Reporting Charges for Leading Diagnoses and Procedures by Hospitals and Ambulatory Surgical Centers

PURPOSE: This rule establishes procedures for reporting charges for leading diagnoses and procedures by hospitals and ambulatory surgical centers to the Department of Health. (1) Hospitals and ambulatory surgical centers shall report to the Department of Health by March 1 of each year, the charges as of December 31 of the previous year for the diagnoses and procedures listed in Exhibit C of this rule, included herein. (2) The Department of Health may develop and publish reports pertaining to individual providers. The reports and the data they contain shall be public information and may be released on magnetic media. The Department of Health shall make the reports and data available for a reasonable charge based upon incurred costs. (3) The Department of Health may develop reports and release data upon request which do not directly or indirectly identify individual providers. The reports and data shall be public information and may be released on magnetic media. The Department of Health shall make the reports and data available for a reasonable charge based upon incurred costs. (4) Any provider which determines it temporarily will be unable to comply with any part of this rule or with the provisions of a previously submitted plan of correction can provide the Department of Health with written notification of the expected deficiencies and a written plan of correction. The notification and plan of correction shall include the section number and text of the rule in question, specific reasons why the provider cannot comply with the rule, an explanation of any extenuating factors which may be relevant, the means the provider will employ for correcting the expected deficiency, and the date by which each corrective measure will be completed. (5) Any provider which is not in compliance with this rule shall be notified in writing by the Department of Health. The notification shall specify the deficiency and the action which must be taken to be in compliance. The chief executive officer or designee shall have ten (10) working days following receipt of the written notification of noncompliance to provide the Department of Health with a written plan for correcting the deficiency. The plan of correction shall specify the means the provider will employ for correcting the cited deficiency and the date that each corrective measure will be completed. (6) Upon receipt of a required plan of correction, the Department of Health shall review the plan to determine the appropriateness of the corrective action. If the plan is acceptable, the Department of Health shall notify the chief executive officer or designee in writing and indicate that implementation of the plan should proceed. If the plan is not acceptable, the Department of Health shall notify the chief executive officer or designee in writing and indicate the reasons why the plan was not accepted. A revised, acceptable plan of correction shall be provided to the Department of Health within ten (10) working days. (7) Failure of the provider to submit an acceptable plan of correction within the required time shall be considered continued and substantial noncompliance with this rule unless determined otherwise by the director of the Department of Health. (8) Failure of any provider to follow its accepted plan of correction shall be considered continued and substantial noncompliance with this rule unless determined otherwise by the director of the Department of Health. (9) Any provider in continued and substantial noncompliance with this rule shall be notified by registered mail and reported by the Department of Health to its Bureau of Hospital Licensing and Certification, Bureau of Narcotics and Dangerous Drugs, Bureau of Emergency Medical Services, Bureau of Home Health Licensing and Certification, Bureau of Radiological Health, State Public Health Laboratory, Bureau of Special Health Care Needs, the Division of Medical Services of the Department of Social Services, the Division of Vocational Rehabilitation of the Department of Elementary and Secondary Education and to other state agencies that administer a program with provider participation. The Department of Health shall notify the agencies that the provider is no longer eligible for participation in a state program. (10) Any provider that has been declared to be ineligible for participation in a state program shall be eligible for reinstatement by correcting the deficiencies and making written application for reinstatement to the Department of Health. Any provider meeting the requirements for reinstatement shall be notified by registered mail. The Department of Health shall notify state agencies that administer a program with provider participation that the provider’s eligibility for participation in a state program has been reinstated. EXHIBIT C List of Diagnoses and Procedures List of Inpatient Diagnoses Cesarean section