions Code. Reference: Section 1188.877, Health and Safety Code; Sections 14087.3 and 14132, Welfare and Institutions Code; Statutes of 1982, Chapter 1594, Section 77; Statutes of 1983, Chapter 323, Section 149; Statutes of 1984, Chapter 258, Items 4260-106-001 and 890; Statutes of 1984, Chapter 268, Section 66; Statutes of 1985, Chapter 111, Items 4260-106-001 and 890; Section 14105.97, Welfare and Institutions Code; Statutes of 1998, Chapter 324, Items 4260-101-0001 and 0890; and Statutes of 2000, Chapter 52, Items 4260-101-0001.
1. New subsection (k) filed 5-24-89 as an emergency exempt from OAL review pursuant to Welfare and Institutions Code section 14105.97; operative 5-24-89 (Register 89, No. 21). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 9-21-89. For prior history, see Register 85, No. 52.
2. Certificate of Compliance as to 5-24-89 order disapproved and new subsection (k) filed 9-29-89 as an emergency; operative 9-29-89 (Register 89, No. 41). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 1-2-90.
3. Certificate of Compliance as to 9-29-89 order including amendment of subsection (k)(2) filed 10-30-89 (Register 89, No. 45).
4. New subsection (l) filed 6-18-90 as an emergency; operative 6-18-90 (Register 90, No. 32). A Certificate of Compliance must be transmitted to OAL by 10-16-90 or emergency language will be repealed by operation of law on the following day.
5. Certificate of Compliance as to 6-18-90 order transmitted to OAL 10-3-90 and filed 10-23-90 (Register 90, No. 49).
6. Amendment of subsections (k) and (k)(2)-(6) and Note filed 7-16-92 as an emergency; operative 7-16-92 (Register 92, No. 29). A Certificate of Compliance must be transmitted to OAL 11-13-92 or emergency language will be repealed by operation of law on the following day.
7. Amendment filed 9-25-92 as an emergency; operative 10-1-92 (Register 92, No. 40). A Certificate of Compliance must be transmitted to OAL 1-25-93 or emergency language will be repealed by operation of law on the following day.
8. Certificate of Compliance as to 7-16-92 order transmitted to OAL 11-10-92 and filed 12-22-92 (Register 92, No. 52).
9. Certificate of Compliance as to 9-25-92 order transmitted to OAL 1-22-93 and filed 3-9-93 (Register 93, No. 11).
10. Editorial correction adding History 9 (Register 95, No. 25).
11. Amendment of subsections (g)(1)(A)2. and (g)(1)(B)3. filed 7-21-98 as an emergency; operative 7-27-98 (Register 98, No. 30). A Certificate of Compliance must be transmitted to OAL by 11-24-98 or emergency language will be repealed by operation of law on the following day.
12. Editorial correction of History 11 (Register 99, No. 2).
13. Certificate of Compliance as to 7-21-98 order transmitted to OAL 11-23-98 and filed 1-7-99 (Register 99, No. 2).
14. Amendment of subsection (g)(2) and amendment of Note filed 3-1-99 as an emergency; operative 3-1-99 (Register 99, No. 10). A Certificate of Compliance must be transmitted to OAL by 6-29-99 or emergency language will be repealed by operation of law on the following day.
15. Reinstatement of section as it existed prior to 3-1-99 emergency amendment by operation of Government Code section 11346.1(f) (Register 99, No. 33).
16. Amendment of subsection (g)(2) and amendment of Note filed 8-10-99 as an emergency; operative 8-10-99 (Register 99, No. 33). A Certificate of Compliance must be transmitted to OAL by 12-8-99 or emergency language will be repealed by operation of law on the following day.
17. Certificate of Compliance as to 8-10-99 order transmitted to OAL 12-2-99 and filed 1-13-2000 (Register 2000, No. 2).
18. Amendment of subsections (g)(1)(A)2. and (g)(1)(B)3., new subsection (m) and amendment of Note filed 7-16-2002; operative rates for services provided on or after 8-1-2000 pursuant to Stats. 2000, c. 52 Items 4260-101-0001 and 0890 (Register 2002, No. 29).
19. Certificate of Compliance as to 7-16-2002 order, including repealer of subsection (m), transmitted to OAL 11-12-2002 and filed 12-24-2002 (Register 2002, No. 52).
20. Amendment of subsection (a) and new subsections (m)-(n)(4) filed 4-10-2003 as an emergency; operative 4-10-2003 (Register 2003, No. 15). A Certificate of Compliance must be transmitted to OAL by 8-8-2003 or emergency language will be repealed by operation of law on the following day.
21. Certificate of Compliance as to 4-10-2003 order transmitted to OAL 8-7-2003 and filed 9-15-2003 (Register 2003, No. 38).