RATE METHODOLOGY INPUTS BY CODE - …...• Sphygmomanometer • Exam Lights • Otoscope • Reflex...

Rate Methodology Inputs by Code HCPCs 2018 P a g e | 1

RATE METHODOLOGY INPUTS BY CODE

Methodology In the development of rates for new procedure codes resulting from annual HCPCS updated, the

Department began using the following rate methodology, for rates effective January 1, 2018. The

Department’s rate methodology incorporates four factors: indirect and direct care salary

expenses, facility expenses, administrative expenses, and capital expenses, for all services

required as part of each fee-for-service rate. Each factor is detailed below.

All Facility, Administrative, and Capital-Overhead expenses are reduced to per employee cost and

multiplied by the total FTE required to provide services per Medicaid client.

Please note, Dental, Physician Administered Drugs, and Durable Medical Equipment codes are

setting using a different methodology and are not include in the list below.

For details on the methodology for procedure codes that can be billed with a TC modifier and 26

modifier please see the HCPCS 2018 rate methodology document.

Indirect and Direct Care Salary expectations for direct and indirect care workers based on the Colorado mean wage for

each position, direct and indirect care hours for each position, the full-time equivalency

required for the delivery of services to Medicaid clients. Wages are determined by the

Bureau of Labor Statistics (BLS) and are updated by the Bureau every two years. Direct and

indirect care hours required and the full-time equivalent of each position are based on

procedure description from the AMA CPT® Professional Edition.

Facility Expense Expectations This factor incorporates the facility type using property records listing square footage and

actual value. Facility expenses also include estimated repair and maintenance expenses,

utility expenses, and phone and internet expenses. Repair and maintenance price per square

foot is determined using industry standards and varies for facilities that are leased and

facilities that are owned. Utility pricing includes gas and electricity which are determined

annually through the Public Utility Commission which provides summer and winter rates as

well as thermal conversions for appropriated pricing. Internet and phone services are

determined using the Comcast Business Class website estimates. Finally, miscellaneous

expenses are determined to capture additional inputs, such special events that are necessary

but not easily categorized and do not occur in specific frequencies or time intervals.

2

Administrative Expectations Identifies computer, software, office supply costs, and the total number of employees to

determine administrative and operating costs per employee.

Capital Expectation This expense incorporates capital expenses, outside of the facility, that are directly related

to providing the services to Medicaid clients. Capital Overhead Expenses are prorated over

the estimated life of the equipment or estimated warranty of the equipment.

Feedback received • Radiology providers contacted the department about our radiology rates with the

TC and 26 modifiers. Based on this feedback, an adjustment was made to the

inputs included in the TC and 26 modifier rates.

Inputs by Code for Stakeholder Feedback When providing feedback, please provide metrics and/or relevant documentation to

substantiate feedback. Please note that Dental Codes, Durable Medical Equipment, and

Physician Administered Drug Codes are not included in this document as that have a specific

methodology.

The tables below detail the following information for each code:

• Proc Code is the is the CPT or HCPCs code for each specific procedure

• BLS Position(s) is the title and position number from the Bureau of Labor Statistics

website.

• BLS Wage is the Colorado wage associated to the applicable BLS position (Not

Including Taxes and Benefits).

Proc Code BLS Position(s)

BLS Wage(s) (Not Including

Taxes and Benefits)

Expected Direct Care Hours per procedure

Expected Indirect Care

Hours per procedure Capital Included

15730

Oral and Maxillofacial

Surgeons 29-1022 $132.09 2.75 0.17

• Stethoscope

• Exam Table

• Exam Chair

• Sphygmomanometer

• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale


Surgeons 29-1022 $132.09 0.50 0.17

Registered Nurses 29-1141

$33.92 0.50 0.17

https://www.bls.gov/bls/blswage.htm

https://www.bls.gov/bls/blswage.htm

3



Taxes and Benefits)




