2014 opps final rule: learn what sweeping changes cms ...• apc system recalibration and...

2014 OPPS Final Rule: Learn What Sweeping Changes CMS Finalized

An HCPro audio conference presented on

December 18, 2013

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• The 2014 OPPS Final Rule: Learn What Sweeping Changes CMS Finalizedmaterials package is published by HCPro, a division of BLR.

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Presented By:

Jugna Shah, MPH, is the president and founder of Nimitt Consulting, Inc., a firm specializing in case‐mix payment system design, development, and implementation. She has extensive experience helping providers understand and address the ongoing clinical, operational, and financial implications of Medicare’s outpatient prospective payment system based on APCs. She has educated and audited hospitals on their drug administration coding and billing practices. She has contributed to several books and numerous OPPS/APC articles over the past 12 years. She is also a contributing editor to HCPro's Briefings on APCs.

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Presented By:

Valerie A. Rinkle, MPA, is associate director within the healthcare practice at Navigant Consulting. She has 30 years of healthcare experience, including 10 years as revenue cycle director for Asante Health System in Medford, Ore., and over a decade of nationwide consulting to health systems and practices regarding Medicare and Medicaid payment systems and compliance. She is the author of numerous articles on OPPS and hospital‐based clinics.

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Agenda

• Section 1: Annual OPPS Updates

• Section 2: Significant CY 2014 Policy & Payment Changes

• Section 3: Other Related Items

• Section 4: Summary & Q/A

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CY 2014 OPPS Final Rule Files

• Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Hospital Value‐Based Purchasing Program; Organ Procurement Organizations; Quality Improvement Organizations; Electronic Health Records (EHR) Incentive Program; Provider Reimbursement Determinations and Appeals

• Download the APC/OPPS Final Rule: CMS‐1601‐FC

– https://s3.amazonaws.com/public‐inspection.federalregister.gov/2013‐28737.pdf

– CMS Fact Sheet on HOPPS: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact‐Sheets/2013‐Fact‐Sheets‐Items/2013‐11‐27‐3.html

– Federal Register version available on Dec 10th

• Comments due 60 days from the FR publication date

• Comments limited to new codes & their APC assignments

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Section 1: Routine Annual OPPS Updates and System Recalibration

• Conversion factors and protected hospitals

• Outlier payment policy

• Review of status indicators

• APC system recalibration and reclassification

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Overall System Update

• APC payments to increase by a 1.7% (market basket increase less certain factors).

• CMS projects to spend more on OPPS in CY 2014 due to the inclusion of costs currently payable under other payment systems, such as the clinical laboratory fee schedule (CLFS) and the Durable Medical Equipment Prosthetic Orthotic Schedule (DMEPOS).

• Beneficiaries can expect to see changes in their copayments in CY 2014 due to a number of the policies CMS has finalized. In the aggregate, beneficiary copayments are 21.7%.

• Providers will need to carefully assess financial impact given CMS has finalized some of its major proposals related to E/M clinic visits and expanded packaging.

• Don’t forget about sequestration, which results in a 2% reduction in payment. The payment reduction is applied after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.

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Conversion Factors and Protected Hospitals• 2013 national conversion will increase by 1.7% (market basket increase of

2.5% minus 0.5% for productivity and minus 0.3% due to Affordable Care Act provisions).

– $72.672 *– for hospitals that meet quality reporting requirements

– $71.219 *– for hospitals failing to meet quality reporting requirements

• Children’s hospitals and cancer centers have a permanent hold harmless protection and CMS will continue a payment adjustment so that cancer centers’ OPPS payment‐to‐cost ratio (PCR) is equivalent to the average PCR of all other OPPS hospitals; PCR of 0.89 finalized for CY 2014.

• Rural SCHs and EACHs will continue to receive a 7.1% payment adjustment for OPPS services, excluding separately payable drugs, biologicals, and devices paid under the pass‐through payment policy, and items paid at cost. CMS may evaluate this in the future.

* This does not reflect the 2% reduction due to sequestration still in effect.9

2013 Outlier Payment Policy

• Line item level for all separately payable APCs except separately payable drugs, biologicals, radiopharmaceuticals, brachytherapy sources, and cost paid items

• Outlier pool = 1% of total OPPS payments; and 0.12% of outlier pool for CMHC for partial hospitalizations

• Two‐threshold model– Multiplier threshold set at 1.75– The fixed dollar threshold = $2,025

• CMS pays hospitals 50% of the difference when both thresholds are met

• CMHCs subject to a different formula with a multiplier threshold of 3.4 applied to APC 173; and no fixed dollar threshold

• Outlier payment reconciliation at cost report settlement

2014 Final Outlier Payment Policy

• No change

• Outlier pool still 1% of total OPPS payments; but 0.16% of the outlier pool for CMHC for partial hospitalizations

• Two‐threshold model– No change to the multiplier threshold– Fixed dollar threshold = $2,900

• No change

• No change

• No change

Outlier Policy

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Reclassification of HCPCS/CPT Codes and APC System Recalibration• Reclassification and recalibration of HCPCS/CPT codes, APCs, and

status indicators

– Annual updates required.

– CMS applies the “2 times rule,” which means items/services within an APC group are reviewed to determine comparability of resource use; if the geometric mean cost of the highest‐cost item/service in an APC group is 2x greater than the lowest‐cost item/service within the group, then CMS may reconfigure the APC by moving codes in/out of the group or create new APCs. Low‐volume codes are excluded.

– New/deleted/modified HCPCS/CPT codes also impact APC group configurations.

– Changes in packaging status and/or other status indicators results in impact.

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Providers should review the codes in Addendum B with comment indicator CH as well as all of the codes in Addendum P to better understand CMS’ changes for CY 2014.

Addendum B & OPPS Status Indicators• Status indicators (SI) are assigned to each CPT/HCPCS code and tell us

something about how the service is paid

– Services paid under OPPS (SI = G, H, K, N, P, Q, R, S*, T*, U, V & X)

– Services paid under another payment system (SI = A, C, F, L & Y)

– Services not recognized under OPPS but may be recognized by other institutional providers or there may be a better HCPCS code (SI = B)

– Services not payable by Medicare (SI = M, E)

– Services/CPT codes deleted (SI = D)

– J1 = new status indicator for comprehensive APCs beginning CY 2015

* The word “significant” has been removed from the description of these status indicators in 2014

Remember: Changes in status indicators can result in APC payment changes from one year to the next.

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Review of Packaging & Status Indicators• Unconditionally packaged status “N”

– ALWAYS packaged services – no separate payment

• Conditionally packaged status “Q”

– Sometimes packaged services – services OFTEN packaged, but also separately payable in certain circumstances

• Q1 (“STVX” packaged codes)

• Q2 (“T” packaged codes)

• Q3 (codes that may be paid through a composite APC)

• CMS continues to remind providers that they NEED to report ALL services regardless of whether they are always or sometimes separately payable. In other words, just because a service is packaged doesn’t mean providers should stop reporting it!

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• CH: Active HCPCS codes in current and next calendar year; status indicator and/or APC assignment changes that need to be studied

– 2727 HCPCS/CPT codes flagged as “CH”

• NI: Indicator used by CMS also in the Addendum B Excel file to highlight new codes which may or may not have an interim APC assigned to them

– 398 HCPCS/CPT codes designated as “NI”

• CMS accepting comments until mid‐January 2014

• Important to utilize for CPT/HCPCS Updates

Tip: Filter Addendum B by comment indicator “CH” and by “NI” to help isolate codes with major changes and those open for comment.

Reminder About Comment Indicators

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Reassignment/Recalibration: Examples of Deleted CPT/HCPCS Codes

Status indicator D = deleted codes … though deleted, there may be replacements!

