Providers need to be aware of new modifiers added by CMS in the 2016 OPPS final rule, including a data collection and payment modifier that go into effect January 1, 2016.
Data collection modifier limited to one C-APC
Providers will only have to report a new data collection modifier when reporting related/adjunctive services associated with one comprehensive APC (C-APC), the stereotactic radiosurgery (SRS) C-APC, rather than all C-APCs, which is what CMS originally proposed.
Because so many commenters expressed concerns and raised many operational and technical questions to CMS about using the new modifier to report related/adjunctive services for all C-APCs, CMS backed off its original proposal, says Jugna Shah, MPH, president and founder of Nimitt Consulting, based in Washington, D.C., and Spicer, Minnesota.
“This is really great news for two reasons,” says Shah. “First, it shows that CMS listens when providers speak, and particularly when they raise good operational points. Second, it will be easier for providers to operationalize the use of this modifier for the SRS C-APC, only rather than for all C-APCs.”
CMS will require modifier –CP (adjunctive service related to a procedure assigned to a C-APC procedure, but reported on a different claim) for adjunctive services related to SRS services described by the following codes but reported on a separate claim:
- 77371, radiation treatment delivery, SRS, complete course of treatment cranial lesion(s) consisting of one session; multi-source Cobalt 60-based
- 77372, radiation treatment delivery, SRS, complete course of treatment cranial lesion(s) consisting of one session; linear accelerator based
CMS expects the new modifier to be used with adjunctive services provided within 30 days prior to SRS treatment.
“It may be easier for providers to bill claims for these services for the entire month rather than trying to keep track of applying modifier –CP,” says Rinkle.
CMS explains what it means by related or adjunctive in the final rule by stating:
…services that are integral, ancillary, supportive, or dependent that are provided during the delivery of the comprehensive service. This includes the diagnostic procedures, laboratory tests and other diagnostic tests, and treatments that assist in the delivery of the primary procedure; visits and evaluations performed in association with the procedure; uncoded services and supplies used during the service; outpatient department services delivered by therapists as part of the comprehensive service; durable medical equipment as well as prosthetic and orthotic items and supplies when provided as part of the outpatient service; and any other components reported by HCPCS codes that are provided during the comprehensive service, except for mammography services and ambulance services…
Examples of the types of questions commenters raised about reporting the new modifier, include:
- Should facilities report adjunctive planning and preparation services when furnished in a setting outside of the hospital outpatient department?
- Are adjunctive services limited to preoperative testing and planning services only?
- Does the modifier apply to services performed by different physicians within a health system?
CMS did not answer these questions in the final rule, but instead indicated that it will address these and other issues in sub-regulatory guidance prior to January 1, 2016.
The agency also noted in the final rule that it may consider its proposal to expand the use of this modifier to all C-APCs in the future.
CMS adds modifier –CT
As a result of the Protecting Access to Medicare Act of 2014, CMS is introducing modifier –CT (computed tomography services furnished using equipment that does not meet each of the attributes of the National Electrical Manufacturers Association [NEMA] XR-29-2013 standard) effective January 1, 2016.
Providers will need to append this modifier to a predetermined list of CPT®/HCPCS codes for CT scans when the services are furnished on equipment that does not adhere to NEMA standard XR-29-2013.
Those codes are:
- 70450–70498
- 71250–71275
- 72125–72133
- 72191–72194
- 73200–73206
- 73700–73706
- 74150–74178
- 74261–74263
- 75571–75574
When these codes are reported with the modifier on a claim to be paid separately (i.e., not packaged into a composite APC or C-APC), CMS will impose a 5% payment reduction in 2016 and a 15% payment reduction beginning in 2017. This payment reduction applies under both the Medicare Physician Fee Schedule and the OPPS.
For more information on requirements for reporting modifier –CT, see CMS Transmittal 3402.
APC restructuring
CMS followed through with its proposal to restructure APCs for nine clinical families, with a few tweaks for specific services and procedures based on commenter suggestions.
“This may be the single largest restructuring of APC groups since the inception of OPPS,” says Shah. “And it’s likely just the beginning.”
CMS based the new groupings on the following:
- Greater simplicity and improved understandability of the OPPS APC structure
- Improved clinical homogeneity
- Improved resource homogeneity
- Reduced resource overlap in longstanding APCs
Following restructuring of ophthalmology and gynecology APCs in the 2015 OPPS final rule, CMS finalized restructuring in the following clinical families in the 2016 final rule:
- Airway endoscopy procedures
- Cardiovascular procedures and services
- Diagnostic tests and related services
- Eye surgery and other eye-related procedures
- Gastrointestinal procedures
- Gynecologic procedures and services
- Incision and drainage and excision/biopsy procedures
- Imaging-related procedures
- Orthopedic procedures
For full details of changes to APCs relevant for your facility, see section III.D of the final rule.
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].