2015 OPPS Update
Georgeann Edford RN, MBA, CCS-P
Coding Compliance Solutions LLC
Summary of Major Provisions
Payment policies and rates for Outpatient Hospital and ASCs.
I. Background
II. Wage Index
III. Packaging
A.
B.
Comprehensive APCs (C-APCs)
Other Packaging
IV. Outpatient Quality Reporting Changes
V. ASC
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Background
Balanced Budget Act of 1997 added
section 1833(t) to Title XVIII of the
Social Security Act
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Rate-per-service according to the APC
group assigned to a service.
Includes:
• Most outpatient hospital services
• Exclusions outlined in 42CFR
§419.22
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UPDATES AFFECTING
OPPS RATES
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2015 Payment Update
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Increase of 2.2%
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Based on inpatient market basket percentage increase of 2.9%
IPPS minus the multi-factor productivity adjustment of 0.5% and
minus the 0.2% Affordable Care Act adjustment.
Continuing to implement the 2.0% point reduction in hospitals
failing to meet the hospital outpatient reporting requirements by
applying a 0.980 reporting factor to the OPPS payments.
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IPPS Changes
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Wage Index
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CMS updated the labor market area data to use the OMB 2013
delineations, using 2010 Census data
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Resulted in shifts from rural to urban and urban to rural
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Previous MSAs were based on 2000 Census data
Urban to Rural – 37 counties and 12 hospitals negatively
impacted (3 year transition)
Rural to Urban – 105 counties and 81 hospitals positively
impacted (1 year transition)
For APC costs, 60 percent of estimated claims costs for a
geographic area wage variation was calculated using the same
FY 2015 pre-reclassified wage index that the IPPS uses to
standardize costs.
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Recalibration of APC Weights
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CMS goal to use the most
appropriate cost information in
setting the APC relative payment
weights.
2013 Claims
Data
Construction of database.
Rates for 2015 calculated using
claims data from calendar year
2013 adjudicated through June
30, 2014.
Matched to most recent cost
report data filed by hospital in
CMS claims data
Established the geometric mean
natural cost of a single procedure
claim was ≤ $55
Created “pseudo” single
procedure claims
Certain services (codes) on
bypass list
Continued composite APCs for
multiple imaging services.
Hospital Specific
Cost to Charge
Ratios (CCR)
Single and
Pseudo single
claims
OPPS Relative Weights
Bypass list
(Addendum N)
Most recent cost
report data
Composite APCs
Section II.A.3
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OPPS Conversion Factor
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Conversion Factor Updates
A budget neutrality
adjustment factor of 1.0005
Market Basket Update
added to the conversion
factor to ensure that the
Affordable Care Act (ACA)
cancer hospital payment
adjustment is budget neutral. Multifactor Productivity Reduction
Estimated payments for
outliers were maintained at
1.0 percent of total OPPS
payments for CY 2015
2015
+2.9%
-0.5%
OPD adjustment to fee schedule
increase factor
-0.3%
Overall Update
2.2%
National Unadjusted Payment Rate
$74.144
Note: Hospitals that fail to meet the Hospital Outpatient Quality Reporting
requirements will receive a 2.0% reduction resulting in -0.3 payment
reduction in the conversion factor to $71.219.
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Other Payments and Adjustments
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Cancer Hospital Payment – CMS will continue its policy to provide additional payments
to Cancer hospitals consistent with payment-to-cost ratios (PCR) with payment
adjustments. Target PCR of 0.89 will be used to determine the CY2015 cancer hospital
payment adjustment paid at cost report settlement.
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Drugs, Biologicals and Radiopharmaceuticals – Payment for the acquisition and
pharmacy overhead costs of separately payable drugs and biologicals that do not
have pass-through status remains at average sales price (ASP) plus 6%.
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Outliers – outlier payment that equals 50 percent of the amount by which the cost
of furnishing the service exceeds 1.75 times the APC payment amount when both
the 1.75 multiple threshold and the final fixed-dollar threshold of $3,100 are met.
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ASC payment Update of 1.4% based on CPI-U of 1.7% and MFP adjustment of
0.5 percent.