without complications or comorbidities, or both Four-day stay DRG 371 Vaginal delivery without complicating diagnoses Two-day stay DRG 373 Normal newborn Two-day stay DRG 391 List of Outpatient Procedures* Operations on the Nervous System Epidural pain block CPT-4 62278 Injection of anesthetic substance (including narcotics), diagnostic or therapeutic; lumbar or caudal epidural, single ICD-9 03.91 Injection of anesthetic into spinal canal for analgesia Carpal tunnel release CPT-4 64721 Neuroplasty or transposition, or both; median nerve at carpal tunnel ICD-9 04.43 Release of carpal tunnel Operations on the Eye Radial keratotomy (surgical correction of myopia) CPT-4 65771 Radial keratotomy ICD-9 11.75 Radial keratotomy Cataract removal, with intraocular lens implant CPT-4 66983 Intracapsular cataract extraction with insertion of intraocular lens prosthesis (one stage procedure) CPT-4 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (for example, irrigation and aspiration or phacoemulsification) ICD-9 13.19 Other intracapsular extraction of lens, plus ICD-9 13.71 Insertion of intraocular lens prosthesis at time of cataract extraction, one (1) stage ICD-9 13.59 Other extracapsular extraction of lens, plus ICD-9 13.71 Insertion of intraocular lens prosthesis at time of cataract extraction, one (1) stage Removal of secondary cataract CPT-4 66821 Discussion of secondary membranous cataract (opacified posterior lens capsule, anterior haloid, or both); laser surgery (for example, YAG laser) (one (1) or more stages) ICD-9 13.64 Discussion of secondary membrane (after cataract) Secondary insertion of intraocular lens/Exchange of intraocular lens CPT-4 66985 Insertion of intraocular lens prosthesis (secondary implant), not associated with concurrent cataract removal CPT-4 66986 Exchange of intraocular lens ICD-9 13.72 Secondary insertion of intraocular lens prosthesis Operations on the Ear, Nose, Mouth and Pharynx Myringotomy, with or without tubes CPT-4 69421 Myringotomy including aspiration or eustachian tube inflation, or both, requiring general anesthesia CPT-4 69436 Tympanostomy (requiring insertion of ventilating tube), general anesthesia ICD-9 20.01 Myringotomy with insertion of tube Nasal fracture, closed reduction CPT-4 21320 Manipulative treatment, nasal bone fracture; with stabilization ICD-9 21.71 Closed reduction of nasal fracture Septoplasty CPT-4 30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft ICD-9 21.88 Other septoplasty Tonsillectomy without adenoidectomy CPT-4 42825 Tonsillectomy, primary or secondary; under age 12 CPT-4 42826 age 12 or over ICD-9 28.2 Tonsillectomy without adenoidectomy Tonsillectomy with adenoidectomy CPT-4 42820 Tonsillectomy and adenoidectomy; under age 12 CPT-4 42821 age 12 or over ICD-9 28.3 Tonsillectomy with adenoidectomy Operations on the Cardiovascular System Cardiac catheterization, left heart CPT-4 93510 Left heart catheterization, retrograde, from the brachial artery, axillary artery or femoral artery; percutaneous CPT-4 93511 by cutdown CPT-4 93514 Left heart catheterization by left ventricular puncture CPT-4 93524 Combined transseptal and retrograde left heart catheterization ICD-9 37.22 Left heart cardiac catheterization Varicose vein ligation and stripping CPT-4 37720 Ligation and division and complete stripping of long or short saphenous veins ICD-9 38.5 Ligation and stripping of varicose veins Endoscopic Procedures Bronchoscopy, diagnostic CPT-4 31622 Bronchoscopy; diagnostic, (flexible or rigid), with or without cell washing or brushing ICD-9 33.22 Fiber-optic bronchoscopy ICD-9 33.23 Other bronchoscopy Dilation of esophagus CPT-4 43455 Dilation of esophagus, by balloon or dilator; under fluoroscopic guidance CPT-4 43456 retrograde ICD-9 42.92 Dilation of esophagus Upper GI endoscopy, diagnostic CPT-4 43235 Upper gastrointestinal endoscopy including esophagus, stomach and either the duodenum, jejunum, or both, as appropriate; complex diagnostic ICD-9 44.13 Other endoscopy of small intestine Endoscopy of small intestine, diagnostic CPT-4 44360 Small intestinal endoscopy, enteroscopy beyond second portion of duodenum; diagnostic ICD-9 45.13 Other endoscopy of small intestine Colonoscopy, diagnostic CPT-4 45378 Colonoscopy, fiber-optic, beyond splenic flexure; diagnostic, with or without colon decompression ICD-9 45.23 Colonoscopy Sigmoidoscopy, diagnostic CPT-4 45330 Sigmoidoscopy, flexible fiber-optic; diagnostic ICD-9 45.24 Flexible sigmoidoscopy Operations on the Digestive System Cholecystectomy (gall bladder removal) CPT-4 49310 Laparoscopy, surgical; cholecystectomy (any method) ICD-9 51.23 Laparoscopic cholecystectomy Inguinal hernia repair CPT-4 49500 Repair inguinal hernia, under age 5 years, with or without hydrocelectomy CPT-4 49505 Repair inguinal hernia, age 5 or over ICD-9 53.00 Unilateral repair of inguinal hernia, not otherwise specified ICD-9 53.01 Repair of direct inguinal hernia ICD-9 53.02 Repair of indirect inguinal hernia Diagnostic