© 1999-2011 abbey & abbey, consultants, inc. slide # 1 opps update for cy2011 version 12.0 -...

© 1999-2011 Abbey & Abbey, Consultants, Inc. Slide # 1

OPPS Update for CY2011

Version 12.0 - GenericNotes © 1994-2011, Abbey & Abbey, Consultants, Inc.

CPT® Codes – © 2010-2011 AMA

Sponsored By:

APCNow Web Sitewww.APCNow.com

Presented By:

Duane C. Abbey, Ph.D., CFPAbbey & Abbey, Consultants, Inc.

[email protected] http://www.aaciweb.comhttp://www.APCNow.com http://www.HIPAAMaster.com


Presentation Faculty

Duane C. Abbey, Ph.D., CFP – Dr. Abbey is a healthcare consultant and educator with over 20 years of experience. He has worked with hospitals, clinics, physicians in various specialties, home health agencies and other health care providers.

His primary work is with optimizing reimbursement under various Prospective Payment Systems. He also works extensively with various compliance issues and performs chargemaster reviews along with coding and billing audits.

Dr. Abbey is the President of Abbey & Abbey, Consultants, Inc. A wide range of consulting services is provided across the country including charge master reviews, APC compliance reviews, in-service training, physician training, and coding and billing reviews.

Dr. Abbey is the author of eleven books on health care, including:•“Non-Physician Providers: Guide to Coding, Billing, and Reimbursement”•“Emergency Department: Coding, Billing and Reimbursement”, and •“Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance”.

His most recent books are:“Compliance for Coding, Billing & Reimbursement A Systematic Approach to Developing a Comprehensive Program”, “Introduction to Healthcare Payment Systems”, and “The Medicare Recovery Audit Contractor Program” are available from the CRC Press a Division of Taylor and Francis.


This workshop and other material provided are designed to provide accurate and authoritative information. The authors, presenters and sponsors have made every reasonable effort to ensure the accuracy of the information provided in this workshop material. However, all appropriate sources should be verified for the correct ICD-9-CM Codes, ICD-10-CM Diagnosis Codes, ICD-10-PCS Procedure Codes, CPT/HCPCS Codes and Revenue Center Codes. The user is ultimately responsible for correct coding and billing. The author and presenters are not liable and make no guarantee or warranty; either expressed or implied, that the information compiled or presented is error-free. All users need to verify information with the Fiscal Intermediary, Carriers, other third party payers, and the various directives and memorandums issued by CMS, DOJ, OIG and associated state and federal governmental agencies. The user assumes all risk and liability with the use and/or misuse of this information.

Disclaimer


To review the 2011 updates to the key features of the OPPS and the APC payment system.

To appreciated the trends in modifications being made to OPPS and APCs over the years.

To understand the complex nature of APCs and associated compliance issues including RAC concerns.

To appreciate the impact of proper coding and billing on APCs.

To understand the impact of the 2011 changes on the chargemaster, charges and the cost report for APCs.

To review the 2011 update on high impact areas such as observation, the Emergency Department, interventional radiology and associated areas.

To review changes to the Provider-Based Rule (PBR) for 2011.

To discuss anticipated future changes and directions for OPPS and APCs.

OPPS Update for CY2011Objectives


APCs – Ambulatory Payment Classifications APGs – Ambulatory Patient Groups ASC – Ambulatory Surgical Center CAH – Critical Access Hospital CCRs – Cost-to-Charge Ratios CPT – Current Procedural Terminology E/M – Evaluation and Management FFS – Fee-for-Service HCPCS – Healthcare Common Procedure Coding System ICD-9-CM – International Classification of Diseases, Ninth Edition, Clinical MAC – Medicare Administrative Contractor MedPAC – Medicare Advisory Commission MPFS – Medicare Physician Fee Schedule NCCI – National Correct Coding Initiative AWV – Annual Well Visit PPPS – Personalized Preventive Plan Services

OPPS Update for CY2011Acronyms/Terminology


NCD/LCD – National/Local Coverage Decision NTIOL –New Technology Intraocular Lens OCE – Outpatient Code Editor OPD – [Hospital] Outpatient Department OPPS – [Hospital] Outpatient Prospective Payment System PHP – Partial Hospitalization Program PM – Program Memorandum PPS – Prospective Payment System QIO – Quality Improvement Organization SI – Status Indicator ASC – Ambulatory Surgical Center RBRVS – Resource Based Relative Value System MPFS – Medicare Physician Fee Schedule Developed through RBRVS

Note: The Federal Register entry has pages of acronyms!

OPPS Update for CY2011Acronyms/Terminology


OPPS Update for CY2011General Comments

APCs are becoming increasingly complex and more difficult to understand. Enormous Federal Register entries are now the norm.

APCs represent a payment system that is out of control. Significantly increased bundling through packaging is still being added.

APCs appear to be moving back toward APGs. There are wide variations in payments from year to year. Significant compliance concerns exist within the overall APC payment

system. In some cases these compliance concerns result because of lack of

explicit guidance from CMS. At some point the RAC auditors will become more involved in APCs.

APCs and the underlying coding systems (i.e., CPT and HCPCS) generate constant change and the need to update.