HCPCS Code Short Descriptor SI APC

Payment Rate Short Descriptor CI SI APC

Payment Rate

$ Change in Pmt Rate

0124T Conjunctival drug placement T 0232 $144.79 Conjunctival drug placement CH D $0.00 ($144.79)

0183T Wound ultrasound T 0013 $71.54 Wound ultrasound CH D $0.00 ($71.54)

0186T Suprachoroidal drug delivery T 0237 $1,442.12 Suprachoroidal drug delivery CH D $0.00 ($1,442.12)

0192T Insert ant segment drain ext T 0673 $2,977.93 Insert ant segment drain ext CH D $0.00 ($2,977.93)

13150 Cmplx rpr e/n/e/l 1.0 cm/< T 0135 $393.38 Cmplx rpr e/n/e/l 1.0 cm/< CH D $0.00 ($393.38)

19102 Bx breast percut w/image T 0005 $625.24 Bx breast percut w/image CH D $0.00 ($625.24)

19103 Bx breast percut w/device T 0037 $1,118.54 Bx breast percut w/device CH D $0.00 ($1,118.54)

19290 Place needle wire breast Q1 0340 $49.64 Place needle wire breast CH D $0.00 ($49.64)

19295 Place breast clip percut Q1 0340 $49.64 Place breast clip percut CH D $0.00 ($49.64)

23331 Remove shoulder foreign body T 0022 $1,661.08 Remove shoulder foreign body CH D $0.00 ($1,661.08)

32201 Drain percut lung lesion T 0070 $412.39 Drain percut lung lesion CH D $0.00 ($412.39)

37204 Transcatheter occlusion T 0082 $7,671.18 Transcatheter occlusion CH D $0.00 ($7,671.18)

37205 Transcath iv stent percut T 0229 $8,656.82 Transcath iv stent percut CH D $0.00 ($8,656.82)

37206 Transcath iv stent/perc addl T 0229 $8,656.82 Transcath iv stent/perc addl CH D $0.00 ($8,656.82)

37207 Transcath iv stent open T 0229 $8,656.82 Transcath iv stent open CH D $0.00 ($8,656.82)

37208 Transcath iv stent/open addl T 0229 $8,656.82 Transcath iv stent/open addl CH D $0.00 ($8,656.82)

37210 Embolization uterine fibroid T 0229 $8,656.82 Embolization uterine fibroid CH D $0.00 ($8,656.82)

42802 Biopsy of throat T 0253 $1,147.39 Biopsy of throat CH D $0.00 ($1,147.39)

43219 Esophagus endoscopy T 0384 $2,117.02 Esophagus endoscopy CH D $0.00 ($2,117.02)

43228 Esoph endoscopy ablation T 0422 $1,867.35 Esoph endoscopy ablation CH D $0.00 ($1,867.35)

43256 Uppr gi endoscopy w/stent T 0384 $2,117.02 Uppr gi endoscopy w/stent CH D $0.00 ($2,117.02)

43258 Operative upper GI endoscopy T 0419 $926.78 Operative upper gi endoscopy CH D $0.00 ($926.78)

October 2013 Addendum B January 2014 Addendum B

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Reassignment/Recalibration: Examples of New CPT/HCPCS CodesSeveral new category III codes and new procedure CPT codes. Please review and add to the Charge Description Master.



Payment Rate

0335T $0.00 Extraosseous joint stblztion NI T 0062 $2,012.19

0336T $0.00 Lap ablat uterine fibroids NI T 0174 $8,593.40

0337T $0.00 Endothel fxnassmnt non‐invaNI S 0097 $70.18

0338T $0.00 Trnscth renal symp denrv unl NI S 0279 $2,576.44

0339T $0.00 Trnscth renal symp denrv bil NI S 0279 $2,576.44

0340T $0.00 Ablate pulm tumors + extnsn NI T 0423 $4,106.19

0342T $0.00 Thxp apheresis w/hdl delip NI S 0112 $3,065.68

10030 $0.00 Guide cathet fluid drainage NI T 0006 $159.66

19081 $0.00 Bx breast 1st lesion strtctc NI T 0005 $702.08

19083 $0.00 Bx breast 1st lesion us imag NI T 0005 $702.08

19085 $0.00 Bx breast 1st lesion mr imag NI T 0005 $702.08

23333 $0.00 Remove shoulder fb deep NI T 0020 $640.91

23334 $0.00 Shoulder prosthesis removal NI T 0022 $1,736.53

37236 $0.00 Open/perq place stent 1st NI T 0229 $9,119.70

37237 $0.00 Open/perq place stent ea addNI T 0083 $4,410.41

37238 $0.00 Open/perq place stent same NI T 0229 $9,119.70

37239 $0.00 Open/perq place stent ea addNI T 0083 $4,410.41

37241 $0.00 Vasc embolize/occlude venouNI T 0082 $8,842.66

37242 $0.00 Vasc embolize/occlude arteryNI T 0082 $8,842.66

37243 $0.00 Vasc embolize/occlude organNI T 0082 $8,842.66

37244 $0.00 Vasc embolize/occlude bleedNI T 0082 $8,842.66


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Section 2: Significant 2014 Changes

• Use of new cost centers to calculate relative weights

• Collapsing E/M clinic visit codes and payment

• Packaging expansion and its implications

• 29 Comprehensive APCs

• Examining overall financial impact – complicated!

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Use of New Cost Centers to Calculate APC Relative Weights• Implemented in 2013, CMS will continue to use CCRs from the implantable device

cost center (2,936 hospitals reported the implantable device cost center)

• CMS will use new cost centers for MRI, CT, and cardiac catheterization to calculate APC relative weights for 2014

• CMS has data from the following number of hospitals:

– 1,853 hospitals for MRI (53% use direct assignment or dollar value)

– 1,956 hospitals for CT (54% use direct assignment or dollar value)

– 1,367 hospitals for cardiac catheterization

• Commenters raised significant concerns regarding CT & MRI because of inaccurate cost report allocation based on square footage

• CMS adjusted CT & MRI CCRs to exclude “square footage hospitals” applicable for 4 years to give these hospitals time to change their allocation methodology

• Significant impacts to certain APCs is depicted in Table 3 and Table 4 and shows the uptick in CT & MRI CCRs by excluding square footage hospitals

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Significant Changes to Imaging APC Payment Rates

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APC APC Description

2013 APC

Rate

Table 3 ‐ %

Change due

to CCRs as

Proposed

2014 APC

Rate

% Change ‐

adj CCR &

all other

policies

$ Change in

APC Rate

0282 Miscellaneous Computed Axial Tomography $98.87 ‐38.1% $79.56 ‐19.5% ‐$19.31

0332 Computed Tomography with Contrast $173.58 ‐34.0% $126.47 ‐27.1% ‐$47.11

8005 CT and CTA without Contrast Composite $400.28 ‐33.9% $306.30 ‐23.5% ‐$93.98

0331

Combined Abdomen and Pelvis CT without

Contrast $306.05 ‐32.9% $241.79 ‐21.0% ‐$64.26

8006 CT and CTA with Contrast Composite $682.10 ‐29.0% $548.28 ‐19.6% ‐$133.82

0334 Combined Abdomen and Pelvis CT with Contrast $482.58 ‐28.8% $390.13 ‐19.2% ‐$92.45

0283 Computed Tomography with Contrast $297.15 ‐27.0% $249.00 ‐16.2% ‐$48.15

0662 CT Angiography $339.24 ‐27.0% $291.96 ‐13.9% ‐$47.28

0333

Computed Tomography without Contrast

followed by Contrast $329.34 ‐26.4% $280.40 ‐14.9% ‐$48.94

0383 Cardiac Computed Tomographic Imaging $267.20 ‐24.8% $222.01 ‐16.9% ‐$45.19

0336

Magnetic Resonance Imaging and Magnetic

Resonance Angiography without Contrast $338.49 ‐19.3% $294.78 ‐12.9% ‐$43.71

8008 MRI and MRA with Contrast Composite $1,038.94 ‐18.9% $927.43 ‐10.7% ‐$111.51

8007 MRI and MRA without Contrast Composite $706.85 ‐18.5% $621.30 ‐12.1% ‐$85.55

0337


Resonance Angiography without Contrast $549.47 ‐18.2% $492.92 ‐10.3% ‐$56.55

0284


Resonance $454.56 ‐14.9% $426.49 ‐6.2% ‐$28.07

0080 Diagnostic Cardiac Catheterization $2,649.52 ‐8.7% $2,586.98 ‐2.4% ‐$62.54

Significant Changes to Imaging APC Payment Rates (cont.)

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APC APC Description

2013 APC

Rate

Table 3 ‐ %

Change due

to CCRs as

Proposed

2014 APC

Rate

% Change ‐

adj CCR &

all other

policies

$ Change in

APC Rate

0276 Level I Digestive Radiology $82.72 15.2% $101.84 23.1% $19.12

0378 Level II Pulmonary Imaging $336.40 15.2% $430.87 28.1% $94.47

0396 Bone Imaging $261.68 15.5% $323.94 23.8% $62.26

0390 Level I Endocrine Imaging $150.04 15.8% $183.40 22.2% $33.36

0395 GI Tract Imaging $256.76 16.2% $323.78 26.1% $67.02

0402 Level II Nervous System Imaging $458.34 16.2% $533.18 16.3% $74.84

0398 Level I Cardiac Imaging $308.99 16.3% $383.10 24.0% $74.11

0262 Plain Film of Teeth $35.88 16.9% $42.63 18.8% $6.75

0377 Level II Cardiac Imaging $679.68 17.0% $1,153.62 69.7% $473.94

0267 Level III Diagnostic and Screening Ultrasound $154.74 17.2% $190.84 23.3% $36.10

0406 Level I Tumor/Infection Imaging $300.09 17.4% $382.77 27.6% $82.68

0403 Level I Nervous System Imaging $264.09 18.9% $162.68 ‐38.4% ‐$101.41

0266 Level II Diagnostic and Screening Ultrasound $99.32 25.1% $134.57 35.5% $35.25

0265 Level I Diagnostic and Screening Ultrasound $64.57 29.9% $90.05 39.5% $25.48

8004 Ultrasound Composite $196.61 30.2% $285.58 45.3% $88.97

What Allocation Method Does Your Hospital Use?• CMS responded to commenters that hospitals should review their

cost reports and their allocation method for major moveable equipment (MME)

