hfma new jersey 2016 charge master update …...overall impact of 2016 opps changes top 10 cpt code...

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2016 Charge Master Update

Mike KovarPartnerWeiserMazars LLP

Taylor PedoneManagerWeiserMazars LLP

New Jersey HFMADecember 16, 2015

Introductions

Mike Kovar has led over 500 charge master, revenue capture, and patient charge compliance reviews. He received his Masters’ in Business Administration from Loyola University of Chicago, is an advanced member of HFMA, and is a frequent speaker nationally on charge master and other revenue capture-related issues.

Taylor Pedone has a background in assessment and implementation of process improvement initiatives across the revenue cycle including charge capture, patient financial services, denials, strategic and transparent pricing, and compliance. She is a Certified Professional Coder (CPC).

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Learning Objectives

In our session, we will cover the following:

� How to prepare your charge master and related processes and systems for 2016

� Charge master and charge capture process changes related to the 2016 Outpatient Prospective Payment System changes

� CPT Code additions, revisions, and deletions for 2016

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Charge Master Impacts

Charge master must accurately align with the various sub-systems that are linked to it. These sub-systems can include:

� Order entry module of the billing system

� Charge encounter forms, Preference Lists

� Electronic medical record

� Ancillary department systems such as the Radiology Information System, Laboratory Information Systems and Pharmacy systems

� Bill scrubbers

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Charge Master-Other Payors� There are other payors besides Medicare and their coding

requirements may vary

� Understanding the CPT Code/Revenue Code requirements of your top payors besides Medicare is critical

– Top 3 to 5 manager care payors

– Medicaid

� Managed Care Rate sheets and Medicaid provider manual are good resources

– Interaction will Contracting, Revenue Cycle are essential

� Review contract terms/ provider manuals/ remittance advices, etc.

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Charge Master Update Tools� The following resources are usually required:

• 2016 OPPS Final Rule and, if available, January OPPS Medicare Transmittal

• 2016 AMA CPT Manual

• 2016 HCPCS Code listing

• Other major payor information as applicable

MANY CHARGE MASTER MAINTENANCE TOOLS HAVE SOME OF THESE CAPABILITIES

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Charge Master Update-Approach

– Proactive versus reactive approach

• Initiate and complete prior to January 1, 2016

– Active Clinical Department participation and ownership

– Establish deadlines and monitor compliance

– Implement CPT, HCPCS and UB-04 Revenue Code revisions and verify accuracy in the system

– Educate clinicians and finance professionals

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Charge Master Update-Compliance Tracking

� Monitor high risk areas of the charge master post-implementation January 1, 2016

– Set up a tracking mechanism for high risk areas of charge master changes

• Track for minimum of 3 months

– Perform a claims review for selected charge master update issues

• Ensure claims are post-bill scrubber

– Initiate corrective actions as necessary

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Charge Master Update-Medicare Regulatory Process

� CMS publishes proposed annual rule changes to OPPS in July/August each year in the Federal Register

– Comments due 30 days post publication in Federal Register

� CMS publishes final annual changes to OPPS in October/November each year in the Federal Register

– Implementation is January 1 each year

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Charge Master Update-Medicare Regulatory Process

� CMS through their sub-regulatory process details required OPPS changes for the MACs using Medicare Program Transmittals

– January OPPS changes published in January transmittal in late December/early January each year

• Primary focus is OPPS annual changes

– Additional changes to OPPS issued for implementation in April, July, and October each year

• Pharmacy is usually most significant area

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2016 Hospital Outpatient ProspectivePayment System (OPPS) and Ambulatory Surgery Payment System

(ASC) Final Rule

� Published in the Federal Register on November 13, 2015

– Federal Register provides a list of OPPS contacts at CMS including phone numbers (Page 39200). For example:

� 0.4% decrease in Medicare payments in 2016 to all hospitals including cancer and children’s hospitals and CMHCs (2.3% increase in 2015)

– $133 million decrease from 2015

Overall Impact of 2016 OPPS Changes

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� This decrease is primarily attributed to a 2.0% decrease in the conversion factor to redress inappropriate inflation of OPPS payment rates and remove $1.0 billion in excess packaged payments related to the new 2014 Laboratory packaging policy.

– CMS overestimated the adjustment for the 2014 laboratory packaging policy and underestimated the spending for laboratory services paid under the Clinical Laboratory Fee Schedule (CLFS) rather than under OPPS by $1.0 billion

• Overpayment for packaging of Laboratory under OPPS

• Payment for same services under both OPPS & CLFS


� Impacts on different “hospital categories” are as follows:

– urban hospitals -0.4%

– rural hospitals -0.6%

– sole community rural hospitals -0.6%

– urban hospitals 500 + beds -0.1%

– major teaching hospitals 0.1%

– non-teaching hospitals -0.7%

– governmental hospitals -0.3%

– proprietary hospitals -1.1%

– CMHCs 23.1%


Overall Impact of 2016 OPPS Changes (cont’d)

� For CMHCs the 23.1% increase can be attributed to APC recalibration

– APC 172 $96.44 payment in 2015 decreased to $94.49 for renumbered APC 5851

– APC 173 $114.27 payment in 2015 increased to $143.00 for renumbered APC 5852

� Total beneficiary liability for copayments would decrease as an overall percentage of total payments

– 19.3% estimated in 2016 versus 20.5% in 2015

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� CMS has a publicly available file to estimate the impact of the 2016 OPPS rule on it’s website for every OPPS hospital.

