december 2010 jean c. russell, ms, rhit, circc [email protected]@epochhealth.com...
TRANSCRIPT
December 2010
Jean C. Russell, MS, RHIT, CIRCC [email protected]
Richard Cooley, BA, CCS [email protected]
518-430-1144
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Agenda• Reimbursement Impact• Policy Changes
• Preventative Services• Physician-owned Facilities• GME/IME Provision Changes• Physician Supervision Rules
• Cardiology Changes• Drugs, Drug Payment and Administration• Other Changes • Hospital Data Quality Indicators• NY Medicaid APG Update
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AbbreviationsASP – Average Sales PriceAWV - Annual Wellness VisitCMHC – Community Mental Health CenterMPFS – Medicare Physician Fee ScheduleNPP – Non-Physician PractitionersPBD – Provider-based DepartmentPHP – Partial Hospitalization ProgramPPACA/ACA - Patient Protection and Affordable Care Act 2010PPPS - Personalized Prevention Plan ServicesUSPSTF – US Preventative Services Task Force
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Payment ImpactHospitals that met the quality indicator reporting
requirements will get the full 2.35% increaseReflects market-basket update of 2.6% less 0.25%
reduction required by PPACA2.0% reduction in payment update factor if hospital did
not meet the quality indicator reporting requirementsCompared to 2.1% increase in 2009
Conversion factor:$68.876 - Met quality reporting standards
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Outlier CalculationsCalculation methodology unchanged
1st Threshold: Line-item cost exceeds 1.75 times APC payment
2nd Threshold: Line-item cost exceeds APC payment plus $2,025 Down from $2,175 last year
When both thresholds met Outlier payment = 50% * Cost – 1.75 * APC payment 50% of the cost that exceeds 1.75 times APC payment
[cost = charges * RCC]
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Hold Harmless TOPsExisting hold-harmless transitional outpatient
payments (TOPs) paid to rural hospitals and Sole Community Hospitals with 100 or fewer beds expires at the end of the year
CMS does not have the authority to extend these payments without legislation
AMA and HANYS are both urging Congress to pass legislation to extend this provision.
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Deductible ChangesInpatient deductible will increase from
$1100 to $1132Outpatient deductible will increase form
$155 to $162
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Partial HospitalizationContinue two-tiered payment approach But created separate rates for CMHCs
and HospitalsRates based on the number of services
provided each dayA rate for 3 servicesA separate rate for 4 or more services
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Partial HospitalizationCMHC - Per diem rates
APC 172 Level I Partial Hospitalization3 services$130 - per diem
APC 173 Level II Partial Hospitalization 4 or more services$164 - per diem rate
Rates based on a two year transition period for CMHCs
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Partial HospitalizationPHP - Per diem rates
APC 175 Level I Partial Hospitalization3 services$205 - per diem
APC 176 Level II Partial Hospitalization 4 or more services$238 - per diem rate
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APC Status IndicatorsNo changes to any Status IndicatorsReview of the Composite Status Indicators:
“Q1” - “STVX-packaged codes”“Q2” - “T-packaged codes”“Q3” – Procedure codes that may be paid
through a composite APC based on composite-specific criteria or separately through single code APCs when composite criteria is not met
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Original Composite APCs1. Mental Health Services – Partial
Hospitalization
2. Low dose prostate brachytherapy
3. Cardiac EP (electrophysiologic) evaluation and ablation services
4. Extended ED observation and monitoring
5. Extended Clinic observation and monitoring
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Multiple Imaging ServicesAdded in 2009 for five imaging composite APCsSingle APC payment for two or more imaging
procedures provided using same imaging modalityThe imaging composite APCs are:
1. Ultrasound2. CT and CTA w/o contrast3. CT and CTA with contrast 4. MRI and MRA w/o contrast 5. MRI and MRA w/contrast
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Services Performed During Critical Care
Services listed in the CPT® book that are included in critical care when performed during the critical period Example chest x-ray
These services should not be reported separately in CY 2010 and prior years for hospitals and physicians
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Services Performed During Critical Care
Effective for 2011 these ancillary services can be reported when provided in conjunction with critical care services
These services are now assigned a status indicator of Q3 (composite)
They will be conditionally packaged when performed with a 99291 (critical care)
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Policy Changes
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Preventative ServicesNo coinsurance or copayment for certain preventive
services recommended by the USPSTFPersonalized Prevention Plan Services (PPPS) are
