License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

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Hospital Low Volume Adjustment Instructions

Criteria for Low-volume Payment Adjustment

For fiscal year 2018, a hospital must have less than 1,600 Medicare discharges, consistent with the discharge criterion that applied for fiscal years 2011 through 2017. For fiscal years 2019 through 2022, a hospital must have less than 3,800 total discharges. The new law also extends the mileage criterion that applied for fiscal years 2011 through 2017, that the hospital be located more than 15 road miles from the nearest subsection (d) hospital, for fiscal year 2018 through fiscal year 2022. For fiscal year 2018, a qualifying hospital’s add-on payment is calculated using a continuous linear sliding scale ranging from 25 percent for low-volume hospitals with 200 or fewer Medicare discharges to 0 percent for low-volume hospitals with greater than 1,600 Medicare discharges. For fiscal years 2019 through 2022, the add-on payment is calculated using a continuous linear sliding scale ranging from 25 percent for low-volume hospitals with 500 or fewer discharges to 0 percent for low-volume hospitals with greater than 3,800 discharges. For fiscal year 2023 and subsequent fiscal years, the qualifying criteria and payment adjustment revert to the preexisting requirements.

Continuing Qualifying Hospitals

A hospital that is seeking to continue to qualify to receive a low-volume hospital payment adjustment should submit to its MAC a written request to continue to receive a low-volume payment adjustment. This written request must state that the hospital meets the mileage and discharge criteria applicable for fiscal year 2018 under the amendments provided by the Bipartisan Budget Act of 2018. For hospitals that qualified for the low-volume adjustment in fiscal year 2017, this written verification could be a brief letter to the MAC stating that the hospital continues to meet the low-volume hospital distance criterion as documented in a prior low-volume hospital status request.

Newly Qualifying Hospitals

A hospital that is seeking to newly qualify to receive a low-volume hospital payment adjustment based on the mileage and discharge criteria applicable for fiscal year 2018 under the amendments provided by the Bipartisan Budget Act of 2018 must submit to its MAC a written request for low-volume hospital status, including documentation that the hospital meets the fiscal year 2018 discharge and mileage criteria. For example, the use of a Web-based mapping tool as part of documenting that the hospital meets the mileage criterion for the low-volume hospital adjustment is acceptable.

Please submit documentation to j15.reimbursement@cgsadmin.com

Reviewed: 12.02.22

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Hospital Low Volume Adjustment Instructions

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