Tracking and verifying that correct payment is received is difficult. It is critical to track adjudication and overall payment.

Major issues with hospital charges, CCRs and the cost report are present.

Federal Register Fanatics Look for how many times the word ‘believe’ is used by CMS. What are you allowed to ‘believe’?


OPPS Update for CY2011General Comments

Note: All citations to the Federal Register are to the official Federal Register is published on November 24, 2010. This Federal Register is 781 pages!!

Official Title for this OPPS Update Federal Register: Hospital Outpatient Prospective Payment System and CY 2011 Payment

Rates; Ambulatory Surgical Center Payment System and CY 2011 Payment

Rates; Payments to Hospitals for Graduate Medical Education Costs; Physician Self-Referral Rules and Related Changes to Provider

Agreement Regulations; Payment for Certified Registered Nurse Anesthetist Services Furnished

in Rural Hospitals and Critical Access Hospitals• Note that there are even more topics addressed such as the

Provider-Based Rule (PBR), physician supervision requirements, changes in observation.

• All the contents of this FR should be carefully studied.• Additional information is available at the CMS website:

https://www.cms.gov/HospitalOutpatientPPS/


APC Fundamentals Encounter Driven System

• Some Exceptions – Example: Two separate blood transfusions on the same day or two imaging services at different times on the same day.

CPT/HCPCS Code Driven

• If the service is not coded with a CPT or HCPCS (and/or proper modifiers), then there will be absolutely no payment!

APC Grouper Multiple APCs from Given Claim Inpatient-Only Procedures

• Surgery, if performed outpatient, will not be paid at all! (Patient Liability?)

• How is this list determined? Covered, Non-Covered and Payment System Interfaces

• Example: Self-Administrable Drugs Pass-Through Payments – Directly Based on Charges Made – Covert

Charges to Costs How?

OPPS Update for CY2011APC Background Information


APC Weight, and Thus Payment, Determination Hospital Charges Converted to Costs

• How is this done?

• Do we charge for everything?

• Do we charge correctly for everything? Statistical Process Using the Costs

• Geometric Mean

• Mean Cost for Given APC/Mean Cost for All APCs = the APC Weight Variation of Costs Within a Given APC Category

• 2-Times Rule – If highest cost is more than twice the lowest cost then violation.

• 2-Times Rule Exception List Examples:

o APC=0080 Diagnostic Cardiac Catheterization

o APC=0604 Level 1 Hospital Clinic Visits



Use of Claims to Statistically Develop the APC Weights

Because outpatient encounters often involve multiple services, the APC grouping process often (if not a majority of the time) generates multiple APCs.

CMS can use only pure claims, that is, claims that group to a single APC. These are called ‘singleton’ claims.

CMS is trying very hard to get around this situation because most of the claims filed by hospitals never get considered when the actual APC weights are determined.

• Small Example: CPT=86891 – Intra- or Post-Operative Blood Salvage

A device is used to save blood, reprocess the blood and generally re-infuse.

Is it possible to have ONLY 86891 on a claim? What kind of payment do we have for 86891? What are the costs involved?



APC Cost Outliers Complicated Two-Tiered Formula Based on Excessive Costs - How are costs determined? Nationally, does CMS make full outlier payments?

Provider-Based Rule (42 CFR §413.65) Provider-Based Clinics Provider-Based Clinical Services Potentially, two claim forms filed – CMS-1450 (UB-04) for technical

component and CMS-1500 (1500) for professional component. Reduction in payment for professional component

• Site-of-Service Differential in RBRVS (MPFS)

• Place-of-Service (POS) driven on CMS-1500 Series of Criteria to Meet If to be Provider-Based

• On-Campus versus Off-Campus

• See Physician Supervision Developments Important Changes in rules, regulations and interpretations.



ASCs – Ambulatory Surgical Centers In CY2008 CMS Started a Hybrid of APCs and RBRVS FR entries for APCs will now also be for ASCs ASC Surgery List

• Regular ASC Surgeries

• Office-Based Surgeries New Additions

• Conditions for Coverage (CfCs) New Acronym

• Additions and Deletions to Lists Payment Formula

• ASC Surgery 65% of APC

• Office-Based Surgeries – Lesser of: 65% of APC or Non-Facility PE RVU from MPFS

• Physician Paid Facility MPFS (As With Hospitals) Separate Payment for Certain Ancillary Services Did all the features of APCs translate over?



OPPS Update for CY2011By The Numbers

Basically a 2.6% Market Basket Update Less 0.25% by ACA Thus, 2.35% Increase – Conversion Factor = $68.876 Assumes Quality Reporting – 2.00% Decrease If Not ($67.530)

• Conversion Factor $66.059 in CY2009 to $67.439 for CY2010 Wage Index Changes See IPPS Statewide CCRs See Table 15 SCHs 7.10% Increase on Budget Neutral Basis (Includes EACHs) Cost Outlier

Fixed Threshold from $2,175.00 for CY2010 to $2,025.00 for CY2011• This is a fairly significant decrease.• Remember, there is a double threshold, ‘1.75 times the APC

payment’ threshold is unchanged. Labor-Related Calculation Remains the same. Co-Payment Amounts

Still struggling to get to the target of a 20% coinsurance to calculate the copayment amount.