• Ensure the recommended methods of “direct assignment” or “dollar value” for Worksheet A, Column 2 for Capital‐Related Costs—Movable Equipment are used

• If not, request approval from your MAC 90 days in advance of making the appropriate changes

• In the final rule, CMS states, “We believe that, by adopting more refined CCRs, we are fostering more careful cost reporting”

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APC Reconfiguration of Hospital E/M Visit and ED Codes• CMS proposed to replace the current five levels of visit codes for each visit

type (i.e., Type A ED, Type B ED, & new and established clinic visits) with three HCPCS codes representing a single level of payment for each of the three visit types, respectively

• CMS ONLY finalized the collapsing of E/M codes for the clinic visit APCs

– For CY 2014, HCPCS code G0463 replaces CPT codes 99201–99205 & 99211–99215 and is assigned to APC 0634

– The payment rate for this new clinic visit APC is based on the mean costs of Level 1 through Level 5 visit codes from CY 2012 OPPS claims data and is $92.53

• CMS did NOT finalize a similar collapse of Type A and Type B ED codes; all 5 levels of existing CPT and HCPCS G‐codes should be reported for 2014, but this may change in CY 2015

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Visit TypeHCPCS

CodeAPC Payment

HCPCS Code

APC PaymentDollar Impact

% Change

99201 0604 $56.77 $92.53 $35.76 63.0%99202 0605 $73.68 $92.53 $18.85 25.6%99203 0606 $96.96 $92.53 ($4.43) (4.6%)99204 0607 $128.48 $92.53 ($35.95) (28.0%)99205 0608 $175.79 $92.53 ($83.26) (47.4%)99211 0604 $56.77 $92.53 $35.76 63.0%99212 0605 $73.68 $92.53 $18.85 25.6%99213 0605 $73.68 $92.53 $18.85 25.6%99214 0606 $96.96 $92.53 ($4.43) (4.6%)99215 0607 $128.48 $92.53 ($35.95) (28.0%)

99281 0609 $51.82 0609 $55.65 $3.83 7.4%99282 0613 $92.16 0613 $100.91 $8.75 9.5%99283 0614 $143.36 0614 $166.45 $23.09 16.1%99284 0615 $229.37 0615 $293.71 $64.34 28.1%99285 0616 $344.71 0616 $455.93 $111.22 32.3%

G0380 0626 $67.78 0626 $51.92 ($15.86) (23.4%)G0381 0627 $54.12 0627 $61.67 $7.55 14.0%G0382 0628 $89.89 0628 $91.71 $1.82 2.0%G0383 0629 $136.30 0629 $163.27 $26.97 19.8%G0384 0630 $207.31 0630 $312.43 $105.12 50.7%

CY 2013 Final for CY 2014 Potential Payment

Clinic Visit

G0463 0634

Type A ED Visit

Type B ED Visit

Payment Impact for E/M Clinic and ED Visit Codes

Implications of CMS’ APC Reconfiguration of Hospital Clinic Visits

• All visit levels will be paid at a single rate regardless of the acuity of the patients or the types of hospital/nursing services rendered.

• CMS says with a prospective payment system based on averages, payments across low vs. high acuity patients will average out

• Providers should examine their own volumes and see whether they will see a payment increase or decrease for their clinic visits

• Providers should review all status indicator “V” CPT/HCPCS codes to see whether other specific codes more appropriately describe the services being rendered compared to the single new HCPCS G‐code

• For Medicare billing, facility‐specific visit guidelines may not be needed, but other payers are likely to require CPT reporting, which means guidelines will be needed

• Providers will need to report all clinic E/M CPT codes to payers who do not recognize CMS’ single HCPCS, and map these codes in the CDM to the single new HCPCS code for Medicare patients

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CDM Description CPT Price

Medicare

HCPCS Price

New Pt Lvl 1 99201 75.00$ G0463 75.00$

New Pt Lvl 2 99202 125.00$ G0463 125.00$

New Pt Lvl 3 99203 225.00$ G0463 225.00$

New Pt Lvl 4 99204 325.00$ G0463 325.00$

New Pt Lvl 5 99205 425.00$ G0463 425.00$

Est Pt Lvl 1 99211 50.00$ G0463 50.00$

Est Pt Lvl 2 99212 100.00$ G0463 100.00$

Est Pt Lvl 3 99213 200.00$ G0463 200.00$

Est Pt Lvl 4 99214 300.00$ G0463 300.00$

Est Pt Lvl 5 99215 400.00$ G0463 400.00$

Current CMS Regulations Governing Hospital Charges and charge practices ‐CMS Program Manuals ‐ Provider Reimbursement (PUB. 15)Provider Reimbursement Manual Part I, Chapter 22 Determination of Cost of Services to BeneficiariesSection 2202.4 Definition of Charges Section 2203 Provider Charge Structure as Basis for Apportionment

“Charges refer to the regular rates established by the provider for services rendered to both beneficiaries and to other paying patients. Charges should be related consistently to the cost of the services and uniformly applied to all patients whether inpatient or outpatient.”

Sample of Likely CDM Update for New G0463

Status Indicator “V” CPT/HCPCS Codes

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Relative Weight

Payment Rate

G0463 Hospital outpt clinic visit Q3 0634 1.2732 $92.53

90945 Dialysis one evaluation V 0633 4.5113 $327.85

92002 Eye exam new patient V 0632 1.3283 $96.53

92004 Eye exam new patient V 0632 1.3283 $96.53

92012 Eye exam establish patient V 0632 1.3283 $96.53

92014 Eye exam&tx estab pt 1/>vst V 0632 1.3283 $96.53

95250 Glucose monitoring cont V 0632 1.3283 $96.53

99495 Trans care mgmt 14 day disch V 0632 1.3283 $96.53

99496 Trans care mgmt 7 day disch V 0632 1.3283 $96.53

G0101 Ca screen;pelvic/breast exam V 0631 1.0401 $75.59

G0175 Opps service,sched team conf V 0633 4.5113 $327.85

G0245 Initial foot exam pt lops V 0631 1.0401 $75.59

G0246 Followup eval of foot pt lop V 0631 1.0401 $75.59

G0248 Demonstrate use home inr mon V 0632 1.3283 $96.53

G0249 Provide inr test mater/equip V 0632 1.3283 $96.53

G0402 Initial preventive exam V 0632 1.3283 $96.53

Extended Assessment and Management (EAM) Services• CMS is replacing the two Composite APCs, APC 8002 (Level I extended

assessment and management composite) and APC 8003 (Level II extended assessment and management composite), with a SINGLE new Composite APC

• To generate the new EAM Composite APC 8009, the following criteria must be met:

– Single new HCPCS clinic visit code, a Level 4 or 5 Type A ED visit, or a Level 5 Type B ED visit must be present along with 8 or more hours of observation time

– The HCPCS code for a direct admit to observation and the CPT codes for critical care remain in place

– No SI = T procedure on the same claim

– CY 2014 payment rate for new EAM APC is $1,199 compared to existing payment rates of $440 for APC 8002 and $798 for APC 8003

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The payment rate does increase dramatically, but this is in part due to many other services no longer generating separate payment under CMS’ expanded packaging.

