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And Happy Thanksgiving to You Too!

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Monday, December 2, 2013

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On the afternoon before Thanksgiving at 4:26 pm, my email inbox dinged with the arrival of the much anticipated 2014 OPPS Final Rule announcement. The Proposed Rule released earlier this year contained the most significant proposed changes to the Outpatient Prospective Payment System since its inception in 2000, including major changes to visit levels, the new concept of “comprehensive APCs”, and dramatic increases in packaging. So would CMS carry through on all these proposals? I anxiously began to read…

So let’s start with some good news:

  • They are not consolidating the five ED levels into one visit level. For 2014, hospitals will continue to use their existing self-defined five “E&M” levels to report ED visits. And there are still five incremental payment levels for these ED services.
  • They did finalize the establishment of comprehensive APCs but are delaying the implementation of this until 2015 and making some favorable modifications. Comprehensive APCs bundle the payment of all adjunctive services into the payment of the procedure code for 29 device-dependent APCs.
  • They eliminated two categories of proposed packaging – ancillary services with a status indicator of “X” and diagnostic tests on the bypass list. This means that routine x-rays, pathology services, a number of diagnostic respiratory services, plus many other services will not be packaged in 2014, but will continue to be paid separately.
  • They modified the packaging of add-on codes to exclude drug administration services and add-on codes associated with the future comprehensive APCs. For 2014 these types of add-on codes will continue to be paid separately.
  • They are creating new HCPCS codes to allow two levels of payment for skin substitute applications – a lower level of payment for low-cost skin substitutes and a higher level of payment for high-cost skin substitutes since the actual skin substitutes will be packaged.

But of course, CMS did not forsake or modify all of their proposals for 2014.

  • The five levels of new and established clinic visits (10 codes in total) are being deleted and replaced with one clinic visit code – G0463 with an unadjusted payment rate of $92.53.
  • The two levels of Observation composites (Extended Assessment and Management composites) are being consolidated into one composite level. This composite will be paid when at least eight observation hours are billed on the same day or the day after a clinic visit (G0463), a high level ED visit (99284, 99285, G0384, or 99291) or a direct referral to observation (G0379) if there is not a procedure code with an SI of “T”. The Observation composite unadjusted payment rate is $1,198.91.
  • Packaging has been extended to include:
  • All drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure including stress agents and Cysview
  • Drugs and biologicals that function as supplies when used in a surgical procedure including skin substitutes with the modification of two payment levels noted above
  • Clinical Diagnostic Laboratory Tests with the exceptions of laboratory tests unrelated to a primary service (billed on a 14x type of bill) and molecular pathology tests
  • Procedures described by add-on codes with the exceptions of drug administration codes and add-on codes associated with the proposed comprehensive APCs
  • Stress test (CPT code 93017) when performed with myocardial perfusion imaging
  • Device removal procedure when performed with a separately coded device repair or replacement procedure
  • Providers will no longer report device credits using modifiers FB and FC, but will now use value code FD and report the amount of the actual credit.
  • The nuclear medicine-to-radiopharmaceutical edits are being removed for 2014 although providers are still expected to report these services correctly. CMS is considering whether to continue claim processing procedure-to-device edits when comprehensive APCs are implemented in 2015. It was not clearly stated in the final rule whether these types of edits will remain for 2014.
  • The remaining stereotactic radiosurgery (SRS) HCPCS codes are being replaced with the SRS CPT codes, specifically HCPCS code G0173 is replaced with CPT code 77372 and HCPCS codes G0251, G0339 and G0340 are replaced with CPT code 77373. The final rule also provides guidance on the correct usage of the SRS CPT codes.

Obviously there is a lot more information and details in the over 1200 pages of the display copy of the Final Rule, but hopefully this addresses the major changes in which most providers are interested. We encourage everyone to listen and read carefully over the next month to gather all the information you will need for the new year concerning OPPS. In this week’s newsletter, please notice the 2014 Winter Outpatient Webinar that MMP will be presenting on December 12, 2013 at 1:00 pm CDT. In this webinar we will address the CPT and HCPCS code changes for 2014 and the OPPS final rule.

Happy Thanksgiving, Merry Christmas, and Happy New Year!!

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.