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Prosthetic Device Systems
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Payment under the OPPS for implantable DME, implantable
prosthetics, and medical and surgical supplies.
Prosthetic supplies are currently excluded from payment
under the OPPS and are paid under the DMEPOS Fee
Schedule, even when provided in the HOPD.
Many implantable prosthetic devices are part of a device
system.
Such device systems include the implantable part or parts
and also certain non-implantable prosthetic supplies that are
integral to the overall function of the medical device, part of
which is implanted and part of which is external to the patient.
Prosthetic supplies provided in the HOPD are reclassified and
are included in payment as “medical and surgical supplies”.
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Comprehensive APCs
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Define a comprehensive APC classification for the
provision of a primary service that includes all adjunctive
services provided to support the delivery of the primary
service.
A comprehensive APC (C-APC) treats all services
individually reported HCPCS codes as one
comprehensive service for the provision of a primary
service into which all other services reported on the claim
are packaged.
C-APC represents a single Medicare payment and a
single co-payment under OPPS.
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Device Dependent Comprehensive APCs (Device Sensitive)
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In CY 2014, 39 device dependent APCs were
identified.
For CY 2015, the device dependent APCs were
consolidated into 26 of the available 28 C-APCs.
Three (3) device dependent APCs remain.
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Examples of CY-2015 C-APCs
TABLE 7 (Excerpt)
Clinical Family
C-APC
APC Title
CY 2015 Payment
AICDP (5)
0090
Level II Pacemaker/Similar Procedure
AICDP
0107
Level I ICD and Similar Procedures
$22,907.64
BREAS (1)
0648
Level IV Breast and Skin Surgery
$7,461.40
ENTXX (1)
0259
Level VII ENT Procedures
$29,706.85
EPHYS (3)
0084
Level I Electrophysiologic Procedures
EYEXX (2)
0293
Level IV Intraocular Procedures
$8,446.54
GIXXX (1)
0384
GI Procedures with Stents
$3,173.83
NSTIM (3)
0061
Level II Neurostim./Related Procedures
$5,288.58
ORTHO (1)
0425
Level V Musculoskeletal Procedures
$10,220.00
PUMPS (1)
0227
Implantation of Drug Infusion Device
$15,566.34
RADTX (1)
0067
Single Session Cranial SRS (Stereotactic
Radiosurgery)
$9,765.40
UROGN (3)
0202
Level V Gynecologic Procedure
$3,977.63
UROGN
0385
Level I Urogenital Procedures
$6,822.35
VASCX (3)
0229
Level III Endovascular Procedures
$9,624.10
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$872.92
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Complexity Adjustments
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Qualifying “J1” code combinations or combinations of “J1”
services and certain add-on codes that are subsequent to
the primary code from the originating C-APC, will receive
a complexity adjustment.
The complexity adjustment arises when the code
combination represents a complex, costly form or version
of the primary service according to the following criteria:
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Frequency of 25 or more claims reporting the code combination
(frequency threshold); and
Violation of the 2 times rule (cost threshold).
Therefore, the highest payment for any code combination
for services assigned to a C-APC would be the highest
paying C-APC in the clinical family.
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Complexity Adjustment Process
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Pairs of procedure codes with SI “J1” meet the complexity adjustment requirement of commonly occurring
and exhibiting materially greater resource requirements.
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The pair of procedure codes were then assessed to confirm clinical validity as a complex subset of the
primary procedure and the pair of procedure codes are identified as complex, and primary service along
with the combination of procedure codes were subsequently reassigned. Once all pairs of procedures
described by HCPCS codes assigned to status indicator “J1” have been evaluated, all claims identified
for reassignment for each primary service are combined and the group is assigned to a higher level CAPC within a clinical family of C-APCs, that is, an APC with greater estimated resource requirements than
the initially assigned C-APC and with appropriate clinical homogeneity.
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If a pair of procedure codes did not meet the requirement for a materially greater resource requirement or
did not occur commonly, the pair of procedure codes was not considered to be complex, and primary
service claims with that combination of procedure codes are not reassigned. All pairs of procedures
described by HCPCS codes assigned to status indicator “J1” for each primary service are similarly
evaluated.
