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2017 OPPS proposed rule looks to implement provider-based changes

2017 OPPS proposed rule looks to implement provider-based changes

CMS is looking to implement the Section 603 provisions of the Bipartisan Budget Act of 2015 regarding off-campus, provider-based departments (PBD) by January 1, 2017, according to the 2017 OPPS proposed rule (https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-16098.pdf). The agency is proposing to pay the nonfacility or office Medicare Physician Fee Schedule (MPFS) amount to the performing/supervising physician and preclude hospitals from billing on a UB-04 form or receiving OPPS payment for services performed at these locations for 2017, but plans to explore other options for 2018 and beyond.

Physicians would be paid at the higher nonfacility rate of the MPFS, but only hospitals that have employed or contracted physicians that reassign their billing to the hospital would get paid under the MPFS for these services.

Hospitals would be able to bill claims on CMS-1500 forms for physicians who have already reassigned their billing to the hospital, as in the case of employed physicians. Otherwise, hospitals would have the option of enrolling the location as the type of provider or supplier it wishes to bill to meet the requirements of that payment system (e.g., ambulatory surgery center or group practice).

"This proposal will be very challenging for hospitals that have community physicians practice at their off-campus outpatient departments that will no longer be paid under OPPS," says Valerie Rinkle, MPA, lead regulatory specialist and instructor for HCPro, a division of BLR, in Middleton, Massachusetts.

"These physicians would bill with the office place of service code and the hospital would have to figure out how to get compensated," she says. "This will likely require hospitals to rewrite their agreements with these physicians."

CMS’ proposal for operationalizing Section 603 comes as somewhat of a surprise since the burden is being placed squarely on providers, with CMS’ own systems not ready to allow existing billing practices, says Jugna Shah, MPH, president and founder of Nimitt Consulting, Inc.

"Some providers hoped CMS would delay implementation and others speculated that modifier ?PO might get repurposed for CY 2017," says Shah. "Perhaps commenters will be able to offer CMS solutions that will minimize provider operational burden."

CMS writes in the proposed rule:

We intend the policy we are proposing in this proposed rule to be a temporary, 1-year solution until we can adapt our systems to accommodate payment to off-campus PBDs for the non-excepted items and services they furnish under the applicable payment system, other than OPPS.

 

CMS would allow certain excepted items and services to still be billed under the OPPS:

  • All items and services furnished in a dedicated emergency department
  • Items and services furnished in a hospital department within 250 yards of a remote location of the hospital and within 250 yards of the main hospital (i.e., on-campus)
  • Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015

Hospitals could also continue to bill for services at these facilities that are not paid under the OPPS, such as laboratory services.

Off-campus PBDs built and billing before November 2, 2015, would retain grandfathered status or what CMS calls "excepted" status and continue billing under the OPPS, but the proposed rule includes some caveats. While the agency proposes that a change in ownership would not change an off-campus PBD’s excepted status as long as the new owner assumes the same provider agreement, a change in location would. However, CMS is requesting comments on this provision and whether certain exceptions should apply for situations beyond a hospital’s control such as a natural disaster.

Off-campus PBDs that expand services beyond those offered and billed before November 2, 2015, will not be allowed to bill them under the OPPS. CMS has proposed clinical families based on APCs that would determine whether those expanded services would continue to be excepted (see Table 21 on page 342 of the proposed rule).

CMS also proposed a 90-day Medicare EHR incentive program reporting period in 2016 for all eligible professionals, eligible hospitals, and critical access hospitals (CAH). If passed, the reporting period would be 90 continuous days between January 1, 2016, and December 31, 2016. CMS proposed the elimination of clinical decision support and computerized order entry objectives and measures for eligible hospitals and CAHs attesting under the program. The thresholds for the modified stage 2 for 2017 and stage 3 for 2017 and 2018 would be reduced. These proposed changes do not apply to the Medicaid EHR incentive program.