excluded from payment under the OPPSAnnual Wellness Visits (AWV) that provide PPPS will
be paid on the Physician Fee ScheduleCMS will pay for either the practitioner or the facility for
the AWV provided in a facility settingOnly a single payment will be allowed (no split)
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Preventive ServicesServices with deductible and coinsurance waived:
Vaccines: Pneumococcal, Influenza and Hepatitis BScreening MammographyScreening pap smear and pelvic examsSome Colorectal Cancer screening testsBone Mass MeasurementMedical Nutrition TherapyCardiovascular Screening blood testsUltrasound screening for abdominal aortic aneurysmSmoking and Tobacco Cessation
TABLE 48B – LIST OF HCPCS CODES RECOGNIZED AS PREVENTATIVE SERVICES
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Preventative ServicesServices not covered:
Glaucoma ScreeningProstate ScreeningSome Colorectal Cancer ScreeningECG for the Initial Preventative Physical Exam
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Preventive Services Deductible is waived for colorectal cancer screening
tests that become diagnosticAll surgical services on the same date as a
colorectal screening will be part of the same clinical encounter and have no deductible
A new HCPCS modifier will be appended to the code when the screening becomes diagnosticNew Modifier: PT – Colorectal cancer screening test
converted to diagnostic test or other procedure
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Preventative Services90658 – no longer payable under OPPSReplaced by Influenza virus vaccine, split virus, 3+
years:Q2035 – afluriaQ2036 – flulavalQ2037 – fluvirinQ2038 - fluzoneQ2039 - NOS
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Preventative ServicesThe AWV is reported with two new HCPCS
codes effective January 1, 2011 – APC Status Indicator A:G0438 – Annual wellness visit, including
PPPS, first visit G0439 – Annual wellness visit, including
PPPS, subsequent visit
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Physician-Owned FacilitiesFor the more than 200 physician-owned hospitals
across the US:The ACA prohibits the development of new
physician-owned hospitals And expansion of existing physician-own hospitalsThere must be a provider agreement in effect by the
end of 2010
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Direct/Indirect Graduate Medical Education Changes
New provision from the ACA redistributes unused residency slots
CMS required to identify unused residency slots and redistribute them to certain hospitals w/ qualified residency programs
Priority will be given to hospitals in a state with a resident-to-populations ratio in the lowest percentile (not New York)
Goal is to increase the number of primary care physicians
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Direct/Indirect Graduate Medical Education ChangesSpecifies how hospitals should count residency
hours for certain training and research activities and patient care in physician officesCMS will count time spent by residents in a non-
provider setting toward direct GME (DGME) and IME costs if the hospital incurs the costs of resident salaries and fringe benefits
CMS will count resident time spent in certain non-patient care activities while training for DGME purposes
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Physician Supervision
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Key 2011 ChangesChanged the definition of “immediately available”Created a list of Extended Duration services that
require “direct supervision” for the beginning, followed by “general supervision” for the remainder
Extended CAH and added Rural Hospitals to the exception to the supervision rules required for Therapeutic services
Plans to convene a panel beginning in 2012 to determine the level of supervision required for different services
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Physician SupervisionThree levels of supervision in the hospital
outpatient setting have been defined as:General – Overall direction of physician, but
presence is not required during the performance
Direct – Physician is present on-site and “immediately” available if needed
Personal – Physician is present in the room
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Physician Supervision of Therapeutic Services
Outpatient Therapeutic Services“Direct Supervision” required for outpatient hospital
and HBD paid by Medicare“We assume the physician requirement is met on
hospital premises because staff physicians would always be nearby within the hospital. The effect of the regulations in this final rule is to extend this assumption to a department of a hospital that is located on the campus of the hospital”
As clarified in CY 2009 OPPS Final Rule
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Changed Definition of Direct Supervision
Removed the reference to “on the same campus” or “in the off-campus provider-based department of the hospital” and removed the definition of “in the hospital or CAH”
Revised – “Direct supervision means that the physician or NPP must be immediately available to furnish assistance and direction throughout the performance of the procedure.”