Drug Packaging Threshold $60.00 for CY2009 moved to $65.00 for CY2010 and $70.00 for CY2011

Final ASC Conversion Factor - $41.939 ($41.939/$68.876 = 60.89%)



TOPs – Transitional Outpatient Payment Pre-BBA Payments vs. OPPS Payments

• Starting January 1, 2011 – No longer in effect for SCHs and Rural Hospitals with Less Than 100 Beds That Are Not SCHs.

See also, Children’s Hospitals and Cancer Hospitals• Permanently Held Harmless under TOPs• “The many public comments we received have identified a broad

range of very important issues and concerns associated with the proposed cancer hospital adjustment. After consideration of these public comments, we have determined that further study and deliberation related to these issues is critical.” (Page 71887 – 75 FR 71887)

Wage Index “The IPPS wage index that we are adopting in this final rule with

comment period includes all reclassifications that are approved by the Medicare Geographic Classification Review Board (MGCRB) for FY 2011.” (Page 71878 – 75 FR 71878)

Reclassifications Under Section 508 – Highly specialized situations. See FY2010 IPPS/LTCH PPS Federal Register dated June 2, 2010.



Wage Index – Continued

“… we continue to believe that using the IPPS wage index as the source of an adjustment factor for the OPPS is reasonable and logical, given the inseparable, subordinate status of the HOPD within the hospital overall. Therefore, as we proposed, we are using the final FY 2011 IPPS wage indices for calculating OPPS payments in CY 2011.” (Page 71879 – 75 FR 71879)


OPPS Update for CY2011Recalibration of APC Relative Weights

Recalibration and Rebasing Process OPPS Update Federal Registers – Typically Long Discussions Calculation of Median Costs Within APC Categories Single Procedure Claims versus Multiple Procedure Claims

• Methodology Carried Over From DRGs – Doesn’t Really Work• Pseudo Single Procedure Claims• Bypass Codes

CCRs – Cost-to-Charge Ratios from Cost Reports• See Revenue Code-to-Cost Center Crosswalk• CT & MRI Equipment – Major Moveable vs. Building Equipment

(Page 103 – CMS-1504-FC) Device Dependent APCs – Expensive Implant or Supply Item Is Larger

than Payment for Service Blood and Blood Products Still Equalizing Payments Due To

Incorrect CCRs Updated CPT/HCPCS Codes Updated Status Indicators Affecting Packaging

• See Also – Packaged Revenue Codes – Table 3 Payment Variations See 2-Times Rule + Payment Change Limitations Composite APCs Observation, Pulmonary Rehab, Etc.


OPPS Update for CY2011Recalibration of APC Relative Weights

Recalibration and Rebasing Process Observation Composite – Minor Surgical Procedures Creating SI=“T”

Packaging• CMS did comment to this (page 209 – CMS-1504-FC), but clearly

CMS did not understand the question that was raised.• Brief Example: Patient presents through the ED with chest pains

and a minor laceration. Chest pain protocol directs observation while the minor laceration generates an SI=“T” so that the observation payment is packaged into the laceration repair payment, creating a significant loss.

Multiple Imaging Families – Started in CY2009• Significant Concerns By Hospitals• Continue with the Composite APCs (8004-8008)

Packaging Services• See SI=“Q1”, “Q2”, and “Q3”• Dependent and Independent Methodology• CPT=19295 – Localization Clip, Breast SI=“Q1” – APC=0340 -

$46.23 for CY2011• Other Specific CPT/HCPCS Codes – Including SI=“N”


As usual there are hundreds of changes for both CPT and HCPCS. The rate of change for 2011 is in a fairly normal range.

HOWEVER, some of the CPT changes have a significant impact on APC grouping and the logic in the I/OCE (Integrated Outpatient Coded Editor). Therapeutic Vascular Catheterization Services - Major revisions to CPT.

For Lower Extremities (sub-inguinal). Here is one sequence:• 37224 – Revascularization, endovascular, open or percutaneous,

femoral/popliteal artery(s), unilateral; with transluminal angioplasty• 37225 – with atherectomy, includes angioplasty within the

same vessel, when performed• 37226 – with transluminal stent placement(s), includes

angioplasty within the same vessel, when performed

• 37227 - with transluminal stent placement(s) and atherectomy, includes angioplasty within the

same vessel Note the ‘open or percutaneous’ and also the hierarchical

structuring of the angioplasty, atherectomy and stent placements. See pages 172-182 of CMS-1504-FC for APC assignment and

payment calculations.

OPPS Update for CY2011CPT/HCPCS Changes For CY2011



High APC Impact CPT/HCPCS Changes Endovascular Revascularization CPT Codes (37220-37235)

• CMS had to map combinations of old codes into new codes and then determine median costs and then assign APCs. The actual payment amount for the APCs includes other cost data.

• 37205+36245+75960+35454 37221 (As An Example) Median Cost = $6,710.00 APC=0083 For CY2011 APC=0083 Pays $3,780.18

o Note that there is quite a difference between the median cost and the actual payment amount for APC=0083.