– 2016 OPPS NPRM Facility-Specific Impacts

Provider Number

CBSA Code

Total Discounted

Units

Rural Sole Community and

Essential Access Hospitals

Post Reclassification

Wage Index All Rural

Urban/Rural Geographic

Location Region

Disproportionate Share Patient Percentage

Outpatient Cost-to-

Charge Ratio

Estimated 2015 OPPS Payment

Estimated 2016 OPPS Payment

Estimated 2016 Outlier

Payment

010001 20020 230,531.0 0 0.6938 0OURBAN ESC 28.0% 0.137 $38,597,993.14 $36,094,041.84 $72,193.28

010005 01 446,958.4 0 0.8270 1RURAL ESC 27.5% 0.207 $24,459,130.82 $24,074,875.87 $1,703.86

010006 22520 54,740.3 0 0.6872 0OURBAN ESC 23.0% 0.128 $17,619,724.69 $16,988,831.92 $16,599.24


Top 10 CPT Code Winners-2016 Versus 2015

HCPCS Code Short Descriptor CI SI APC

2016 Payment Rate

October 2015 Payment Rate

Payment Variance

0100T Prosth retina receive&gen CH T 1599 $95,000.00 $ 3,122.56 $91,877.44

0312T Laps impltj nstim vagus CH J1 5464 $26,728.39 $ - $26,728.39

54411 Remov/replc penis pros comp CH J1 5377 $14,088.02 $ - $14,088.02

54417 Remv/replc penis pros compl CH J1 5377 $14,088.02 $ - $14,088.02

62360 Insert spine infusion device CH J1 5471 $15,350.22 $ 3,662.54 $11,687.68

0316T Replc vagus nerve pls gen CH J1 5464 $26,728.39 $17,106.04 $9,622.35

20696 Comp multiplane ext fixation CH J1 5125 $10,537.90 $ 2,602.13 $7,935.77

27356 Remove femur lesion/graft CH J1 5125 $10,537.90 $ 2,602.13 $7,935.77

24362 Reconstruct elbow joint CH J1 5125 $10,537.90 $ 3,364.30 $7,173.60

27441 Revision of knee joint CH J1 5125 $10,537.90 $ 3,364.30 $7,173.60


Top 10 CPT Code Losers-2016 Versus 2015

HCPCS Code Short Descriptor CI SI APC

2016 Payment Rate

October 2015 Payment Rate

Payment Variance

0308T Insj ocular telescope prosth J1 5494 $17,550.83 $23,084.33 -$5,533.50

27412 Autochondrocyte implant knee CH J1 5123 $4,969.26 $10,224.00 -$5,254.74

47511 Insert bile duct drain CH D $ 4,095.89 -$4,095.89

23450 Repair shoulder capsule CH T 5122 $2,395.59 $ 6,322.79 -$3,927.20

23460 Repair shoulder capsule CH T 5122 $2,395.59 $ 6,322.79 -$3,927.20

24330 Revision of arm muscles CH T 5122 $2,395.59 $ 6,322.79 -$3,927.20

28264 Release of midfoot joint CH T 5121 $1,455.26 $ 5,219.15 -$3,763.89

26686 Treat hand dislocation CH T 5122 $2,395.59 $ 5,569.47 -$3,173.88

22612 Lumbar spine fusion CH J1 5124 $7,064.07 $10,224.00 -$3,159.93

24365 Reconstruct head of radius CH J1 5124 $7,064.07 $10,224.00 -$3,159.93

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OPPS Background

� Outpatient Prospective Payment System (OPPS) was first implemented on August 1, 2000

� Medicare pays for hospital outpatient services on a rate-per-service basis that varies based on the ambulatory payment classification (APC) assigned to the service

– Healthcare Common Procedure Coding System (HCPCS) is used to identify and group services in an APC

• HCPCS includes both CPT and HCPCS Level II Codes

• Payment is based on status indicators (See Addendum D1)

� All services within an APC are comparable clinically and relative to resource use.

– Service are not considered comparable relative to resource use if the highest mean cost for an item or service in an APC is more than 2 times greater than the lowest mean cost of an item or service in the same APC.

OPPS Background

� Hospitals excluded from OPPS:

– Maryland hospitals for services paid under the cost containment waiver

– Critical access hospitals

– Hospitals outside the 50 states, the District of Columbia, and Puerto Rico

– Indian Health Service hospitals

Updates Affecting OPPS Payments

� Approximately 163 million (versus 161 million in 2015) final action claims for services provided in a hospital outpatient setting from January 1, 2014 through December 31, 2014 were used to calculate the 2016 rates

� Single/”pseudo” claims process used in previous years was again used for 2016 rate setting purposes

– Medicare lists bypassed HCPCS Codes to determine single claims in Addendum N

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� Hospital-specific overall ancillary and department cost-to-charge ratios (CCRs) used to convert charges to estimated costs through application of a revenue code-to-cost center crosswalk

� Most recent submitted, in most cases, cost reports beginning in CY 2013 used to calculate CCRs (cost-to-charge ratio) to be used to calculate costs for the CY 2016 OPPS payment rates

– To calculate APC costs, Medicare calculated hospital specific overall ancillary CCRs and hospital-specific departmental CCRs for each hospital with 2014 claims data

Updates Affecting OPPS Payments� CMS implemented 25 comprehensive APCs (C-APCs) for 2015

– Comprehensive APCs are HCPCS Codes designated as the primary service (SI=J1) for which there is a single payment for all services that are considered as integral, ancillary, supportive and adjunctive to the primary service

• Only excludes services not covered by Medicare Part B or

services not payable under OPPS such as:

– Self-administerable drugs not considered supplies

– Pass-through drugs and devices

– Ambulance services

– Diagnostic and screening mammography

– Recurring therapy services

– Brachytherapy

– Preventive services


� CMS is adding 10 more C-APCs in 2016 (Almost 800 HCPCS Codes included in 35 C-APCs)

– Originally in proposed rule, 9 additional C-APCs

• Level 5 Musculoskeletal Procedures added in final rule

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– Comprehensive Observation Services APC 8011

• Replaces Extended Assessment & Management Composite APC 8009

• New Status Indicator J2 assigned

• Must meet all the following requirements:

– No SI=T on the claims

» If there is a status T procedure on claim, the observation will be packaged

– Must have at least 8 units of G0378

– Must have a G0379, 99281 through 99285, G0384, 99291 or G0463

– No SI= J1 on claim

– Payment = $2,174.14

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� Stereotactic Radiosurgery (SRS) C-APC 5671 to be revised

– It includes the following CPT Codes:

• 77371 - Radiation treatment delivery, SRS, complete course of treatment cranial lesion, one session; multi-sourced Cobalt 60-based

– Treatment planning services frequently occur on same day (Included in the C-APC)

• 77372 - Radiation treatment delivery, SRS, complete course of treatment cranial lesion, one session; linear accelerator based

– Treatment planning services occur typically on different dates of services (Not included in C-APC)


� Stereotactic Radiosurgery (SRS) C-APC 5671 to be revised

– For 2016 that the following treatment planning services will be paid in addition to the C-APC:

• CT localization (77011, 77014)

• MRI imaging (70551, 70552, 70553)

• Clinical treatment planning (77280, 77285, 77290, 77295)

• Physics consultation (77336)

• HCPCS Modifier “CP” required on each of the above services

• HCPCS Modifier “CP” also required on all adjunctive services related to 77371 and 77372 reported on a different claim

� Similar to SRS, CMS had proposed for 2016 to require the “CP” HCPCS modifier on all services adjunctive to a C-APC primary service when the adjunctive services are billed on a different claim

– Will not be implemented in 2016


� C-APC 5881 Payment for claims reporting inpatient only services on patient that dies prior to admission will be implemented in 2016

– Replaces composite APC 0375

– Comprehensive payment for all services on the claim when “CA” modifier present with an inpatient only procedure

� The composite APCs for LDR prostate brachytherapy, mental health services and multiple imaging procedures continue “as is” for 2016

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OPPS Packaging Policy Changes for 2016

� Ancillary services/procedures consider clinically similar to currently conditionally packaged categories of ancillary services considered integral, ancillary, dependent, supportive, or adjunctive to the primary service will be conditionally packaged

– 2015 $100 geometric mean cost criteria for packaging eliminated

– Also excluded are:

• Certain psychiatric and counseling services that are considered by CMS to be visits and not ancillary such as psychotherapy, etc.

• Drug administration and add-on drug administration CPT Codes


� The following ancillary services/procedures APCs will be conditionally packaging in 2016:


� The following ancillary services/procedures CPT Codes will be conditionally packaged in 2016:

HCPCS Code Short Descriptor CI SI APC Payment Rate

0110T Nos quant sensory test CH Q1 5734 $91.18

0207T Clear eyelid gland w/heat CH Q1 5734 $91.18

0232T Njx platelet plasma CH Q1 5734 $91.18

0296T Ext ecg recording CH Q1 5734 $91.18

0297T Ext ecg scan w/report CH Q1 5734 $91.18

11720 Debride nail 1-5 CH Q1 5734 $91.18

11980 Implant hormone pellet(s) CH Q1 5734 $91.18

11981 Insert drug implant device CH Q1 5734 $91.18

11982 Remove drug implant device CH Q1 5734 $91.18

11983 Remove/insert drug implant CH Q1 5734 $91.18

15852 Dressing change not for burn CH Q1 5734 $91.18

15860 Test for blood flow in graft CH Q1 5734 $91.18

20665 Removal of fixation device CH Q1 5734 $91.18

29125 Apply forearm splint CH Q1 5734 $91.18

29126 Apply forearm splint CH Q1 5734 $91.18

30300 Remove nasal foreign body CH Q1 5734 $91.18

30901 Control of nosebleed CH Q1 5734 $91.18

36425 Vein access cutdown > 1 yr CH Q1 5734 $91.18

36591 Draw blood off venous device CH Q1 5734 $91.18

36592 Collect blood from picc CH Q1 5734 $91.18

36600 Withdrawal of arterial blood CH Q1 5734 $91.18

36680 Insert needle bone cavity CH Q1 5734 $91.18

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40804 Removal foreign body mouth CH Q1 5734 $91.18