There is no longer any reference to the particular physical boundary
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Changed Definition of Direct Supervision
Allows greater flexibility in providing for direct supervision from a location other than the hospital or HBD campus
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NPP Supervision of OP Tx Services
CMS will allow certain non-physician practitioners (NPP) to provide direct supervision for all therapeutic services
Services must be those they are authorized to personally perform according to their state scope of practice rules and hospital-granted privileges:NP, PA, certified nurse mid-wives, clinical
nurse specialists, licensed clinical social workers, clinical psychologists
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Non-Surgical Extended Duration Therapeutic Services
“Extended Duration Services”Direct supervision required for the
initiation of the service, followed by general supervision for the remainder of the service
“Initiation of the service”Beginning portion that ends when the
patient is stable
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Extended Duration Services1. Tx Service must be extended duration
2. Service must consist largely of significant monitoring
3. Service must be sufficiently low risk
4. Service cannot be surgicalIncludes – ObservationExcludes – Chemotherapy/Blood
TransfusionsTABLE 48A – LIST OF NONSURGICAL EXTENDED DURATION THERAPEUTIC SERVICES
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Physician Supervision –of Diagnostic Services
Medicare Physician Fee Schedule Relative Value File – Indicator, for example:01 = Procedure must be performed under the general
supervision of a physician02 = Procedure must be performed under the direct
supervision of a physician03 = Procedure must be performed under the personal
supervision of physician
[https://www.cms.gov/PhysicianFeeSched/PFSRVF/list.asp#TopOfPage]
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Examples02 – Direct Supervision of a Physician
77058 and 77059 – MRI of the breast93282-93284 – ICD device program
evaluation
01 – General Supervision of a Physician59025 – Fetal non stress test72192 – CT of the pelvis w/o dye
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Physician Supervision –of Diagnostic Services
MPFS supervision indicator explicitly applies to hospitalsPaid in accordance with Section 1833 of the ActThis is the section that is the OPPS Authority
Does not apply to CAHsPaid in accordance with Section 1834 of the ActTherefore CAHs are not subject to this supervision
requirement
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Diagnostic TestsNPPs cannot function as supervisory
“physicians” for diagnostic testingMust follow the supervision requirements
as listed in the MPFS
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CAH CoPCAH CoPs recognize the statutory authority to be
staffed by NPPs rather than physicians, provided a MD or OD, NP, PA or clinical nurse specialist is available to provide care at all times the CAH operates.
That is, they are on call and immediately available by phone and able to be on-site within 30 minutes
However, “CoPs apply largely at the facility level, while payment regulations apply at the service level.”
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CAH Exception to RuleCMS issued a statement on March 15,
2010 indicating that they would not enforce the rules for direct supervision of outpatient therapeutic procedures performed in CAHs in CY 2010.
They have extended this statement for CY 2011.
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Small Rural HospitalsIncreased the scope to include small rural
hospitals100 or fewer bedsGeographically located in a rural areas or
paid through OPPS with a wage index for a rural area
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Cardiology and Endovascular
Revascularization Coding Changes
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Cardiology ChangesCardiac Catheterization: 19 non-congenital codes
have been deleted and 20 new codes have been created:Two are new code families for cardiac
catheterizations: one for congenital heart disease and one for all others
One new code for the administration of a pharmacological agent during a cardiac cath
One new code for an exercise study during a cardiac catheterization
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Cardiology ChangesPrevious multiple code reporting has been replaced
by single code reporting for diagnostic catheterization procedures, other than the congenital heart disease cardiac caths:Left heart cath used to require multiple codes - 93510,
93543,93555. For 2011, report 93452 onlyImaging supervision, interpretation and report and
injection is now included in the code 93452
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TABLE 11.—CY 2009 CODE COMBINATIONS, FREQUENCIES, AND SIMULATED MEDIAN COSTS FOR NEW CY 2011 CARDIAC CATHETERIZATION-RELATED CODES
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Endovascular Revascularization of the Lower Extremity
16 new codes for endovascular revascularization of the lower extremity - Table 6 lists the new codes
