Hospital outpatient and ASU policy
and payment changes for 2015
Robin Ingalls-Fitzgerald, CCS, CPC, FCS, CEDC,
CEMC
Overview
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Definitions
Off-campus, and data collection
Modifiers
Policy and Payment Changes
Provider Based (PBE)
 A hospital department/clinic
Physician and/or non-physician practitioner ( NPP)
employed by the hospital(2010)
Operational requirements for PBE as listed in 42 CFR 413.65 such as:
 PBE may be on campus or located within 35 miles of the main campus
 Operates under the main provider license (hospital)
 Physician and staff working within the clinic are under the same
reporting structure as all other departments of the hospital
 Signage, name badges, business cards, letterheads, logos, etc.,
identify the department as a part of the hospital
 Patients are registered as hospital patients
PBE Clinic
 On campus: physical area immediately adjacent to the main provider (hospital); other
structures within 250 yards of main hospital buildings.
 Off-campus: means a department that is either created by, or acquired by, a hospital
that is the main provider for the purpose of furnishing outpatient hospital services
under the name, ownership, and financial and administrative control of the main
provider, in accordance with the provisions of this section.
A remote location of a hospital comprises both the specific physical facility that
serves as the site of services for which separate payment could be claimed under the
Medicare or Medicaid program, and the personnel and equipment needed to deliver
the services at that facility. The entity is located within a 35-mile radius of the campus
of the provider.
Off-Campus Provider-Based
Departments
 CMS proposes to begin collecting data on services
furnished in off-campus provider-based departments
beginning in 2015 by requiring hospitals and
physicians to report a modifier for those services
furnished in an off-campus provider-based
department on both hospital and physician claims.
Collection of Data Off-Campus
Provider
 Citing the trend toward hospital acquisition of physician offices and
subsequent treatment of those locations as off-campus provider-based
outpatient departments, CMS has determined that a better understanding
is needed of how this trend is affecting Medicare. Toward that end, CMS is
proposing to collect information on the type and frequency of physicians’
services and outpatient hospital services furnished in off-campus providerbased departments (facility located more than 250 yards from the main
hospital building), beginning Jan. 1, 2015. CMS proposes to create a HCPCS
modifier that will be reported with every code for physicians’ services and
outpatient hospital services furnished in an off-campus provider-based
department of a hospital. Presumably, CMS would use the data it collects
to justify any future site-neutral payment policies.
Collection of Data Off-Campus
Provider
 CMS believes the most efficient and equitable means of gathering
information across two different payment systems would be to
create a HCPCS modifier to be reported with every code for
physicians’ services and outpatient hospital services furnished in an
off-campus provider based department of a hospital on both the
CMS-1500 claim form for physicians’ services and the UB-04 form
(CMS Form 1450) for hospital outpatient services. CMS hopes to
collect information on the type and frequency of physicians’
services and outpatient hospital services furnished in off campus
provider based departments beginning January 1, 2015
Modifiers and Reimbursement
 What are modifiers?
Two character codes that add value to the description of the service provided
Tell a story / exhibitionists – bring attention to a code for reimbursement
Usage must always be supported by documentation / medical record
 Common usage
Two procedures were appropriately performed even though generally not
provided in the same encounter
Patient returned for a second procedure to treat a complication performed
earlier in the same day
Report similar but different procedures on different body parts or at different
encounters
Office visit and a procedure were performed on the same day
Modifier -25
 Significant, separately identifiable E/M
 Same patient, same day encounter
If a procedure and a significant and separately
identifiable E/M service occur during the same visit,
both may be billed
 Documentation supports the scenario
 Reimbursement for proper usage
Payment consideration for each code identified
Modifier -50
 Bilateral procedures
Used to report procedures conducted on opposite
sides of the body
Modifier -50 is restricted to surgical procedures
 Reimbursement for proper usage
150% of fee schedule
Modifier -59
 Distinct Procedural Service identifies
procedures/services not normally reported together,
but appropriately billable under the circumstances.
 Appropriate Usage
Documentation indicates two separate procedures
performed on the same day by the same physician
Represented by a different session or patient
encounter, different procedure or surgery, different
site, or separate injury (or area of injury)
Modifier -59 new for 2015
 New coding requirements related to Healthcare Common
Procedure Coding System (HCPCS) modifier -59 could
impact your reimbursement.
 Change Request (CR) 8863notifies MACs and providers
that the Centers for Medicare & Medicaid Services (CMS) is
establishing four new HCPCS modifiers to define subsets of
the -59 modifier, a modifier used to define a “Distinct
Procedural Service.”
 Make sure your billing staffs are aware of the coding
modifier changes
Four new HCPCS modifiers
 XE Separate Encounter, A Service That Is Distinct 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 Usual Components Of
The Main Service
Modifier -59 new for 2015
 These modifiers, collectively referred to as X{EPSU} modifiers,
define specific subsets of the 59 modifier. CMS will not stop
recognizing the 59 modifier but notes that CPT instructions state
that the -59 modifier should not be used when a more descriptive
modifier is available. CMS will continue to recognize the-59
modifier in many instances but may selectively require a more
specific -X{EPSU} modifier for billing certain codes at high risk for
incorrect billing. For example, a particular NCCI PTP code pair may
be identified as payable only with the -XE separate encounter
modifier but not the -59 or other X{EPSU} modifiers. The -X{EPSU}
modifiers are more selective versions of the 59 modifier so it would
be incorrect to include both modifiers on the same line
Ambulatory Surgical Centers policy and
payment changes for 2015
Comprehensive-APCs
In the CY 2014 OPPS/ASC final rule, CMS adopted a Comprehensive-APC policy to
expand the categories of related items and services packaged into a single payment for a
comprehensive primary service under the OPPS, in order to make the OPPS more consistent
with a prospective payment system. CMS created Comprehensive-APCs to prospectively
pay under the OPPS for high cost device dependent services in 29 device dependent APCs
using a single payment for the hospital stay, CMS delayed implementation of this policy to
CY 2015 to provide CMS and hospitals with more time to evaluate and comment further on
the policy.