Expanded OPPS Packaging for CY 2014• CMS proposed to package an additional 7 different categories of

services that it believes to be “integral, ancillary, supportive, dependent, or adjunctive” to other services

• CMS modified its proposals and is finalizing 5 of the 7 categories for CY 2014 – Addendum P lists specific CPT codes

– Drugs, biologicals, and radiopharmaceuticals that function as supplies in a diagnostic test or procedure

– Drugs and biologicals that function as supplies or devices in a surgical procedure

– Certain clinical laboratory tests

– Certain procedures described by add‐on codes

– Device removal procedures

• CMS is updating its list of OPPS packaged items and services in 42 CFR 419.2(b)

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Drugs, Biologicals, & Radiopharmaceuticals That Function as Supplies in a Diagnostic Test or Procedure• Currently, contrast agents and diagnostic

radiopharmaceuticals are the only two subcategories of the broader category of drugs, biologicals, and radiopharmaceuticals that are packaged under the OPPS because they function as supplies that CMS says are integral and supportive of diagnostic tests or procedures

• CMS defines a diagnostic test or procedure as any kind of test or procedure performed to aid in the diagnosis, detection, monitoring, or evaluation of a disease or condition

– A diagnostic test or procedure includes tests or procedures performed to determine which treatment option is optimal

– A diagnostic test or procedure can have multiple purposes, but at least one purpose must be diagnostic

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Drugs, Biologicals, and Radiopharmaceuticals That Function as Supplies in a Diagnostic Test or Procedure (cont.)• CMS has identified one new class of drugs and one specific drug that fits

within the category of drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure:

– Stress agents

• Drugs used in diagnostic tests to evaluate certain aspects of cardiac function and used in performing myocardial perfusion imaging (MPI), primarily reported with CPT code 78452

• HCPCS J0151 (replaces J0152) and J2785 are assigned status indicator “N” for CY 2014

– Cysview

• Used for “cystoscopic detection of non‐muscle invasive papillary cancer of the bladder,” which is diagnostic

• Cysview is more of a drug that functions as a supply when used in a diagnostic test or procedure

• HCPCS code C9275 (Cysview) is assigned status indicator “N” for CY 2014

30

Biologicals That Function as Supplies in a Surgical Procedure• Skin substitutes are mostly used in the outpatient setting for

treatment of diabetic foot ulcers and venous leg ulcers

• Currently skin substitutes are paid as biologicals under OPPS under the ASP methodology and subject to the drug packaging threshold

• But CMS believes they fit into the packaging category of drugs and biologicals that function as supplies in a surgical procedure

• CMS states that because a skin substitute must be used to perform surgical procedures in the CPT range of 15271–15278, they function as necessary supplies for the repair procedures and should be packaged

31

Biologicals That Function as Supplies in a Surgical Procedure (cont.)• Commenters raised concerns about CMS packaging skin substitutes equally into

procedures since they have widely varying costs.

• CMS agreed and modified its proposal by creating two groups for packaging. See Table 13 & be sure to check your cost & charges for these items:

– High = weighted average cost > $32 per square cm

– Low = weighted average cost < $32 per square cm

– Liquid or powder skin substitutes that are per milliliter or per milligram will simply be packaged into the surgical procedure in which they are used

• New coding requirements. See Table 14.

– High‐cost skin substitutes to be billed using existing skin substitute application CPT codes 15271–15278

– New HCPCS C‐codes to be reported for low‐cost skin substitutes in CY 2014:

• C5271, C5272, C5273, C5274, C5275, C5276, C5277 & C5278

• Code edits will be in place checking for high‐cost skin substitutes reported with CPT codes and low cost with the new C‐codes

32

Clinical Laboratory Tests

• Clinical laboratory tests currently paid under the Clinical Laboratory Fee Schedule (CLFS) will be packaged (status indicator “N”) when the labs are ordered by the same practitioner who performs the primary service & are related and supportive to the primary service and performed on the same date of service as any other OPPS service.

• Molecular pathology tests will continue to be paid under the CLFS even when included on the 13x claim (CPT codes 81200–81333 and 81400–81408, and 81479).

• Additionally, clinical lab tests will be paid separately only when billed on a 14x claim and meet one of the two following criteria. Further instructions forthcoming.

– The lab test is the only service provided on that date of service

– The lab test is on the same date of service as the primary service but is ordered for a different purpose than the primary service by a practitioner different than the practitioner who ordered the primary service

This is a change in billing practice and in the definition of a 14x claim.33

Example of Lab Packaging (From CMS in the Final Rule)• A beneficiary has eye surgery scheduled with physician A, an

ophthalmologist, but also has an order from physician B, a cardiologist, for unrelated laboratory tests. The beneficiary goes to the hospital for the eye procedure and decides to have the laboratory tests that have been ordered by physician B for a different purpose than the eye procedure on the same date of service.

• While the laboratory test is on the same date of service as the eye procedure, the laboratory tests are ordered for a different purpose than the primary service by a practitioner different than the practitioner who ordered the eye procedure.

• In this situation, the hospital can bill Medicare for the unrelated laboratory tests on a 14x claim and receive separate payment under the CLFS, similar to when the laboratory tests are the only service performed in the hospital outpatient department on a given date of service.

34

Example of Lab Packaging (From CMS in the Final Rule) (cont.)• However, if, in this example, physician A also ordered some laboratory

tests as a part of a preoperative evaluation for the eye procedure and the beneficiary had the tests on the same date of service as the eye procedure, then the hospital would report those laboratory tests on a 13x claim along with the eye surgery.

• Payment for those preoperative laboratory tests would be packaged into the payment for the surgery, which is the primary procedure that would be paid separately.

• It will be the hospital’s responsibility to determine when to separately bill laboratory tests on the 14x claim according to this description of these limited exceptions.

• CMS will issue revised contractor instructions for billing for these laboratory tests on a 14x bill type in January 2014, and will also create claims processing edits.

35

Clinical Laboratory Tests (cont.)

• Medicare Claims Processing Manual Chapter 16 – Laboratory Services

• For all hospitals (including CAHs) except Maryland waiver hospitals, if a patient receives hospital outpatient services on the same day as a specimen collection and laboratory test, then the patient is considered to be a registered hospital outpatient and cannot be considered to be a non‐patient on that day for purposes of the specimen collection and laboratory test.

• This is the exception CMS is referencing – the specimen collection and lab test (i.e., reference test) presumably ordered by a different physician for a different purpose can be billed on a 14X bill for CLFS payment.

36

Clinical Laboratory Tests (cont.)

• If any hospital (other than a CAH or a Maryland waiver hospital) only collects or draws a specimen from the patient and the patient does not also receive hospital outpatient services on that day, the hospital may choose to register the patient as an outpatient for the specimen collection or bill for these services as non‐patient on the 14x bill type.

• In order to be paid under CLFS, the hospital must bill on a 14X bill type. After Jan. 1, 2014, if the test is billed on a 13X, it will not receive payment.

• If the “from” and “through” dates on 837i/UB04 span more than one date, lab services on any of those dates are considered packaged UNLESS ordered for a different purpose than the primary service by a practitioner different than the practitioner who ordered the primary service. CMS will likely clarify the date of service exception in upcoming instructions.

37

Certain Categories of Add‐On Codes

• CMS had proposed to unconditionally package (status indicator N) 273 add‐on codes but is only finalizing packaging of 243 as shown in Addendum P

• Examples of codes:

– Surgery range such as skin graft add‐on codes (15111 & 15131)

– Imaging codes such as x‐ray in surgery and ultrasound vascular access codes (74301 & 76937)

– Cardiology codes such as color Doppler and electrophysiology 3D (93325 & 93613)

• CMS modified its proposal and did NOT finalize packaging device‐dependent add‐on codes or drug administration add‐on codes such as additional infusion hours or additional injections based on the comments it received, but says it will review these in the future

38

Device Removal Procedure Codes

• Device removal procedures are sometimes described by a code that may include repair or replacement. Other times, device removal procedures are described by separate codes that only describe the surgical procedure to remove a device.

• Device removal procedures are frequently performed with procedures to repair or replace devices, but not always.

• As a result, for CY 2014 CMS will package all separately coded device removal procedures when performed with a separately coded device repair or replacement procedure.

• There are 68 device removal procedure codes being conditionally packaged (status indicator “Q2”) and they are listed in Addendum P.

• Remember, status indicator “Q2” means no separate payment is made when the CPT code occurs on the same date of service as another procedure code with status indicator “T”.

39

Clarification of Why Supplies Are Being Packaged• CMS says that supplies are a large category of items typically either

for single patient use or with a shorter life than equipment

• Packaged supplies can include certain drugs, biologicals, and radiopharmaceuticals

• As part of its annual review of OPPS for CY 2014, CMS found that it was paying for many supplies separately that should be packaged

• Take‐home surgical dressings will no longer receive separate payment when billed by an outpatient hospital

• The only supplies that are sometimes paid separately via the DMEPOS are prosthetic supplies

• For CY 2014, CMS has finalized revising the status indicator for all supplies described by HCPCS A‐codes (except for prosthetic supplies) from status indicator “A” to “N”

40

Service Areas Not Finalized for CY 2014 Packaging• CMS did not finalize conditional packaging (status indicator of Q1) for 425

ancillary codes due to concerns raised by commenters

– The following codes WILL continue to be separately payable in CY 2014:

• Surgery range such as remove nasal foreign body code (30300)

• Numerous imaging codes such as chest x‐rays (71021–71035)

• Radiation oncology codes such as radiation therapy dose plan (77300)

• Blood bank codes such as fresh frozen plasma (96927)

• Pathology codes such as tissue exam by pathologists (88302–88309)

• Respiratory & pulmonary codes such as pulmonary stress tests (94620 & 94621)

• CMS also did not finalize the packaging of diagnostic tests for CY 2014, but plans to continue studying these services for future packaging

Exception: CMS DID finalize conditional packaging of CPT 93107 Stress Test41

Looking Ahead … Expect More Packaging • CMS says the packaging finalized here is not “exhaustive” and that it will continue analyzing other services

• It is likely that for CY 2015, we’ll see more packaging proposals possibly for the areas that CMS did not finalize for CY 2014 including the packaging of imaging services with associated surgical procedures in CY 2015

• Comprehensive APCs coming in 2015

• Beyond 2015 … even more bundles, packaging, and comprehensive style APCs

42

Comprehensive APCs

• CMS proposed to create 29 comprehensive APCs from the 39 existing device‐dependent APCs. CMS chose this first “set” of comprehensive APCs based on the most costly device‐dependent services.