Table 7 lists the old combination of codesMany of the new codes were reported with a combination
of old codesPer the CPT® book the codes are inclusive of accessing
and selective catheterizing the vessel, related radiology S&I, embolic protection, closure and imaging to document the completion of the procedure
TABLE 6. NEW ENDOVASCULAR REVASCULARIZATION CPT PROCEDURE CODES EFFECTIVE JANUARY 1, 2011
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Drugs, Drug Payment and Administration
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2010 Drug ThresholdKeeping with the $5 per year increaseDrugs with a cost greater than $70 per
day will be paid separatelyCost calculation includes acquisition and
pharmacy overheadCalculated costs less than $70 per day will
be packaged
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Pass-Through DrugsEighteen pass-through drugs and biologicals will
expire (FR Table 27)Five became status NThirteen became status K
Forty-two pass-through drugs and biologicals for 2011 (FR Table 28)Thirty-six from 2010
Fifteen changed HCPCS codes
Six new drugs
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CY 2011 HCPCS
Code CY 2011 Long Descriptor
Final CY 2011
SIFinal CY 2011 APC
C9274Crotalidae polyvalent immune fab (ovine), 1 vial
G 9274
C9275Injection, hexaminolevulinate hydrochloride, 100 mg, per study dose
G 9275
C9276 Injection, cabazitaxel, 1 mg G 9276
C9277Injection, alglucosidase alfa (Lumizyme), 1 mg
G 9277
C9278 Injection, incobotulinumtoxin A, 1 unit G 9278
C9279 Injection, ibuprofen, 100 mg G 9279
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CY 2010 HCPCS
Code
CY 2011 HCPCS
Code CY 2011 Long DescriptorFinal CY 2011 SI
Final CY 2011 APC
C9255 J2426 Injection, paliperidone palmitate, extended release, 1 mg G 9255
C9256 J7312 Injection, dexamethasone intravitreal implant, 0.1 mg G 9256
C9258 J3095 Injection, telavancin, 10 mg G 9258
C9259 J9307 Injection, pralatrexate, 1 mg G 9259
C9260 J9302 Injection, ofatumumab, 10 mg G 9260
C9261 J3357 Injection, ustekinumab, 1 mg G 9261
C9263 J1290 Injection, ecallantide, 1 mg G 9263
C9264 J3262 Injection, tocilizumab, 1 mg G 9624
C9265 J9315 Injection, romidepsin, 1 mg G 9625
C9266 J0775 Injection, collagenase clostridium histolyticum, 0.01 mg G 1340
C9267 J7184Injection, von Willebrand factor complex (human), Wilate, per 100 IU VWF: RCO
G 9267
C9268 J7335 Capsaicin 8% patch, per 10 square centimeters G 9268
C9269 J0597 Injection, C-1 Esterase inhibitor (human), Berinert, 10 units G 9269
C9271 J3385 Injection, velaglucerase alfa, 100 units G 9271
Q2025 J8562 Fludarabine phosphate, oral, 10 mg G 1339
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Drug PaymentPass-through drugs paid at average sales
price (ASP) + 6% Non-packaged, non-Pass-through drugs
paid at ASP + 5%
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Nuclear Medicine and FB Modifier
No-cost diagnostic radiopharmaceuticals that are provided at no cost must be reported with FB Modifier
For Nuclear Medicine Scans listed in Table 29 (FR)Twenty-two APCs listed in Table 29Posted annually on the CMS Web site at
http://www.cms.gov/HospitalOutpatientPPS a file that contains the APC offset amounts
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Oral Antiemetics“The majority of commenters opposed the
proposal to continue the CY 2010 policy of no longer exempting the oral and injectable forms of 5-HT3 antiemetics from the packaging threshold.” 2011 FR
Translation: The majority of commenters want 5-HT3 antiemetics to be paid
CMS Response: 5-HT3 antiemetics will continure to be packaged
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Drug AdministrationNo major changes Continue to reimburse using the five-level
APC structure for drug administration services
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Description Medicare Other PayerDrug Screen Qual Multi-Class Chromatography 80100
Drug Screen Qual Multi-Class Not Chromatography G0434 80104
Drug Screen Qual Single Class G0431 80101
Drug Confirmation Each 80102
New drug testing codes for 2011
80104—DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES OTHER THAN CHROMATOGRAPHIC METHOD, EACH PROCEDUREG0434—DRUG SCREEN, OTHER THAN CHROMATOGRAPHIC; ANY NUMBER OF DRUG CLASSES, BY CLIA WAIVED TEST OR MODERATE COMPLEXITY TEST, PER PATIENT ENCOUNTER
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E/M Technical LevelsNo national visit technical reporting guidelines
Continue to use hospital internal guidelines
New Vs Established guidelines not changedEstablished – “registered” patient at the hospital w/in
the past three years
CMS encourages RACs and MACs to review hospital internal guidelines when performing auditsCurrently there are no RAC activities involving visit
levels
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“Triage-Only” VisitCMS does not specify the type of hospital staff who
may provide services“Billing a visit code in addition to another service
merely because the patient interacted with hospital staff … is inappropriate. A hospital may bill a visit code based on the hospital’s own coding guidelines which must reasonably relate the intensity of hospital resource to different levels of HCPCS codes. Services furnished must be medically necessary and documented.”