41250 Repair tongue laceration CH Q1 5734 $91.18

41800 Drainage of gum lesion CH Q1 5734 $91.18

42809 Remove pharynx foreign body CH Q1 5734 $91.18

46600 Diagnostic anoscopy spx CH Q1 5734 $91.18

51701 Insert bladder catheter CH Q1 5734 $91.18

51702 Insert temp bladder cath CH Q1 5734 $91.18

51736 Urine flow measurement CH Q1 5734 $91.18

51798 Us urine capacity measure CH Q1 5734 $91.18

53601 Dilate urethra stricture CH Q1 5734 $91.18

53661 Dilation of urethra CH Q1 5734 $91.18

57150 Treat vagina infection CH Q1 5734 $91.18



64402 N block inj facial CH Q1 5734 $91.18

65205 Remove foreign body from eye CH Q1 5734 $91.18




65430 Corneal smear CH Q1 5734 $91.18

67820 Revise eyelashes CH Q1 5734 $91.18

68200 Treat eyelid by injection CH Q1 5734 $91.18

68801 Dilate tear duct opening CH Q1 5734 $91.18

69200 Clear outer ear canal CH Q1 5734 $91.18

76510 Ophth us b & quant a CH Q1 5734 $91.18

85097 Bone marrow interpretation CH Q2 5674 $440.53

86870 Rbc antibody identification CH Q2 5673 $209.42

86890 Autologous blood process CH Q1 5673 $209.42

86891 Autologous blood op salvage CH Q1 5674 $440.53

86927 Plasma fresh frozen CH S 5673 $209.42

86931 Frozen blood thaw CH Q1 5673 $209.42



88120 Cytp urne 3-5 probes ea spec CH Q2 5673 $209.42

88184 Flowcytometry/ tc 1 marker CH Q2 5673 $209.42

88307 Tissue exam by pathologist CH Q2 5673 $209.42

88309 Tissue exam by pathologist CH Q2 5674 $440.53

88319 Enzyme histochemistry CH Q2 5674 $440.53

88333 Intraop cyto path consult 1 CH Q2 5674 $440.53

88342 Immunohisto antb 1st stain CH Q2 5673 $209.42

88344 Immunohisto antibody slide CH Q1 5673 $209.42

88346 Immunofluor antb 1st stain CH Q2 5673 $209.42

88348 Electron microscopy CH Q2 5674 $440.53

88358 Analysis tumor CH Q2 5673 $209.42

88360 Tumor immunohistochem/manual CH Q2 5673 $209.42

88361 Tumor immunohistochem/comput CH Q2 5673 $209.42

88362 Nerve teasing preparations CH Q2 5674 $440.53

88366 Insitu hybridization (fish) CH Q1 5673 $209.42

88367 Insitu hybridization auto CH Q2 5673 $209.42

88368 Insitu hybridization manual CH Q2 5673 $209.42

88374 M/phmtrc alys ishquant/semiq CH Q1 5673 $209.42

88377 M/phmtrc alys ishquant/semiq CH Q1 5673 $209.42

89251 Cultr oocyte/embryo <4 days CH Q2 5673 $209.42

89258 Cryopreservation embryo(s) CH Q2 5674 $440.53

89272 Extended culture of oocytes CH Q2 5674 $440.53

89280 Assist oocyte fertilization CH Q2 5674 $440.53

89346 Storage/year oocyte(s) CH Q2 5673 $209.42

91133 Electrogastrography w/test CH Q1 5734 $91.18

92020 Special eye evaluation CH Q1 5734 $91.18

92060 Special eye evaluation CH Q1 5734 $91.18

92065 Orthoptic/pleoptic training CH Q1 5734 $91.18

92081 Visual field examination(s) CH Q1 5734 $91.18

92083 Visual field examination(s) CH Q1 5734 $91.18

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92136 Ophthalmic biometry CH Q1 5734 $91.18