• Other APCs Considered APC=0229 – $8,025.25 APC=0319 - $13,898.71

• Note: Without much doubt, payment for these new revascularization codes is skewed, probably downward. It will take several years for the payment amount to stabilize based on costs determined from charges. It will be two years before cost data is available directly for the new codes.

Hospitals should carefully model the financial impacts.



High APC Impact CPT/HCPCS Changes

Diagnostic Coronary Catheterization Services (Non-Congenital)• Comprehensive Reworking of These Codes for CPT• Previous Code Structure –

Catheterization APCs Generally Pays For This Component Injection Radiological S&I

o Combination of Codes Used• New Code Structure Utilizes Single Codes for Catheterizations and

Associated Services• Everything goes into APC=0080 $2,726.85• See Pages 182-192 of CMS-1504-FC For Discussion

There is a comment period available on the methodology that CMS used to calculate this payment.

Be sure to check for financial impact in your setting. This change will probably create some significant financial changes.



Other CPT/HCPCS Changes

Some of the other changes have created some reaction for APCs.

Critical Care CPT=99291

• CPT is now stating that the associated services (e.g., chest x-ray, intubation, vascular access, etc.) can be separately reported on the hospital, facility side.

• Over the years there has been some controversy in this area relative to the NCCI edits and variable CMS guidance.

• “Therefore, for CY 2011, we will continue to recognize the existing CPT codes for critical care services and are establishing a payment rate based on our historical data, into which the cost of the ancillary services is intrinsically packaged, and we will implement claims processing edits that will conditionally package payment for the ancillary services that are reported on the same date of service as critical care services in order to avoid overpayment.” (Page 71988 – 75 FR 71988)



HCPCS Changes The January 1, 2011 update for HCPCS contains approximately 146 new

codes and modifiers. Most of the changes have low impact on APCs and the APC grouping

process as such. Most of the changes are of interest to Chargemaster Coordinators and

selected service areas. Among the New Modifiers

• “-PT” – Colorectal Cancer Screening Converted to Diagnostic Test

• “-GU” – Wavier of Liability Statement Issues As Required By Payer Policy, Routine Notice

Among the New Codes

• G0157-G0161 – PT/OT/ST Services in the Home

• G0162-G0164 – Skilled Services by LPN or RN

• G0438-G0439 – AWV with PPPS

• G0436-G0437 – Smoking and Tobacco Cessation Counseling

• G8647-G8674 – Orthopedic Functional Status Change


OPPS Update for CY2011Composite APCs – Issues and Changes

Composite APCs Observation – APC=8002 and APC=8003

• See Minor Surgery – Status Indicator “T” Bundling Issue• APC 8002 $394.22/$381.34 and APC 8003 $714.33/$705.27

LDR Prostate Brachytherapy – APC=8001• CPT=55875+77778• CY2011 $3,229.24; CY2010 $3,112.61

Electrophysiology Studies – APC=8000• APC 8000 $10,787.46/$10,118.25• Problematic Area – High variability of services, thus costs.

Mental Health Services – APC=0034• See Payment Limit for APC=0176 (Full Day Partial Hospitalization)• APC 0034 - $238.33/$210.89

Multiple Imaging – APCs – 8004, 8005, 8006, 8007, 8008• See new CPT Sequence 74176-74178• “As we stated in the CY 2010 final rule with comment period (74 FR

60399), we do not agree with the commenters that multiple imaging procedures of the same modality provided on the same date of service but at different times should be exempt from the multiple imaging composite payment methodology.” (Page 71858)


OPPS Update for CY2011On-Going APC Issues

New CPT/HCPCS Codes – CMS Process and Timeframes Inclusion of the comment process – Timing Considerations

H1N1 Vaccine and Vaccination Discussion Variation Within APC Categories

2-Times Rule Statistical Measure of Too Much Variation• “… the median cost of the highest cost item or service within an

APC group is more than 2 times greater than the median of the lowest cost item or service within that same group.” (Page 71900 – 75 FR 71900)

• Question: How many years can an APC be repeatedly on the list?• How is this affecting you?

0057 Bunion Procedures 0058 Level I Strapping and Cast Application 0060 Manipulation Therapy 0076 Level I Endoscopy Lower Airway 0080 Diagnostic Cardiac Catheterization 0083 Coronary and Noncoronary Angioplasty and Percutaneous

Valvuloplasty



Variation Within APC Categories 0105 Repair/Revision/Removal of Pacemakers, AICDs, or Vascular

Devices 0133 Level I Skin Repair 0142 Small Intestine Endoscopy 0203 Level IV Nerve Injections 0235 Level I Posterior Segment Eye Procedures 0245 Level I Cataract Procedures without IOL Insert 0303 Treatment Device Construction 0304 Level I Therapeutic Radiation Treatment Preparation 0340 Minor Ancillary Procedures 0341 Skin Tests 0343 Level III Pathology 0432 Health and Behavior Services 0433 Level II Pathology 0604 Level 1 Hospital Clinic Visits 0607 Level 4 Hospital Clinic Visits 0664 Level I Proton Beam Radiation Therapy



New Technologies Movement from New Technologies to Clinical APCs

Specific APC Categories – Payment and Code Mappings (Selected Examples) Myocardial PET Imaging (APC 0307) Implantalbe Loop Recorder Monitoring (APC 0691) Upper GI Endoscopy (APCs 0141, 0384, and 0422) Pain Related Procedures (APCs 0203, 0204, 0206, 0207, and 0388) Device Construction for IMRT (APC 303) Skin Repair (APCs 0134 and 0135) Group Psychotherapy (APCs 0322, 0323, 0324, and 0325)

• These APCs, among others, certainly are worthy of comments relative to inappropriate payment levels and/or APC assignment. CMS is generally not inclined to move from their cost data approach.