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Hospital Technical GuidelinesContinues to be critical that hospital
develop and follow and audit against their own technical E/M guidelines
For both the emergency departmentType B emergency departments (“fast
trak”)And hospital based clinics
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Changes to Inpatient-Only ListCriteria for removing from IP-only listMost outpatient departments are equipped to
provide the services to the Medicare populationThe simplest procedure described by the code
may be performed in most outpatient departments
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Criteria for ChangeThe procedure is related to codes that have
already been removed from the inpatient listA determination is made that the procedure is
being performed in numerous hospitals on an outpatient basis
A determination is made that the procedure can be appropriately and safely performed in an ASC
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CPT Code Long DescriptorCY 2011 APC Assignment
CY 2011 Status Indicator
21193Reconstruction of mandibular rami; horizontal, vertical, C, or L osteotomy; without bone graft
0256 T
21395
Open treatment of orbital floor blowout fracture; periorbital approach with bone graft (includes obtaining graft
0256 T
25909Amputation, forearm, through radius and ulna; reamputation
0049 T
Removing three procedures from the inpatient list
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Align Physician Payment with Hospital Payment?
Comment
Other commenters stated that physician’s payment should be aligned with the hospital payment; if the hospital is not paid, then the physician payment should not be allowed.
Response
…payment for physicians’ services are outside of the scope of the OPPS payment policy and of this OPPS/ASC final rule with comment period.
…we continue to believe that education is critical… we expect hospitals to use this knowledge and to educate physicians with regard to the appropriate setting for the procedures they furnish.
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Pass-through DeviceOne new pass-through device (status H)
October, 2010C1749– Endoscope retrograde
imaging/illumination colonoscope device (implantable)
Pass-through device list updated quarterly
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Brachytherapy SourcesAPC status indicator UContinue to be paid on APCs based on
costFR Table 37 provides details
Continue to be subject to outlier payment provision
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No Cost/Full Credit and Partial Credit Devices
BackgroundAffects payment for recalls of devices as a result
of failuresManufacturers have offered devices without
cost to the hospitalEnsure that payment rates for procedures
involving devices reflect only the full costs of those devices
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Full and Partial OffsetReduce OPPS payment for specified APCs
100 % (FB modifier) of the device offset amount when a hospital furnishes a specified device without cost or with a full credit
50 % (FC modifier) of the device offset amount when the hospital receives partial credit in the amount of 50 percent or more of the cost for the specified device
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APC Changes for 2011Criteria to continue for 2011
Affects Surgical APCs that use an implantable device
Devices must remain in the body (at least temporarily)
Device off-set must be at least 40% of APC cost.Adjustment is made (based on FB or FC modifier)
when APC is in Table 26, and device is in Table 25 (provided in OPPS Final Rule).
