California
Organized Outpatient Clinics.
22 CCR 51509.1
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26 segments
22 CCR 51509.1
22 CCR 51509.1
§ 51509.1. Organized Outpatient Clinics. Procedure Code Maximum Allowance Z7500 Use of examining or treatment room $21.66 Z7504 Use of cast room Z7506 Use of operating room or cystoscopic room--first hour Z7508 first subsequent half hour Z7510 second subsequent half hour maximum charges Z7512 Use of recovery room Z7514 Payment for room and board and general nursing care for stays of less than 24 hours, including ordinary medication Z7612 Unlisted services By Report
(a)
Reimbursement for organized outpatient clinic services shall be the usual charges made to the general public not to exceed the maximum reimbursement rates listed in this section.
(b)
Organized outpatient clinics with surgical facilities, as defined in Health and Safety Code Section 1204(b), shall be reimbursed as follows.
(1)
Payment for surgical procedures may be made either directly to the clinic or separately to the clinic, physician or dentist for the services provided by each provider.
(A)
Reimbursement for clinic services shall not exceed the amounts listed in (3).
(B)
Reimbursement for physician or dental services, normally provided in an office setting as determined by the Department, shall not exceed 80 percent of the maximum allowed under Section 51509.1(e), or Section 51506, as appropriate.
(C)
Reimbursement for physician or dental services, not normally provided in an office setting as determined by the Department, shall not exceed the full amount allowed under Section 51509.1(e), or Section 51506, as appropriate.
(2)
Payment for nonsurgical procedures shall:
(A)
Be made directly to the clinic.
(B)
Not exceed the amounts payable in accordance with Section 51509.1(e).
(3)
Maximum reimbursement rates for clinic services, when surgery is provided, shall be as follows:
31.
49
92.
83
185.
65
16.
59
37.
13
(c)
Community clinics and free clinics, as defined in Health and Safety Code Section 1204(a), and county operated organized outpatient clinics not subject to reimbursement as a hospital outpatient department under Section 51509, shall be reimbursed directly.
(1)
Reimbursement for physician services and the services of nonphysician medical practitioners shall be made in accordance with the provisions of Section 51503.
(2)
Maximum reimbursement rates for other services shall not exceed the maximum payment under the program for the same services by individual providers.
(3)
Reimbursement for take-home drugs dispensed by clinics that have obtained permits pursuant to Business and Professions Code Section 4063 et seq. shall not exceed the amounts payable for drug ingredient cost under Section 51513. No dispensing fee or markup shall be paid.
(d)
Rural health clinics, as defined in Section 51115.5, shall maintain adequate financial and statistical records to allow determination of the cost of covered services furnished to Medi-Cal beneficiaries.
(1)
Reimbursement for rural health clinic services provided by a rural health clinic that is an integral part of a hospital and is operating under common licensure with other departments of the hospital shall be on the basis of reasonable cost, as specified in Section 450.30(a)(10)(i), Title 42, Code of Federal Regulations.
(2)
Reimbursement for rural health clinic services provided by all other rural health clinics shall be on the basis of an interim cost-reimbursement rate per clinic visit established for the clinic under the principles established in Title 42, Code of Federal Regulations, Section 450.30 (a) (10) (ii) or (iii) (A). These interim reimbursements shall be subjected to reconciliation to reasonable cost and any screening guidelines or tests of reasonableness established by the Health Care Financing Administration.
(e)
Organized outpatient clinics, not qualifying under (b), (c) or (d), shall be reimbursed directly.
(1)
Reimbursement for physician services and the services of nonphysician medical practitioners shall be made in accordance with the provisions of Section 51503.
(2)
Maximum reimbursement rates for other services shall not exceed the maximum payment under the program for the same services by individual providers.
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