Device Payment Device Dependent APCs No Cost/Full Credit and Partial Credit Hospitals, overall, tend to undercharge for devices. See issues such as

charge compression.



Drugs, Biological, and Radiopharmaceuticals

Transitional Pass-Through Payment Process

Packaging Criteria

Payment Offset Policy for Diagnostic Radiopharmaceuticals

• “Establishing the “FB” modifier to correctly account for diagnostic radiopharmaceuticals received free of charge allows for the diagnostic radiopharmaceutical to be reported and coded correctly on the same claim as the nuclear medicine scan, therefore fulfilling the required radiolabeled product edits.” (Page 71935 – 75 FR 71935)

CMS Posting Offset Amounts for All Affected APCs

Policy-Packaged Drugs and Devices

340B Hospitals – Data Considerations



Drugs, Biological, and Radiopharmaceuticals

“… we have encouraged hospitals to consider reporting all drugs in revenue code 0636 (Pharmacy-Extension of 025X; Drugs Requiring Detailed Coding) only to improve HCPCS coding for packaged drugs and biologicals in our claims data to improve the accuracy of our ASP+X calculation. We continue to believe that more complete data from hospitals identifying the specific drugs that were provided during an episode of care will improve payment accuracy for separately payable drugs in the future. However, we believe hospitals should report diagnostic radiopharmaceuticals with the most appropriate revenue code, and we are confident that coding for diagnostic radiopharmaceuticals will occur because of our claims edits for radiolabeled products.” (Pages 71965 – 75 FR 71965)

• See also Revenue Codes 025X and 062X. What is CMS trying to tell us?



Brachytherapy Sources – See Various A-Codes and C-Codes Congressional Mandate – Pay Separately

• Otherwise CMS would probably package these sources into the associated service.

Pass-Through Payment (Sort Of) Up To CY2009 – SI=“H” “K” “U”• CMS’s interpretation of ‘charges adjusted to cost’ is interesting.

CMS Has Developed a Discrete ‘Mini’ APC System for Sources• Eligible for Cost Outliers• SCH 7.10% Increase• New Brachytherapy Sources Individual APCs-External Data

“Nevertheless, we believe that prospective payment for brachytherapy sources based on median costs from claims calculated according to the standard OPPS methodology is appropriate and provides hospitals with the greatest incentives for efficiency in furnishing brachytherapy treatment.” (Page 71879 – 75 FR 71879)

“Under the budget neutral provision for the OPPS, it is the relativity of costs of services, not their absolute costs, that is important, and we believe that brachytherapy sources are appropriately paid according to the standard OPPS payment approach.” (Page 71879 – 75 FR 71879)



Drug Administration Services An area of considerable changes over the last several years. Coding and Charge Capture Difficulties APC Panel Recommendation – Pay separately for CPT 96368 and 93676,

that is, concurrent infusion and additional pushes

• CMS has rejected this recommendation and will continue with the five level APC structure for injections and infusions.

APC CY2011 CY2010 CY2009

0436 $26.35 $25.67 $25.03

0437 $36.88 $37.44 $36.66

0438 $75.58 $75.69 $74.32

0439 $128.44 $126.78 $126.80

0440 $205.86 $219.96 $191.06



Partial Hospitalization Services Hospitals vs. CMHCs

• Two Tiered Costs Structure – Cost Report Data HCRIS• Two Sets of APCs

APC=0172/0173 Level I and II at CMHC APC=0175/0176 Level I and II at Hospital

“… we have decided to provide a 2-year transition to CMHC rates based solely on CMHC data for the two CMHC PHP APC per diem rates. For CY 2011, the CMHC PHP APC Level I and Level II rates will be calculated by taking 50 percent of the difference between the CY 2010 final hospital-based medians and the CY 2011 final CMHC medians and adding that number to the CY 2011 final CMHC medians.” (Page 71993 – 75 FR 71993)

APC CY2011 CY2010

0172 $129.64 $149.84

0173 $164.43 $210.89

0175 $204.89 [$149.84]

0176 $238.33 [$210.89]



Partial Hospitalization Services Cost Report Data for CMHCs Through HCRIS Separate Cost Outlier Payments to CMHCs

• “After consideration of the public comments we received, we are finalizing our CY 2011 proposal to set a separate outlier threshold for CMHCs.” (Page 71995 – 75 FR 71995)

Inpatient-Only Procedures Commenters continue to recommend doing away with this list.

