2016 OPPS
Rule Changes
Maggie Fortin, CPC, CPC-H, CHC
Senior Manager
Janet Hodgdon, CPA, CPC
Director
December 2015
OPPS - Talking points
• CMS Objectives
- Incentivize efficient care
- Reduce administrative burden for more accuracy of
payment
• Achieve long-term goal to create a single prospective payment for
the entire outpatient encounter by packaging payment for all
C–APC services
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Final Payment Updates
Market Basket
Multifactor Productivity
ACA
Packaged lab issue
2.4%
(.5)%
(.2)%
(2.0)%
Overall update
(.3)%
ALSO:
Statutory reduction for failure to meet quality reporting of 2%
Wage index to be used will be final IPPS
OVERALL DECREASE IN PAYMENTS ESTIMATED AT $133 MILLION
Other Updates and Adjustments
SCH rural
adjustment for
outpatient
continues at
7.1%
Drugs, biologicals
and radiopharmaceuticals
are set at the
ASP plus 6%
OPPS
Operational
Updates
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OPPS
CMS continues to revise the “packaging "of
items and services to make the system more
prospective
Rework: Composite APC logic
Addition to the new C-APC list
In the 2016 OPPS rule change we continue to see CMS
implementing changes to this ever-evolving complex
payment system
Movement of certain APC weights
Reclassification of current APC groups
Changes and additions to APC status
indicators
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2016 Comprehensive APC
Comprehensive APC definition: a
primary service payment inclusive
of integral, supportive, dependent
and adjunctive services and items
provided to support the delivery of
the primary service
Comprehensive APC will be paid a
single payment when a primary
procedure is performed and all
other services related and reported
on the claim will be packaged with
few exceptions
This newest APC
category recognizes an
additional 10 clinical
groups in 2016
STATUS INDICATOR J1
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Comprehensive APC Packaging
• Comprehensive APC logic uses the expanded definition of
“packaging”
- Payment is packaged for adjunctive and secondary items, services
and procedures
• Including diagnostics and treatments*, evaluation and assessments,
uncoded ancillary, drugs, supplies and equipment
- Identification of the most costly procedure at the claim level
resulting in:
• A single prospective payment
∗ Repetitive, recurring account billing will continue to be allowed;
UB-04 Occurrence Span code 74 (IOM 100-04, Section 60)
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C-APC Packaging Exclusion
• Certain services are excluded from C-APC logic and will remain
separately payable
Ambulance
Diagnostic and screening mammography
Brachytherapy
PT, OT and ST services provided under a plan of care
• Allowed to be billed separately as a recurring account
- Preventive services
- Self-administered drugs
-
• Drugs that are usually self-administered and do not function as supplies in the
provision of the comprehensive service
- Services assigned to OPPS status indicator ‘‘F’’ (Hepatitis B vaccines and
corneal tissue acquisition)
- Certain Part B inpatient services
• Ancillary Part B inpatient services payable under Part B when the primary ‘‘J1’’
service for the claim is not a payable Part B inpatient service (for example,
exhausted Medicare Part A benefits, beneficiaries with Part B only)
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C-APC Complexity Adjustments
• Expanded logic for complexity adjustments
• When a code combination represents a complex costly form
or version of the primary service
- CMS developed a list of “family” related HCPC codes
• Two or more status indicator J1 procedures reported on the
same claim
• System will default to the highest APC in the family group
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C-APC Complexity Adjustments
Examples
Primary
SI
Primary
APC
Assignment
Secondary
J1 or
Add-on
HCPC Code
Secondary
Short
Descriptor
J1
5123
25545
Treat fracture
of ulna
J1
26531
Revise
knuckle with
implant
5123
5123
Primary
HCPC
Code
Primary
Short
Descriptor
25607
Treat fx rad
extra-articular
26531
Revise knuckle
with implant
27726
Repair fibula
nonunion
J1
28300
Incision of heel
bone
J1
J1
5123
Secondary
Secondary
APC
SI
Assignment
Complexity
Adjusted HCPC
Assignment
Complexity
Adjusted APC
Assignment
5123
5607A
5124
J1
5123
6531A
5124
27720
Repair of
tibia
J1
5123
7726A
5124
28304
Incision of
midfoot bones
J1
5123
8300A
5124
APC “Family” Payment Rates
5123
Level 3 Musculoskeletal Procedures
J1
67.4027
