11/14/2014
The 2015 OPPS Rules
 Proposed Rule
 Published on July 8, 2014 on the CMS website
 CMS-1613-P
ED Facility Coding Update – 2015
 Final Rule




D Karen Marsh
Published on October 31, 2014
CMS-1618-FC
1052 pages
719 public comments submitted
OPPS Final Rule 1613-FC
Addenda List
CMS Website
Addendum
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/HospitalOutpatient-Regulations-and-Notices-Items/CMS-1613FC.html?DLPage=1&DLSort=2&DLSortDir=descending
Addendum B
Payment Rates and Status Indicators
If
paid
How
much
CMS-1613-FC
Description
Common Use
A
OPPS APC
List, SI and payments by APC list
B
Final payment by HCPCS Code
Look up payment rates, Status
Indicators
C
Final HCPCS codes payable by APC
Determine which codes are in
each APC
D1
OPPS Payment Status Indicators
Description of each SI
D2
Final comment Indicators
Indicate new or changed codes
E
Codes paid only as Inpatient
Inpatient only codes
J
Ranks to determine primary assignment
in composite APC
Not used
L
OPPS Out Migration Adjustment
Not used
M
HCPCS codes assigned for Composite
APCs
What is included in APC 8009
(ED/Observation)
N
Bypass codes for creating “pseudo”
single procedure claims
To determine geometric mean for
costs
Costs for HOP services by HCPC code
Frequency stats, cost info
Cost – Stats
Addendum B
Sort by Status Indicator Q1
Packaging
with an
S/T/V
Codes
1
11/14/2014
Addendum D-1
Status Indicators
Status Indicator
Q1
Q2
Q3
Utilization
Increased Outpatient Bundling
Definition
Paid under OPPS; Addendum B
displays APC assignments when
services are separately payable.
Paid under OPPS; Addendum B
displays APC assignments when
T-Packaged Codes
services are separately payable.
Paid under OPPS; Addendum B
displays APC assignments when
services are separately payable.
Addendum M displays composite
APC assignments when codes are
paid through a composite APC.
(1) Composite APC payment based
Codes That May Be Paid Through a
on OPPS composite-specific
Composite APC
payment criteria. Payment is
packaged into a single payment for
specific combinations of services.
(2) In other circumstances, payment
is made through a separate APC
payment or packaged into payment
for other services.
STV-Packaged Codes
Packaging
• Increase in number of
codes packaged
• Impacts services that were
previously paid separately
• Single payment covers the
Comprehensive costs of all services
• Continue to expand
APCs
CMS-1613-FC Addendum D-1 – Final OPPS Status Indicators for CY 2015
Moving towards “Mini DRGs”
in the Outpatient Arena
APC Advisory Expert Panel
http://www.cms.gov/Reg
ulations-andGuidance/Guidance/FA
CA/Downloads/082514HOP-Panel-MeetingAgenda.pdf
Modern Healthcare , July 11, 2014
ACEP Comments
Composite APC for Extended Assessment and Management
• While costs to beneficiaries in short stay observation are
significantly less than the inpatient deductible ($1216 in
2014), we urge CMS to consider options to minimize the
financial burden for the beneficiary associated with selfadministered drugs while they are receiving observation
services.
• We strongly support efforts to count outpatient observation
toward the 3-day stay.
ACEP Comments on OPPS for 2015 – published on ACEP.org website
ACEP Comments
Collapsing Outpatient Facility Codes
We appreciate that CMS did not finalize its 2014 proposal to reduce
the 10 levels of Emergency Department (ED) facility codes and
APCs to two and support CMS’ proposal to continue the current
policy in 2015. We agree that further analysis is needed to assess
any proposed changes in the payment structure for ED visits,
particularly since the range of acuity and complexity of patient
conditions is so great. Our members’ experience is
such that even in instances when patients are judged to be very
stable at triage, some subsequently require substantial resources.
We are also pleased to see recently published research that did not
substantiate concerns about “upcoding” in the emergency
department (ED) as a result of using EHRs.1
ACEP Comments on OPPS for 2015 – published on ACEP.org website
2
11/14/2014
ACEP Comments
Documenting Site of Service
We understand the need for accurate data regarding costs, and in
that context, we again urge CMS to require hospitals to report
the site of observation services, i.e., in a dedicated unit versus
an inpatient floor, in order to determine
Conversion Factor
$74.144 for 2014
Compared to $72.78 in 2014
No QDRP = $72.661
Hospital Outpatient Quality Reporting (OQR) Program
In addition to proposing removal and addition of measures, CMS
notes that public reporting of the claims-based measure OP-15, “Use
of Brain Computed Tomography (CT) in the Emergency Department
for Atraumatic Headache” was deferred in previous rulemaking, and
that deferral continues. Therefore, we must restate our objections
to proposed measure OP-15, and ask CMS to remove this
measure from the final rule.