• Why is CMS so adamant about having this list?• “We continue to believe that the inpatient list is a valuable tool for

ensuring that the OPPS only pays for services that can safely be performed in the hospital outpatient setting, and we will not eliminate the inpatient list at this time.” (Page 71997 – 75 FR 71997)

Additions and Deletions to the List “We expect hospitals to be aware of the services that are being

provided in the outpatient setting. Hence, we do not believe that it is appropriate to pay the hospital for the ancillary services furnished when the patient receives an inpatient only service in the hospital outpatient setting.” (Page 71997 – 75 FR 71997)



“-CA” Modifier – APC=0375 APC 0375 - Ancillary Outpatient Services When Patient Expires

• Example: Patient rushed to hospital ED, taken to surgery and then expires without being admitted to hospital.

• Blanket payment for various types of procedures. Better Database and Proper Utilization

• CY2011 $6,372.10

• CY2010 $5,965.94

• CY2009 $4,770.52

• CY2008 $5,006.13 Question: Why don’t we use a process similar to the “-CA” modifier for

inpatient only procedures that are inadvertently performed on an outpatient basis?

• We could do away with the inpatient-only list, and at least there would be a default average payment for such services instead of making then the patient’s liability.


OPPS Update for CY2011Physician Supervision Changes

Starting in CY2008 the Issue of Physician Supervision Took On A Life Of Its Own Previous guidance was provided in April 7, 2000 Federal Register

relative to direct physician supervision at off-campus provider-based clinics.

In CY2008 CMS started clarifying their guidance on this requirement as part of the Provider-Based Rule (PBR).

From CY2008 to the present there has been significant discussions in the Federal Registers and changes to the CMS manuals.

Distinguish• Diagnostic vs. Therapeutic Supervision• Off-Campus vs. On-Campus (Out-of-Hospital) vs. In-Hospital• General vs. Direct vs. Personal Supervision

General Application of “Incident-To” From the SSA CAH Issue – Differences in requirement from the CAH CoPs and the

PBR Supervision requirements. Note: At issue is a significant compliance concern. If auditors were to

determine that proper physician supervision was not provided, then recoupments could be demanded.



Physician Supervision Discussions

“The definition of direct supervision will be revised simply to require immediate availability, meaning physically present, interruptible, and able to furnish assistance and direction throughout the performance of the procedure but without reference to any particular physical boundary. Since the new definition will now apply equally in the hospital or in on-campus or off-campus PBDs, we are removing paragraphs (a)(1)(iv)(A) and (B) of §410.27 altogether. The new definition of direct supervision under §410.27(a)(1)(iv) will now state, “For services furnished in the hospital or CAH or in an outpatient department of the hospital or CAH, both on- and off-campus, as defined in section 413.65 of this subchapter, ‘direct supervision’ means that the physician or nonphysician practitioner must be immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician or nonphysician practitioner must be present in the room when the procedure is performed.” (Page 72008 – 75 FR 72008)



Physician Supervision “For pulmonary rehabilitation, cardiac rehabilitation, and intensive

cardiac rehabilitation services, direct supervision must be furnished by a doctor or medicine or osteopathy as specified in §§410.47 and 410.49, respectively.” (Page 72008 – 75 FR 72008)

“This new definition of direct supervision will apply to hospitals and CAHs equally beginning in CY 2011. However, as already discussed, we are extending our notice of non-enforcement to CAHs and small rural hospitals with 100 or fewer beds through CY 2011.” (Page 72008 – 75 FR 72008)

“This extension will allow CAHs and small rural hospitals to prepare to meet this definition of direct supervision in CY 2012.” (Page 72008 – 75 FR 72008)

“Although commenters again requested this year that we revise our definition of immediately available to recognize availability by telephone or modes other than in person, we believe that the requirement for physical presence distinguishes direct supervision from general supervision.” (Page 72008 – 75 FR 72008)



Physician Supervision “… we intend to establish an independent review process to assess the

appropriate supervision levels for specific services.” (Page 72008 – 75 FR 72008)

Nonsurgical Extended Duration (Therapeutic) Services• Infusions, Injections, Observation• Not Chemotherapy or Blood Transfusions• ‘Initiation’ vs. ‘Stable’

Partial Hospitalization Services at CMHCs• Only General Supervision

Diagnostic Services See MPFS Supervision Levels• General• Direct • Personal

Exactly, where does this leave us relative to the physician supervision requirements? (See also, proposed H.R. 6376)

• A major change appears to be that the supervising physician or qualified NPP does not have to be on the campus, just immediately available.

• See ‘clinical appropriateness’ and ‘ability to step in and perform’.


OPPS Update for CY2011Hospital Outpatient Visits

Hospital Outpatient Visits – A Continuing Area of Challenge New vs. Established Patients – Registration within 3 years.

• This will continue even though some concerns. ED Coding and Payment

• Type A vs. Type B• Triage-Only Services – Yes, No, Maybe?