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Changes for 2011APC Changes for 2011
Added APC 318 (Implatation of Cranial Neurostimulator Pulse Generator and Electrode)
Deleted APC 225 (Implantation of Neurostimulator Electrodes, Cranial Nerve)
No changes to the Device List (Table 26)
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BackgroundAllows financial incentive based on quality
control measuresModeled after the inpatient program
(RHQDAPU), but unique to hospital outpatient services
HOP QDRP implemented in 2008, affected the payment rate update for 2009
Affects CY OPPS payment update—2.0 % point reduction in rate increase
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Financial PenaltyImpacts APC paid servicesLose 2% of 2.35% (2011 market-basket
increase) of APC rateStudy of one 300+ bed hospitalImpact equal to $21,800
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Seven Original MeasuresAffected payment update for 2009Five based on Emergency Department (ED) AMI
(acute myocardial infarction) measuresChart-based abstractions
OP–1: Median Time to FibrinolysisOP–2: Fibrinolytic Therapy Received Within 30 Minutes OP–3: Median Time to Transfer to Another Facility for
Acute Coronary Intervention OP–4: Aspirin at Arrival OP–5: Median Time to ECG
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Seven Original MeasuresTwo based on Perioperative Care measures
OP–6: Timing of Antibiotic Prophylaxis OP–7: Prophylactic Antibiotic Selection for
Surgical Patients
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Added Four Imaging Efficiency Measures
Affected payment update for 2010Based on Part B claims data
OP–8: MRI Lumbar Spine for Low Back PainOP–9: Mammography Follow-up RateOP–10: Abdomen CT—Use of Contrast
MaterialOP–11: Thorax CT—Use of Contrast Material
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2011 Continues with Eleven
Hospitals will report on the same eleven measures in 2010 to receive full market basket increase in 2011
Details and updates can be followed on QualityNet website:
http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1196289981244
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CY 2012 Payment Determination
Twelve of the sixteen new measures proposed in 2010 OPPS Rule will be adopted for 2012 and 2013Four new measures reported for 2011
(affecting 2012 update)Eight new measures reported for 2012
(affecting 2013 update)
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CY 2012 Payment Determination1. OP-12: The Ability for Providers with HIT to Receive
Laboratory Data Electronically Directly into their Qualified/Certified EHR System as Discrete Searchable Data
2. OP- 13: Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery
3. OP-14: Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT)
4. OP-15: Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache
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CY 2013 Payment Determination1. OP-16: Troponin Results for Emergency Department
acute myocardial infarction (AMI) patients or chest pain patients (with Probable Cardiac Chest Pain) Received Within 60 minutes of Arrival Immunization Pneumococcal vaccination status Influenza vaccination status
2. OP-17: Tracking Clinical Results between Visits
3. OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients
4. OP-19: Transition Record with Specified Elements Received by Discharged Patients
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CY 2013 Payment Determination5. OP-20: Door to Diagnostic Evaluation by a Qualified
Medical Professional SPECT MPI and stress echocardiography for preoperative evaluation
6. OP-21: ED- Median Time to Pain Management for Long Bone Fracture
7. OP-22: ED- Patient Left Before Being Seen
8. OP-23: ED- Head CT Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT Scan Interpretation Within 45 minutes of Arrival
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CY 2014 Payment DeterminationWill retain the twenty-three from 2013Propose six more, but not finalized
1. Hemoglobin A1c Poor Control in Diabetic Patients
2. Low Density Lipoprotein (LDL-C) Control in Diabetic Patients
3. High Blood Pressure Control in Diabetic Patients
4. Dilated Eye Exam in Diabetic Patients
5. Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients
6. Exposure Time Reported for Procedures Using Fluoroscopy
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Quality Reporting ValidationBeginning with CY 2012 payment determination800 hospitals would be selected randomly (approximately 20
percent of all participating HOP QDRP hospitals) each yearRandomly select up to 48 self reported cases from the total
number of cases (12 per quarter)CMS contractor would request paper copies of medical
documentation corresponding to selected casesCMS contractor would verify that quality data submitted is
accurateHospitals must attain at least a 75 percent validation score to
receive the full OPPS update in CY 2012
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Results to be PublishedData will be published on
http://www.hospitalcompare.hhs.gov
Data will be made public after a preview period
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Medical Visits Will No Longer Package With Higher Intensity Significant Ancillaries
Effective January 1, 2010 Medical visits will no longer package with:more significant ancillaries (e.g., MRIs, mammograms,
CAT scans, etc.)dental proceduresPT, OT, and speech therapies; andcounseling services
In these cases, a coded medical visit will separately pay at the line level
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Significant Procedure APGs With Which Medical Visits Do Not Package
Modifier 25 will be emulated by grouper on all lines grouping to APG 491 (MEDICAL VISIT) when one of these APGs is coded
List found at: http://www.health.state.ny.us/health_care/medicaid/rates/apg/docs/apg_not_package.pdf
Does not include surgical type procedures
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D&TCsImplementation of ancillary billing policy
will be delayed a second time, until April 1, 2011
