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You won’t find these codes in your 2023 code books, but they are effective April 1. The Centers for Medicare & Medicaid Services (CMS) has released coding changes and policy updates for the Outpatient Prospective Payment System (OPPS). The updates include the addition of many new HCPCS Level II codes, the deletion of a few […]
The post OPPS April 2023 Update Brings Coding and Policy Changes appeared first on AAPC Knowledge Center.
But be aware that some of the changes for coding and billing outpatient claims are retroactive to April or January. Many of the changes to Medicare’s Outpatient Prospective Payment System (OPPS) in the July update mirror those in the Medicare Physician Fee Schedule Database (MPFSDB) update for the same quarter — such as the new […]
The post Learn About OPPS Changes in July Update appeared first on AAPC Knowledge Center.
Learn about the 2021 OPPS final rule.
The post OPPS Final Rule Eliminates Inpatient Only List appeared first on AAPC Knowledge Center.
Price transparency overshadows all other finalized Medicare policy updates among hospitals. The Hospital Outpatient Prospective Payment System (OPPS) final rule for calendar year (CY) 2020 offered the usual menu of policy updates, save for one. The estimated 1.3 percent increase to 2020 OPPS payments — less 2.0 percent for hospitals that fail to meet the […]
The post 2020 OPPS Causes Fervor in the Industry appeared first on AAPC Knowledge Center.
Meet outpatient quality reporting requirements or prepare for a payment reduction. Using Hospital Outpatient Prospective Payment System (OPPS) methodology, the Centers for Medicare & Medicaid Services (CMS) based 2019 OPPS payments on 2017 claims data submitted by hospital providers, resulting in an estimated 1.35 percent increase. Hospitals that fail to meet the hospital outpatient quality […]
The post 2019 OPPS Reflects More Site-of-service Payment Equalization appeared first on AAPC Knowledge Center.
Utilization, new codes, device pass-through, and 340B payment policies top the changes in the Centers for Medicare & Medicaid Services’ (CMS) Outpatient Prospective Payment System (OPPS) final rule for 2019. Cutting OPPS Costs CMS said in a fact sheet with the long-winded title of “CMS finalizes Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical […]
The post OPPS Rule for 2019 Includes Curbing Utilization appeared first on AAPC Knowledge Center.
The long-awaited 2019 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule, released July 25, sets the wheels in motion for significant reforms in the way Medicare will pay providers in hospital outpatient settings. The Centers for Medicare & Medicaid Services (CMS) is moving toward site-neutral payments for clinic visits, which will save […]
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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.
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:
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.
Making a checklist to prepare for the OPPS final rule
Editor’s note: Jugna Shah, MPH, president and founder of Nimitt Consulting, writes a bimonthly column for Briefings on APCs, commenting on the latest policies and regulations and analyzing their impact on providers.
The 2017 OPPS final rule will not be out for a couple of weeks, but that doesn’t mean providers can’t be thinking about what their action plan will be once the rule is released.
With only 60 days between the final rule’s release and the January 1 implementation date, providers will be ahead of the curve by spending time now and thinking about the processes they may need to review, change, or implement based on what CMS finalizes and the sort of financial impact the final rule is likely to have.
While I don’t know with 100% certainty what CMS will finalize, revise, delay, or back away from, I offer providers this list of what they should look at immediately upon the rule’s release.
Section 603
With Congress mandating payment changes for all non-grandfathered (those not billing under OPPS prior to November 2, 2015) off-campus, provider-based departments (PBD) starting January 2017, it was no surprise that CMS discussed this issue in the proposed rule. But it was a huge surprise to read CMS’ proposals, which, if finalized, would greatly impact otherwise protected grandfathered locations under Congress’ Section 603.
For example, CMS proposed that if an off-campus PBD moves, changes ownership, or expands its services beyond what it was providing as of November 2, 2015, as defined by APC-based clinical families, then its grandfathered status would be impacted. While this may sound relatively simple, the payment and operational impact would be a nightmare.
There is another aspect of Section 603 and CMS’ proposal to use the Medicare Physician Fee Schedule (MPFS) as the "applicable payment system" for Medicare Part B services provided at non-grandfathered locations or deemed "non-excepted." Specifically, there are many services for which the MPFS has no facility component for the facility costs associated with performing the procedure because they are only provided in hospital outpatient departments or ambulatory surgery centers. For these services, the industry has to wonder what CMS was thinking, as the agency cannot possibly expect to pay nothing for services that would continue to be rendered in off-campus PBDs.
