The 2016 OPPS final rule includes the first negative payment update for the system, but CMS also listened to commenters on a variety of proposals to make them less onerous either operationally or financially.
“CMS’ language is quite firm in parts of the rule when explaining why some proposals were finalized, but the agency also showed its willingness to listen to providers who submitted detailed comments for other proposals,” says Jugna Shah, MPH, president and founder of Nimitt Consulting, based in Washington, D.C., and Spicer, Minnesota.
CMS adds 10 C-APCs
CMS did not change the logic for comprehensive APCs (C-APC) or complexity adjustments in the final rule, but did add 10 new C-APCs for 2016 in addition to the 25 established for the first time for 2015. This is up from the nine CMS proposed, due to the addition of a level 5 for musculoskeletal procedures.
CMS finalized C-APC 8011 (comprehensive observation services) to replace the existing extended assessment and management (EAM) composite APC 8009. Payment for C-APC 8011 will be made when a claim contains a specific combination of services performed with each other (similar to the existing EAM), instead of only using a primary service CPT® code assigned to status indicator J1 like other C-APCs. CMS will use status indicator J2, newly introduced for 2016, to identify these combinations of services for the observation C-APC.
Providers will need to meet all of the following criteria to qualify for C-APC 8011 payment in 2016:
- Claims do not contain a procedure with status indicator T (significant procedure subject to multiple procedure discounting)
- Claims do contain eight or more units of services described by HCPCS code G0378 (observation services, per hour)
- Claims contain G0378 and any one of the following codes on the same date of service or one day prior:
- HCPCS code G0379 (direct referral of patient for hospital observation care) on the same date of service as HCPCS code G0378
- CPT codes 99281–99284 (ED visit for the E/M of a patient [Levels 1-4])
- CPT code 99285 (ED visit for the E/M of a patient [Level 5]) or HCPCS code G0380 (type B ED visit [Level 1])
- HCPCS code G0381–G0384 (type B ED visit [Levels 2–5])
- CPT code 99291 (critical care, E/M of the critically ill or critically injured patient; first 30–74 minutes)
- HCPCS code G0463 (hospital outpatient clinic visit for assessment and management of a patient)
- Claims do not contain a J1 service
CMS originally proposed to only allow high-level ED visits to help generate the observation C-APC, similar to the current EAM composite APC. But this is one of the proposals that CMS agreed with commenters on and determined the observation C-APC should be expanded to include all visit levels, says Shah.
The 2016 national payment rate for C-APC 8011 is $ 2,174.14, and while this payment is significantly higher than the EAM composite APC payment received today, providers should keep in mind that no other services are paid separately under the C-APC logic, says Shah, whereas today other services can, and do, generate separate payment.
“Any analysis that is done on separately payable observation services must be done carefully,” she says.
CMS finalized C-APC 5881 (ancillary outpatient services when patient dies) to replace composite APC 0375, which has the same description. The single, comprehensive payment would be applied for all services reported on the same date and on the same claim as an inpatient-only procedure with modifier –CA (procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission).
As a result of new C-APCs that are not largely based on previous device-dependent APCs, CMS is expanding the list of add-on codes that are evaluated for a complexity adjustment to include all add-on codes that can be appropriately reported with a base code that describes a primary J1 service.
A list of all packaged CPT add-on codes evaluated for a complexity adjustment is included in Table 8 of the final rule.
The other new C-APCs are similar to those established in 2015, assigned to different levels of procedures within similar clinical families.
“Providers need let their payment review and denial staff know about the services related to these C-APCs,” says Valerie A. Rinkle, MPA, Medicare regulatory specialist for HCPro, a division of BLR, in Danvers, Massachusetts.
With previous bundling that led to certain line items no longer being paid separately, many providers had claims routed to staff as denials, she says. If the billing office is alerted to changes in payment policies, providers can mitigate such delays.
Editor’s note: The 2016 OPPS final rule was published in the November 13 issue of the Federal Register. This article was originally published in Briefings on APCs. Email your questions to editor Steven Andrews at [email protected].