– 29 Comprehensive APCs calculated using 136 HCPCS codes from 2012 data and a new status indicator “J1” was created for these APCs

– A single APC payment would be based on costs of all individually reported services on the claim that would be categorically assumed to be adjunctive and supportive of the primary service by virtue of being on the same claim (Line item date of service would not apply for claims spanning dates)

– In the proposed rule, CMS did not address how claims with more than one of the 136 HCPCS (i.e., multiple J1 HCPCS) would be treated or which HCPCS would be defined as the primary service

– CMS finalized its plan to move forward with 29 comprehensive APCs, but will delay implementation until 2015 and will make modifications

43

Comprehensive APCs (cont.)

• CMS listened to comments and made several policy changes and specifically will address how to pay for cases with multiple J1 HCPCS codes to address commenters’ concerns about more complex cases.

• For the comprehensive APCs in CY 2015, expanded packaging will include all services in support of the primary procedure – all supplies, lab, DMEPOS, diagnostic tests, drugs and therapy services are also packaged. CMS acknowledged that for outpatient claims, room & board is included in ancillary charges, so these revenue codes are not applicable.

• PT, OT & SLP therapies provided during an encounter for one of these primary procedures is not the same as outpatient therapy ordered as part of a continuing care plan, and therefore, it is categorically defined as adjunctive and supportive and will be packaged. Functional status codes and modifiers will not be required for these adjunctive therapy services billed on comprehensive APC claims; more instructions forthcoming.

44

45

Estimating Financial Impact

• Not as simple as past years

• Code level comparisons are only one view of impact but they are NOT sufficient to provide the entire picture of payment impact given CMS’ final policy changes for CY 2014

• All CPT codes flagged with comment indicator “CH” in Addendum B should be reviewed to get a sense of the magnitude of the changes

– Look at the 2013 payments received for a sample of claims by department/service line from the first six months of this year and compare these payments to what the 2014 payments would be by using the final payment rates for 2014 AND the new status indicators and packaging logic. NOTE: All of the line items that generate payment today WILL NOT in 2014.

Although the OPPS system is budget neutral, the impact of CMS’ policies on your organization is dependent on your mix of services, coding, charging, and billing practices, and on the combination of services provided on a given date

of service.

46

Examples of Status Indicator “S or T” Procedures With Payment Increases for CY 2014



Payment Rate


% Chg in Pmt Rte

27267 Cltx thigh fx T 0129 $133.65 Cltx thigh fx CH T 0431 $1,252.15 $1,118.50 836.9%

28435 Treatment of ankle fracture T 0129 $133.65 Treatment of ankle fracture CH T 0431 $1,252.15 $1,118.50 836.9%

0308T Insj ocular telescope prosth T 0234 $1,676.62 Insj ocular telescope prosth CH T 0351 $15,551.23 $13,874.61 827.5%

15155 Cult skin graft f/n/hf/g T 0134 $251.48 Cult skin graft f/n/hf/g CH T 0329 $2,260.46 $2,008.98 798.9%

93724 Analyze pacemaker system S 0690 $33.95 Analyze pacemaker system CH S 0691 $275.88 $241.93 712.6%

93745 Set‐up cardiovert‐defibrill S 0690 $33.95 Set‐up cardiovert‐defibrill CH S 0691 $275.88 $241.93 712.6%

15110 Epidrm autogrft trnk/arm/leg T 0135 $393.38 Epidrm autogrft trnk/arm/leg CH T 0329 $2,260.46 $1,867.08 474.6%

15273 Skin sub grft t/arm/lg child T 0135 $393.38 Skin sub grft t/arm/lg child CH T 0329 $2,260.46 $1,867.08 474.6%

15150 Cult skin grft t/arm/leg T 0134 $251.48 Cult skin grft t/arm/leg CH T 0328 $1,371.19 $1,119.71 445.2%

15271 Skin sub graft trnk/arm/leg T 0134 $251.48 Skin sub graft trnk/arm/leg CH T 0328 $1,371.19 $1,119.71 445.2%

15275 Skin sub graft face/nk/hf/g T 0134 $251.48 Skin sub graft face/nk/hf/g CH T 0328 $1,371.19 $1,119.71 445.2%

96373 Ther/proph/diag inj ia S 0437 $39.13 Ther/proph/diag inj ia CH S 0438 $105.90 $66.77 170.6%

96374 Ther/proph/diag inj iv push S 0437 $39.13 Ther/proph/diag inj iv push CH S 0438 $105.90 $66.77 170.6%

96401 Chemo anti‐neopl sq/im S 0437 $39.13 Chemo anti‐neopl sq/im CH S 0438 $105.90 $66.77 170.6%

11719 Trim nail(s) any number T 0012 $28.40 Trim nail(s) any number T 0012 $60.83 $32.43 114.2%

11740 Drain blood from under nail T 0012 $28.40 Drain blood from under nail T 0012 $60.83 $32.43 114.2%

17999 Skin tissue procedure T 0012 $28.40 Skin tissue procedure T 0012 $60.83 $32.43 114.2%

96999 Dermatological procedure T 0012 $28.40 Dermatological procedure T 0012 $60.83 $32.43 114.2%

G0127 Trim nail(s) T 0012 $28.40 Trim nail(s) T 0012 $60.83 $32.43 114.2%

43453 Dilate esophagus T 0140 $483.05 Dilate esophagus CH T 0419 $1,013.05 $530.00 109.7%

55175 Revision of scrotum T 0183 $1,696.84 Revision of scrotum CH T 0205 $3,553.44 $1,856.60 109.4%

76506 Echo exam of head S 0265 $64.57 Echo exam of head CH S 0266 $134.57 $70.00 108.4%

76529 Echo exam of eye S 0265 $64.57 Echo exam of eye CH S 0266 $134.57 $70.00 108.4%


Examples of Status Indicator “S or T” Procedures With Payment Increases for CY 2014



Payment Rate


% Chg in Pmt Rte

26775 Treat finger dislocation T 0045 $1,039.07 Treat finger dislocation CH S 0426 $138.31 ($900.76) (86.7%)

20910 Remove cartilage for graft T 0137 $1,510.07 Remove cartilage for graft CH T 0327 $409.41 ($1,100.66) (72.9%)

27194 Treat pelvic ring fracture T 0045 $1,039.07 Treat pelvic ring fracture CH T 0139 $448.92 ($590.15) (56.8%)

27252 Treat hip dislocation T 0045 $1,039.07 Treat hip dislocation CH T 0139 $448.92 ($590.15) (56.8%)

24535 Treat humerus fracture T 0138 $398.86 Treat humerus fracture T 0138 $173.46 ($225.40) (56.5%)

24655 Treat radius fracture T 0138 $398.86 Treat radius fracture T 0138 $173.46 ($225.40) (56.5%)

25520 Treat fracture of radius T 0138 $398.86 Treat fracture of radius T 0138 $173.46 ($225.40) (56.5%)

25565 Treat fracture radius & ulna T 0138 $398.86 Treat fracture radius & ulna T 0138 $173.46 ($225.40) (56.5%)

26340 Manipulate finger w/anesth T 0138 $398.86 Manipulate finger w/anesth T 0138 $173.46 ($225.40) (56.5%)

77371 Srs multisource S 0127 $7,910.51 Srs multisource CH S 0067 $3,591.65 ($4,318.86) (54.6%)

21315 Closed tx nose fx w/o stablj T 0253 $1,147.39 Closed tx nose fx w/o stablj CH T 0252 $545.14 ($602.25) (52.5%)

27781 Treatment of fibula fracture T 0139 $835.41 Treatment of fibula fracture T 0139 $448.92 ($386.49) (46.3%)

27831 Treat lower leg dislocation T 0139 $835.41 Treat lower leg dislocation T 0139 $448.92 ($386.49) (46.3%)

28405 Treatment of heel fracture T 0139 $835.41 Treatment of heel fracture T 0139 $448.92 ($386.49) (46.3%)

93270 Remote 30 day ecg rev/report S 0097 $66.52 Remote 30 day ecg rev/report CH S 0690 $36.15 ($30.37) (45.7%)

95782 Polysom <6 yrs 4/> paramtrs S 0209 $806.13 Polysom <6 yrs 4/> paramtrs S 0209 $440.12 ($366.01) (45.4%)

95783 Polysom <6 yrs cpap/bilvl S 0209 $806.13 Polysom <6 yrs cpap/bilvl S 0209 $440.12 ($366.01) (45.4%)

95807 Sleep study attended S 0209 $806.13 Sleep study attended S 0209 $440.12 ($366.01) (45.4%)

95950 Ambulatory eeg monitoring S 0209 $806.13 Ambulatory eeg monitoring S 0209 $440.12 ($366.01) (45.4%)

95953 EEG monitoring/computer S 0209 $806.13 Eeg monitoring/computer S 0209 $440.12 ($366.01) (45.4%)

95956 Eeg monitor technol attended S 0209 $806.13 Eeg monitor technol attended S 0209 $440.12 ($366.01) (45.4%)


Estimating Financial Impact for E/M Clinic Visits• Step 1: Determine clinic visit volume by each level for a department

and pull all other CPT transactions on those claims

• Step 2: Create a pivot table with the volumes and percentage of codes appearing with each E/M level claim