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Highest Clinical Family C-APCs
TABLE 7 (Excerpt)
Clinical
Family
C-APC
APC Title
CY 2015
Payment
AICDP (5)
0108
Level II ICD and Similar Procedures
$30,806.39
BREAS (1)
0648
Level IV Breast and Skin Surgery
$7,461.40
ENTXX (1)
0259
Level VII ENT Procedures
$29,706.85
EPHYS (3)
0086
Level III Electrophysiologic Procedures
$14,356.62
EYEXX (2)
0351
Level I Intraocular Procedures
$23,075.30
GIXXX (1)
0384
GI Procedures with Stents
$3,173.83
NSTIM (3)
0318
Level IV Neurostim./Related Procedures
$26,152.16
ORTHO (1)
0425
Level V Musculoskeletal Procedures
$10,220.00
PUMPS (1)
0227
Implantation of Drug Infusion Device
$15,566.34
RADTX (1)
0067
Single Session Cranial SRS (Stereotactic Radiosurgery)
$9,765.40
UROGN (3)
0386
Level II Urogenital Procedures
$13,967.97
VASCX (3)
0319
Level III Endovascular Procedures
$14,840.64
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CY 2015 Packaged CPT Add-On
Table 8 – Codes for Complexity Adjustment
CPT/HCPCS Add-On Code
CY 2015
19297
33225
37222
37223
37232
37233
37234
37235
37237
37239
92921
92925
92929
92934
92938
92944
92998
C9601
C9603
C9605
C9608
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CY 2015 Short Descriptor
Place breast cath for rad
L ventricular pacing lead add-on
Iliac revascularization add-on
Iliac revascularization w/stent add-on
Tibial/peroneal revascularization add-on
Tibial/peroneal revascularization w/ather add-on
Revascularization open/percutaneous tibial/peroneal stent
Tibial/peroneal revascularization stent & ather
Open/percutaneous place stent each add
Open/percutaneous place stent each add
Percutaneous cardiac angio addl art
Percutaneous card angio/athrect addl
Percutaneous card stent w/angio addl
Percutaneous card stent/ath/angio
Percutaneous revascularization bypass graft addl
Percutaneous card revascularization chronic addl
Pulmonary art balloon repair precutaneous
Percutaneous drug-eluding coronary stent bran
Percutaneous drug-eluding coronary stent ather br
Percutaneous drug-eluding coronary revascularization t cabg b
Percutaneous drug-eluding coronary revascularization chro add
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Crosswalks and Device Edits
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Historically CMS had procedure-to-device edits and device-toprocedure edits to ensure that hospitals coded and reported their
costs appropriately.
For CY 2015, CMS created claims processing edits that require a
device code to be present on the claim whenever a procedure code
from any APC recognized as being device-dependent.
Device edits will not apply to procedures assigned to C-APCs that
either do not use implantable medical devices or procedures that do
not have device-to-procedure or procedure-to-device edits.
The term “device-dependent APC” will no longer be used. APCs with
a device offset of more than 40 percent will now be referred to as
“device-intensive” APCs.
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Required Device Code APCs
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Conditional Packaging
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Status indicators “Q1” and “Q2” describe HCPCS codes
where the payment is packaged when it is provided with a
significant procedure but is separately paid when the
service appears on the claim without a significant
procedure.
Claims with a status indicator of “S”, “T”, or “V” includes
codes with status indicator (SI) of “Q3”.
Claims with SI of “J1” receive special processing.
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Example – Conditional Packaging Q1
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Other Packaging
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Packaging occurs with other services/procedure that are
not C-APCs with the most expensive medical devices
Ancillary services with a SI of “X” are conditionally
packaged if the geometric mean cost ≤ $100.
The $100 geometric mean cost initial selection criteria for
the packaging policy is not a hard and fast threshold
above which ancillary services will not be conditionally
packaged; “a basis for selecting this initial set of APCs,
which will likely be updated and expanded in future
years”.
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Status Indicator “X”
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The majority of the services assigned to status indicator
“X” were assigned to status indicator “Q1” (STVPackaged Codes).