ACEP Comments on OPPS for 2015 – published on ACEP.org website
CMS-1613-P pages 232
2014 Packaging
Packaged
Codes
Package the following (those related to the ED and OBS)
1. Drugs that function as supplies when used in a diagnostic test
or procedure
2. Drugs, that function as supplies or devices when used in a
surgical procedurePackaged only
3. Clinical diagnostic lab tests
labs and some
4. Procedures described by an “add-on” code
add on
codes
5. Ancillary services (status
indicator
“X”)
 Unconditionally packaged CPT codes –
 Conditionally packaged CPT codes -
SI = N
SI = Q1 or Q2
CMS-1601-FC
Packaging Rationale
Packaging
Add on Codes
 Averaging payments
 May be more or less on a given patient
 Multiple interrelated items and services into a single payment to
 Create incentive for hospitals to provide services efficiently
 Manage resources with maximum flexibility
 Encourages hospitals to effectively negotiate with suppliers to
reduce the costs of items
 Encourages hospitals to establish protocols
 Promotes predictability and accuracy of payments
Add on Codes
Goal: Become more consistent as a Prospective payment
system rather than a fee-for-service system
CMS-1613-FC pages 197-198
All add on codes except drug administration are
packaged into the primary code
CMS-1613-FC 199, 208
3
11/14/2014
Packaging
Ancillary Services
Q1 Status Indicator Codes
• Delete SI “X”
• Package with SI “Q1” ( S/V/T on claim)
• Refer to SI in Addenda A, B or C
CMS-1613-FC page 205
CMS-1613-FC – Addendum C
Addendum B
Drug Administration Payments
Q1 Status Indicator Codes
CPT
CMS-1613-FC – Addendum B
Key Ancillary Packages
APC Category
2013 Rate
2014 Rate
2015 Rate
96360
$74.69
$105.90
$108.20
96361
$27.01
$29.50
$32.57
96365
$146.24
$172.18
$173.53
96366
$27.01
$29.50
$32.57
96367
$39.13
$43.78
$53.52
96368
$0
$0
$0
96372
$39.13
$43.78
$53.52
96374
$39.13
$105.90
$108.20
96375
$39.13
$43.78
$32.57
96376
$0
$0
$0
• No new drug
admin packaging
• 25% decrease for
Subsequent IVP
• IM > subsequent
IVPs
• 25% increase in
subsequent
infused meds
Packaging
Impact to Hospital
Payment Rate
Debridement/Lacerations/Burns
$98.46
Pulmonary Treatments (Inhalation therapy)
$164.56
ECG tracing
$78.44
Level I plain Films - Chest, Abdomen, Limbs
$59.34
Level II Plain Films – Jaw, Facial bones, Skull, Spine,
$94.98
Level I Diagnostic Ultrasound
Breast, Fetus, Pelvic
$91.66
Level II Minor Procedures
Splints, Strapping, Cardiac Monitor
$52.35
Level III Minor Procedures – Nosebleed, ABG, NG
tube, Foley
$131.69
Level II Eye Treatments, remove foreign bodies
$100.81
 Hospitals are still required to still code according to CPT and CMS
rules so that appropriate rate setting can occur in the future
 Change in reimbursement for Medicare patients – will vary at each
site based on current patient population (acuity, drug
administration utilization, ancillary services)
 Ability to track what is packaged
CMS-1613-FC – Addendum C
4
11/14/2014
OIG E/M Study
Included as an attachment in the OPPS CMS-1613-FC
E/M
Coding
Office of the Inspector General
May 2014 OEI-04-10-00181
OIG E/M Study
OIG E/M Study
Recommendations
ED Visits
small
portion of
study
49 charts
8.8%
Office of the Inspector General
May 2014 OEI-04-10-00181
Page 14
Educate physicians
•
Review claims from
high coding
physicians
•
Follow up on claims
that were errors
Office of the Inspector General
May 2014 OEI-04-10-00181
Page 27
Evaluation and Management Levels
Comments and Responses
Public Comment
•
CMS E/M Statistics
CY 2013
Medicare E/M Levels CY 2013
CMS Response
50.0%
45.0%
Support decision not to propose changing to
one ED visit
Appreciate support
40.0%
Appreciate support
One visit level is not appropriate for the ED
and it would create a “payment bias”
Requires additional study
Continue as is for the foreseeable future
No comment
CMS should work with the AMA to create
facility specific ED visit CPT codes
If AMA created facility specific CPT codes
CMS will consider such codes for OPPS
Develop 3 trauma specific HCPCS codes for
trauma patients when trauma team is used
Will consider as they continue to study
Percentage of Total
35.0%
Commended CMS on the decision to proceed
with caution for any ED visit changes
30.0%
25.0%
20.0%
15.0%
10.0%
CMS-1613-FC pages 517-518
5.0%
0.0%
EM Levels 2013
99281
1.3%
99282
5.2%
99283
20.0%
99284
45.2%
99285
27.4%
99291
0.9%
E/M Level
CMS-1613-FC
Addendum Cost-Stats
5
11/14/2014
EM Payment Rate Comparisons
2013 / 2014 / 2015
E/M Frequency Table
CY 2013
HCPCS
99281
99282
99283
99284
99284
99285
99285
99291
99291
SI
V
V
V
V
Q3
V
Q3
S
Q3
APC
609
613
614
615
0615O
616
0616O
617
0617O
Payment
Rate
$60.46
$112.74
$198.31
Total
Frequency
275,054
1,077,815
4,179,395
4,829,305
4,623,719
3,314,085
2,415,332
112,709
92,601
20,920,015
.