15733


Surgeons 29-1022 $132.09 3.25 0.17

• Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale


Surgeons 29-1022 $132.09 0.75 0.17


$33.92 0.75 0.17

19294 Registered Nurses

29-1141 $33.92 2.00 0.17

• Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale

20939 Physicians and

Surgeons, All Other 29-1069

$115.17 0.17 0.05

• Electrocephalogram

• Reflex Hammer

• Exam Chair

• Exam Table



$115.17 1.89 0.17

• Compound Microscope

• Nasal Endoscope

• Medical Lights

• Exam Chair

• Exam Table

• Nasal Endoscope Light Source/ Monitor System



$115.17 2.03 0.17


• Nasal Endoscope

• Medical Lights

• Exam Chair

• Exam Table


4



Taxes and Benefits)






$115.17 1.78 0.17


• Nasal Endoscope

• Medical Lights

• Exam Chair

• Exam Table




$115.17 1.90 0.17


• Nasal Endoscope

• Medical Lights

• Exam Chair

• Exam Table




$115.17 1.22 0.17


• Nasal Endoscope

• Medical Lights

• Exam Chair

• Exam Table


32994

Surgeons 29-1067 $125.63 1.22 0.17

• EKG Machine

• Stress Testing Machine System Cost

• Holter Monitors

• Vascular Ultrasound Machine


• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

Cardiovascular Technologists and Technicians 29-

2031

$32.94 0.00 0.50

5



Taxes and Benefits)




33927

Surgeons 29-1067 $125.63 7.00 1.00

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

•


$33.92 0.00 1.00

Surgeons 29-1067 $125.63 4.50 0.45


$33.92 5.25 0.45

33928

Surgeons 29-1067 $125.63 6.00 1.00

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

•


$33.92 0.00 1.00

Surgeons 29-1067 $125.63 4.50 0.45


$33.92 5.25 0.45

33929

Surgeons 29-1067 $125.63 3.00 0.50

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

•


$33.92 0.00 0.50

6


BLS Wage(s) (Not

Including Taxes and Benefits)

Expected Direct

Care Hours per

procedure


Hours per procedure • Capital Included

34701

Surgeons 29-1067 $125.63 3.17 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 0.50 0.17


$33.92 0.50 0.17

34702

Surgeons 29-1067 $125.63 4.55 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 1.00 0.17


$33.92 1.00 0.17

34703

Surgeons 29-1067 $125.63 3.51 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 0.50 0.17


$33.92 0.50 0.17

34704

Surgeons 29-1067 $125.63 4.88 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 1.00 0.17


$33.92 1.00 0.17

7



Taxes and Benefits)



Hours per procedure • Capital Included

34705

Surgeons 29-1067 $125.63 4.17 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 0.50 0.17


$33.92 0.50 0.17

34706

Surgeons 29-1067 $125.63 5.21 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 1.00 0.17


$33.92 1.00 0.17

34707

Surgeons 29-1067 $125.63 3.23 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 0.50 0.17


$33.92 0.50 0.17

34708

Surgeons 29-1067 $125.63 5.21 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 1.00 0.17


$33.92 1.00 0.17

8



Taxes and Benefits)




34709 Surgeons 29-1067 $125.63 0.83 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

34710

Surgeons 29-1067 $125.63 2.00 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 0.50 0.17


$33.92 0.50 0.17

34711 Surgeons 29-1067 $125.63 0.83 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

34712

Surgeons 29-1067 $125.63 2.50 0.17 • Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale

Surgeons 29-1067 $125.63 0.50 0.17


$33.92 0.50 0.17

9



Taxes and Benefits)




34713 Surgeons 29-1067 $125.63 0.17 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

34714 Surgeons 29-1067 $125.63 0.42 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

34715 Surgeons 29-1067 $125.63 0.67 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

34716 Surgeons 29-1067 $125.63 0.83 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table

10



Taxes and Benefits)




36465

Physicians and Surgeons, All Other 29-1069

$115.17 0.25 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table


$33.92 0.00 0.17

36466


$115.17 0.25 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table


$33.92 0.00 0.17

36482


$115.17 0.33 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table


$33.92 0.00 0.17

36483


$115.17 0.33 0.17

• EKG Machine


• Holter Monitors



• Stethoscope

• Pulse Oximeter

• Exam Chair

• Exam Table


$33.92 0.00 0.17

11



Taxes and Benefits)