In the CY 2015 OPPS/ASC proposed rule, CMS is proposing several additional
Comprehensive-APCs, including some lower cost device dependent APCs not proposed last
year and 2 new APCs for other procedures and technologies that are either largely device
dependent or represent single session services with multiple components. CMS is also
proposing the restructuring and consolidation of some of the current device dependent
APCs with similar costs based on the 2013 claims data. After the APC consolidation and
restructuring we are proposing a total of 28 Comprehensive-APCs for 2015 versus the 29
Comprehensive-APCs that were described in the CY 2014 final rule.
Ambulatory Surgical Centers
example
 CMS is proposing to restructure and consolidate two
comprehensive APCs that represent single session services
with multiple components.
 These two new comprehensive APCs are C-APC 0067 for
single-session cranial stereotactic radiosurgery (SRS) and
C-APC 0351 for intraocular telescope implantation. In
addition, they are proposing to reassign CPT codes 77424
and 77425 that describe intraoperative radiation therapy
treatment (IORT) to C-APC 0648 (Level IV Breast and Skin
Surgery)
Ambulatory Surgical Centers
example
 For the endovascular clinical family (renamed Vascular
Procedures, VASCX), CMS is proposing to combine C-APCs
0082, 0083, 0104, 0229, 0319, and 0656 to form three
proposed levels of comprehensive endovascular procedure
APCs:
1) C-APC 0083 (Level I Endovascular Procedures);
2)C-APC 0229 (Level II Endovascular Procedures); and
3)C-APC 0319 (Level IV Endovascular Procedures).
More CMS fun
 CMS is also proposing three new clinical families: Gastrointestinal
Procedures (GIXXX) for gastrointestinal stents, Tube/Catheter Changes
(CATHX) for insertion of various catheters, and Radiation Oncology
(RADTX), which would include C-APC 0067 for single session cranial SRS. As
a result of the proposed CY 2015 comprehensive APC policy, the devicedependent APCs would no longer exist in CY 2015 because these APCs will
have all been converted to comprehensive APCs. CMS is proposing to
create claims processing edits that require any of the device codes used in
the previous device-to-procedure edits to be present on the claim for all
procedures assigned to any of the 26 proposed comprehensive APCs (of a
total of 28 proposed comprehensive APCs).
PROPOSED APCs THAT WILL REQUIRE A DEVICE CODE ON A CLAIM WHEN
A PROCEDURE ASSIGNED TO ONE OF
THESE APCs IS REPORTED
APC
APC Title
APC
APC Title
0039
Level III Neurostimulator
0318
Level IV Neurostimulator
0061
Level II Neurostimulator
0319
Level IV Endovascular
0083
Level I Endovascular
0384
GI Procedures with Stents
0084
Level I EP
0385
Level I Urogenital
0085
Level II EP
0086
Level III EP
0386
Level II Urogenital
0089
Level III Pacemaker
0435
Level V Musculoskeletal
0090
Level II Pacemaker
0107
Level I ICD
0427
Level II Tube/Catheter
0108
Level II ICD
0202
Level V Female Reproductive
0622
Level II Vascular Access
0227
Level Implantation of Drug Infusion
0229
Level II Endovascular
0648
Level IV Breast Surgery
0259
Level VII ENT Procedures
0652
Insertion of IP/Pl catheter
0293
Level IV Intraocular
0655
Level IV Pacemaker
Diagnostic Tests on the Bypass List
and Changes to the Status Indicator
 CMS is also proposing to conditionally package ancillary services which are
usually billed with a primary service and have a geometric mean cost equal
or less than $100. These ancillary services primarily include minor diagnostic
tests. CMS will continue to pay for these services separately in those
instances where hospitals provide such services alone and without another
primary service during the same encounter. CMS proposes that preventive
services will continue to be paid separately.
 CMS is proposing to delete status indicator “X” and assign ancillary services
that are currently assigned status indicator “X” to either status indicator
“Q1” or “S” (significant procedures that don’t receive a multiple procedure
reduction). The specific codes for the diagnostic tests on the bypass list that
CMS is proposing to be conditionally package are listed in Addendum P of
this proposed rule.
Questions or Comments?
 Questions
 comments
websites
 http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/r57soma.pdf
 http://www.cms.gov/Newsroom/MediaReleaseDatabase/F
act-sheets/2014-Fact-sheets-items/2014-07-03-4.html
 http://www.ofr.gov/OFRUpload/OFRData/201426183_PI.pdf
 http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/Downloads/R1422OTN.pdf
CONTACT TODAY’S SPEAKER…
 Robin Ingalls-Fitzgerald, CCS, CPC, FCS, CEDC, CEMC
CEO/President robin@mrsnh.com
Medical Reimbursement Specialists, LLC Codeaid LLC
PO BOX 486
266 A Summer St
Bristol, NH 03222
Office PHONE: (603) 217-0006
Cell Phone (603) 236-9465
FAX: (603)-947-1458
www.mrsnh.com