D.C. Mun. Regs. r. 29-9299
For purposes of this section, the following terms shall have the meanings ascribed:
Base year - The standardized year on which rates for all hospitals for outpatient hospital services are calculated to derive a prospective payment system.
Budget target - The total amount that DHCF anticipates spending on all hospital outpatient claims during a fiscal year.
Conversion Factor - The dollar value based on DHCF's budget target, multiplied by the final EAPG weight for each EAPG on a claim to determine the total allowable payment for a visit.
Consolidation - Collapsing multiple significant procedures into one EAPG during the same visit which used to determine payment under the EAPG classification system reimbursement methodology.
Department of Health Care Finance - The single state agency responsible for the administration of the District of Columbia's Medicaid program.
DHCF Fiscal year - The period between October 1st and September 30th; used to calculate the District's annual budget.
Discounting - The reduction in payment for an EAPG when significant procedures or ancillary services are repeated during the same visit or in the presence of certain CPT/HCPCS modifiers.
EAPG Grouper/Pricer Software - A system designed by 3M Health Information Systems to process HCPCS/CPT and diagnosis code information in order to assign patient visits at the procedure code level to the appropriate EAPG and apply appropriate bundling, packaging, and discounting logic to calculate payments for outpatient visits.
EAPG Relative Weight - The national relative weights calculated by 3M Health Information Systems.
EAPG Adjusted Relative Weight - The weight assigned to the patient grouping after discounting, packaging, or consolidation.
Enhanced Ambulatory Patient Grouping (EAPG) - A group of outpatient procedures, encounters, or ancillary services reflecting similar patient characteristics and resource use; incorporates the use of diagnosis codes Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) procedure codes, and other outpatient data submitted on the claim.
General Hospital - A hospital that has the facilities and provides the services that are necessary for the general medical and surgical care of patients, including the provision of emergency care by an emergency department in accordance with 22-B DCMR§ 2099.
Grouper Version - Numeric identifier used by 3M Health Information Systems to distinguish any updates made to the software.
In-District Hospital - Any hospital defined in accordance with 22-B DCMR § 2099 that is located within the District of Columbia.
New Hospital - A hospital without an existing Medicaid provider agreement that is enrolled to provide Medicaid services after September 30, 2014.
Observation Status - Services rendered after a physician writes an order to evaluate the patient for services and before an order for inpatient admission is prescribed.
Outpatient Hospital Services - Preventative, diagnostic, therapeutic, rehabilitative, or palliative services rendered in accordance with 42 C.F.R. § 440.20(a).
Out-of-District Hospital - Any hospital that is not located within the District of Columbia. The term does not include hospitals located in the State of Maryland and specialty hospitals identified under 22-B DCMR § 2099.
Packaging - Including payment for certain services in the EAPG payment, along with services that are ancillary to a significant procedure or medical visit.
Specialty Hospital - A hospital that meets the definition of "special hospital" as set forth in 22-B DCMR § 2099 as follows: (a) defines a program of specialized services, such as obstetrics, mental health, orthopedics, long term acute care, rehabilitative services or pediatric services; (b) admits only patients with medical or surgical needs within the defined program; and (c) has the facilities for and provides those specialized services.
Visit - A basic unit of payment for an outpatient prospective payment system.
D.C. Mun. Regs. r. 29-9299