• Step 3: Perform a department financial impact analysis as shown in the next slide using 2013 and 2014 status indicators and payment rates

• Alternatively, you could pull a sample of claims and hand price them using 2013 payment rates and rules and 2014 payment rate and rules

– Use the October 2013 and the January 2014 Addenda B to assign status indicators, APCs, and payment rates to each code

– Price out each line item on the claim and then total to see the impact

49

Estimating Financial Impact for E/M Clinic Visits (cont.)

50

Visit HCPCS

Medicare

FFS Volume

% of Clinic

claims 2013 Pmt Est 2013 Pmt 2014 Pmt Est 2014 Pmt

99213 15,000 100% 73.68$ 1,105,200.00$ 92.53$ 1,387,950.00$

36415 12,000 80% 3.00$ 36,000.00$ ‐$ ‐$

80053 9,000 60% 14.53$ 130,770.00$ ‐$ ‐$

80051 7,500 50% 9.64$ 72,300.00$ ‐$ ‐$

80061 6,500 43% 18.42$ 119,730.00$ ‐$ ‐$

82952 5,000 33% 5.39$ 26,950.00$ ‐$ ‐$

36600 300 2% 23.43$ 7,029.00$ 98.25 29,475.00$

82810 200 1% 12.00$ 2,400.00$ ‐$ ‐$

1,500,379.00$ 1,417,425.00$

(82,954.00)$ Difference

Total Estimated Impact

Looking at Financial Impact for Clinic Claims

51

HCPCS Rev Code Description SI APC Pmt

99213‐25 0510 Lvl 3 Est Pt Clinic Visit V 73.68$

94621 0460 Pulm stress test/complex X 179.86$

80053 0300 Comprehen metabolic panel A 14.53$

82810 0300 Blood gases o2 sat only A 12.00$

36600 0300 Withdrawal of arterial blood Q3* 23.43$

Total 303.50$

HCPCS Rev Code Description SI APC Pmt

G0463 0510 Hospital outpt clinic visit Q3 92.53$

94621 0460 Pulm stress test/complex X 243.71$

80053 0300 N

82810 0300 N

36600 0300 Withdrawal of arterial blood Q3* 98.25

Total 434.49$

Difference 130.99$

36600 part of critical care & trauma composite APCs

Example of Pulmonologist Clinic Visit Claim ‐ 2013 Codes & APC Rates

Example of Pulmonologist Clinic Visit Claim ‐ 2014 Codes & APC Rates

36600 part of critical care & trauma composite APCs

Example of Financial Impact for Skin Substitutes and Add‐On Codes

52

HCPCS

Code

Short Descriptor SI APC Units APC

Payment

Rate

2013

Total

Payment

HCPCS

Code

SI APC Units APC

Payment

Rate

2014 Total

Payment

99284‐25 Emergency dept visit Q3 0615 1 $229 $229 GXXXA V 635 1 $294 $294

15271 Skin sub graft trnk/arm/leg T 0134 1 $251 $251 15271 T 0135 1 $1,371 $1,371

15272 Skin sub graft t/a/l add‐on T 0133 1 $43 $43 15272 N 1 $0 $0

Q4102 Oasis wound matrix K 1241 1 $8 $8 Q4102 N 1 $0 $0

A6242 Hydrogel drg <=16 in w/o bdr A 1 $6 $6 A6242 N 1 $0 $0

A6441 Pad band w>=3" <5"/yd A 1 $1 $1 A6441 N 1 $0 $0

Total $538 $1,665 $1,127

HCPCS

Code

Short Descriptor SI APC Units APC

Payment

Rate

2013

Total

Payment

HCPCS

Code

SI APC Units APC

Payment

Rate

2014 Total

Payment

99284‐25 Emergency dept visit Q3 0615 1 $229 $229 GXXXA V 635 1 $294 $294

15260 Skin full graft een & lips T 0136 1 $1,112 $1,112 15260 T 0136 1 $1,371 $1,371

15261 Skin full graft add‐on T 0136 1 $556 $556 15261 N 1 $0 $0

Q4102 Oasis wound matrix K 1241 1 $8 $8 Q4102 N 1 $0 $0

A6242 Hydrogel drg <=16 in w/o bdr A 1 $6 $6 A6242 N 1 $0 $0

A6441 Pad band w>=3" <5"/yd A 1 $1 $1 A6441 N 1 $0 $0

Total $1,911 $1,665 ($246)

2013 Addendum B 2014 Addendum BTotal

Claim

Impact

2013 Addendum B 2014 Addendum BTotal

Claim

Impact

Example of Packaging Impact for Nuclear Medicine• Stress Agents HCPCS codes J0151 (replacing J0152) and

J2785 are finalized to be unconditionally packaged. CMS is treating these agents as functioning as supplies, therefore packaged into the primary procedure.

• CPT code 93017 (Cardiovascular stress test …) finalized for conditional packaging since it is often performed as a part of myocardial perfusion imaging (MPI). CMS believes that, because stress testing is both integral and ancillary to MPI, it should be packaged into MPI when a stress test accompanies MPI.

53

A Reminder About Charging

HCPCS Rev Code Description Price* 2009 APC Rate

78478TC 0341 MPI Wall Motion 300$ Pkgd

78480TC 0341 MPI Ejection Fraction 200$ Pkgd

78465TC 0341 MPI SPECT, Multiple 1,500$ 774.13$

HCPCS Rev Code Description Price* 2012 APC Rate

78452TC 0341 MPI SPECT, Multiple w/WM&EF 1,500$ 673.13$

HCPCS Rev Code Description Price* 2014 APC Rate*

78452TC 0341 MPI SPECT, Multiple w/WM&EF 2,000$ 1,153.62$

MPI Coding Prior to CY 2010

MPI Coding Beginning CY 2010 ‐ Illustrating Pricing Problem

MPI Coding Beginning CY 2010 ‐ Illustrating Correct Pricing Strategy

* CY 2014 APC also packages Stress Agents and Excercise Stress test 93017, so it is extremely

important to continue charging the J code for the stress agent & 93017 when also performed!

54

Looking at Financial Impact for Extended Assessment and Management Claims

55

Simple Direct Admit Observation Case HCPCS Dates Units 2013 SI 2013 Pmt 2014 SI 2014 Pmt DifferenceDirect Admit G0379 1/1/2014 1 Q3 EAM Q3 EAMObservation Hours G0378 1/1/2014 23 N EAM N EAMIV Push Initial 96374 1/1/2014 1 S $39.13 S $105.90IV Push Add'l New Drug 96375 1/1/2014 1 S $39.13 S $43.78IV Push Add'l Same Drug 96376 1/2/2014 2 N $0.00 N $0.00CT Lumbar Spine w/dye 72132 1/1/2014 1 Q3 $297.15 Q3 $249.00

EAM Composite V $440.07 V $1,198.91Total $815.48 $1,597.59 $782.11

Complex Direct Admit Observation Case HCPCS Dates Units 2013 SI 2013 Pmt 2014 SI 2014 Pmt DifferenceDirect Admit G0379 1/1/2014 1 Q3 EAM Q3 EAMObservation Hours G0378 1/1/2014 23 N EAM N EAMEKG 93005 1/1/2014 1 S $26.67 S $27.12Nebulizer tx 94640 1/1/2014 1 S $35.09 S $78.19Pulmonary Stress Test 94621 1/2/2014 1 X $179.86 Q1 $243.71Chest X-ray 72020 1/1/2014 1 X $45.95 X $57.35IV Infusion Initial 96365 1/1/2014 1 S $146.24 S $172.18IV Infusion Subsequent 96367 1/2/2014 1 S $39.13 S $43.78Hydration 96361 1/1/2014 4 S $108.04 S $118.00Hydration 96361 1/2/2014 8 S $216.08 S $236.00

EAM Composite V $440.07 V $1,198.91Total $1,237.13 $2,175.24 $938.11

Section 3: Other Key Items From the Rule and Medicare Physician Fee Schedule Updates

• Physician supervision and the Inpatient‐only list

• Drugs, radiopharmaceuticals, and blood & blood products

• Drug administration

• Stereotactic radiosurgery

• Device‐related procedure APCs and the FB/FC modifier

• Partial hospitalization

• Hospital Outpatient Quality Reporting Initiative

• Off‐Campus Provider‐Based Clinics

• Condition of Payment for Outpatient Therapeutic Services

• ASC Updates

• Physician Fee Schedule Changes56

Physician Supervision and the Inpatient‐Only List• Physician supervision

– All rules remain in effect

– CMS to begin enforcing physician supervision requirements for CAHs and rural hospitals starting January 1, 2014

• Inpatient‐Only List (status indicator C)

– The list continues, which means Medicare will only provide payment for services on the list when provided in the inpatient setting due to the nature of the procedure and the need for postoperative recovery time/monitoring

• New 2‐midnight benchmark for assuming medical necessity of inpatient status will not be required for stays where an inpatient‐only procedure is performed. Caution: cancelled inpatient‐only procedures!!