For the services that are currently assigned status
indicator “X” that were not conditionally packaged under
the policy, re-assigned to status indicator “S” (Procedure
or Service, Not Discounted When Multiple), indicating
separate payment and that the services are not subject to
the multiple procedure reduction.
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Single Major Procedure
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Comprehensive APC payment policy includes all covered
OPD services on a hospital outpatient claim reporting a
primary service that is assigned to status indicator “J1,”
and excludes services that cannot be covered as OPD
services or that cannot by statute be paid under the
OPPS.
Payment for outpatient department services that are
similar to therapy services and delivered either by
therapists or non-therapists is packaged as part of the
comprehensive service.
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Other Packaging
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Claims with a single HCPCS code that were previously assigned “F,” “G,” “H,” “K,” “L,” “R,” “U,” or “N” and was not a SI
“Q1” (“STV-packaged”) or “Q2” (“T-packaged”) code were classified as a Single Procedure Minor Claim.
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Claims with multiple HCPCS codes that were assigned SI of “F,” “G,” “H,” “K,” “L,” “R,” “U,” or “N”; claims that contain
more than one code with SI “Q1” (“STV-packaged”) or more than one unit of a code with SI of “Q1” but no codes with SI
of “S,” “T,” or “V” on the same date of service; or claims that contain more than one code with SI indicator “Q2” (Tpackaged), or “Q2” and “Q1,” or more than one unit of a code with SI “Q2” but no code with SI “T” on the same date of
service = Multiple Procedure Major Claim.
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Multiple Procedure Minor Claim. Claims with multiple HCPCS codes that were assigned status indicator “F,” “G,” “H,”
“K,” “L,” “R,” “U,” or “N;” claims that contain more than one codes with SI of “Q1” (“STV-packaged”) or more than one
unit of a code with an SI of “Q1” but no codes with SI of “S,” “T,” or “V” on the same date of service; or claims that
contain more than one code with SI “Q2” (T-packaged), or “Q2” and “Q1,” or more than one unit of a code with SI of
“Q2” but no code with status indicator “T” on the same date of service.
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Non-OPPS claims. Claims for therapy services paid sometimes under OPPS that were billed with revenue codes
indicating that the therapy services would be paid under the Physician Fee Schedule.
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Packages Revenue Codes
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Package the costs assigned to revenue codes with
charges without assigned HCPCS codes.
Table 4
Revenue Code
Description
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Pharmacy; General Classification
251
Pharmacy; Generic Drugs
252
Pharmacy; Non-Generic Drugs
254
255
Pharmacy; Drugs Incident to Other Diagnostic Services
Pharmacy; Drugs Incident to Radiology
257
Pharmacy; Non-Prescription
258
Pharmacy; IV Solutions
259
Pharmacy; Other Pharmacy
260
IV Therapy; General Classification
261
262
IV Therapy; Infusion Pump
IV Therapy; IV Therapy/Pharmacy Svcs
263
IV Therapy; IV Therapy/Drug/Supply Delivery
264
IV Therapy; IV Therapy/Supplies
269
IV Therapy; Other IV Therapy
270
Medical/Surgical Supplies and Devices; General Classification
271
Medical/Surgical Supplies and Devices; Non-sterile Supply
272
Medical/Surgical Supplies and Devices; Sterile Supply
275
Medical/Surgical Supplies and Devices; Pacemaker
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Brachytherapy Services
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Per-source payment methodology specific to each
source’s radioisotope, radioactive intensity, and stranded
or non-stranded configuration, supplemented by payment
based on the number of sources used in a specific clinical
case, will continue despite rigorous comments.
CMS stated “a prospective payment system relies upon
the concept of averaging, where the payment may be
more or less than the estimated cost of providing a
service for a particular patient.”
HCPCS code C2635 – 90 day life
HCPCS code C2636 – November 2013 (2005)
HCPCS code C2644 – July 2014 (iodine I-125 sodium
iodide and cesium-131 chloride)
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Outlier Payment Thresholds
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CY 2014 fixed-dollar threshold of $2,900
Proposed CY 2015 fixed-dollar threshold of $3,100
Final CY 2015 fixed-dollar threshold is $2,775
For CMHCs, if a CMHC’s cost for partial hospitalization
services, paid under either APC 0172 or APC 0173,
exceeds 3.40 times the payment rate for APC 0173, the
outlier payment will be calculated as 50 percent of the
amount by which the cost exceeds 3.40 times the APC
0173 payment rate.