Critical Care Codes – CPT Changes See Status Indicator “Q1”• “For CY 2011, the AMA CPT Editorial Panel is revising its guidance

for the critical care codes to specifically state that, for hospital reporting purposes, critical care codes do not include the specified ancillary services. Beginning in CY 2011, hospitals that report in accordance with the CPT guidelines will begin reporting all of the ancillary services and their associated charges separately when they are provided in conjunction with critical care.” (Page 71988 – 75 FR 71988)

• “…, and we will implement claims processing edits that will conditionally package payment for the ancillary services that are reported on the same date of service as critical care services in order to avoid overpayment.” (Page 71988 – 75 FR 71988)



Visit Reporting Guidelines

“We continue to believe that, based on the use of their own internal guidelines, hospitals are generally billing in an appropriate and consistent manner that distinguishes among different levels of visits based on their required hospital resources. As a result of our updated analyses, we are encouraging hospitals to continue to report visits during CY 2011 according to their own internal hospital guidelines.” (Page 71989 – 75 FR 71989)

“We agree with the commenters that national guidelines should be clear, concise, and specific with little or no room for varying interpretations, and that hospitals should have at least 1 year to prepare for the transition. If the AMA were to create facility specific CPT codes for reporting visits provided in HOPDs, we would certainly consider such codes for OPPS use.” (Page 71990 – 75 FR 71990)

• How amazing! CMS seems to suggest that the AMA through CPT should develop new codes and/or national guidelines!



Outpatient Visit Payment Changes – Clinic Visits and ED Visits

APC Description CY2011 CY2010 CY2009

0604 Clinic Lev 1 $52.36 $57.92 $55.34

0605 Clinic Lev 2 $75.13 $69.68 $68.23

0606 Clinic Lev 3 $99.71 $89.12 $87.71

0607 Clinic Lev 4 $128.48 $113.44 $116.77

0608 Clinic Lev 5 $168.92 $167.52 $155.05

CPT APC 2011Pay

2010 Pay

2009 Pay

SI

99281 0609 $51.77 $53.16 $52.66 V

99282 0613 $87.25 $87.85 $86.14 V

99283 0614 $139.14 $140.18 $136.70 V

99284 0615 $222.58 $223.17 $217.91 Q3

99285 0616 $329.54 $329.73 $323.90 Q3


OPPS Update for CY2011Additional Issues

Preventive Services Affordable Care Act increased the number of covered preventive

services. Payment by Medicare is at 100% for the most part.

• PSA (Prostate Specific Antigen) is fully paid• AWV – Annual Wellness Visit

“That is, we will pay either the practitioner or the facility for furnishing the AWV providing PPPS in a facility setting, and only a single payment under the MPFS will be allowed.” (Page 72016 – 75 FR 72016)

How will this work? Not paid through OPPS. See the rather lengthy Table 48B.

Colorectal Cancer Screening New Modifier “-PT” to report procedures in lieu of the screening.

Multiple Procedure Reductions for Physical Therapy See MPFS. Payment for PT/OT/ST is determined from the MPFS and

RBRVS although paid through claims on the UB-04. Status Indicators

No major changes.


OPPS Update for CY2011Ambulatory Surgical Centers

ASC Payment Process Now a hybrid of APCs and MPFS. Calculation of ASC Payments Depends on Lists of Surgical Procedures

• Office-Based vs. OP Hospital vs. IP Hospital

• ASCs Surgical Procedures Include Office-Based and Certain OP Hospital Surgeries The process for determining these lists is all-important for ASCs.

Concerns for excluding surgeries from ASCs. Treatment of new codes. Determination of covered services, drugs, biologics, etc.

Transitional Payment Rate Are No Longer In Use Many issues that are present for OPPS in general (e.g., “-FB” and “-FC”

modifiers, preventive services, etc.) are present for ASCs also.

• See NTIOLs relative to cataract surgery.

• Significant discussions for cataract surgeries at ASCs.


OPPS Update for CY2011Reporting Quality Data

HOP QDRP Quality Measures There is an extensive discussion in the Federal Register addressing

Quality Data Reporting. Quality Reporting In Multiple Settings “ … we continue to believe that it is also appropriate and desirable to

adopt for the HOP QDRP measures that have been specifically developed for application only in the hospital outpatient setting because hospital outpatient settings present unique challenges in the operational and clinical aspects of care…” (Page 72065 – 75 FR 72065)

For CY2010 – Continued 7 measures and added 4 new imaging measures

“For the CY 2011 payment determination, we did not add any new HOP QDRP measures. We indicated our sensitivity to the burden upon HOPDs associated with chart abstraction and stated that we seek to minimize the collection burden associated with quality measurement.” (Page 72066 – 75 FR 72066)



HOP QDRP Quality Measures Expansion for CY2012, CY2013 and CY2014

• Process for Determining Measures• CY2012

“In summary, for the CY 2012 payment determination, we are retaining the 11 existing HOP QDRP measures from the CY 2011 payment determination, adding one new structural measure, and adding 3 new claims-based imaging efficiency measures for a total of 15 measures.” (Page 72083 – 75 FR 72083)

OP-12: The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their Qualified/Certified EHR System as Discrete Searchable Data

OP-13: Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery

OP-14: Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT)

OP-15: Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache




• CY2013 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

OP-17: Tracking Clinical Results between Visits OP-18: Median Time from ED Arrival to ED Departure for

Discharged ED Patients OP-19: Transition Record with Specified Elements Received by

Discharged Patients OP-20: Door to Diagnostic Evaluation by a Qualified Medical

Professional OP-21: ED- Median Time to Pain Management for Long Bone

Fracture OP-22: ED- Patient Left Before Being Seen 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




• CY2014 “After consideration of the public comments we received, we

are finalizing the retention of the 23 measures adopted for the CY 2013 payment determination, but are not at this time adopting any of the new measures proposed for the CY 2014 payment determination. As of now, a total of 23 measures will be used for the CY 2014 payment determination.” (Page 72094 – 75 FR 72094)

Beyond CY2014, CMS Is considering a number of other measures number 35 as listed in the Federal Register.