$333.67
.
$492.49
.
$656.69
% of Total
1.3%
5.2%
20.0%
23.1%
22.1%
15.8%
11.5%
0.5%
0.4%
100.0%
% of Total E/M Level
1.3%
99281
5.2%
99282
20.0%
99283
45.2%
99284
27.4%
99285
0.9%
99291
2013 Rate
2014 Rate
Level 1
EM Level
$51.82
$55.65
2015 Rate
$60.46
Level 2
$92.16
$100.91
$112.74
Level 3
$143.36
$166.45
$198.31
Level 4
$229.37
$293.71
$333.67
Level 5
$344.71
$455.93
$492.49
Critical Care
$535.86
$634.94
$656.69
100.0%
Q3
Composite APC (Observation)
34% of the levels are paid as a composite APC
Increases to compensate for ancillary packaging
Addendum B – OPPS 2013, 2014, 2015
CMS-1613-FC
Addendum Cost-Stats
E/M Payment Table
Type A versus Type B
ED Volume Comparisons
Year
Type A
Type B
Total ED
Visits
2010
16,263,221
227,463
16,490,684
2011
17,233,890
246,797
17,480,687
2012
18,476,771
243,891
18,720,662
2013
20,920,015
221,156
21,141,171
1% of ED visits are coded as Type B ED Visits
Type A
EM Level
2014
Level 1
$55.65
Level 2
$100.91
Level 3
$166.45
Level 4
$293.71
Level 5
$455.93
Critical Care $634.94
Type A
2015
$60.46
$112.74
$198.31
$333.67
$492.49
$656.69
Type B
2014
$51.92
$61.67
$91.71
$163.27
$312.43
$634.97
Type B
2015
$62.70
$69.49
$112.93
$198.91
$304.26
$656.69
Addendum B – OPPS 2014, 2015
CMS-1404-FC,1504FC,1525FC_OPPS Median Files by HCPCS/CPT
CMS-1613-FC Addendum Cost-Stats
CMS-1613-FC Addendum Cost-stats
E & M Distribution – Average ALL
35
Public Comments on ED E/M Coding
9/1/2012 – 8/31/2013
2012
30
2013
25
20
15
10
5
0
99281
99282
99283
99284
99285
99291
http://www.publicintegrity.org/2012/09/20/10811/hospitalsgrab-least-1-billion-extra-fees-emergency-room-visits
6
11/14/2014
Outpatient Payer Mix
Trauma Activation Rule
 Can only be paid with Critical Care 99291
What percentage of ED patients
are Medicare patients?