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NEW CPT AND LEVEL II HCPCS CODES
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New Code Process
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CPT codes (Category I and III) are
established by the American Medical
Association (AMA).
Level II HCPCS codes are established by
the CMS HCPCS Workgroup.
Code changes that affect payment are
updated annual rule making and are
published quarterly through OPPS
Change Requests(CR).
Codes published in the quarterly update
appear in Addendum B with the status
indicator of “N1”
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Category I –
CPT Codes
Category III –
CPT Codes
Level II
HCPCS Codes
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APC Assignment to New Codes
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New CPT and Level II HCPCS codes are assigned to interim
status indicator (SI) and APC assignments.
These interim assignments are finalized in the OPPS/ASC final
rules according to the following timeframe.
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Category III CPT Codes
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In the July 2014 OPPS quarterly update interim OPPS
status indicators and APCs for 17 of the 27 new Category
III CPT codes were made effective July 1, 2014.
The Category III CPT codes that were implemented in
July, 2014 are: 0347T, 0348T, 0349T, 0350T, 0355T,
0356T, 0358T, 0359T, 0360T, 0362T, 0364T, 0366T,
0368T, 0370T, 0371T, 0372T, and 0373T.
Table 18 outlines these codes with their respective status
indicators.
CPT and Level II HCPCS codes that will become effective
January 1, 2015, are flagged with comment indicator “NI”
in Addendum B.
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New CPT Codes
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For new codes that describe wholly new services, versus
revised codes that describe services for which APC and
status indicator assignments are already established,
CMS does not receive the new codes in time to propose
payment rates in the proposed rule published in July.
For the new and revised CPT codes that are publicly
available and provided in time for evaluation in the CY
2016 OPPS/ASC proposed rule, APCs and SO will be
assigned.
For new codes that are not received in time for the
proposed 2016 OPPS/ASC proposed rule, G codes,
interim APCs and SI would be and the new CPT codes
would be implemented the following year (2017).
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OPPS Changes
VARIATIONS WITHIN APC’S
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Under the OPPS, hospital outpatient services are paid on a rate-per-service
basis, where the service may be reported with one or more HCPCS codes.
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Payment varies according to the APC group to which the independent service or
combination of services is assigned.
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Each APC relative payment weight represents the hospital cost of the services
included in that APC.
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Subject to certain exceptions, the items and services within an APC group cannot
be considered comparable with respect to the use of resources if the highest cost
for an item or service in the group is more than 2 times greater than the lowest
cost for an item or service within the same group (referred to as the “2 times
rule”).
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The proposed rule identified APCs with violations of the “2 times rule” identified
with “CH” comment indicator.
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2 Times Rules Exception Criteria
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Resource homogeneity;
Clinical homogeneity;
Hospital outpatient setting utilization;
Frequency of service (volume); and
Opportunity for upcoding and code fragments.
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Exceptions To The 2 Times Rule
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OPPS Changes
VARIATIONS IN APCS
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Specific Codes/APCs
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Cardiovascular CPT 93229 (APC 0435)
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GI Services (APCs 0142, 0361, 0418 and 0422)
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CPT 43211 and 43254 became effective 1/1/2014 initially assigned APC
0419, changed to APC 0141.
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CPT 43240 from APC 0419 to APC 0422
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CPT 91035 from APC 0361 to APC 0361 (Stays the same)
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CPT 0355T, 91110, 91111 and 91112 to APC 0142
Gynecologic Procedures (APC 0188, 0189, 0192, 0193 and 0202)
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Changes in CY 2014 APC 0192, APC 0193 and APC 0195
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APC 0387 to APC 0190 (Level II Hysteroscopy to Hysteroscopy)
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CPT 57155 Insertion of uterine tandem and/or vaginal ovoids for clinical
brachytherapy) from APC 0193 to APC 0192 (Level III Female Reproductive
Procedures)
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Hysteroscopic Procedures
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Additional Changes
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Cystourethroscopy, Transprostatic Implant Procedures
and Other Genitourinary Procedures
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Five levels of APCs in CY 2014 that contain cystourethroscopy
and genitourinary procedures. Procedures assigned to APC
0429 more appropriately assigned to APC 0161 or ACP 0163.