CMS’ unexpected and hastily configured proposals create such large operational and financial problems that the industry is hoping the agency will simply retreat and delays the implementation of Section 603, or at a minimum revert to paying grandfathered facilities under the OPPS for all of their services, regardless of clinical service expansion, site relocation, or ownership changes. There is precedent for CMS to postpone implementation beyond statutory deadlines. If there were ever a situation where delay is advised, this is one.
Hopefully, providers sent in a surfeit of comments regarding these and other issues and outstanding questions related to the agency’s Section 603 implementation proposals. I hope CMS will acknowledge its proposals have administrative, operational, and financial gaps that are so large, it will be impossible to move forward by January. But even if CMS does choose to put off its proposals until proper payment mechanisms are developed, Congress was clear in its language requiring changes by January 1, 2017, so something is likely going to have to occur.
CMS’ proposals, if finalized, would have drastic long-term implications for all providers, including those who believe that their grandfathered status would protect them; the sad reality is that under CMS’ proposals, there will be massive operational and financial impact, so this is the first topic in the final rule that everyone should review.
Packaging proposals
Providers have gotten used to CMS expanding packaging in each OPPS rule, as the agency calls packaging an essential part of a prospective payment system. With CMS’ expansion of lab packaging from date of service to claim level this year, we should not be surprised if the agency finalizes its proposal of expanding the conditional packaging logic of CPT codes assigned to status indicators Q1 and Q2 to the claim level.
Claim-level packaging of these types of ancillary services will have a huge financial impact on providers submitting multiday claims, such as those for chemotherapy and radiation therapy services, despite the fact that multiday claims for these types of services are not required.
Currently, status indicators Q1 and Q2 are packaged into other OPPS services when provided on the same date of service, even when submitted on a claim that spans more than one day. If CMS finalizes its proposal, providers that continue submitting multiday claims when monthly or series claims are not required should not be surprised when they find themselves no longer receiving separate payment for many services.
This is the time for providers to assess whether they submit multiday claims for any services beyond the required repetitive services listed in the Medicare Claims Processing Manual, Chapter 1, section 50.2.2. While it is true the manual states that is is an option to bill nonrepetitive services on multiday claims, it did not have financial implications. At least, until this year, with the claim-based packaging of labs and proposal for claim-based packaging of Q1 and Q2 services. Providers should determine why they are billing multiday claims and what it would take to change their billing processes. If they elect not to move away from multiday claims, then assessing the financial impact that will occur is an important exercise to go through prior to January 1.
The other packaging proposal providers should look for in the final rule involves the use of modifier -L1 for reporting unrelated laboratory tests when they occur on a claim with other OPPS services. CMS proposes to delete the modifier for CY 2017 as it believes that the vast majority of labs should be packaged regardless of whether they are unrelated to other OPPS payable services.
This would have a big impact on providers who provide reference laboratory or nonpatient services, which the agency requires to be reported on the same claim as other OPPS services performed on the same date. Today, the use of the -L1 modifier allows providers to identify these services as separate and unrelated to the other OPPS services so that payment is received from the Clinical Laboratory Fee Schedule.
If CMS finalizes its proposal to eliminate modifier -L1, we can hope the agency will also update its instructions for reporting reference laboratory services so they can be separately paid even when provided on the same date of service or claim as other OPPS services. If CMS does not make a change, then providers can again expect to see a large financial impact. Both of these packaging proposals should be looked at immediately in the final rule.
Device-intensive procedures
The final set of proposals providers will want to review relates to the changes proposed for device-intensive procedures. This is a place where we hope to see CMS finalizing changes as proposed.
For example, CMS proposes to use the implantable device cost-to-charge ratio (CCR) to calculate pass-through device payments for hospitals that file cost reports designating that cost center, as this is a more accurate CCR for determining separate pass-through payment. Currently, only about two-thirds of hospitals use the implantable device CCR, which means the remaining one-third need to examine their cost reporting process.
Providers should determine whether they are in the group that reports the implantable cost center; if a provider is not reporting, it should find out why and begin making changes. This will have an impact on facilities’ ability to generate much better pass-through payment going forward, when applicable. It will also ensure future payment rates for device-intensive procedures reflect more accurate payment of the device.
Finally, it will be interesting to see whether CMS finalizes the addition of another 25 comprehensive APCs (C-APC) encompassing 1,844 additional status indicator T services; if it does, a financial impact analysis of these services will also be important, as this will be a large increase in C-APCs for a one-year span.
I plan to discuss these and other final rule changes in my next column, as well as in HCPro’s annual OPPS final rule webcast December 1 (see www.hcmarketplace.com for details), but in the meantime I hope the above checklist will be useful to providers now and in the first weeks of the rule’s release.