Subsection 351-5-4-05 - PAYMENT CALCULATIONPursuant to 39-A M.R.S.A. §209-A, the medical fee schedule for services rendered by health care facilities must reflect the methodology and categories set forth in the federal Centers for Medicare and Medicaid Services ambulatory payment classification system for outpatient services. Fees for procedure codes are calculated by multiplying the base rate times the APC weight. In the event of a dispute regarding the fee listed in Appendix IV, the listed relative weight times the base rate controls.
1. For procedure codes with no CPT®/HCPCS code or for procedure codes with a status indicator of N, there is no separate payment.2. If the ACH Fee, CAH Fee or ASC Fee listed in Appendix IV is $0.00 for a procedure code with a status indicator other than N, then payment must be calculated at 75% of the health care provider's usual and customary charge.3. When two or more procedure codes with a status indicator of T are billed on the same date of service, the highest weighted code is paid at 100% of the fee listed in Appendix IV and additional T status code procedures are paid at 50% of the fee listed in Appendix IV. Add-on codes are not subject to discounting.4. When one or more procedure codes with a status indicator of N are billed without any other outpatient services (i.e. non-patient referred specimens or the facility collects the specimen and furnishes only the outpatient labs on a given date of service, etc.), payment must be calculated at 75% of the provider's usual and customary charge. C.M.R. 90, 351, ch. 5, § 351-5-4, subsec. 351-5-4-05