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CPT 50590 (APC 0169) to APC 0163.
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HCPCs C9735 to APC 0150 to CPT 0377T (APC 0150)
Nervous System
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CPT 64616 Chemodenervation of muscles to APC 0204 to APC
0206.
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CPT 62263 and 62264 to APC 0203 and APC 0207.
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CPT 90867, 90868 and 90869 from APC 0216 to APC 0218
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Ocular Changes
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Major cornea transplant codes reassigned to APC 0673
(Level III Intraocular Procedures)
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Imaging Changes
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APC 0269, 0270 and 0697
Echocardiography services –
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CPT 76825 and 76826 reassigned to APC 0269
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CPT 93308 from APC 0697 (deleted) to more appropriate APCs
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CPT 78071 and 78072 more appropriately assigned to APCs
0263 and 0317.
Proton Beam Therapy
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Several changes to radiation therapy APCs.
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CPT 77520 from APC 0664 to APC 0412
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CPT 77522 from APC 0664 to APC 0667
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CPT 77523 and 77525 to APC 0667
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Delete APC 0664
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Other Changes
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Epidermal Autograft – CPT 15110 from APC 0329 (Level
IV skin repair) to APC 0327
Image Guided Breast Biopsy -19102 and 19103 APC
assignments
CY 2014 CPT codes 19081, 19083, and19085 are
imaging codes based on specific guidance devices
assigned from APC 0005 to APC 0037.
Payment for replacement CPT codes 19082, 19084 and
19086 which describe add-on procedures, was packaged
fro 2014.
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OPPS Payment for Devices
PASS-THROUGH PAYMENTS
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Pass-Through Payments - 2015
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There is currently one device category eligible for passthrough payment; HCPCS code C1841 (Retinal
prosthesis, includes all internal and external components)
HCPCS code C1841 device category will expire from
pass-through payment status after December 31, 2015.
CY 2016 will package HCPCS code C1841 into costs
related to the procedure with which the device is reported.
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OPPS Payment
DRUGS, BIOLOGICALS AND
RADIOPHARMACEUTICALS
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Expiring Pass-Through Status
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OPPS Payment
HOSPITAL OUTPATIENT VISIT
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E&M Encounters – No Changes
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Alphanumeric HCPCS code, G0463 (Hospital outpatient
clinic visit for assessment and management of a patient),
for hospital use only representing any clinic visit under the
OPPS.
HCPCS code G0463 is assigned to new APC 0634 with a
rate of $92.53.
Emergency Department and Critical Care codes are not
affected and will continue
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Clinic and ED Visit Codes / APCs
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INPATIENT ONLY PROCEDURES
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Inpatient Only List
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The established criteria upon which we make such a determination are as
follows:
1.
2.
3.
4.
5.
Most outpatient departments are equipped to provide the services to the
Medicare population.
The simplest procedure described by the code may be performed in
most outpatient departments.
The procedure is related to codes that we have already removed from
the inpatient list.
A determination is made that the procedure is being performed in
numerous hospitals on an outpatient basis.
A determination is made that the procedure can be appropriately and
safely performed in an ASC, and is on the list of approved ASC
procedures or has been proposed by us for addition to the ASC list.
• CMS did not identify any procedures that potentially could be removed
from the inpatient list for CY 2014
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Solutions
53
Inpatient Only Procedures
•
CMS did not identify any procedures that potentially could
be removed from the inpatient list for CY 2015. Therefore,
we proposed not to remove any procedures from the
inpatient list for CY 2015.
Georgeann Edford - Coding Compliance
Solutions
54
Conclusion
•
•
•
Read the CY 2015 OPPS Claims Accounting
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/Hospital-OutpatientRegulations-and-Notices-Items/CMS-1613-FC.html
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/index.html
Georgeann Edford - Coding Compliance
Solutions
55