92140 Glaucoma provocative tests CH Q1 5734 $91.18

92228 Remote retinal imaging mgmt CH Q1 5734 $91.18

92230 Eye exam with photos CH Q1 5734 $91.18

92250 Eye exam with photos CH Q1 5734 $91.18

92270 Electro-oculography CH Q1 5734 $91.18

92283 Color vision examination CH Q1 5734 $91.18

92284 Dark adaptation eye exam CH Q1 5734 $91.18

92285 Eye photography CH Q1 5734 $91.18

92286 Internal eye photography CH Q1 5734 $91.18

92287 Internal eye photography CH Q1 5734 $91.18

92311 Contact lens fitting CH Q1 5734 $91.18



92315 Rx cntact lens aphakia 1 eye CH Q1 5734 $91.18

92325 Modification of contact lens CH Q1 5734 $91.18

92520 Laryngeal function studies CH Q1 5734 $91.18

92541 Spontaneous nystagmus test CH Q1 5734 $91.18

92542 Positional nystagmus test CH Q1 5734 $91.18

92548 Posturography CH Q1 5734 $91.18

92552 Pure tone audiometry air CH Q1 5734 $91.18

92561 Bekesy audiometry diagnosis CH Q1 5734 $91.18

93024 Cardiac drug stress test CH Q1 5734 $91.18



93225 Ecg monit/reprt up to 48 hrs CH Q1 5734 $91.18

93226 Ecg monit/reprt up to 48 hrs CH Q1 5734 $91.18

93701 Bioimpedance cv analysis CH Q1 5734 $91.18

93786 Ambulatory bp recording CH Q1 5734 $91.18

93788 Ambulatory bp analysis CH Q1 5734 $91.18

93922 Upr/l xtremity art 2 levels CH Q1 5734 $91.18

94014 Patient recorded spirometry CH Q1 5734 $91.18

94200 Lung function test (mbc/mvv) CH Q1 5734 $91.18

94452 Hast w/report CH Q1 5734 $91.18

94453 Hast w/oxygen titrate CH Q1 5734 $91.18

94620 Pulmonary stress test/simple CH Q1 5734 $91.18

94644 Cbt 1st hour CH Q1 5734 $91.18

94667 Chest wall manipulation CH Q1 5734 $91.18

95004 Percut allergy skin tests CH Q1 5734 $91.18

95044 Allergy patch tests CH Q1 5734 $91.18

95060 Eye allergy tests CH Q1 5734 $91.18

95180 Rapid desensitization CH Q1 5734 $91.18



95801 Slp stdy unatnd w/anal CH Q1 5734 $91.18

95803 Actigraphy testing CH Q1 5734 $91.18

95860 Muscle test one limb CH Q1 5734 $91.18

95861 Muscle test 2 limbs CH Q1 5734 $91.18

95865 Muscle test larynx CH Q1 5734 $91.18

95870 Muscle test nonparaspinal CH Q1 5734 $91.18

95905 Motor &/ sens nrve cndj test CH Q1 5734 $91.18

95922 Autonomic nrv adrenrg inervj CH Q1 5734 $91.18

95923 Autonomic nrv syst funj test CH Q1 5734 $91.18

95970 Analyze neurostim no prog CH Q1 5734 $91.18

96103 Psycho testing admin by comp CH Q1 5734 $91.18

99195 Phlebotomy CH Q1 5734 $91.18

G0166 Extrnl counterpulse, per tx CH Q1 5734 $91.18

G0237 Therapeutic procd strg endur CH Q1 5734 $91.18

G0416 Prostate biopsy, any mthd CH Q2 5673 $209.42

G0455 Fecal microbiota prep instil CH Q1 5734 $91.18

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� Four drugs considered as integral to surgical procedures will be packaged in 2016


� For laboratory, the following new packaging policies will be implemented in 2016:

– All molecular pathology tests will be excluded from packaging including new tests added in the future (Assigned SI=A)

– Preventive laboratory tests are excluded and also assigned SI=A

• Examples include PSA screening test, etc.

– Expand conditional packaging provision to include packaging of all laboratory tests provided during the same encounter unless provided by a different provider or for a different reason (L1 modifier to be used)

• Previously conditional packaging only applied to laboratory tests provided on the same day of the primary services.

• Expands packaging to include all laboratory tests on a multiple day single outpatient encounter


� For laboratory, the following new packaging policies will be implemented in 2016:

– Revised use of L1 modifier

• L1 will only be used when laboratory tests are provided by a different provider or for a different reason by the OPPS provider on the same claim as other unrelated services.

• L1 will no longer be required when laboratory services are the only items on the claim.

– SI changed to Q4 for all conditionally packaged laboratory tests

– CMS will implement edits which change SI from Q4 to A with a 13X bill type when only Q4 services appear on the claim

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Updates Affecting OPPS PaymentsOutlier Payments

� For hospitals, outlier payments are made that equal 50 percent of the amount by which the cost of furnishing the services exceeds 1.75 times the APC payment when the following thresholds are met:

– Cost of furnishing the service by the hospital exceeds 1.75 times the APC payment amount; and

– Exceeds a $3,250 fixed-dollar threshold ($2,775 in 2015)

– For example: Total Charges =$10,000; CCR=0.50; APC payment= $1,000

Total Cost of Service=$10,000 X 0.50 = $5,000

Is $5,000 Cost of Service > 1.75 X $1,000 APC Payment= $1,750 YES

Is $5,000 Cost of Service > $3,250 Fixed dollar threshold YES

Outlier payment = ($5,000-$1,750) X 50% = $1,625

OPPS APC Group Policies

OPPS APC Group Policies

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2016 OPPS APC Specific Policies

� For new technology APCs, there are currently 37 cost bands. 11 additional cost bands (Levels 38-48):


2016 OPPS APC Group Policies� Cardiac Rehabilitation CPT Codes: 93797, 93798, G0422, and G0423

will now be paid the same amount under a single APC: 5771

� Diagnostic Tests and related services APCs consolidated from 19 APCs to 4 APCs

– Impacts EKGs, EMGs, EEGs, pulmonary

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� For 2016, CMS will restructure and consolidate the imaging and nuclear medicine APC structure from 54 APCs to 26 APCs (25 in proposed rule)



� For 2016, CMS will restructure and consolidate the orthopedic related APC structure from 24 APCs to 10 APCs (9 in proposed rule)

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� For 2016, CMS will restructure and consolidate the APCs in the following areas:

– Skin procedures from 8 APCs to 5 APCs (APCs 5051-5055)

– Excision/Biopsy and Incision Drainage procedures from 7 APCs to 4 APCs (APCs 5071-5074)

– Gastrointestinal procedures from 23 APCs to 13 APCs (APCs 5301-5303, 5311-5313, 5331,5341, 5351, 5352, 5391, 5392)

– Urology procedures from 16 APCs to 7 APCs ( APCs 5371-5377)

– Vascular procedures from 7 APCs to 3 APCs (APCs 5181-5183)

2016 Payment Changes for Devices

� Pass-through Devices

– Devices with pass through status eligible for pass through payment for at least 2 years but not more than 3 years

– Devices no longer eligible for pass through payment are packaged into the cost of the procedure

– As of January 1, 2016, there are three devices eligible for pass-through payment

• C2624 Implantable wireless pulmonary artery pressure sensor with delivery catheter including all system components

• C2623 Catheter, transluminal angioplasty, drug coated, non-laser

• C2613 Lung biopsy plug with delivery system

– Increased transparency in pass through device application process


� Pass-through Devices

– Reporting of device required for all device-intensive APCs in 2016

• Return to provider if no device present

� Payment adjustment for discontinued device-intensive procedures

– Modifier 73 used when procedure requiring anesthesia discontinued due to extenuating circumstances or due to circumstances threatening the well-being of the patient after the patient has been prepped and is brought to the room but prior to administration of the anesthesia

• Payment is 50% of the OPPS payment rate

• Reduce by 100% the cost of the device for device-dependent APCs

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� Payment adjustment for discontinued device-intensive procedures

– Modifier 74 used when procedure is discontinued after anesthesia administration and procedure started due to extenuating circumstances or due to circumstances threatening the well-being of the patient.


