APC Update for CY2008 Sponsored By: APCNow Web Site www.APCNow.com Presented By: Duane C. Abbey, Ph.D., CFP Abbey & Abbey, Consultants, Inc. Duane@aaciweb.com http://www.aaciweb.com http://www.APCNow.com http://www.HIPAAMaster.com Version 9.0 - Generic Notes © 1994-2007, Abbey & Abbey, Consultants, Inc. CPT® Codes – © 2005-2006 AMA © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 1 Presentation Faculty Duane C. Abbey, Ph.D., CFP – Dr. Abbey is a health care consultant and educator with over 20 years of experience. He has worked with hospitals, clinics, physicians in various specialties, home health agencies and other health care providers. His primary work is with optimizing reimbursement under various Prospective Payment Systems. He also works extensively with various compliance issues and performs chargemaster reviews along with coding and billing audits. Dr. Abbey is the President of Abbey & Abbey, Consultants, Inc. and the co-founder of the HealthCare Consulting Group, L.C. These firms provide a wide range of consulting services across the country including charge master reviews, APC compliance reviews, in-service training, physician training, and coding and billing reviews. Dr. Abbey is the author of seven books on health care including: “Non-Physician Providers: Guide to Coding, Billing, and Reimbursement” “Emergency Department: Coding, Billing and Reimbursement”, and “Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance”. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 2 Disclaimer This workshop and other material provided are designed to provide accurate and authoritative information. The authors, presenters and sponsors have made every reasonable effort to ensure the accuracy of the information provided in this workshop material. However, all appropriate sources should be verified for the correct ICD-9-CM Codes, ICD-10-CM Diagnosis Codes, ICD-10-PCS Procedure Codes, CPT/HCPCS Codes and Revenue Center Codes. The user is ultimately responsible for correct coding and billing. The author and presenters are not liable and make no guarantee or warranty; either expressed or implied, that the information compiled or presented is errorfree. All users need to verify information with the Fiscal Intermediary, Carriers, other third party payers, and the various directives and memorandums issued by CMS, DOJ, OIG and associated state and federal governmental agencies. The user assumes all risk and liability with the use and/or misuse of this information. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 3 APC Update for CY2008 Objectives To review the proposed and final Medicare APC payment system and changes for CY2008. To review various APC weight changes and updates. To understand key issues within APCs and the proposed changes. To discuss increased packaging and bundling within APCs. To appreciate the need for hospitals to assess changes and make suggestions and comments to CMS. To review the various data files that CMS provides with APCs. To appreciate technical component E/M coding for the ED and providerbased clinics. To discuss the different CMS changes including supplies, drugs and devices. To review changes for ASCs relative to APCs. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 4 APC Update for CY2008 Acronyms/Terminology APCs – Ambulatory Payment Classifications APGs – Ambulatory Patient Groups ASC – Ambulatory Surgical Center CAH – Critical Access Hospital CCRs – Cost-to-Charge Ratios CPT – Current Procedural Terminology E/M – Evaluation and Management FFS – Fee-for-Service HCPCS – Healthcare Common Procedure Coding System ICD-9-CM – International Classification of Diseases, Ninth Edition, Clinical MAC – Medicare Administrative Contractor MedPAC – Medicare Advisory Commission MPFS – Medicare Physician Fee Schedule NCCI – National Correct Coding Initiative © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 5 APC Update for CY2008 Acronyms/Terminology NCD/LCD – National/Local Coverage Decision NTIOL –New Technology Intraocular Lens OCE – Outpatient Code Editor OPD – [Hospital] Outpatient Department OPPS – [Hospital] Outpatient Prospective Payment System PHP – Partial Hospitalization Program PM – Program Memorandum PPS – Prospective Payment System QIO – Quality Improvement Organization SI – Status Indicator ASC – Ambulatory Surgical Center RBRVS – Resource Based Relative Value System MPFS – Medicare Physician Fee Schedule Developed through RBRVS © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 6 APC Update for CY2008 APC Background Information APC Fundamentals Encounter Driven System • Some Exceptions – Example: Two separate blood transfusions on the same day. CPT/HCPCS Code Driven • If the service is not coded with a CPT or HCPCS (and/or proper modifiers), then there will be absolutely no payment! APC Grouper Multiple APCs from Given Claim Inpatient-Only Procedures • Surgery, if performed outpatient, will not be paid at all! (Patient Liability?) • How is this list determined? Covered, Non-Covered and Payment System Interfaces • Example: Self-Administrable Drugs Pass-Through Payments – Directly Based on Charges Made – Covert Charges to Costs How? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 7 APC Update for CY2008 APC Background Information APC Weight, and Thus Payment, Determination Hospital Charges Converted to Costs • How is this done? • Do we charge for everything? • Do we charge correctly for everything? Statistical Process Using the Costs • Geometric Mean • Mean Cost for Given APC/Mean Cost for All APCs = the APC Weight Variation of Costs Within a Given APC Category • 2 Times Rule – If highest cost is more than twice the lowest cost then violation. • 2 Times Rule Exception List Examples: o APC=0043 – Clsd Fx Tx (FTT) o APC=0438 – Level III Drug Admin © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 8 APC Update for CY2008 APC Background Information Use of Claims to Statistically Develop the APC Weights Because outpatient encounters often involve multiple services, the APC grouping process often (if not a majority of the time) generates multiple APCs. CMS can use only pure claims, that is, claims that group to a single APC. These are called ‘singleton’ claims. CMS is trying very hard to get around this situation because most of the claims filed by hospitals never get considered when the actual APC weights are determined. • Small Example: CPT=86891 – Intra- or Post-Operative Blood Salvage A device is used to save blood, reprocess the blood and generally re-infuse. Is it possible to have ONLY 86891 on a claim? What kind of payment do we have for 86891? What are the costs involved? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 9 APC Update for CY2008 APC Background Information APC Cost Outliers Complicated Two-Tiered Formula Based on Excessive Costs - How are costs determined? Nationally, does CMS make full outlier payments? Provider-Based Rule (42 CFR §413.65) Provider-Based Clinics Provider-Based Clinical Services Potentially, two claim forms filed – CMS-1450 (UB-04) for technical component and CMS-1500 (1500) for professional component. Reduction in payment for professional component • Site-of-Service Differential in RBRVS (MPFS) • Place-of-Service (POS) driven on CMS-1500 Series of Criteria to Meet If to be Provider-Based • On-Campus versus Off-Campus • See Physician Supervision Developments © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 10 APC Update for CY2008 APC Background Information ASCs – Ambulatory Surgical Centers Going to a hybrid of APCs and RBRVS for CY2008 FR entries for APCs will now also be for ASCs ASC Surgery List • Regular ASC Surgeries • Office-Based Surgeries New Payment Formula • ASC Surgery 65% of APC • Office-Based Surgeries – Lesser of: 65% of APC or Non-Facility PE RVU from MPFS • Physician Paid Facility MPFS (As With Hospitals) Separate Payment for Certain Ancillary Services Did all the features of APCs translate over? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 11 APC Update for CY2008 CPT/HCPCS Changes Between CPT and HCPCS there are more than 400 new codes, 12 new HCPCS modifiers and then a number of changes for existing codes/modifiers. Note that we have a new modifier “-FC”, Partial Credit Received for Replaced Device, along with the current “-FB” modifiers. Also, there are three new modifiers, “-EA”, “-EB”, “-EC” for use with Erythopoetic Stimulating Agent ESA. Categories of Changes Cardiac MRI Gastrostomy Tubes Subcutaneous Infusions Laparoscopic Hysterectomy Smoking & Tobacco Cessation Alcohol and/or Substance Abuse Screening Telephone-Based E/M Online E/M Team Conferences Specimen Collection © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 12 APC Update for CY2008 CPT/HCPCS Changes New CPT/HCPCS Injections • 90769 Sc ther infusion, up to 1 hr, SI="S" - APC=0440 $114.64 • 90770 Sc ther infusion, addl hr, $ 25.13 SI="S" - APC=0437 • 90771 Sc ther infusion, reset pump, SI="S" - APC=0438 $ 51.22 • 90776 Tx/pro/dx inj same drug adon, SI="N“ New APC Series Coding Implications? 0133 Level I Skin Repair SI=“T” 1.3340 $4,437.26 0134 Level II Skin Repair SI=“T” 2.1114 $81.48 0135 Level III Skin Repair SI=“T” 4.6816 $134.08 0136 Level IV Skin Repair SI=“T” 15.4399 $288.30 0137 Level V Skin Repair SI=“T” 20.9338 $958.33 © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 13 APC Update for CY2008 Increased Bundling CMS Proposed Significantly Increased Bundling Long Federal Register Discussion • From Page 42667, August 2, 2007 – “Packaging costs into a single aggregate payment for a service, encounter, or episode of care is a fundamental principle that distinguishes a prospective payment system from a fee schedule. In general, packaging the costs of supportive items and services into the payment for the independent procedure or service with which they are associated encourage hospital efficiencies and also enables hospitals to manage