38222


$115.17 0.50 0.17

• Stethoscope

• Exam Table

• Exam Chair

• Hemotology Analyzer

• Flow Cytometer

• Coagulation Analyzer

• Slide Stainer


$33.92 0.00 0.17

38573

Surgeons 29-1067 $125.63 2.90 0.17 • Compound Microscope

• Endoscopic Video System

• Medical Lights

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 0.50 0.17


$33.92 0.50 0.17

43286



• Medical Lights

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 1.00 0.17


$33.92 1.00 0.17

43287



• Medical Lights

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 1.00 0.17


$33.92 1.00 0.17

43288



• Medical Lights

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 1.00 0.17


$33.92 1.00 0.17

12



Taxes and Benefits)




55874 Physicians and Surgeons, All Other 29-1069

$115.17 0.50 0.17



• Medical Lights

• Exam Chair

• Exam Table

58575

Surgeons 29-1067 $125.63 2.17 0.17 • OB/GYN Table

• Stool

• Instrument Stand

• Ultrasound Machine

• Endoscope Video System

• Endoscope Light Source

• Colposcope

Surgeons 29-1067 $125.63 0.50 0.17


$33.92 0.50 0.17

64912

Surgeons 29-1067 $125.63 2.50 0.17

• Electrocephalogram

• Reflex Hammer

• Exam Chair

• Exam Table

Surgeons 29-1067 $125.63 0.75 0.17


$33.92 0.75 0.17

64913 Surgeons 29-1067 $115.17 0.42 0.17



• Medical Lights

• Exam Chair

• Exam Table

71045


$115.17 0.04 0.03 • Radiologist Computer Monitors

• Desk

• Chair

• X-Ray Machine

Radiologic Technologists 29-

2034 $30.60 0.03 0.03

13



Taxes and Benefits)




71046



• Desk

• Chair

• X-Ray Machine


2034 $30.60 0.07 0.03

71047



• Desk

• Chair

• X-Ray Machine


2034 $30.60 0.10 0.03

71048



• Desk

• Chair

• X-Ray Machine


2034 $30.60 0.13 0.03

74018


$115.17 0.04 0.03 • Radiologist

Computer Monitors

• Desk

• Chair

• X-Ray Machine


2034

$30.60 0.03 0.03

74019



• Desk

• Chair

• X-Ray Machine


2034 $30.60 0.07 0.03

14



Taxes and Benefits)




74021



• Desk

• Chair

• X-Ray Machine


2034 $30.60 0.10 0.03

81105-81112

Medical and Clinical

Laboratory Technicians 29-

2012

$20.16 1.50 0.05


• PCR Thermocycler

• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• Other Lab Equipment

• DNA Sequencer

• DNA Recovery- Blood Sample

• Reagent Kit

• Inherited Disease Sequencing Panel

81120



2012

$20.16 1.50 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• Gene Analyzer

• Other Equipment

• DNA Recovery Kit for FFPE

• Isocitrate Dehydrodrogenase 1 Soluble Kit

15



Taxes and Benefits)




81121



2012

$20.16 1.50 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• Gene Analyzer

• Other Equipment)

• DNA Recovery Kit for FFPE

• Isocitrate Dehyrogenase Kit

81175



2012

$20.16 1.50 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• DNA Sequencer

• Other Equipment


• Reagent Kit

• Gene Panel

• AmpliSeq Gene Library

16



Taxes and Benefits)




81176



2012

$20.16 1.50 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• DNA Sequencer

• Other Equipment


• Reagent Kit

• GenePanel

• Gene Library

• Index Adaptor

81238



2012

$20.16 1.50 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• DNA Sequencer

• Other Equipment


• Reagent Kit GenePanel

• Gene Library

17



Taxes and Benefits)




81248



2012

$20.16 1.50 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• DNA Sequencer

• Other Equipment


• Reagent Kit

• Custom Gene Panel

• Gene Library

• Index Adaptor

81248



2012

$20.16 1.50 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• DNA Sequencer

• Other Equipment


• Reagent Kit


• Gene Library

• Index Adaptor

18



Taxes and Benefits)