 Code G0390 – Trauma Response
 Payments”:
2010 payment = $833.93
2011 payment = $924.48
• Based on 122 hospitals
2012 payment = $788.79
• Total volume 4.7 million visits
2013 payment = $914.47
2014 proposed= $961.51
Volume
Medicare
Commercial
Medicaid
Self Pay
Other
882,384
1,229,984
1,216,972
944,888
440,305
2012 payment = $888.97
(99291= 656.69)
CMS rejected request to add other E/M codes as eligible in the 2011 rule
No specific mention of trauma activation code in the proposed OPPS 2014 or 2015 rules
Percentage
18.6%
26.0%
25.7%
20.3%
10.3%
Addendum B Final Rules: 2010, 2011, 2012, 2013, 2014, 2015
E/M – National Guidelines
CMS-1613-FC page 512
Clinic Visits
CMS-1613-FC page 516
ED Visits
Observation
CMS-1613-FC page 516
7
11/14/2014
Observation -Issues to Watch
As mentioned in the CMS OPPS Final Rule for 2013

Time Based
Should there be a time limit for Observation, i.e. 24-48 hours
Should OBS visits that span >48 hours and are medically
necessary automatically qualify for inpatient status

Payment Alignment
Short Stay DRG versus Outpatient payment structure
Physician payment in line with hospital reimbursement

Patient Issues
Co-payment for outpatient services versus inpatient
SNF/ rehab 3 day inpatient requirement to qualify
No relevant changes in 2015
Observation Proposal
 Two Midnight Rule (part of the Inpatient Prospective Payment
Rule)
 Hospital stays that last over a minimum of 2 midnights will be
considered to be an inpatient stay
 Hospital stays that are less than 2 midnights will be considered as
an Observation patient
 Physician should write an order if they anticipate that the physician
will require stay of at least 2 midnights
 Delayed implementation until December 31, 2013
CMS-1599-FC Inpatient PPS
Observation Proposal
 Single Extended Assessment & Management Composite APC
(8009)
 Levels 4/5 ED or clinic E/M visit, critical care or direct referral
code
 Day of admission or 1 day earlier
 No T status on claim on admission date or 1 day earlier
Reimbursement
Example
 Single payment of $1234.22
 ED visit level, and any packaged codes (TBD)
 All Observation hours
 Any packaged Observation codes
Rules Summary
Hospital Detailed Bill
 ED Level (99284/99285 or 99291) must be on claim
 Observation hours will show on a separate line
 APC 8009 will show next to E/M level to indicate bundling
of E/M and OBS hours
 Payment will show on the E/M line
 Observation hours will show as “0”
 Drug administration will show on separate lines
 Drug administration will show as reimbursable
 Lab charges will show on separate lines
 Lab charges will be bundled and show as “O”
 Radiology charges will show on separate lines
 Radiology charges will show as reimbursable
Level 4 ED visit, 13 hours of Observation, 2 IV push injections,
5 lab tests and 1 radiology test
8
11/14/2014
Hospital EOB - Medicare
Charges versus Reimbursement
ED + OBS paid here
ED Level
Charge
Reimbursement
E/M Level
$1419.50
$833.13
Includes OBS hours
Observation Hours
$484.25
0
Included in E/M as APC 8009
Drug Administration
$322.75
$104.02
Lab
$946.25
0
Bundled (new in 2014)
Medications
$73.75
0
Bundled
Misc / Supplies
$295.00
0
Bundled
$4,555.00
$1,021.70
OBS Hours
Drug
Admin
Lab codes
Paid
B
u
n
d
l
e
Totals
49
Comments
Patient co-payment $272.07
AMA CPT 2014 Update
CPT
Changes
 541 Total Changes
– 264 New Codes
– 143 Deleted Codes
– 134 Revised Codes
New CPT Codes 2015
CPT Code
20604
20606
20611
90630
Deleted CPT Codes 2015
New CPT codes effective January 1, 2015
Arthrocentesis, aspiration and/or injection, small joint or bursa (e.g..
Fingers, toes); small joint or bursa (e.g.. fingers, toes) with ultrasound
guidance , with permanent reading and recording
Arthrocentesis, aspiration and/or joint, intermediate joint or bursa (e.g..
Leg, temporomandibular, acromioclavicular, wrists, elbow or ankle,
olecranon bursa) with ultrasound guidance, with permanent reading and
recording
Arthrocentesis, aspiration and/or joint, major joint or bursa(e.g. shoulder,
hip, knee, subacromial bursa) with ultrasound guidance , with permanent
reading and recording
CPT Code
21800
Deleted codes after December 31, 2014
Closed treatment of rib fracture, uncomplicated, each
Influenza vaccine, quadravalent (IIV4) split virus, preservative free, for intradermal use.
9
11/14/2014
Revised CPT Codes 2015
CPT
Code
Immunizations
Description only changes (Information Only)
Arthrocentesis, aspiration and/or injection, small joint or bursa
20600 (e.g.. Fingers, toes); small joint or bursa (e.g.. fingers, toes)
without ultrasound guidance
Arthrocentesis, aspiration and/or joint, intermediate joint or
20606 bursa (e.g.. Leg, temporomandibular, acromioclavicular, wrists,
elbow or ankle, olecranon bursa) without ultrasound guidance
Arthrocentesis, aspiration and/or joint, major joint or bursa(e.g.