CMS proposed that EHR incentive program participants that have not yet demonstrated meaningful use attest to the modified stage 2 by October 1, 2017. This is in part due to the fact that after publishing the 2015 EHR Incentive Programs Final Rule, CMS realized it was not possible for new incentive program participants to attest to stage 3. However, any eligible hospital, eligible professional, or CAH that has attested to meaningful use in the past will report to different systems.

The proposed rule states that some eligible professionals who have not demonstrated meaningful use but intend to attest in 2017 and transition to MIPS should be granted a hardship exception.

CMS also proposed modifying the measure calculations for the EHR incentive program. Under the proposal, actions in the numerator must occur during the reporting period when the period is a full calendar year. If the reporting period is not a full calendar year, the numerator must be reported in the same calendar year as the reporting year.

CMS also proposed removing six procedures from its inpatient-only list, including four spine procedures as well as two laryngoplasty procedures. CMS is requesting comments on whether to remove total knee arthroplasty from the inpatient-only list in the future.

"The deletion of procedures from the inpatient-only list is long overdue," says Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, chief operating officer and founder, First Class Solutions, Inc., in Maryland Heights, Missouri. "It’s unfortunate that the knee arthroplasty wasn’t included. I question whether there is value to the inpatient-only list any longer."

Some conditional packaging status indicators are currently based on the date of service, while others package based on the claim’s from and through dates, meaning packaging crosses all dates encompassed in those fields (FL6) of the claim. For CY 2017, CMS proposes to change its packaging logic for all conditional packaging status indicators so that it occurs at the claim level.

The proposal would change the logic for status indicators Q1 and Q2, which currently package items or services provided on the same date of service as those assigned status indicator S, T, and V. CMS also proposes deleting modifier ?L1 (separately reportable laboratory test), which had been operationally burdensome and confusing to report, led to a billion dollar CMS miscalculation, and was subsequently replaced in functionality with status indicator Q4. If CMS finalizes its proposal, all laboratory tests that appear on a claim with other hospital services would be packaged, even if ordered by a different provider for a different diagnosis than the other services.

For more information, see CMS’ fact sheet, available at: www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-06.html.

HCPro.com – HIM Briefings

Briefings on Accreditation and Quality, November 2017

Editor’s Note: Click the PDF button above for a full edition of the November 2017 edition of Briefings on Accreditation and Quality

CMS immediate jeopardy follows possible restraint, seclusion issues

This September, a Missouri hospital found out the hard way that when not addressed quickly, restraint and seclusion deficiencies can threaten a hospital’s ability to remain open, as well as who keeps their job. CMS twice this year ruled that Mercy Hospital Springfield was putting patients in immediate jeopardy for what it deemed abusive incidents, including some involving restraint and seclusion. This included one incident where a nurse pinned a violent patient to the floor and didn’t report it.

Surveyors on the lookout for suicide hazards

Annually, there are 460,000 emergency department visits that occur following cases of self-harm, and the patients treated during those visits are six times more likely to make another suicide attempt in the future. Nationally, suicide is the 10th leading cause of death, a fact that hasn’t gone unnoticed by CMS or The Joint Commission.

Q&A: How to improve patient handoffs

Patient handoffs continue to be a major concern for hospitals. In September, The Joint Commission published Sentinel Event Alert 58 on inadequate handoff communications and its effect on patient care. Handoffs (also known as transitioning) are the passing of patients between caregivers, plus the information that caregivers exchange during the process. The latter represents a major point of failure for healthcare; each handoff runs the risk of key treatment information being garbled, forgotten, or not passed on.

Joint Commission’s top-cited standards list gives hospitals plenty to work on

In what is likely a result of a new survey matrix, new or revised Life Safety and Environment of Care requirements, and increased pressure from CMS, hospitals scored much worse across the board on The Joint Commission’s list of most challenging standards for the first half of 2017, compared to the same period last year. The Joint Commission released its list in the September issue of Perspectives.