81249



2012

$20.16 1.50 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• Gene Sequencer

• Other Equipment


• Reagent Kit

• Gene Panel

• Gene Library

81258



2012

$20.16 1.50 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• DNA Sequencer

• Other Equipment


• Reagent Kit


• Gene Library

• Index Adaptor

81259



2012

$20.16 1.50 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• Gene Sequencer

• Other Equipment


• Reagent Kit

• Gene Panel

• Gene Library

19



Taxes and Benefits)




81269



2012

$20.16 1.50 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• Gene Sequencer

• Other Equipment


• MLPA Reagents

• Rnase A (1 ML of 4MG/1ML Solution)

• MLPA P140 HBA Probe Mix

81283



2012

$20.16 1.07 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• Gene Sequencer

• Other Equipment


81334



2012

$20.16 1.5 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• Gene Sequencer

• Other Equipment


• Reagent Kit


• Gene Library

• Index Adaptor

20



Taxes and Benefits)




81520



2012

$20.16 11.00 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• nCounter DX Analysis System

• Other Equipment

• High Pure FFPE RNA Iso Kit

• Prosigna Kit- Required Reagents

81521



2012

$20.16 11.00 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave


• Other Equipment


• MammaPrint Kit

81541



2012

$20.16 11.00 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave


• Other Equipment


• Prolaris Kit

21



Taxes and Benefits)




81551



2012

$20.16 11.00 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave


• Other Equipment


• Confirm MDX Kit

86008



2012

$20.16 0.13 0.05 • Allergy Analyzer

• ELISA Kit

86794



2012

$20.16 0.13 0.05 • Allergy Analyzer

• ZIKA Elisa Kit

87634



2012

$20.16 1.07 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• Other Equipment

• RSV Swab Kit

• Oral Swab RNA Isolation Kit

22



Taxes and Benefits)




87662



2012

$20.16 1.07 0.05



• Centrifuge

• pH meter

• Freezer

• Fridge

• Autoclave

• Other Equipment

• DNA/RNA Recovery- Blood Sample

93792 Physicians and Surgeons, All Other 29-1069

$115.17 0.00 0.17

• Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale

93793 Payroll and

Timekeeping Clerks 43-3051

$21.75 0.07 0.17 • No special

equipment

94617

Respiratory Therapists 29-1126

$28.82 0.42 0.17

• Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale

• Pulse Oximeter

• Electrocardiograph Machine

• Treadmill

Respiratory Therapy

Technicians 29-2054

$19.69 0.50 0.17

23



Taxes and Benefits)




94618

Cardiovascular Technologists and Technicians 29-

2031

$32.94 0.10 0.08

• Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale

• Treadmill

• Pulse Monitor

• Spirometer

Respiratory Therapy

Technicians 29-2054

$19.69 0.17 0.08

95249 Registered Nurses

29-1141 $33.92 0.20 0.17

• Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale

96573


$115.17 0.25 0.17

• Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale

• Phototherapy Light

Nursing Assistants 31-1014

$14.49 0.50 0.17

96574


$115.17 0.33 0.25

• Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale

Nursing Assistants 31-1014

$14.49 1.25 0.33

24



Taxes and Benefits)




97763

Orthotists and Prosthetists

29-2091 $27.75 0.25 0.17

• Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale

Occupational Therapy Aides

31-2012 $15.15 0.08 0.08

C9738 Physicians and Surgeons, All Other 29-1069

$115.17 0.12 0.17

• Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale

G0515 Occupational

Therapists 29-1122

$41.55 0.20 0.05

• Stethoscope

• Exam Table

• Exam Chair


• Exam Lights

• Otoscope

• Reflex Hammer

• Thermometer

• Scale

Date post:	24-Jun-2020
Category:	Documents
Upload:	others
View:	4 times
Download:	0 times

RATE METHODOLOGY INPUTS BY CODE - …...• Sphygmomanometer • Exam Lights • Otoscope • Reflex...

Documents