$4,969.26
$993.86
5124
Level 4 Musculoskeletal Procedures
J1
95.8165
$7,064.07
$1,412.82
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Observation Stays
• 2015 Observation service logic: services deemed
payable (criteria met) and not “packaged”, currently
pay an APC 8009
- Observation G0378 or direct admit to observation
G0379/G0378
- No major procedure (SI = T)
- 8 or more units of service (Rev code 762)
- Emergency room E&M 99284 or 99285 or Critical Care
99292 or Clinic G0463
- Unadjusted $1,235
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New C-APC for Observation Stays
2016 Observation services; APC 8011
• Criteria
- Observation G0378 or direct admit to observation
G0379/G0378
- No major procedure (SI=T)
- No status indicator J1 procedure
- 8 or more units of service (Rev code 762)
- Any level Emergency Room (99281-99285)
• CMS will deem all other OPPS services and items to be
adjunctive; creating a single payment C-APC
- Exception SI = F, G, H, L and U
• Unadjusted $2,275
- Status indicator J2
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Lab Packaging - Expanded
• CMS will only provide lab testing payments when:
- Only service on the claim
- Lab ordered by a different practitioner for a different purpose
from the primary service on the claim
- Continued use of the L1 Modifier
• Expands FISS editing for lab packaging to the entire claim;
not just primary service dates
• New status indicator definition added to Q4
• Excludes lab packaging for CPT codes in the ranges of 81200
through 81383, 81400 through 81408 and 81479 (molecular
lab)
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Status Indicators Affected by
2016 Updates
ADDENDUM D1. - FINAL OPPS PAYMENT STATUS INDICATORS FOR CY 2016
Status
Item/Code/Service
Indicator
A
Services furnished to a hospital outpatient that are paid under a
fee schedule or payment system other than OPPS, for example:
● Ambulance Services
OPPS Payment Status
Not paid under OPPS. Paid by MACs under a fee
schedule or payment system other than OPPS.
Services are subject to deductible or coinsurance
unless indicated otherwise.
● Separately Payable Clinical Diagnostic Laboratory Services
● Separately Payable Non-Implantable Prosthetics and Orthotics
● Physical, Occupational, and Speech Therapy
Not subject to deductible or coinsurance.
● Diagnostic Mammography
● Screening Mammography
C
Inpatient Procedures
Not paid under OPPS. Admit patient.
Bill as inpatient.
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Status Indicators Affected by
2016 Updates
Status
Indicator
Q1
Q2
Q3
Q4
Item/Code/Service
OPPS Payment Status
STV-Packaged Codes Paid under OPPS; Addendum B displays APC assignments when services are separately
payable.
1. Packaged APC payment if billed on the same date of service as a HCPCs code assigned
status indicator “S,” “T,” or “V.”
2. In other circumstances, payment is made through a separate APC payment.
T-Packaged Codes
Paid under OPPS; Addendum B displays APC assignments when services are separately
payable.
1. Packaged APC payment if billed on the same date of service as a HCPCs code assigned
status indicator “T.”
2. In other circumstances, payment is made through a separate APC payment.
Codes that may be Paid under OPPS; Addendum B displays APC assignments when services are separately
paid through a
payable.
composite APC
Addendum M displays composite APC assignments when codes are paid through a
composite APC.
1. Composite APC payment based on OPPS composite-specific 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.
Conditionally
Paid under OPPS or CLFS.
packaged laboratory 1. Packaged APC payment if billed on the same claim as a HCPCs code assigned published
tests
status indicator “J1,” “J2,” “S,” “T,” “V,” “Q1,” “Q2,” or “Q3.”
2. In other circumstances, laboratory tests should have a SI = A and payment is made
under the CLFS.
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Status Indicators Affected by
2016 Updates
Status
Indicator
J1
J2
Item/Code/Service
OPPS Payment Status
Hospital Part B services paid through a
comprehensive APC
Paid under OPPS; all covered Part B services on the claim are
packaged with the primary "J1" service for the claim, except services
with OPPS SI=F,G, H, L and U; ambulance services; diagnostic and
screening mammography; all preventive services; and certain Part B
inpatient services.
Hospital Part B services that may be paid Paid under OPPS; Addendum B displays APC assignments when
through a comprehensive APC
services are separately payable.