57

The Inpatient‐Only List (cont.)

• Inpatient‐Only List (status indicator C)

– CMS reviews the list annually and typically identifies codes to remove

• For CY 2014, CMS didn’t propose removal of any procedures

• Instead, CMS added the codes in the table below to the Inpatient‐Only list

58

Updates for Payment of Drugs, Biologicals, Radiopharmaceuticals, and Blood and Blood Products• Packaged drugs (status indicator N)

– CMS raised the drug packaging threshold from $80 to $90

– All 5HT3 antiemetics continue to be packaged, with the exception of palonosetron hydrochloride

– Contrast agents and diagnostic radiopharmaceuticals remain packaged

• Separately payable drugs (status indicator K)

– Separate payment for drugs with a mean daily cost > $90

– 2014 payment level continues at ASP + 6%

• Pass‐through drugs (status indicator G)

– 2014 payment level continues at ASP + 6%

– 14 drugs, biologicals, and/or radiopharmaceuticals lose pass‐through status and either become separately payable or packaged; 26 retain pass‐through status and continue to be assigned status indicator G

59

Status Indicator “K” Drugs No Longer Separately Payable in CY 2014

60



Payment Rate


% Chg in Pmt Rate

C9248 Inj, clevidipine butyrate K 9248 $2.82 Inj, clevidipine butyrate CH N $0.00 ($2.82) (100.0%)

C9358 SurgiMend, fetal K 9358 $12.43 Surgimend, fetal CH N $0.00 ($12.43) (100.0%)

C9360 SurgiMend, neonatal K 9360 $12.10 Surgimend, neonatal CH N $0.00 ($12.10) (100.0%)

C9363 Integra Meshed Bil WoundK 9363 $29.83 Integra meshed bil wound maCH N $0.00 ($29.83) (100.0%)

J0210 Methyldopate hcl injectionK 2210 $42.40 Methyldopate hcl injection CH N $0.00 ($42.40) (100.0%)

J0288 Ampho b cholesteryl sulfa K 0735 $14.00 Ampho b cholesteryl sulfate CH N $0.00 ($14.00) (100.0%)

J0348 Anidulafungin injection K 1349 $0.85 Anidulafungin injection CH N $0.00 ($0.85) (100.0%)

J0900 Testosterone enanthate inK 1434 $33.36 Testosterone enanthate inj CH N $0.00 ($33.36) (100.0%)

J1212 Dimethyl sulfoxide 50% 50K 1221 $79.32 Dimethyl sulfoxide 50% 50 mlCH N $0.00 ($79.32) (100.0%)

J1452 Intraocular Fomivirsen na K 1441 $85.00 Intraocular fomivirsen na CH N $0.00 ($85.00) (100.0%)

J1590 Gatifloxacin injection K 1437 $86.33 Gatifloxacin injection CH N $0.00 ($86.33) (100.0%)

J2265 Minocycline hydrochlorideK 1423 $0.58 Minocycline hydrochloride CH N $0.00 ($0.58) (100.0%)

J2700 Oxacillin sodium injeciton K 1347 $2.19 Oxacillin sodium injeciton CH N $0.00 ($2.19) (100.0%)

J2785 Regadenoson injection K 9244 $53.43 Regadenoson injection CH N $0.00 ($53.43) (100.0%)

J2788 Rho d immune globulin 50 K 9023 $17.48 Rho d immune globulin 50 mcCH N $0.00 ($17.48) (100.0%)

J2790 Rho d immune globulin injK 0884 $82.69 Rho d immune globulin inj CH N $0.00 ($82.69) (100.0%)

J2941 Somatropin injection K 7034 $69.13 Somatropin injection CH N $0.00 ($69.13) (100.0%)

J7178 Human fibrinogen conc inj K 1414 $0.93 Human fibrinogen conc inj CH N $0.00 ($0.93) (100.0%)

J7527 Oral everolimus K 1444 $6.48 Oral everolimus CH N $0.00 ($6.48) (100.0%)

J8510 Oral busulfan K 1307 $11.03 Oral busulfan CH N $0.00 ($11.03) (100.0%)

J8562 Oral fludarabine phosphatK 1339 $81.77 Oral fludarabine phosphate CH N $0.00 ($81.77) (100.0%)

J9178 Inj, epirubicin hcl, 2 mg K 1167 $1.18 Inj, epirubicin hcl, 2 mg CH N $0.00 ($1.18) (100.0%)

J9201 Gemcitabine hcl injection K 0828 $7.96 Gemcitabine hcl injection CH N $0.00 ($7.96) (100.0%)

J9212 Interferon alfacon‐1 inj K 1447 $17.06 Interferon alfacon‐1 inj CH N $0.00 ($17.06) (100.0%)


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Payment Rate

Short Descriptor CI SI APC

Payment Rate


90704 Mumps vaccine sc N $0.00 Mumps vaCH K 1454 $162.34 $162.34

J1455 Foscarnet sodium injection N $0.00 Foscarnet CH K 1455 $28.98 $28.98

J2515 Pentobarbital sodium inj N $0.00 PentobarbCH K 1456 $32.27 $32.27

J2760 Phentolaine mesylate inj N $0.00 Phentolai CH K 1458 $119.61 $119.61

J3350 Urea injection N $0.00 Urea injecCH K 1459 $122.40 $122.40

J7191 Factor VIII (porcine) N $0.00 Factor viii CH K 1464 $0.20 $0.20

J9213 Interferon alfa‐2a inj N $0.00 InterferonCH K 1460 $53.66 $53.66

J9215 Interferon alfa‐n3 inj N $0.00 InterferonCH K 1473 $31.80 $31.80


There are far MORE CPT/HCPCS codes that generate separate payment today that will NOT in CY 2014 as a result of CMS’ new packaging policies.

Examples of Packaged Services in 2013 That Will Be Separately Payable in CY 2014

Drugs Losing Pass‐Through Status

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Updates for Payment of Drugs, Biologicals, Radiopharmaceuticals, and Blood and Blood Products (cont.)• Therapeutic radiopharmaceuticals (status indicator K)

– APC rates based on manufacturer‐submitted data or CMS’ usual rate‐setting method

– 2014 payments still based on ASP + 6% but rates move up and down

– CMS finalized removal of nuclear medicine procedure‐to‐radiolabeled product edits; hospitals still expected to report all codes/services provided

• Brachytherapy sources

– CMS continues to compute payment rates based on claims data and the usual rate‐setting process

– Some payment rate fluctuations exist

• Blood and blood products

– CMS continues to apply its long‐standing special cost‐to‐charge calculation methodology, including when blood products are contained within Comprehensive APCs

– APC payment rates fluctuate for the blood and products

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Pass‐Through Devices, New Value Code FD for Device Credits and Device‐Related Edits

• The following 3 devices will lose pass‐through status as of Jan. 1, 2014:

– C1830 (Powered bone marrow biopsy needle)

– C1840 (Lens, intraocular [telescopic])

– C1886 (Catheter, extravascular tissue ablation, any modality [insertable])

• No devices to receive pass‐through payment for CY 2014.

• CMS is eliminating hospital reporting of modifiers FB/FC when a device is received at no charge/full credit or if a device is replaced with at least 50% partial credit from the manufacturer. Instead, hospitals are to report the amount of the credit with new value code “FD” (Credit Received from the Manufacturer for a Replaced Medical Device).

• At least for 2014, CMS will retain device‐to‐procedure edits, but is eliminating radiopharmaceutical‐to‐nuclear medicine procedure edits since the agency no longer believes they are necessary. Providers are duly warned to continue reporting as if the edits were in place.

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2014 Drug Administration

• No coding or billing changes for CY 2014 – this makes 5 years in a row!!!