laparoscopy CPT-4 58980 Laparoscopy, diagnostic (separate procedure) ICD-9 54.21 Laparoscopy Cystoscopy CPT-4 52000 Cystourethroscopy (separate procedure) ICD-9 57.32 Other cystoscopy Sterilization Vasectomy CPT-4 55250 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) ICD-9 63.73 Vasectomy Tubal ligation CPT-4 58982 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) CPT-4 58983 with occlusion of oviducts by device (for example, band, clip, or Falope ring) ICD-9 66.21 Bilateral endoscopic ligation and crushing of fallopian tubes ICD-9 66.22 Bilateral endoscopic ligation and division of fallopian tubes ICD-9 66.29 Other bilateral endoscopic destruction or occlusion of fallopian tubes Gynecological Operations Conization of cervix CPT-4 57520 Conization of cervix, with or without fulguration, with or without dilation and curettage, with or without repair (any method) ICD-9 67.2 Conization of cervix Laser destruction of cervical lesion CPT-4 57513 Cauterization of cervix; laser ablation ICD-9 67.39 Other excision or destruction of lesion or tissue of cervix Diagnostic D & C CPT-4 58120 Dilation and curettage, diagnostic therapeutic (nonobstetrical), or both ICD-9 69.09 Other dilation and curettage Operations on the Musculoskeletal System Bunionectomy CPT-4 28110 Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure) CPT-4 28290 Hallux valgus (bunion) correction, with or without sesamoidectomy; simple exostectomy (Silver type procedure) CPT-4 28292 Keller, McBride or Mayo type procedure CPT-4 28293 resection of joint with implant CPT-4 28294 with tendon transplants (Joplin type procedure) CPT-4 28296 with metatarsal osteotomy (for example, Mitchell, Chevron, or concentric type procedures) CPT-4 28297 Lapidus type procedure CPT-4 28298 by phalanx osteotomy CPT-4 28299 by other methods (for example, double osteotomy) ICD-9 77.51 Bunionectomy with soft tissue correction and osteotomy of the first metatarsal ICD-9 77.52 Bunionectomy with soft tissue correction and arthrodesis ICD-9 77.53 Other bunionectomy with soft tissue correction ICD-9 77.54 Excision or correction of bunionette ICD-9 77.57 Repair of claw toe ICD-9 77.58 Other excision, fusion and repair of toes ICD-9 77.59 Other bunionectomy Hammertoe correction CPT-4 28285 Hammertoe operation; one toe (for example, interphalangeal fusion, filleting, phalangectomy) ICD-9 77.56 Repair of hammertoe Knee arthroscopy, diagnostic CPT-4 29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure) ICD-9 80.26 Arthroscopy, knee ICD-9 80.36 Biopsy of joint structure, knee Knee arthroscopy, removal of cartilage CPT-4 29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral including any meniscal shaving) ICD-9 80.6 Excision of semilunar cartilage of knee Ganglionectomy, hand or wrist CPT-4 25111 Excision of ganglion, wrist (dorsal or volar); primary CPT-4 26160 Excision of lesion of tendon sheath or capsule (for example, cyst, mucous cyst, or ganglion), hand or finger ICD-9 82.21 Excision of lesion of tendon sheath of hand Operations on the Integumentary System Breast biopsy, incisional CPT-4 19101 Biopsy of breast; incisional ICD-9 85.12 Open biopsy of breast Removal of breast lesion CPT-4 19120 Excision of cyst, fibroadenoma, or other benign or malignant tumor, aberrant breast tissue, duct lesion or nipple lesion (except 19140), male or female, one or more lesions ICD-9 85.21 Local excision of lesion of breast Miscellaneous Diagnostic and Therapeutic Procedures CAT scan of head, without contrast CPT-4 70450 Computerized axial tomography, head or brain; without contrast material ICD-9 87.03 Computerized axial tomography of head CAT scan of head, with and without contrast CPT-4 70470 Computerized axial tomography, head or brain; without contrast material, followed by contrast material(s) and further sections ICD-9 87.03 Computerized axial tomography of head Contrast myelogram of spine CPT-4 61055 Cisternal or lateral cervical (C1-C2) puncture; with injection of drug or other substance for diagnosis or treatment (C1-C2) or CPT-4 62284 Injection procedure for myelography or computerized axial tomography, or both, spinal (other than C1-C2 and posterior fossa), plus CPT-4 72270 Myelography, entire spinal canal, radiological supervision and interpretation ICD-9 87.21 Contrast myelogram Mammography CPT-4 76092 Screening mammography, bilateral (two view film study of each breast) ICD-9 87.37 Other mammography (X-ray imaging of the breast, other than xerography) CAT scan of abdomen, without contrast CPT-4 74150 Computerized axial tomography, abdomen; without contrast material ICD-9 88.01 Computerized axial tomography of abdomen CAT scan of abdomen, with and without contrast CPT-4 74170 Computerized axial tomography, abdomen; without contrast material, followed by contrast material(s) and further sections ICD-9 88.01 Computerized axial tomography of abdomen Diagnostic ultrasound, abdomen and retroperitoneum CPT-4 76700 Echography, abdominal, B-scan or real time with