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OPPS Proposed Rule Significantly Affects Coding

Michelle Leppert, for HealthLeaders Media, July 10, 2013

Under the proposed rule Outpatient Prospective Payment System, evaluation and management coding and reimbursement for hospital outpatients could change dramatically. The changes may reflect "CMS's desire to create payment parity between the hospital-based clinic setting and physician offices," says one expert.

CMS released a number of proposed changes to the Outpatient Prospective Payment System payment system July 8. The 2014 OPPS Proposed Rule is shorter than normal at 718 pages, but the proposed changes are significant and probably the most sweeping changes since the inception of OPPS, says Jugna Shah, MPH, president and founder of Nimitt Consulting.


See Also: CMS Releases Proposed OPPS, Physician Fee Rules


The proposed changes to the OPPS payment system are just as significant as the changes proposed in the 2014 IPPS Proposed Rule, says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc., in Danvers, Mass. "Just when we thought CMS couldn't shake things up more than the two-midnight proposal in IPPS, they are shaking up OPPS just as much."

Evaluation and management

Evaluation and management (E/M) coding and reimbursement for hospital outpatients could change dramatically.

Currently, hospitals report five different levels of E/M CPT® codes for new patient clinic visits, established patient clinic visits, and Type A ED visits, and HCPCS G-codes for Type B ED visits. Under the proposal, CMS would replace all of these codes with three new HCPCS G-codes. The G-codes would be assigned to three different visit APCs:

  • One APC for all clinic visits
  • One APC for all Type A ED visits
  • One APC for all Type B ED visits
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