– Modifier 52 used when procedure is partially reduced, completed or cancelled and no anesthesia is required.


• Proposal to reduce by 100% the cost of the device for device-dependent APCs will not be implemented

2016 Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals

� For drugs and biologicals, pass-through payment is the amount by which the drug or biological exceeds the portion of the otherwise applicable Medicare OPD fee schedule that is associated with the drug or biological (SI=G)

� Due to the postponement of the Part B Drug Competitive Acquisition Program, CMS pays the rate paid in the physician's office setting for all drugs and biologicals with pass-through status

– ASP + 6%


� 12 drugs and biologicals with pass-through status ending December 31, 2015

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� 32 drugs/biologicals have pass-through status (SI=G) in 2016





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� $100 per day cost threshold for separate payment (SI=K) of non-pass through drugs with payment at ASP+6% ($95 in 2015)

� Biosimilar products will be treated in a manner comparable to other drugs

– Pass through status determination and the $100 packaging threshold apply

� Packaging determinations will be made on a drug-specific basis rather than a HCPCS Code-specific basis for those HCPCS codes that describe the same drug or biological but different doses

� Non-pass-through therapeutic radiopharmaceuticals (per day cost of $100) payment is ASP + 6%

� Currently three diagnostic radiopharmaceuticals with pass-through payment

• A9586 Florbetapir f18, diagnostic, per study dose, up to 10 millicuries

• C9458 Florbetaben, f18, diagnostic, per study dose, up to 8.1 millicuries

• C9459 Flutemetamol, f18, diagnostic, per study dose, up to 5 millicuries


� Blood clotting factors under OPPS to be paid at ASP+6%

� Methodology for calculating high cost versus low cost skin substitutes is changing for 2016

– Skin substitutes with a weighted average mean unit cost (MUC) above $26 per square cm or per day cost (PDC) greater than $773 will be classified as “high cost”


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� 5 Biologicals that were in the skin substitute category because these products are typically used for internal surgery procedures to reinforce or repair soft tissues and not typically used to promote healing of skin.

– They will be packaged since they are integral to the surgical procedure

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Other 2016 OPPS Payment and Coding Changes

� Hospital coding and payment for visits

– Current single HCPCS Code G0463 for clinic visits will continue to be used in 2016

– No changes to current ED level structure


� Chronic Care Management visits

– CPT Code 99490- Chronic care management, at least 20 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month, with following required elements:

• 2 or more chronic conditions expected to last at least 12 months or until patient’s death;

• Chronic conditions place patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and

• Comprehensive care plan established, implemented, revised, or monitored



– The following additional requirement apply for hospitals to bill these visits:

• Documentation of the beneficiary’s agreement to have the services provided in the hospital medical record or in the beneficiary’s medical record that can be accessed by the hospital;

• Medical record documentation of all elements of the services were explained and offered to the beneficiary and they were provided the option to accept or decline the services;

• Only one hospital can bill for the services in a single calendar month service period

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– The following additional requirements apply for hospitals to bill this CPT Code:

• Creation of a structured clinical record in the EHR

• Access to care 24 hours/7 days per week

• Continuity of care with a designated practitioner

• Care management for chronic conditions

• Documentation of patient-centered plan of care

• Plan of care provided to beneficiary using EHR

• Management of care transition between various practitioners

• Coordination of care with home and community based providers

• Enhanced communication through secure messaging, internet, or other asynchronous non-face-to face consultations

• Use of EHR technology that has been certified under OC Health Information Technology Certification Program


• Partial Hospitalization

– Payment based on type of provider and number of services


• Inpatient only list is detailed in Addendum E

• 9 CPT Codes removed from the inpatient only list

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2016 Nonrecurring Policy Changes

• Advanced Care Planning Services

– Two CPT Codes created in 2015:

• 99497 Advanced care planning including explanation and discussion of advanced directives such as standard forms by qualified health professional, first 30 minutes, face-to-face with patient, family member and/or surrogates

– Packaged in 2015

– Changed to Status Indicator Q1 for 2016

• 99498 Advanced care planning including explanation and discussion of advanced directives such as standard forms by qualified health professional, each additional 30 minutes, face-to-face with patient, family member and/or surrogates

– Packaged in 2015 and 2016

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• Payment for CT Services

– CT exams provided using equipment that does not meet the attributes of the North American Electrical Management (NEMA) standards will result in:

• 5% payment reduction for the technical component in 2016

• 15% payment reduction for the technical component in 2017

• Limited to the following “CT” CPT Codes: 70450-70498, 71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-74178, 74261-74263, 75571-75574

– Modifier ”CT” must be put on claims for above CT studies performed on equipment not meeting the NEMA standards


• Lung Cancer Screening with low dose CT

– Two new HCPCS Codes implemented:

• G0296 Counseling visit to discuss need for low dose CT

• G0297 Low dose CT for lung cancer screening

• Corneal Tissue Payment in HOPD and ASC

– Corneal tissue acquisition costs related to use for non-corneal transplants such as tissue patches for glaucoma shunt surgery would no longer be paid separately

• Packaged in HOPD and ASC

• V2785 HCPCS Code for corneal acquisition costs would be reported and paid separately with the following CPT Codes: 65710, 65730, 65750, 65755, 65756, 65765, 65767

2016 OPPS Payment Status and Comment Indicators

• Addendum B of the Federal Register is your "guide"

– Pay attention to items with the following status indicators changes:

• “J2"-This status indicator has been added for payment of the C-APC for observation APC 8011

• “Q4”- This status indicator is used for conditionally packaged laboratory tests.

