Outpatient Hospital Fee Schedule Frequently Asked Questions (FAQs)

HCPCS requirements should be based upon the published values on the RF774 table.  The RF774 table defines whether a HCPC code is required, optional or not required when billed with specific bill type and revenue code combinations. If this indicator is optional, a HCPC code is not required, but may be reported if applicable.

Yes. In October 2011, AHCCCS completed a rebase for outpatient fee schedule. Part of the goal of this rebase was to make the AHCCCS system more Medicare-like. In the Medicare OPPS these procedures as well as other maternity-related procedures are included as bundling triggers. So, in order to make the system more Medicare-like, AHCCCS made the decision to also treat them as bundling triggers.

AHCCCS follows the guidelines as outlined in the Medicare Physicians Fee Schedule multiple procedure indicators to define those codes to which multiple procedure reductions apply. Procedures which are considered for multiple surgical evaluation are found on the RF724 extract.

No, RF774 (not RF773) defines whether or not a HCPC code is required, optional or not required when billed with a specific revenue code. If this indicator is optional, a HCPC code should not be required, but may be reported if applicable.

No, AHCCCS does not pay separately for services billed with 68X revenue codes. The services provided are billable with the 45X Emergency Room Revenue Codes. If a patient becomes an inpatient, services billed with the 68X revenue code are not reimbursable, neither are they allowed for outlier consideration.

For dates of service prior to 10/1/2011 –
Bundle only those applicable services on the same date of service as each bundling trigger.

For example:
Claim dates of service 10/1 - 10/2 Bundling trigger procedure (as defined on RF797) occurs on 10/1 and there is no bundling trigger procedure on 10/2. Only those applicable services (as defined on RF796) which occur on 10/1 should be subject to bundling.

Claim dates of service 10/1 - 10/2 Bundling trigger procedure (as defined on RF797) occurs on 10/1 and there is also an additional bundling trigger procedure that occurs on 10/2. Those applicable services (as defined on RF796) which occur on 10/1 and 10/2 should be subject to bundling.

For dates of service on and after 10/1/2011 –
Bundle applies to those applicable services within a claim, regardless of the date of service of bundling triggers.

For example:
Claim dates of service 10/1 - 10/2 Bundling trigger procedure (as defined on RF797) occurs on 10/1 and there is no bundling trigger procedure on 10/2. All applicable services (as defined on RF796) which occur on either 10/1 or 10/2 should be subject to bundling.

Any Outpatient (OP) services (including Dialysis) billed under the hospitals NPI, (in the absence of a contract specifying otherwise) should be valued under OPFS.

Except in rare instances, AHCCCS covers medically necessary services. Limits in our system are not benefit limits, but rather serve as triggers for internal review of the services provided to members. AHCCCS, like most payors, including Medicare, does not publish the limits used for internal reviews of claims for services provided to our members.

Possible Action Code values are:

• 01-Override Multiple Surgery Discount
• 02-Override Frequency Service Limit
• 04-Override Correct Coding Initiative (CCI) Edits
• 05-Override Bundled Revenue Codes
• Values 07, 08 and 09 are not associated with OPFS and are utilized for internal AHCCCS processing only.

Valuation of OPFS claims will be based upon the beginning date of service on the claim. This is consistent with historical OP Cost to Charge and current In-patient (IP) methodologies.

Revenue codes do not trigger bundling. Bundling triggers are Health Care Financing Administration (HCFA) Common Procedure Coding System (HCPCS/CPT) procedure based and can be found on RF797.
HCPCS/CPT procedures trigger bundling (RF797), actual bundled services are revenue code based (RF796).

Yes, 51X (clinic) revenue codes are covered under OPFS for all Providers (both Indian Health Service (IHS) and non-IHS) and were also covered services under the prior cost to charge methodology.

All surgeries which are subject to multiple surgery logic are listed in the RF724 extract, if a service is not listed on this extract it is not subject to multiple surgery logic.

Fee schedules are generally updated annually.

Fee schedules are generally updated annually.

Units of service on OP claims are generally related to the HCPCS/CPT code reported rather than the revenue code. HCPCS/CPT units that exceed table allowances will be reviewed. There should not be any problems as long as services are correctly billed as these limits are consistent with industry standards.

J code rates are based on the physician fee schedule rates, and closely matched Medicare when they were updated in the spring.

Peer group modifiers are terms used to describe the percent (%) of the Fee Schedule that AHCCCS will reimburse groupings of Hospitals. This % is automatically applied and has no reporting requirements.

AHCCCS will follow OCE edits, but may not implement all or at the same time, as Medicaid coverage differs from Medicare in some areas.

AHCCCS has not fully implemented status indicators at this time. However, AHCCCS is following the logic for most status indicators through our internal tables.

Yes, use bill type 137.

All hospital claims must be submitted on either a hardcopy UB92 claim form or via the 837I electronic file format.

Should not be an issue, no change to the allowance of date spans for OP.

No change to current IP requirements.

AHCCCS doesn't allow the Trauma Revenue codes (681 682 683 684 and 685) because the hospitals receive supplemental payments each year to cover their incremental trauma expenses.

No, RF773 defines whether or not a HCPC/CPT code is valid for reporting with a specific revenue code only; it does not indicate coverage of that service.

Yes, as appropriate for the hospital and the service associated with the revenue code.

No, if no rate is found on RF133 the service will default to the rate on the OPFS fee schedule.

Observation bundling is only applied if the claim has not already applied either ER or surgical bundling triggers.

No, rules are equal to ER. For example, some services are excluded from surgical bundling but not ER bundling.

No, rules are equal to ER. Surgical bundling exceptions do not apply.

No, bundling trigger lines never bundle regardless of the associated revenue code billed.