• Heart Failure – 12 Measures• Emergency Department – 7 Measures



Changes in Payment for GME/IME Costs

“The recently enacted Patient Protection and Affordable Care Act (Pub. L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub. L. 111-152) made a number of statutory changes relating to the determination of a hospital’s FTE resident count for direct GME and IME payment purposes and the manner in which FTE resident limits are calculated and applied to hospitals under certain circumstances.” (Page 72134 – 75 FR 72134)

Counting Resident Time in Non-provider Settings

Counting Resident Time for Didactic and Scholarly Activities and Other Activities

Reductions and Increases to Hospitals’ FTE Resident Caps for GME Payment Purposes

Preservation of Resident Cap Positions from Closed Hospitals

• This is a fairly esoteric topic. See teaching hospitals.



Physician Self-Referral Prohibition “Section 1877 of the Act, also known as the physician self-referral law:

(1) prohibits a physician from making referrals for certain “designated health services” (DHS) payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership or compensation), unless an exception applies; and (2) prohibits the entity from filing claims with Medicare (or billing another individual, entity, or third party payer) for those DHS furnished as a result of a prohibited referral.” (Page 72240 – 75 FR 72240)

A series of changes was mandated by Section 6001(a)(2) of ACA.• Physician Ownership and Provider Agreement• Expansion of Facility Limitations• Prevent Conflicts of Interest• Patient Safety• Converting from ASC• Enforcement• Publication of Information• CoPs for Hospitals• Collection of Information



CRNA Services at Rural Hospitals and CAHs

“In the FY 2011 IPPS/LTCH PPS final rule (75 FR 50299), we adopted a policy that would allow otherwise eligible critical access hospitals (CAHs) or hospitals that have reclassified from urban to rural status under section 1886(d)(8)(E) of the Act and 42 CFR 412.103 to receive reasonable cost payments for anesthesia services and related care furnished by nonphysician anesthetists (referred to in this section as CRNA pass-through payments), effective for cost reporting periods beginning on or after October 1, 2010.” (Page 72256 – 75 FR 72256)

“We are amending the regulations at 42 CFR 412.113(c)(2)(i)(A) to provide for an effective date of December 2, 2010, for all hospitals and CAHs to begin receiving CRNA pass-through payments for anesthesia services and related care furnished by nonphysician anesthetists.” (Page 72257 – 75 FR 72257)

• This appears to be a technical correction relative to dates and timing for application of these provisions.


OPPS Update for CY2011Special Issues

Charges, Cost-to-Charge Ratios (CCRs) and Cost Reporting “Since the implementation of the OPPS, some commenters have raised

concerns about potential bias in the OPPS cost-based weights due to ‘‘charge compression,’’ which is the practice of applying a lower charge markup to higher-cost services and a higher charge markup to lower-cost services.” (74 FR 60342)

• Note: Interesting that this became an issue with MS-DRGs, not APCs.

RTI, International (outside consulting firm) made recommendations. “Specifically, we created one cost center for ‘‘Medical Supplies

Charged to Patients’’ and one cost center for ‘‘Implantable Devices Charged to Patients.’’ This change split the CCR for ‘‘Medical Supplies and Equipment’’ into one CCR for medical supplies and another CCR for implantable devices.” (74 FR 60343)

Changes in the cost reporting process will take three years due to the cost report cycle.

The OPPS CY2011 Federal Register continues to discuss CCR challenges through the cost report.


APCs Represent CMS’s Most Complex Prospective Payment System The Federal Register Entries Are Becoming Enormous We are into the Eleventh Year (Depending on how you count) of APCs –

The variation in payments continues to be a roller coaster although there appears to be a little more stability.

Significant policy changes continue to be developed, specifically increased packaging and more composite APCs.

Apparently there will no national guidelines for technical component E/M coding for the ED and provider-based clinics. (AMA Develop?)

Physician supervision within the Provider-Based Rule has become a major issue due to CMS clarifying guidance.

The cost report and appropriate CCRs have become an issue although this problem has been evident since APCs were implemented.

While there continue to be areas of difficulty (e.g., singleton claims for weight development), CMS is whittling away at issues.

Hospitals should anticipate that APCs will continue to change at a rapid pace during the coming years.

OPPS Update for CY2011Summary and Conclusions

© 1999-2011 abbey & abbey, consultants, inc. slide # 1 opps update for cy2011 version 12.0 -...

Documents

cfp abbey abbey

president of abbey abbey

billing reimbursement

billing reviews

correct coding

disclaimer slide

billing audits

apc compliance reviews