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OPPS Proposed Rule Significantly Affects Coding

Michelle Leppert, for HealthLeaders Media, July 10, 2013

One of the most notable changes is the packaging of laboratory tests, Hoy says. "Those tests have never been part of packaging at all. They've been paid on the Clinical Lab Fee Schedule."

On the face of it, some procedure APC rates are certainly higher as a result of CMS' packaging proposal, but hospitals will need to perform a detailed financial impact to truly begin to understand the impact these policies will have on their bottom line, says Shah.

For example, all of the "add-on" type drug administration codes (e.g.,, each additional hour codes, additional injections, additional/sequential infusions etc.) are proposed to be packaged, which meansCMS will only pay for what it calls the main/primary procedure or the initial service codes in the case of drug administration.

These "primary" or initial service codes have a much higher proposed payment rate compared to today's APC rates for those same codes, but the question is whether this single payment will cover what is paid by multiple APCs today, says Shah. Again, without computing a financial impact analysis it will be nearly impossible to assess impact. "In addition, future payment rates are likely to suffer since providers typically do not pay as close attention to reporting packaged services [those with a status indicator of N]," she adds.

CMS also proposes replacing existing device-dependent APCs with 29 new comprehensive APCs.

CMS is proposing to make a single payment when a primary procedure is on the claim and all other services would be packaged, Shah says. CMS has proposed a new status indicator "J1" to identify HCPCS codes that would be paid under this comprehensive APC.

A claim with the new proposed status indicator "J1" will trigger a comprehensive APC payment for the claim, meaning a single APC will be paid while all other items and services on the same date of service will no longer generate separate payment," Shah says.Additional proposed changes

CMS proposed other changes, including:

  • Keeping the payment level for separately payable drugs, biologicals, and therapeutic radiopharmaceuticals at average sales price plus 6%
  • Increasing the drug packaging threshold to $90
  • Continuing to apply the 7.1% adjustment to OPPS payments to certain rural sole community hospitals, including essential access community hospitals
  • Beginning to enforce physician supervision requirements for critical access hospitals
  • Removing various edits like device-to-procedure edits and nuclear medicine and radiopharmaceutical edits
  • Eliminating modifiers -FB and -FC and instead requiring hospitals to report the amount of the credit in the amount portion for value code "FD" (Credit Received from the Manufacturer for a Replaced Medical Device). Hospitals would report value code FD when the hospital receives credit for a replaced device that is 50% or greater than the cost of the device.

CMS did not propose to remove any procedures from the inpatient-only list.

Comment on the proposed rule

CMS is asking for provider comments about the proposed rule. The proposed rule will appear in the July 19 Federal Register. You can download the display copy from the Federal Register. CMS will accept comments on the proposed rule until September 6, and will respond to all comments in a final rule to be issued by November 1. As always, Shah stresses the importance of hospital involvement and urges organizations to provide comments and feedback to CMS.

"This time it is even more critical for providers to comment on the proposed rule," Shah says. Comment thoughtfully and give examples, she says.

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