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