N.M. Admin. Code § 8.324.10.15

Current through Register Vol. 35, No. 21, November 5, 2024

Section 8.324.10.15 - REIMBURSEMENT

Ambulatory surgical centers must submit claims for reimbursement on the CMS-1500 claim form or its successor.

See 8.302.2 NMAC, Billing for Medicaid Services. Once enrolled, providers receive instructions on documentation, billing and claims processing.

A. Inclusion of all services in the facility fee: All services furnished by the facility are considered reimbursed in the facility fee and cannot be billed separately. The amount paid will be the lesser of the facility's usual and customary charge or the maximum allowed by medicaid.

B. Reimbursement methodology: The facility fee maximum is established at a level which considers the surgical procedure and the area in which the facility is located. Each surgical procedure is assigned to one of nine surgical groups, based on the complexity of the procedure. Each of these surgical groups has a separate reimbursement level. The level of reimbursement is determined by medicaid by utilizing the medicare carrier for procedures payable to ambulatory surgical centers by medicare regulations. The list of surgeries payable under medicare regulations also designates the assigned surgical group for payment purposes. The list is available from the medicare carrier.

(1) For those procedures for which medicare has not established a reimbursement level, MAD assigns the procedure to one of the nine surgical groups. The assignment is based upon the complexity of the procedure or its similarity to procedures within the surgical groups developed by medicare.

(2) Reimbursement is made at the level established by medicaid for that surgical group.

C. Reimbursement for multiple procedures: When more than one covered surgical procedure is performed during the same surgical encounter, reimbursement is made at the rate for the most complex procedure plus fifty percent of the applicable rate for any additional procedures.

D. Reimbursement for laboratory services:

(1) The following laboratory services are considered included in the facility fee and are not reimbursed separately:

(a) hematocrit;

(b) hemoglobin (colorimetric); and

(c) routine urinalysis, without microscopy.

(2) For an ambulatory surgical center to be reimbursed for laboratory tests which are not included in the facility fee, the following conditions must be met:

(a) ambulatory surgical center laboratories must be separately certified and enrolled as clinical laboratories with valid CLIA numbers;

(b) laboratory tests billed must fall within the approved laboratory specialties/ subspecialties for which the laboratory has been certified;

(c) laboratories must have separate New Mexico medical assistance program provider participation applications approved by MAD to bill for laboratory tests not included in the facility fee; and

(d) laboratory tests must be performed on the premises of ambulatory surgical centers and not sent out to reference laboratories. See 8.324.2 NMAC, Laboratory Services.

E. Reimbursement for diagnostic imaging and therapeutic radiology services: Diagnostic radiological, diagnostic ultrasound, peripheral vascular flow measurements and nuclear medicine studies furnished by a facility are considered covered services, but payment is considered to be made within the facility fee and are not separately reimbursed services. See 8.324.3 NMAC, Diagnostic Imaging and Therapeutic Radiology Services.

N.M. Admin. Code § 8.324.10.15

2/1/95; 8.324.10.15 NMAC - Rn, 8 NMAC 4.MAD.759.6 & A, 11/1/04, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024