SECTION 355.8121. Reimbursement to Ambulatory Surgical Centers

(a) For dates of service on and after the date that the modernized Medicaid Management Information System (MMIS) becomes operational, providers will be reimbursed based on an outpatient prospective payment system (OPPS).

(1) The OPPS utilized is 3M™ Enhanced Ambulatory Patient Groups (EAPG) calculator.

(2) EAPGs are a visit-based classification system intended to reflect the type of resources utilized in outpatient encounters for patients with similar clinical characteristics.

(b) For services provided prior to the date that the modernized MMIS becomes operational, subject to the specifications, conditions, and limitations established by the Texas Health and Human Services Commission, payment for ambulatory surgical center facility services is made based on Medicare rules and prospectively determined rates, unless otherwise specified by the department.

(c) Payment for services provided in or by an ambulatory surgical center, other than ambulatory surgical center facility services, is made under other provisions of the state plan, as appropriate to the service and the provider performing the service.

(d) Physicians must bill the Medicaid Program separately for services they provide in an ambulatory surgical center.

Source Note: The provisions of this §355.8121 adopted to be effective February 7, 1984, 9 TexReg 490; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; transferred effective September 1, 1997, as published in the Texas Register December 11, 1998, 23 TexReg 12660; amended to be effective November 26, 2023, 48 TexReg 6735