– Complete list of 2016 status indicators are listed in Addendum D1

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2016 OPPS Payment Status and Comment Indicators

• Addendum B of the Federal Register is your "guide"

– Pay attention to items with the following comment indicators:

• "CH"-Active HCPCS code with change in status indicator or APC assignment or active HCPCS code that is being discontinued.

• "NI"-Existing code with substantial change in 2016 with code descriptor or APC assignment

• “NP”-New code for 2016 or existing 2015 code with substantial change in 2016 with code descriptor or APC assignment

CPT Code Deletions-Required Actions

� Determine if there is a replacement for CPT Code deletion

– Determine replacement CPT Code

– Is there an impact on pricing?

� Revise charge master and related subsystems

� Provide education to clinical department on how to use the replacement CPT Code

� Verify in the charge master and subsystems that the CPT codes are deleted

� Monitor and test replacement CPT Codes

80

CPT Code Additions-Required Actions� Determine if new CPT Code is new service or replaces a deleted CPT

Code

� Determine if new CPT Code is reimburseable

– Category 3 CPT Codes implemented by CMS in July

� Determine if new CPT Code requires a pricing revision


� Provide education to clinical department on the new line item

� Verify the CPT codes are added correctly

� Monitor and test CPT Codes for accuracy of use

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CPT Code Revisions-Required Actions

� Determine the impact of the CPT Code revision


� Provide education to clinical department

� Verify the CPT code descriptions are revised accurately

� Determine if pricing change is required

� Monitor and test CPT Codes for appropriate use

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Laboratory

� There were 9 chromatography CPT Codes specific to the type of chromatography deleted in 2016

– Replaced by single chromatography code to be used irrespective of method unless constituent specific CPT Code is available

• 82542 Column chromatography includes mass spectrometry, if performed (e.g. HPLC, LC, LC/MS-MS, GC, GC/MS-MS, GC/MS, HPLC/MS) non-drug analytes not elsewhere specified, qualitative or quantitative, each specimen

� There were 2 mass spectrometry CPT Codes based on qualitative(83788) and quantitative analysis (83789) in 2015

– Replaced in 2016 by a revised CPT Code 83789 that includes both qualitative and quantitative mass spectrometry

� Numerous additions and revisions in the Molecular Pathology area again in 2016

83

Laboratory CPT Deletions

84

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Laboratory HCPCS Deletions

85

2015 HCPCS Code Short Descriptor Replacement 2016 Codes

G0431 Drug screen multiple class Applicable Drug Testing CPT Codes

G0434 Drug screen multi drug class Applicable Drug Testing CPT Codes

G0475 Hiv combination assay Applicable Drug Testing CPT Codes

G0476 Hpv combo assay ca screen Applicable Drug Testing CPT Codes

G6030 Assay of amitriptyline Applicable Drug Testing CPT Codes

G6031 Assay of benzodiazepines Applicable Drug Testing CPT Codes

G6032 Assay of desipramine Applicable Drug Testing CPT Codes

G6034 Assay of doxepin Applicable Drug Testing CPT Codes

G6035 Assay of gold Applicable Drug Testing CPT Codes

G6036 Assay of imipramine Applicable Drug Testing CPT Codes

G6037 Assay of nortiptyline Applicable Drug Testing CPT Codes

G6038 Assay of salicylate Applicable Drug Testing CPT Codes

G6039 Assay of acetaminophen Applicable Drug Testing CPT Codes

G6040 Assay of ethanol Applicable Drug Testing CPT Codes

G6041 Assay of urine alkaloids Applicable Drug Testing CPT Codes

G6042 Assay of amphetamines Applicable Drug Testing CPT Codes

G6043 Assay of barbiturates Applicable Drug Testing CPT Codes

G6044 Assay of cocaine Applicable Drug Testing CPT Codes

G6045 Assay of dihydrocodeinone Applicable Drug Testing CPT Codes

G6046 Assay of dihydromorphinone Applicable Drug Testing CPT Codes

G6047 Assay of dihydrotestosterone Applicable Drug Testing CPT Codes

G6048 Assay of dimethadione Applicable Drug Testing CPT Codes

G6049 Asssay of epiandrosterone Applicable Drug Testing CPT Codes

G6050 Assay of ethchlorvynol Applicable Drug Testing CPT Codes

G6051 Assay of flurazepam Applicable Drug Testing CPT Codes

G6052 Assay of meprobamate Applicable Drug Testing CPT Codes

G6053 Assay of methadone Applicable Drug Testing CPT Codes

G6054 Assay of methsuximide Applicable Drug Testing CPT Codes

G6055 Assay of nicotine Applicable Drug Testing CPT Codes

G6056 Assay of opiates Applicable Drug Testing CPT Codes

G6057 Assay of phenothiazine Applicable Drug Testing CPT Codes

G6058 Drug confirmation Applicable Drug Testing CPT Codes

Laboratory CPT Additions

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Laboratory HCPCS Additions

2016 HCPCS Code Short Descriptor

G0475 Hiv combination assay

G0476 Hpv combo assay ca screen

P9070 Pathogen reduced plasma pool

P9071 Pathogen reduced plasma sing

P9072 Pathogen reduced platelets

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Laboratory CPT Revisions

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Radiology� For hip radiography, the CPT Codes restructured based on unilateral 1

view, 2-3 views and minimum of 4 views. There is a comparable structure for bilateral hips.