1. Comprehensive APC payment based on OPPS comprehensivespecific payment criteria. Payment for all covered Part B services
on the claim is packaged into a single payment for specific
combinations of services, except services with OPPS SI=F,G, H, L
and U; ambulance services; diagnostic and screening
mammography; all preventive services; and certain Part B
inpatient services.
2. Packaged APC payment if billed on the same claim as a HCPCS
code assigned status indicator “J1.”
3. In other circumstances, payment is made through a separate APC
payment or packaged into payment for other services.
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Miscellaneous OPPS Updates
Inpatient Only List (Status Indicator C) criteria for
exclusion:
1. Most outpatient departments are equipped to provide the
services to the Medicare population.
2. The simplest procedure described by the code may be performed
in most outpatient departments.
3. The procedure is related to codes that have already been removed
from the inpatient-only list.
4. A determination is made that the procedure is being performed in
numerous hospitals on an outpatient basis.
5. 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.
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Miscellaneous OPPS Updates
Inpatient only procedures deleted in 2016:
• CPT code 0312T; Vagus nerve blocking therapy
• CPT code 20936; Autograft for spine surgery only (includes harvesting
the graft
• CPT code 20937; Autograft for spine surgery only (includes harvesting
the graft); morselized
• CPT code 20938; Autograft for spine surgery only (includes harvesting
the graft); structural, bicortical or tricortical
• CPT code 22552; Arthrodesis, anterior interbody, including disc space
preparation; cervical below C2, each additional interspace
• CPT code 54411; Removal and replacement of all components of a
multi-component inflatable penile prosthesis through an infected field
at the same operative session, including irrigation and debridement of
infected tissue
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Major Restructuring of APC
Groupings
766 APC
in 2015
663 APC
for 2016
With 200+ APC reassigned to
new APC number
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Other
Changes
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Changes/Updates to Reimbursement
• Payment Update for Partial
Hospitalization Programs (PHPs)
- Hospital-based PHPs Per Diem
payments adjusted
• Level I (three services)
• Level II (four or more services)
• Mental Health services rendered on a
single day will not exceed the Level II
PHP per diem
- Changes from APC 0034 to APC 8010
$183.41
$212.67
$212.67
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OPPS Outliers
Outlier payments are
triggered when:
Costs exceed 1.75 times the APC payment
amount and exceeds the APC payment
rate plus a $3,250 fixed dollar threshold
Outlier payments are equal to 50% of the
excess as noted above
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2 Midnight Rule
• Stays less than 2 days may be paid as inpatient admissions
under MS-DRGs
- Based on clinical judgment of admitting physician and
- Must be reasonable and necessary; supported by
documentation in the medical record
• Exception on a case by case basis
• Expectation that consideration of the policy be rare
• RAC review has been transferred to QIO effective
10/01/2015
• QIO will make referrals to the Recovery Auditor for additional
review of high denial rates or failures to improve after QIO
assistance
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Chronic Care Management (CCM)
CMS clarifies the requirements for OPPS payment associated with CCM
- CPT 99490: Chronic care management services (CCM), at least 20 minutes of
clinical staff time directed by a physician or other qualified health care
professional, per calendar month
• Multiple (two or more) chronic conditions expected to last at least 12
months, or until the death of the patient;
• Chronic conditions place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline; and
• Comprehensive care plan established, implemented, revised or
monitored
- Hospital billing under OPPS:
• Service must meet the definition of a hospital outpatient and meet the
supervision requirements for therapeutic care (general supervision)
- Established relationship
• Patient is admitted as an inpatient or registered as an outpatient
in the last 12 months
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Chronic Care Management (CCM)
(cont.)
- Required to have documented in the hospital’s medical record the patient’s
agreement to have the services provided or, alternatively, to have the
patient’s agreement to have the CCM services provided documented in the
beneficiary’s medical record that a hospital can access
• Notation of the beneficiary’s decision to accept or decline the services.
- CMS expects the physician or practitioner under whose direction the services
are furnished to have discussed with the beneficiary that hospital clinical
staff will furnish the services and that the beneficiary could be liable for two
separate copayments from both the hospital and the physician.
- Only one hospital can render care
- Use of a certified EHR is required
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Questions or Comments
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Contact the Presenters
Healthcare Consulting Division
Toll Free: 1-800-244-7444
Fax: 207-774-1793
Maggie Fortin, Senior Manager
Direct Line: 207-791-7547
mfortin@bnncpa.com
Janet Hodgdon, Director
Direct Line: 207-791-7508
jhodgdon@bnncpa.com
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