 

HCPro.com – Briefings on Accreditation and Quality

Briefings on Accreditation and Quality, October 2017

Editor’s Note: Click the PDF button above for a full edition of the October 2017 edition of Briefings on Accreditation and Quality’

Time’s almost up: CMS emergency prep CoPs kick in soon

There’s no more excuses for getting ready to meet the new emergency preparedness Conditions of Participation (CoP). The final version of the rules came out in late June, and surveyors with CMS and The Joint Commission will begin assessing compliance with the new emergency management (EM) CoPs on November 15, regardless of the revision timetable.

The Joint Commission pain management dead-line is approaching fast

The Joint Commission finally has prepublished its new and revised pain management standards. They’ll go into effect on January 1, and there is a lot of work to do between now and then. Facilities should assign teams to research best practices in pain management, get the medical staff working on revising protocols and determining how to gather data on pain management effectiveness, and alert your information technology and electronic health records experts that they will be needed.

How to handle malignant hyperthermia

Malignant hyperthermia (MH) is a key focus for surveyors. Schedule drills for staff on finding the emergency carts with the proper drugs to treat MH, ensure the drugs in those carts are kept up to date, and document education and training in their use.

CMS report focuses on AOs’ life safety short-comings

The annual CMS evaluation of accreditation organizations (AO) is out and in the hands of Congress. CMS thinks all the AOs aren’t doing as well as they should in catching violations and is promising Congress that it’s actively working to change that.

HCPro.com – Briefings on Accreditation and Quality

Exceptions and Exemptions from MIPS Reporting for 2017: What Radiologists Need to Know

In the August 4, 2017 edition of its Advocacy in Action eNews the American College of Radiology (ACR) reported on the Centers for Medicare and Medicaid Services (CMS) announcement regarding the manual application process for a significant hardship exception under the Advancing Care Information (ACI) category of MIPS


Radiology Billing and Coding Blog

Exceptions and Exemptions from MIPS Reporting for 2017: What Radiologists Need to Know

In the August 4, 2017 edition of its Advocacy in Action eNews the American College of Radiology (ACR) reported on the Centers for Medicare and Medicaid Services (CMS) announcement regarding the manual application process for a significant hardship exception under the Advancing Care Information (ACI) category of MIPS


Radiology Billing and Coding Blog

Exceptions and Exemptions from MIPS Reporting for 2017: What Radiologists Need to Know

In the August 4, 2017 edition of its Advocacy in Action eNews the American College of Radiology (ACR) reported on the Centers for Medicare and Medicaid Services (CMS) announcement regarding the manual application process for a significant hardship exception under the Advancing Care Information (ACI) category of MIPS


Radiology Billing and Coding Blog

Exceptions and Exemptions from MIPS Reporting for 2017: What Radiologists Need to Know

In the August 4, 2017 edition of its Advocacy in Action eNews the American College of Radiology (ACR) reported on the Centers for Medicare and Medicaid Services (CMS) announcement regarding the manual application process for a significant hardship exception under the Advancing Care Information (ACI) category of MIPS


Radiology Billing and Coding Blog

Exceptions and Exemptions from MIPS Reporting for 2017: What Radiologists Need to Know

In the August 4, 2017 edition of its Advocacy in Action eNews the American College of Radiology (ACR) reported on the Centers for Medicare and Medicaid Services (CMS) announcement regarding the manual application process for a significant hardship exception under the Advancing Care Information (ACI) category of MIPS


Radiology Billing and Coding Blog

Exceptions and Exemptions from MIPS Reporting for 2017: What Radiologists Need to Know

In the August 4, 2017 edition of its Advocacy in Action eNews the American College of Radiology (ACR) reported on the Centers for Medicare and Medicaid Services (CMS) announcement regarding the manual application process for a significant hardship exception under the Advancing Care Information (ACI) category of MIPS


Radiology Billing and Coding Blog