Lab and radiology services will continue to be paid on the Medicaid fee schedule
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Medicaid SecondaryFor Medicaid recipients who are also covered by
Medicare or commercial insuranceHospital will continue to use old visit code 1400 for monthly
billings of Medicare co‐pays and deductibles for dual eligible enrollees
If the lab or radiology provider is required to bill Medicare or the commercial insurance directly, the lab/radiology provider should do so
The lab/radiology provider should then bill Medicaid for the balance due
The clinic should not report these ancillary lab/radiology services on their APG claim
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New Weights and Rates
APG weights and base rates have been updated – last published update September 2010
Located at : http://www.health.state.ny.us/health_care/medicaid/rates/apg/index.htm#rates
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Carve OutsUpdated regularly– next update 1/1/2011http://nyhealth.gov/health_care/medicaid/rates/
apg/docs/apg_carve_outs.pdfInclusion on this list indicates that service should
not be billed using APGs, since it does not guarantee alternative payment
MRIs no longer carved‐out of the threshold visit, but instead must be billed under APGs
New “premium” drug carve outs added
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New Premium Drug “Class VII” APGNew (1/1/2010) “premium” drug APG, consisting of
certain chemotherapy and pharmacotherapy drugsAll drugs grouping to this class will be carved out of
APGs and billable to the Ordered Ambulatory Fee Schedule
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Capital Add-onsAncillary-only and dental examination visits will
receive capital add-on payments (January 2010)Still no capital add-on payment for visit types:
Medication Administration and Observation onlyPhysical Therapy, groupSpeech Therapy, groupCardiac RehabilitationImmunizationPatient Education
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Pre-Surgery TestingHow to bill pre‐surgical testing for ambulatory
surgery:When ordered by an OPD or D&TC clinic practitioner
for a clinic patient during an APG reimbursable clinic visit Bill using an APG rate code
When ordered by a hospital ambulatory surgery unit or ambulatory surgery center practitioner for a patient referred to the ambulatory surgery facility Bill by the ancillary provider on an ordered ambulatory basis
using the Medicaid fee schedule
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Post-Surgery TestingAll post‐surgical tests, e.g.,
pathology, ordered by the hospital ambulatory surgery unit or ambulatory surgery center practitioner should be billed by the ancillary provider on an ordered ambulatory basis using the Medicaid fee schedule
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Inpatient Only ServicesNot reimbursed under the APG payment
methodology The APG Grouper will automatically reject
these procedures for payment Will be paid through the Inpatient All
Patient Refined ‐Diagnosis Related Groups (APR‐DRG) payment methodology
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Inpatient Only ListThe State's APG Inpatient Only List" is different
from CMS' APC "Inpatient Only List" Providers will need to maintain two lists--one for
APCs and one for APGs The APG list allows for more procedures on an
outpatient basisList is available at:
www.nyhealth.gov/health_care/medicaid/rates/apg/docs/inpatient_only.pdf
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Cardiac RehabilitationThe no‐blend APG list now includes
cardiac rehabilitation, which came off the “never pay” APG list (1/1/2010)
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HIV/AIDs Counseling/TestingEffective January 2011 these rates codes in hospital
OPDs (2893, 3111, 3109) and DT&Cs (1695, 1802, 3109) will be subsumed into the APG system
Will then be paid based on procedures and primary diagnosis code
Should start to report with the APG access rate codes (e.g., 1400, 1407 or 1432)
Details can be found at: http://www.health.state.ny.us/health_care/medicaid/rates/apg/docs/procedure_code_guidance.pdf
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Mental Health APGsCodes for Mental Health APGs implemented
10/1/2010Significant change in how these services are
reportedHowever, the services are not yet being paid under
APGsStill reported with the pre-APG rate codesAwaiting CMS approval for implementationExpect an update at the HANYS webinar Friday
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Known Issue ListLists known issues, changes and other significant
informationRegularly updated Includes situations where claims need to be
resubmitted for appropriate reimbursementFor example – July 2010 grouper included a fix for
2009 E/M and Significant procedure unpaid claims submitted between April and July 1010 – these claims need to be resubmitted for appropriate reimbursement
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2011 APG UpdateHANYS and the Greater New York Hospital
Association Webconference APGs - Friday, December 17, from 3 to 5 p.m
2011 changes and related APGs issues: Base rate changesAPG logic changes for January 2011Mental health APGsAncillary billing policyThe state plan amendment
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Contact UsRichard Cooley
Phone: 518-430-1144
Email: [email protected]
Jean RussellPhone: 518-369-4986
Email: [email protected]
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http://www.EpochHealth.com/
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CPT®
Current Procedural Terminology (CPT®) Copyright 2010 American Medical AssociationAll Rights ReservedRegistered trademark of the AMA
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DisclaimerInformation and opinions included in this presentation are provided based on our interpretation of current available regulatory resources. No representation is made as to the completeness or accuracy of the information. Please refer to your payer or specific regulatory guidelines as necessary.