20610 shoulder, hip, knee, subacromial bursa) without ultrasound
guidance
Professional Edition CPT 2015, page 552
Immunizations
Modifier
59
Exact vaccine product must be reported
Professional Edition CPT 2015, page 552
Modifier -59
Med Learn Reference
10
11/14/2014
Modifier - 59
Modifier -59
• Primary Issues
• Why?
– Used to define a variety of circumstances
– “Incorrectly used as a modifier to bypass the NCCI edits
• Identify different encounters
– “The most widely used modifier”
–
OPPS $11B billed
lines with
-59
“Associated with on
considerable
abuse
and high levels of manual
audits”
Projected error of
$770M
• Identify different anatomical sites
• Identify distinct services
– “CMS is concerned by this pattern of abuse because it siphons
off funds…..”
CMS Transmittal 1422
CMS Transmittal 1422
Modifier - 59
MODIFIER
DEFINITION
XE
Separate encounter, A service that is because it occurred during
a separate encounter
XS
Separate structure, A service that is distinct because it was
performed on a separate organ/structure
XP
Separate Practitioner, A service that is distinct because it was
performed by a different practitioner
XU
Unusual Non-Overlapping Service, The use of a service that is
distinct because it does not overlap the usual components on
the main service
Modifier - 59
CMS Transmittal 1422
CMS Transmittal 1422
Case 1 Analysis
Item
Case
Studies
2013
2014
2015
E/M Level
99284
$229.37
$293.71
$333.67
EKG
93005
$26.67
$0
$0
Chest X-Ray
(Q3)
71020
$45.95
$57.35
$59.34
IVP
96374
$39.13
$105.90
$108.20
SC
96372 x 2
$78.26
$43.78
$53.52
Hydration
96361 x 3
$81.03
$88.50
$97.71
Labs
Varies
Per lab fees
$0
$0
$500.41 (+ Labs)
$589.24
$652.44
TOTAL
CPT
11
11/14/2014
Case 2 Analysis
Case 3 Analysis
CPT
2013
2014
2015
CPT
2013
2014
2015
E/M Level
99284
$229.37
$293.71
$333.67
E/M Level
99285
$344.71
$455.93
$492.49
IVP
96374
$39.13
$105.90
$108.20
CT scan head
(Q3
70491
$297.15
$249.00
$240.83
MRI head (Q3)
70551
$338.49
$294.78
$286.30
Infused med
96365
$146.24
$172.18
$173.53
EKG
93005
$26.67
$27.12
$0
IVP
96374 x 4
$156.52
$423.60
$432.80
Labs
X2
Per fee
schedule
$0
$0
Labs
Varies x3
Per lab fees
$0
$0
$663.66 +
Labs
$721.51
$728.17
$944.62 (+ Labs)
$1300.71
$1339.65
Item
TOTAL
Item
TOTAL
OBS Case (#9) Analysis
Item
2013
2014
2015
E/M Level
99285
$0
$0
$0
Infused med
96365
$146.24
$172.18
$173.53
Add meds infused
96366 x 1
27.01
$29.50
$32.57
IVP add diff meds
96375 x 6
$234.78
$262.68
$195.42
IVP repeats
96376 x 5
$0
$0
$0
Observation
G0378 x 16
$0
$0
$0
Observation
Composite (8009)
Combo ED +
OBS hours
$798.47
$1199.00
$1234.22
Labs
Varies
Per lab fees
$0
$0
$1207 (+ Labs)
$1663.36
$1462.21
TOTAL
CPT
OBS Case (#10) Analysis
2013
2014
2015
E/M Level
Item
99285
$0
$0
$0
EKG (Q1)
93005
$26.67
$0
$0
X-Ray chest
71020
$45.95
$57.35
$59.34
Infused med
96365
$146.24
$172.18
$173.53
Add meds infused
96366 x 20
$540.20
$590
$651.40
IVP add diff meds
96375 x 5
$195.65
$218.90
$162.85
IVP repeats
96376 x 2
$0
$0
$
IM Meds
97362 x 2
$78.26
$87.56
$107.04
Foley Catheter (Q1)
51702
$49.64
$98.25
$0
Observation
G0378 x 39
$0
$0
$0
Observation
Composite
Combo ED +
OBS hours
$798.47
$1199
$1234.22
Labs
Varies x 16
TOTAL
CPT
Per lab fees
$0
$0
$1881 (+ Labs)
$2423.24
$2388.38
Ventilator Management in the ED
CPT 94002
QUESTIONS
71
12