� CPT Codes for operative hip radiography and infant hip radiography eliminated in 2016

� For femur radiography, now 2 CPT codes

� 73551- 1 view

� 73552-minimum 2 views

� For Interventional Radiology, there is continuing efforts to compress separate imaging and surgical component CPT Codes into a single CPT Code that includes both the imaging and surgical components

� Ensure pricing is evaluated to minimize gross revenue contraction

89

Radiology CPT Deletions

� The following CPT Codes were deleted in Radiology

90

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Radiology CPT Additions

� The following CPT Codes were added in Diagnostic Radiology

91

Radiology CPT Deletions

� The following CPT Codes were deleted in Interventional Radiology

92


� The following CPT Codes were added in Interventional Radiology

93

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� The following CPT Codes were added in Interventional Radiology

94


� The following CPT Codes were added in Nuclear Medicine

95

Radiology HCPCS Additions

� The following HCPCS Codes were added in Nuclear Medicine

96


C9458 Florbetaben, f18, diagnostic, per study dose, up to 8.1 millicuries

C9459 Flutemetamol f18, diagnostic, per study dose, up to 5 millicuries

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Radiology CPT Revisions

� The following CPT Codes were revised in Interventional Radiology

97


� The following CPT Codes were revised in Diagnostic Radiology

98


� The following CPT Codes were revised in Nuclear Medicine

99

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Radiation Therapy� Remote afterloading high dose rate radionuclide split in 2016 based on body

location(includes basic dosimetry):

– Skin source brachytherapy

• 77767 lesion diameter up 2.0 cm or 1 channel

• 77768 lesion diameter over 2.0 cm and 2 or more channels

– Interstitial or intracavitary brachytherapy

• 77770 1 channel

• 77771 2-12 channels

• 77772 over 12 channels

� CPT 77778 Interstitial radiation source application, complex now includes supervision, handling, loading of radiation source when performed

– 77776 simple application eliminated

– 77777 intermediate application eliminated

100

Radiation Therapy CPT Deletions

101

Radiation Therapy CPT Additions

102

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Radiation Therapy CPT Revisions

103

Cardiology CPT Deletions

104

Cardiology CPT Additions

105

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Endoscopy CPT Deletions

106

Endoscopy CPT Additions

107

Surgery CPT Deletions

108

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Surgery CPT Additions

109

Pharmacy CPT Deletions

110

Pharmacy HCPCS Deletions

111

2015 HCPCS Code Short Descriptor 2016 Replacement Code

C9025 Injection, ramucirumab J9308

C9026 Injection, vedolizumab J3380

C9027 Injection, pembrolizumab J9271

C9442 Injection, belinostat J9032

C9443 Injection, dalbavancin J0875

C9444 Injection, oritavancin J2407

C9445 C-1 esterase, ruconest J0596

C9446 Inj, tedizolid phosphate J3090

C9449 Inj, blinatumomab J9039

C9450 Fluocinolone acetonide implt J7313

C9451 Injection, peramivir J2547

C9452 Inj, ceftolozane/tazobactam J0695

C9453 Injection, nivolumab J9299

C9454 Inj, pasireotide long acting J2502

C9455 Injection, siltuximab J2860

C9456 Inj, isavuconazonium sulfate J1833

C9457 Lumason contrast agent None

J0886 Epoetin alfa 1000 units esrd Q4081

J9010 Alemtuzumab injection J0202

Q9975 Factor viii fc fusion recomb J7205

Q9976 Inj ferric pyrophosphate cit J1443

Q9977 Compounded drug noc J7999

Q9978 Netupitant palonosetron oral J8655

Q9979 Injection, alemtuzumab J0202

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Pharmacy CPT Additions

112

Pharmacy HCPCS Additions

113


C9460 Injection, cangrelor

J0202 Injection, alemtuzumab

J0596 Injection, ruconest

J0695 Inj ceftolozane tazobactam

J0714 Ceftazidime and avibactam

J0875 Injection, dalbavancin

J1447 Inj tbo filgrastim 1 microg

J1833 Injection, isavuconazonium

J2407 Injection, oritavancin

J2502 Inj, pasireotide long acting

J2547 Injection, peramivir

J2860 Injection, siltuximab

J3090 Inj tedizolid phosphate

J3380 Injection, vedolizumab

J7121 5% dextrose in lac ringers

J7188 Factor viii recomb obizur

J7205 Factor viii fc fusion recomb

J7313 Fluocinol acet intravit imp

J7340 Carbidopa levodopa enteral

J7512 Prednisone ir or dr oral 1mg

J7999 Compounded drug, noc

J8655 Netupitant palonosetron oral

J9032 Injection, belinostat, 10mg

J9039 Injection, blinatumomab

J9271 Inj pembrolizumab

J9299 Injection, nivolumab

J9308 Injection, ramucirumab

Q4161 Bio-connekt per square cm

Q4162 Amnio bio and woundex flow

Q4163 Amnio bio and woundex sq cm

Q4164 Helicoll, per square cm

Q4165 Keramatrix, per square cm

Q9950 Inj sulf hexa lipid microsph

Pain Management CPT Additions

114

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Ophthalmology CPT Deletions

115

Ophthalmology CPT Additions

116

Ophthalmology CPT Revisions

117

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Dermatology CPT Deletions

118

Dermatology Additions

119

Other CPT Deletions

120

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Other CPT Additions

121

Wrap up and Question/ Answers

122

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Presenter Information

Mike Kovar

410-916-0824

[email protected]

Taylor Pedone

440-666-0930

[email protected]

124

hfma new jersey 2016 charge master update …...overall impact of 2016 opps changes top 10 cpt code...

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