– Providers should continue to follow CPT coding guidelines and instructions for drug administration services

• Financial impact

– Review payment impact at the CPT code/service level and APC reconfiguration changes; some codes have greater payment impact than others

– Still no separate APC payment for multiple IV push injections of the same substance/drug or concurrent infusions

65

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Stereotactic Radiosurgery (SRS)

• Since 2007, codes G0173, G0251, G0339, G0340, and 77371 have been in place under OPPS to describe SRS treatment delivery

• For CY 2014 CMS finalized its proposal to eliminate the distinction between robotic and non‐robotic SRS procedures and to replace G0173 with CPT 77372 and to replace G0251, G0339, and G0340 with 77373

• CMS also reassigned some codes to different APCs and released coding guidance for 77371, 77372, and 77373

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Short Descriptor SI APCPayment

Rate Short Descriptor CI SI APC

G0173 Linear acc stereo radsur com S 0067 $3,300.64 Linear acc stereo radsur com CH B $0.00

G0251 Linear acc based stero radio S 0065 $978.25 Linear acc based stero radio CH B $0.00

G0339 Robot lin‐radsurg com, first S 0067 $3,300.64 Robot lin‐radsurg com, first CH B $0.00

G0340 Robt lin‐radsurg fractx 2‐5 S 0066 $2,354.79 Robt lin‐radsurg fractx 2‐5 CH B $0.00

77371 Srs multisource S 0127 $7,910.51 Srs multisource CH S 0067 $3,591.65

77372 Srs linear based B $0.00 Srs linear based CH S 0067 $3,591.65

77373 Sbrt delivery B $0.00 Sbrt delivery CH S 0066 $1,921.30

Payment Rate

HCPCS Code

2014 JanuaryOctober 2013

Partial Hospitalization Program (PHP)

• No changes for CY 2014 – Continuation of the current two‐tier payment structure for the payment of PHP services; two APCs for hospital‐based PHPs and two for community mental health centers (CMHC)

• CMS asked for comments on a variety of topics to restructure the payment of PHP services and received a wide range of comments and says it will take them under advisement

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APC Group Title SI

2013 Paymet

Rate

2014 Payment

Rate$ Chg in Pmt Rte

% Chg in Pmt Rte

0172

Level I Partial Hospitalization (3 services)

for CMHCs P $84.96 $99.04 $14.08 16.6%

0173

Level II Partial Hospitalization (4 or more

services) for CMHCs P $109.67 $111.73 $2.06 1.9%

0175

Level I Partial Hospitalization (3 services)

for Hospital‐based PHPs P $180.71 $190.15 $9.44 5.2%

0176

Level II Partial Hospitalization (4 or more

services) for Hospital‐based PHPs P $228.26 $213.64 ($14.62) (6.4%)

Hospital Quality Data Initiative

• CY2014 & 2015 Payment Determination [collection in 2013 & 2014]

– 24 measures after CMS finalized removal of the following two measures:

• OP‐19 for ED transition discharge record

• OP‐24 Cardiac Rehab referral from outpatient settings

• CY2016 [data collection in 2015] – 4 additional measures finalized for a total of 28

1. Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431) – detailed instructions attributing staff to inpatient versus outpatient settings forthcoming

2. Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures (NQF #0564) Not finalized based on comments

3. *Endoscopy/Poly Surveillance: Appropriate follow‐up interval for normal colonoscopy in average risk patients (NQF #0658)

4. *Endoscopy/Poly surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use (NQF #0659)

5. *Cataracts: Improvement in Patient’s Visional Function within 90 Days Following Cataract Surgery (NQF #1536)

*Chart abstraction measures also being applied to ASCs & PQRS

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Hospital Quality Data Initiative (cont.)• In response to comments, CMS clarified that Part B

outpatient claims are considered for the HOQRP, including those claims for services in the 3‐day payment window split from Part B Inpatient‐Only claims submitted for medical necessity cases

• CMS has published a crosswalk of HOQRP measures from ICD‐9 to ICD‐10 codes available at: http://www.cms.gov/Medicare/Quality‐Initiatives‐Patient‐Assessment‐Instruments/HospitalQualityInits/HospitalOutpatientQualityReportingProgram.html

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New Medicare Condition of Payment for Outpatient Therapeutic Services • CMS finalized its revisions to the Medicare Conditions of

Participation (CoP) for outpatient therapeutic services in hospitals or CAHs that are furnished “incident to” a physician’s or NPP’s services to require that individuals furnishing these services do so in compliance with applicable state law

• Several cases have commanded CMS’ attention where Medicare was billed for “incident to” services that were performed by an individual who did not meet state standards for furnishing those services (e.g., scope or licensure or certification)

• Current Medicare requirements for hospital outpatient therapeutic services do not specifically make compliance with state law a condition of payment for services; the Medicare program has had limited recourse to recoup payments when hospital outpatient therapeutic “incident‐to” services are not furnished in compliance with state law

71

Off‐Campus Provider‐Based Departments• CMS is interested in studying the impact of the increasing trend of

hospitals acquiring physician practices and converting those practices into hospital outpatient departments on Medicare program payments and beneficiary costs

• In the proposed rule, CMS suggested several methods to collect data so it can analyze the frequency, type, and payment for services furnished in off‐campus provider‐based hospital departments

• CMS requested comments on the following and other types of methods:

– New location/service code for all off‐campus‐based departments

– Use of a new modifier on all services provided in off‐campus‐based departments

– New cost centers for off‐campus departments

• CMS received numerous comments and in the CY 2014 OPPS Final Rule indicated that it would continue to study the best way to collect this data – nothing finalized for CY 2014!

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ASC Updates

• Two conversion factors also in place; one for those meeting the quality reporting requirements and another for those who fail. Hospitals that fail to meet quality reporting requirements face a 2% decrease in payment.

– Final conversion factor for 2014 for those who meet quality reporting requirements – $43.321

– Final conversion factor for 2014 for those who fail to meet quality reporting requirements – $42.917

• Based on comments, CMS is adding 4 procedures to the list of ASC covered surgical procedures for CY 2014 = 27415, 27524, 60240 & 60500

• 3 procedures proposed to be added to the list of office‐based procedures & one temporary office‐based procedure is proposed to be moved to the list of regular covered ASC procedures

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ASC Updates (cont.)

• ASCs would continue to use modifiers FB & FC for device credits because they bill on 837p claims where there is no mechanism to report the actual amount of the credit

• CMS is proposing to apply the new expanded packaging categories to ASCs, including lab tests, with the exception of device removal procedures, which will continue separate payment

• Newly proposed ASC QRP measures for 2016 payment year [2015 data reporting] equate to the same measures proposed for hospital OQP

74

Physician Fee Schedule Updates

• Total payments under the PFS are projected as $87 billion, up from $80 billion in 2012. Mental health providers, such as psychiatrists (+6%), clinical psychologists (+8%), and clinical social workers (+8%), will receive some of the biggest increases in payment rates.

• CMS finalized its plan “to pay for non‐face‐to‐face complex chronic care management services for Medicare beneficiaries who have multiple, significant chronic conditions (two or more) . . .” These additional payments to physicians for managing Medicare patients’ chronic care needs will begin in CY 2015. Note: CMS did not discuss these services in OPPS and whether there will be corresponding APCs.

• Per ATRA, CMS will apply the “per beneficiary limits to outpatient therapy services” to outpatient therapy services furnished in CAHs.

• CMS finalized, with modification and deferred to 2015, a centralized review process for IDE clinical studies and other associated coverage policies.

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Physician Fee Schedule Updates (cont.)• CMS will modify its definition of eligible telehealth originating sites

to include HPSA located in rural census tracts of urban areas as determined by the ORHP. This change is intended to improve access to telehealth services in shortage areas. In addition, geographic eligibility will be made annually.

• CMS finalized its definition of technological changes as changes to the tools, machines, supplies, labor, instruments, skills, techniques, and devices by which laboratory tests are produced and used. CMS will review certain codes on the CLFS each year to determine which codes should be proposed during the rulemaking cycle for a payment adjustment due to technological changes.

• CMS did NOT finalize its proposal to cap PE RVUs at OPPS/ASC rates for about 300 procedures furnished in a non‐facility setting. CMS said it “will take additional time to consider issues raised by the public commenters and plans to address this issue in future rulemaking.”

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Summary

• Share this material with others in your organization

• Identify departments likely to face greatest impact

• Review billing processes for outpatient laboratory tests

• Compute financial impact VERY carefully as line item comparisons will be INSUFFICIENT … and misleading given CMS’ E/M clinic visit and packaging policy changes

• Think about operational implications and potential unintended consequences for 2014 and beyond

• Consider and monitor the types of implications CMS’ proposals will have on other payers

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This information is also listed in the instruction email where you found the dial‐in information for the program.

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For instructions on how to claim your credits, please visit the materials download page at

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