image documentation, or both; complete CPT-4 76770 Echography, retroperitoneal (for example, renal, aorta, nodes), B-scan or real time with image documentation, or both; complete ICD-9 88.76 Diagnostic ultrasound of abdomen and retroperitoneum Diagnostic ultrasound, gravid uterus CPT-4 76805 Echography, pregnant uterus, B-scan or real time with image documentation, or both; complete (complete fetal and mater- nal evaluation) CPT-4 76810 complete (complete fetal and maternal evaluation), multiple gestation, after the first trimester ICD-9 88.78 Diagnostic ultrasound of gravid uterus Magnetic resonance imaging, brain, without contrast CPT-4 70551 Magnetic resonance (for example, proton) imaging, brain (including brain stem); without contrast material ICD-9 88.91 Magnetic resonance imaging of brain and brain stem Magnetic resonance imaging, brain, with and without contrast CPT-4 70553 Magnetic resonance (for example, proton) imaging, brain (including brain stem); without contrast material, followed by con- trast material(s) and further sequences ICD-9 88.91 Magnetic resonance imaging of brain and brain stem Magnetic resonance imaging, spinal canal, without contrast CPT-4 72141 Magnetic resonance (for example, proton) imaging, spinal canal and contents, cervical; without contrast material CPT-4 72146 Magnetic resonance (for example, proton) imaging, spinal canal and contents, thoracic; without contrast material CPT-4 72148 Magnetic resonance (for example, proton) imaging, spinal canal and contents, lumbar; without contrast material ICD-9 88.93 Magnetic resonance imaging of spinal canal Magnetic resonance imaging, spinal canal, with and without contrast CPT-4 72156 Magnetic resonance (for example, proton) imaging, spinal canal and contents, without contrast material, followed by con- trast material(s) and further sequences; cervical CPT-4 72157 thoracic CPT-4 72158 lumbar ICD-9 88.93 Magnetic resonance imaging of spinal canal Treadmill stress test CPT-4 93015 Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise or pharmacological stress, or both; continuous electrocardiographic monitoring, with interpretation and report ICD-9 89.41 Cardiovascular stress test using treadmill Electrocardiogram CPT-4 93000 Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report ICD-9 89.52 Electrocardiogram Extracorporeal shockwave lithotripsy, kidney, ureter or bladder, or any combination of these CPT-4 50590 Lithotripsy, extracorporeal shockwave ICD-9 98.51 Extracorporeal shock wave lithotripsy (ESWL) of the kidney, ureter or bladder, or any combination of these *Charges for outpatient procedures shall include the facility’s total customary charges for a specific procedure or group of procedures defined according to ICD-9-CM or CPT-4 codes. Charges shall include fees associated with the preparation of the patient (preoperative phase), performance of the procedure (intraoperative phase) and recovery (postoperative phase): Preoperative phase includes those services and procedures that prepare the patient for the surgical procedure. It shall include, but is not limited to, charges for standard preoperative diagnostic laboratory testing, radiological services, preparatory pharmaceuticals (preoperative medications), skin preparation supplies, and the like. Intraoperative phase includes those services and procedures during the period of time of the actual surgical procedure itself (as identified by ICD-9-CM or CPT-4 code) as performed to eliminate or improve the patient’s diagnostic condition. It shall include, but is not limited to, room charges for the surgery suite, anesthesia and other intraoperative pharmaceuticals, equipment and supplies (drapes/barriers, electrocautery tips and grounding pads, specialized scalpel blades, dressing materials, casting materials and orthopedic supplies, and the like). Postoperative phase includes those services and procedures that are provided to the patient from the point at which the patient exits the surgery suite to the point at which the patient is discharged from the facility. It shall include, but is not limited to, charges for use of the recovery room, dressings, pharmaceuticals, respiratory therapy, supplies and the like. Professional fees for facility-based radiologists, pathologists, anesthesiologists and the like, if they are reported by the facility, shall be reported separately. AUTHORITY: section 192.667, RSMo 2000.* Emergency rule filed Nov. 4, 1992, effective Nov. 14, 1992, expired March 13, 1993. Emergency rule filed March 4, 1993, effective March 14, 1993, expired July 11, 1993. Original rule filed Nov. 4, 1992, effective June 7, 1993. Emergency amendment filed April 1, 1993, effective April 11, 1993, expired Aug. 8, 1993. Emergency amendment filed Aug. 10, 1993, effective Aug. 20, 1993, expired Nov. 18, 1993. Amended: Filed April 1, 1993, effective Dec. 9, 1993. Amended: Filed April 13, 2001, effective Oct. 30, 2001. *Original authority: 192.667, RSMo 1992, amended 1993, 1995.