their resources with maximum flexibility.” From a hospital’s perspective, is the above statement at all true? What are “supportive” items/services? What are “independent” procedures? How does this relate to ‘Separate Procedure Consolidation’ under APGs? Slide # 14 © 1999-2008 Abbey & Abbey, Consultants, Inc. APC Update for CY2008 Increased Bundling CMS Proposed Significantly Increased Bundling CMS want to increase bundling to have APCs be more of a Prospective Payment System (PPS) • Look more like DRGs? • Look less than RBRVS? Comment: For those familiar with APGs, Ambulatory Patient Groups, CMS purposefully moved APCs away from all the bundling in APGs. Now CMS is moving back toward the bundling in APGs. Why the change? (Hint: Think money!) o See APG concept of significant procedure consolidation. For the past several years, new interventional radiology codes have bundled the radiological component into the surgical component even at the CPT level. This is a major change. The discussions in the current APC Federal Register appear to be only the beginning. Also, movement from SI=“S” to SI=“T”. Why? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 15 APC Update for CY2008 Increased Bundling Special Packaging Subcommittee Current Areas for Increased Packaging Consideration Guidance Services • OK, CMS has never liked fluoroscopic guidance, ultrasonic guidance, etc. • This is not a surprising move, but what kind of impact will result? Image Processing Services Intraoperative Services • Wonderful new terminology – ‘Supportive dependent procedures’ provided with ‘independent procedures’. • About 40 codes on the list. G0275 and G0278 are on the list! Does this make any sense?? • What about pre- and post-surgical injections such as antibiotic injections that are not an ‘integral part’? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 16 APC Update for CY2008 Increased Bundling What was CMS’s final decision on bundling? See November 27, 2007 Federal Register No Surprise! • See Table 10 for all the new packaged codes. Study this table with great care! • Be sure to distinguish SI=“N” from SI=“Q” • SI=“Q” is conditional packaging • T-Packaging • STVX-Packaging • Note the remapping of certain packaged codes. What is the potential financial impact of this type of change? • How can we calculate the financial impact? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 17 APC Update for CY2008 Increased Bundling Table 10 Packaging In conclusion, we are finalizing our proposed packaging approach with the modifications discussed above for the CY 2008 OPPS. Table 10 in this final rule with comment period displays the list of packaged services in the categories of guidance, image processing, intraoperative services, radiopharmaceuticals, contrast media, imaging supervision and interpretation, and observation services. Codes in composite APCs, including the two extended assessment and management APCs, are displayed in Addendum M. In Table 10, HCPCS codes with status indicator “N” are always packaged. HCPCS codes with status indicator “Q” are conditionally packaged. Codes with status indicator “Q” that are for imaging supervision and interpretation are packaged only when reported on the same claim on the same day as a procedure with status indicator “T” and are identified as “T-packaged” in the sixth column. Codes that are packaged when they are reported on the same claim with a code with status indicator “S,” “T,” “V,” or “X” on the same day are identified as “STVX-packaged” in the sixth column. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 18 APC Update for CY2008 Increased Bundling Imaging Supervision and Interpretation Services Example 1: CPT=76940, Ultrasonic Guidance Tissue Ablation which goes with CPT=47382, Ablation Liver Tumor(s). CPT Code 2007 Payment 2008 Payment 76940 $73.04 $0.00 47382 $2,296.47 $2,738.71 Total Payment $2,369.51 $2,738.71 Example 2: CPT=74327, Biliary Duct S&I and CPT=47630, Biliary Duct Stone Extraction. CPT Code 2007 Payment 2008 Payment 74327 $164.75 $0.00 47630 $1,245.85 $1,827.28 Total Payment $1,410.60 $1,827.28 © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 19 APC Update for CY2008 Increased Bundling Imaging Supervision and Interpretation Services Example 3: Through a left femoral puncture, a physician advances the catheter into the aorta and performs an aortogram with bilateral runoffs. The physician then manipulates the catheter to the right popliteal artery and successfully perform a balloon angioplasty. The catheter is withdrawn. CPT Code 36200 75630 2007 Payment 36247 35474 75962 Total Payment 2008 Payment $0.00 $1,279.92 $0.00 $0.00 $0.00 $2,639.19 $383.95 $4,303.06 $0.00 $2,890.72 $0.00 $2,890.72 Note: CPT 75962 is SI=“Q”, is “T-Packaged”, and now maps to APC=0083, the same as 35474. But 35474 is SI=“T” which causes 75962 to be packaged. • Any comments/concerns? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 20 APC Update for CY2008 Increased Bundling Diagnostic Radiopharmaceuticals Just as soon as we finally figure out the A9500 sequence of codes which are paid on a pass-through basis, CMS wants to bundle them all! Contrast Agents LOCMS/HOCMS could serve as the basis of a novel! A-Codes for which there is no payment. Then Q-Codes for which there is separate payment. Now Q-Codes which are packaged. • Why even have the Q-Codes? Note: See also the general $60.00 packaging threshold methodology. See a similar concept used in chargemaster maintenance. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 21 APC Update for CY2008 Increased Bundling Development of Composite APCs LDR Prostate Brachytherapy • 55859 - $2,328.56 • 77778 - $ 969.73 $3,298.29 • New Composite Payment - $3,432.71 • Group only when both codes present? • Status Indicator “T” – Discounting Applies EP Studies • Various Groupings of Services • Group A versus Group B • Composite Payment of $8,542.57 Note: This bundling process is taking highly variable situations and then averaging to a great degree. Physicians and hospitals may perform significantly different combinations of services. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 22 APC Update for CY2008 Increased Bundling Service Specific Packaging Basically a number of miscellaneous services which are analyzed by the APC Packaging Subcommittee. CMS Philosophical Thrust If you read the Federal Register carefully, there is a common thread in this area. CMS seems to be taking the approach that if a given CPT code or service is almost always being reported with other codes/services, then the given service should be packaged for payment. • Note: We are addressing the packaging of payments, NOT necessarily the bundling of charges. We must charge (and code) for everything we do. • This whole approach seems to be a turbocharged version of the concept of ‘integral part’. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 23 APC Update for CY2008 Observation Services Observation Services Represent A Very Real Challenge for Almost All Hospitals The main challenge is compliance in terms of a physician order and supporting documentation (medical necessity). CMS has never really given us factual information on why they, CMS, do not want to pay separately for observation services. This is a highly valuable, and sometimes costly, service that helps to reduce higher costs with an inpatient admission. Condition Code 44 is also a mess. • NUBC Definition vs. CMS Definition Who is the ‘Official Code Set Maintainer’? Now CMS wants to package all observation payments. • What are these observation services packaged into? G0379 or 99285 (Did Payment Go Up?) • What about ancillary services in observation? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 24 APC Update for CY2008 Observation Services We thought CMS was simply going to package observations services. Instead, CMS has decided to create two new composite APC categories, 8002 and 8003. “APC 8002 will be assigned when 8 or more units of HCPCS code G0378 (Hospital observation service, per hour) are billed- On the same day as HCPCS code G0379 (Direct admission of patient for hospital observation care); or On the same day or the day after— • ++ CPT code 99205 (Office or other outpatient visit for the evaluation and management of a new patient (Level 5)); or • ++CPT code 99215 (Office or other outpatient visit for the evaluation and management of an established patient (Level 5)).” © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 25 APC Update for CY2008 Observation Services Observation Composite APCs “APC 8003 will be assigned when eight or more units of HCPCS code G0378 (Hospital observation service, per hour) are billed on the same day or the day after CPT code 99284 (Emergency department visit for the evaluation and management of a patient (Level 4)), 99285 (Emergency department visit for the evaluation and management of a patient (Level 5)); or 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).” Payment for these two APCs for 2008 is: APC=8002 $351.04, and APC=8003 $638.66. Diagnosis Requirements Dropped All Direct Admissions Paid (?) © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 26 APC Update for CY2008 Observation Services Observation Composite APCs Questions • Can you think of a situation in which the hospital would use 99205 or 99215? • Is the 99205 or 99215 a technical component code or a professional component code? • Do hospitals always perform a nursing assessment (i.e., G0379) when a patient is directly admitted? • Will this process provide an incentive to perform E/M services in order to insure observation payment? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 27 APC Update for CY2008 Technical Component E/M Coding Extensive Discussion in the Federal Register Coding Documentation Guidelines • No, hospitals are to continue developing their own coding guidelines and use them as directed in the April 7, 2000 Federal Register. • This means that virtually every hospital across the country could have different guidelines and develop different codes for different levels of services. • There seems to be no meaningful indication from CMS as to when we will have any guidelines and/or the nature of the guidelines. Note: Considering CMS’s sudden interest in increasing packaging, someone at CMS may realize that under APGs, the E/M visits were bundled if there was any other service provided. E/M services were separately paid only if provided by themselves. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 28 APC Update for CY2008 Technical Component E/M Coding E/M Code Grouping Even though the fundamental charge/cost data associated with E/M code is flawed (every hospital is using a potentially different mapping), CMS discusses some rather interesting statistical findings and the mapping of the E/M codes to E/M payment APCs is being adjusted. • What is the difference between a ‘new’ patient and an ‘established’ patient? The five-level E/M payment payments will continued. New Visits APC Pay Est. Visits 99201 99202 99203 99204 99205 Level 1 Level 2 Level 3 Level 4 Level 5 99211 99212 99213 99214 99215 © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 29 APC Update for CY2008 Technical Component E/M Coding CMS Is Not Yet Ready To Issue Technical Component E/M Guidelines At this rate, we will lucky to have anything by 2010. HOWEVER, CMS did pull together various Federal Register discussions about E/M levels in the form of eleven principles. Hospital are thus given notice that the individually developed E/M mappings must meet certain criteria. E/M Coding Principles • The coding guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the code (65 FR 18451). • The coding guidelines should be based on hospital facility resources. The guidelines should not be based on physician resources (67 FR 66792). © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 30 APC Update for CY2008 Technical Component E/M Coding Technical Component E/M Coding E/M Coding Principles • The coding guidelines should be clear to facilitate accurate payments and be usable for compliance purposes and audits (67 FR 66792). • The coding guidelines should meet the HIPAA requirements (67 FR 66792). • The coding guidelines should only require documentation that is clinically necessary for patient care (67 FR 66792). • The coding guidelines should not facilitate upcoding or gaming (67 FR 66792). • The coding guidelines should be written or recorded, welldocumented, and provide the basis for selection of a specific code. • The coding guidelines should be applied consistently across patients in the clinic or emergency department to which they apply. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 31 APC Update for CY2008 Technical Component E/M Coding Technical Component E/M Coding E/M Coding Principles • The coding guidelines should not change with great frequency. • The coding guidelines should be readily available for fiscal intermediary (or, if applicable, MAC) review. • The coding guidelines should result in coding decisions that could be verified by other hospital staff, as well as outside sources. Other Changes • Hospitals are to distinguish between ‘new’ vs. ‘established’ even though the definitions for physicians and hospitals is quite different. • CPT 99211 maps into Level I, 99212 and 99213 map into the Level II Clinic APC, 99214 into Level III, and 99215 into Level IV. The new patient E/M codes (99201-99205) will continue as in CY2007, that is, Level I through Level V. • The consultations codes are being dropped from APCs. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 32 APC Update for CY2008 Technical Component E/M Coding Exercise – The Apex Medical Center has established a series of providerbased clinics within a 25-mile radius. There are a number of primary care clinics along with several specialty clinics. AMC codes and bills for both the physicians (professional) and hospital (technical) components. A decision has been made to set the technical component E/M level to be the same as the physicians. Is this a reasonable mapping? How does this affect ‘new’ versus ‘established’ patient coding? What about consultation codes? Any differences between the primary care and specialty E/M coding? • Note: Keep in mind the physician coding is for services performed and hospital coding is for resources utilized. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 33 APC Update for CY2008 Device Dependent APCs Device Dependent APCs These are APCs (similar concept for DRGs) in which the major portion of the APC payment relates to the device being implanted. Many of these services involve multiple codes and thus multiple APCs. However, CMS can only use singleton claims. CMS used three different sets of claims to try to calculate accurate payments in this area. Hospitals also contribute to this situation by not correctly charging for these devices. • What does this mean? Exercise – The Apex Medical Center has acquired a $5,000.00 (acquisition cost) pacemaker. The markup formula is to mark this device up by 10%. AMC’s outpatient CCR is 0.50. How much does CMS think this pacemaker cost AMC? Review Table 24 From Federal Register © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 34 APC Update for CY2008 Payment for Devices Full or Partial Credit For Devices After consideration of the public comments received, we are finalizing a modified policy for certain procedures involving partial credit for a replacement device. Specifically, we will reduce the payment for an implantation procedure assigned to APCs listed in Table 25, below, by one half of the device offset that would be applied if a replacement device were provided at no cost or with full credit, if the credit is 50 percent or more of the replacement device cost. We will recognize the new modifier “FC” for reporting these cases, and we are not adopting the recommendation of the APC Panel to utilize a modifier that specifically reflects the amount of a partial credit for a device as a percentage of the cost of the replacement device. Accordingly, we are implementing the proposed changes to §§419.45(a) and (b) with modification to reflect the 50 percent partial device credit threshold to which the policy will apply. Beneficiary copayment will be based on the reduced payment amount. See “-FB” and “-FC” Modifiers © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 35 APC Update for CY2008 Payment for Devices Table 25 Devices “-FB” and “-FC” Modifiers C1721 AICD, dual chamber C1722 AICD, single chamber C1764 Event recorder, cardiac C1767 Generator, neurostim, imp C1771 Rep dev, urinary, w/sling C1772 Infusion pump, programmable C1776 Joint device (implantable C1777 Lead, AICD, endo single coil C1778 Lead, neurostimulator C1779 Lead, pmkr, transvenous VDD C1785 Pmkr, dual, rate-resp C1786 Pmkr, single, rate-resp C1813 Prosthesis, penile, inflatab C1815 Pros, urinary sph, imp C1820 Generator, neuro rechg bat sys C1881 Dialysis access system C1882 AICD, other than sing/dual © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 36 APC Update for CY2008 Payment for Devices Table 25 Devices “-FB” and “-FC” Modifiers C1891 Infusion pump, non-prog, perm C1895 Lead, AICD, endo dual coil C1896 Lead, AICD, non sing/dual C1897 Lead, neurostim, test kit C1898 Lead, pmkr, other than trans C1899 Lead, pmkr/AICD combination C1900 Lead coronary venous C2619 Pmkr, dual, non rate-resp C2620 Pmkr, single, non rate-resp C2621 Pmkr, other than sing/dual C2622 Prosthesis, penile, non-inf C2626 Infusion pump, non-prog, temp C2631 Rep dev, urinary, w/o sling L8614 Cochlear device/system See Also ASC Discussion for Device Dependent Payment and the Application of the 65% Amount © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 37 APC Update for CY2008 Payment for Devices What is happening to the mandatory C-Codes? Why do we have to code for these C-Codes? Does this have anything to do with capturing costs? Pass-Through Payment Offsets When an item moves from being separately payable under APCs to being bundled into the associated APC payment, then CMS must make appropriate adjustments to the APC payment. Drugs, Biologicals & Radiopharmaceuticals See SI=“G” and $60.00 Threshold Amount for Packaging © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 38 APC Update for CY2008 Blood, Blood Products, Transfusions Blood and Blood Products Grossly Underpaid in Early Years of APCs It took CMS several years to investigate and determine that blood and blood products were being grossly underpaid to hospitals during the early years of APCs. The problem involved using incorrect CCRs which, of course, were not correctly reported by hospitals through the cost reporting process. In CY2005 CMS finally issued the badly needed guidance on coding and billing for blood, blood products and transfusions. The P-Codes are generally up for CY2008. • P9010 – Up 93% - Whole Blood • P9016 – Up 5% - RBC Reduced • P9021 – Up 0.1% - RBCs How is your hospital doing? Do these APC payments actually cover the cost of your blood products? Any problems with coding? What should you be doing? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 39 APC Update for CY2008 Blood, Blood Products, Transfusions Blood Transfusion Payments CMS provides very mixed language in this area. CMS maintains payment is made on an ‘encounter basis’ but then uses a payment mechanism of ‘per day’. • There are often cases in which a patient may present in the morning and then again in the afternoon. The APC Panel and commenters recommended that payment for 36430 be moved to either a true ‘encounter’ basis or should be paid on per unit transfused. • CMS rejected all the recommendations. This means that proper payment for transfusions depends on charge capture and proper pricing in the chargemaster. • Individual Charge Development Per Unit or • Overall Average Charge Development The key issue to base charges on costs. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 40 APC Update for CY2008 Inpatient-Only Services CMS continues to be adamant about keeping the ‘inpatient-only’ surgery list. The reason for keeping the list is that CMS does not have to map every possible outpatient surgery to various APCs. Unfortunately, the inpatient-only list is statistically determined, not clinically determined. If, for some reason, a surgeon starts out performing a regular outpatient surgery, this surgery turns into an ‘inpatient-only’ surgery, the patient is kept overnight in observation and is discharged home the next day, the hospital receive no payment at all! We can use the “-CA” modifier for cases entering through the ED in which the patient expires. A blanket payment is made regardless of the specific surgery. 2007 - $3,569.94 – 2008 - $5,006.13 (APC=0375) Payment has steadily increased as hospital report more cases. Why doesn’t CMS just use the “-CA” modifier for all cases in which an inpatient-only procedure is provided on an outpatient basis? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 41 APC Update for CY2008 Inpatient-Only Services What can a hospital do when an inpatient-only procedure is inadvertently provided on an outpatient basis? Here is an interesting comments from the ASC portion of the APC/ASC update FR entry. • Consistent with the current OPPS payment policy that prohibits facility payments to the hospital for noncovered services (such as those surgical procedures on the OPPS inpatient list) and makes the beneficiary liable for those charges, this proposed policy would make beneficiaries responsible for the ASC charges for noncovered services furnished to them in ASCs. Page 1040 Examination Copy November 27, 2007 Federal Register Clearly CMS views these inpatient-only procedures performed on an outpatient basis as ‘non-covered’. Do you think you would get very far trying to bill the Medicare beneficiary for inpatient-only surgeries performed on an outpatient basis? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 42 APC Update for CY2008 Brachytherapy Sources CMS Is Very Sensitive to Brachytherapy Source Payment Supposed to be pass-through items Some new bundling – LDR Brachytherapy CMS developed a mini-APC system for brachytherapy sources Multiple Uses of a Given Source Long Discussion in the Federal Register New HCPCS New APCs See Table 37 For Listing CMS Will Pay Prospectively Based On Claims Data • Again, this becomes a chargemaster, charge capture and charging issue in order to drive the statistical process used by CMS. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 43 APC Update for CY2008 Brachytherapy Sources Brachytherapy Codes, Mappings – All SI=-”K” A9527 - Iodine I-125, sodium iodide solution, therapeutic, per millicurie APC=2632 $27 C1716 - Brachytherapy source, non-stranded, Gold-198, per source 1716 $33 C1717 - Brachytherapy source, non-stranded, High Dose Rate Iridium-192, per source 1717 $173 C1719 - Brachytherapy source, non-stranded, Non-High Dose Rate Iridium192, per source 1719 $64 C2616 - Brachytherapy source, non-stranded, Yttrium-90, per source 2616 $11,621 C2634 - Brachytherapy source, non-stranded, High Activity, Iodine-125, greater than 1.01 mCi (NIST), per source 2634 $31 C2635 - Brachytherapy source, non-stranded, High Activity, Palladium-103, greater than 2.2 mCi(NIST), per source 2635 $46 C2636 - Brachytherapy linear source, non-stranded, Palladium-103, per 1MM 2636 $42 © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 44 APC Update for CY2008 Brachytherapy Sources Brachytherapy Codes, Mappings – All SI=-”K” C2637 - Brachytherapy source, non-stranded, Ytterbium-169, per source 2637 N/A C2638 - Brachytherapy source, stranded, Iodine-125, per source 2638 $45 C2639 - Brachytherapy source, non-stranded, Iodine-125, per source 2639 $32 C2640 - Brachytherapy source, stranded, Palladium-103, per source 2640 $65 C2641 - Brachytherapy source, non-stranded, Palladium-103, per source 2641 $51 C2642 - Brachytherapy source, stranded, Cesium-131, per source 2642 $97 C2643 - Brachytherapy source, non-stranded, Cesium-131, per source 2643 $63 C2698 - Brachytherapy source, stranded, not otherwise specified, per source 2698 $45 C2699 - Brachytherapy source, non-stranded, not otherwise specified, per source 2699 $31 © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 45 APC Update for CY2008 APCs for ASCs ASCs Are Finally Going to APCs, Well, Sort Of Originally, ASCs were supposed to go to APCs before hospitals. ASCs will be paid only a percentage of the APC payment amount. • However, various rules and grouping processes under APCs will now have to be followed. There are also some complicating factors in that minor procedures, which are typically performed in physician’s office, may be performed in the ASC. How should these services be paid? Also, there are questions about hospitals that are related to ASCs and also ASCs that are owned by physician (and/or joint ventures). Must fully understand APCs and RBRVS to comprehend all of the intertwined concepts that CMS is addressing. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 46 APC Update for CY2008 APCs for ASCs ASCs Are Finally Going to APCs, Well, Sort Of “In this CY 2008 OPPS/ASC proposed rule, we are proposing to update the revised ASC payment system for CY 2008, along with the OPPS. We are also proposing to revise the regulations to make practice expense payment to physicians who perform noncovered ASC procedures in ASCs based on the facility practice expense (PE) relative value units (RVUs) and to exclude covered ancillary radiology services and covered ancillary drugs and biologicals from the categories of designated health services (DHS) that are subject to the physician selfreferral prohibition.” Page 42778 “Under the revised ASC payment system, we cap payment for officebased surgical procedures for which ASC payment would first be allowed beginning in CY 2008 or later years at the lesser of the MPFS nonfacility practice PE RVU amount or the ASC rate developed according to the standard methodology of the revised ASC payment system.” Page 42779 • Note: A full discussion of all these concepts requires a separate workshop. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 47 APC Update for CY2008 APCs for ASCs CMS is completely altering the ASC (Ambulatory Surgical Center) payment system. There are two Federal Register entries of interest: August 2, 2007 Federal Register – Final For Payment Process November 27, 2007 Federal Register – Final For Payment Rates Differentiating between the process and the rates is a bit tricky. CMS could not finalize the CY2008 ASC payments until both the APC and RBRVS payment rates were determined for CY2008. The basic approach CMS is taking is to simply pay ASCs 65% of the hospital APC payment rate. While this is a simple approach, CMS has made some significant modifications. Also, given that APCs are undergoing rather dramatic changes, these changes will translate over to the ASCs as well. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 48 APC Update for CY2008 APCs for ASCs One of the first major changes CMS made for ASCs was to define which surgeries are considered to be ‘ASC Surgeries’, that is, surgical procedures that can be safely and appropriate performed at an ASC. Along with this process, CMS also decided to include on the ASC list minor surgical procedures that can be performed in a physician’s office or clinic. These are referred to as ‘office-based surgeries’. In the past this classification of procedures was not on the ASC list. From the ASC point-of-view, there are: Office-Based Surgeries, ASC Surgeries Surgeries Performed At A Hospital, Outpatient or Inpatient Thus, APCs covers the office-based surgeries, ASC surgeries and then some outpatient procedures that are not approved for ASCs under the Medicare program. Thus, the determination of what is on the list and how a given surgery is classified is important. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 49 APC Update for CY2008 APCs for ASCs Prior to CY2008, the office-based procedures generated no payment to ASCs. The physician performing these services was paid the full RBRVS amount. Any payment to the ASC had to be by arrangement between the physician and the ASC. Now that the office-based procedures are on the ASC list, CMS had to make decisions as to how they are to be paid. CMS could simply pay at 65% of the APC payment. However, even a cursory look at APC payments result in the conclusion that rather significant payments are made in some cases. Let us consider three CPT codes: 10080 - I&D Pilonidal Cyst, Simple 10081 - I&D Pilonidal Cyst, Complicated 11044 - Debridement skin, subcutaneous tissue, muscle and bone © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 50 APC Update for CY2008 APCs for ASCs APC Payments For Sample Codes CPT APC SI Payment Copay1 10080 0006 T $ 89.59 $ 17.92 10081 0007 T $736.26 $147.25 11044 0682 T $438.32 $158.65 Copay2 $ 87.66 Note that for APCs there is a vast payment difference between 10080 and 10081. Also, both of these procedures can be office-based. Thus, CMS decided that the payment formula should be: ASC payment is the lesser of: 65% of the APC payment OR Non-Facility PE RVU payment. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 51 APC Update for CY2008 APCs for ASCs RBRVS for Sample Codes CPT 10080 10081 11044 Work 1.19 2.47 4.11 NonFacPE 2.89 3.77 4.64 FacPE 1.10 1.47 3.66 MM 0.11 0.24 0.43 The conversion factor (CF) for CY2008 is $34.0682. Both 10080 and 10081 are classified as ‘office-based’ procedures. In order to apply the formula, we must calculate the Non-Facility PE RVU: 10080 – 2.89 * $34.0682 = $ 98.46 10081 – 3.77 * $34.0682 = $ 128.44 Applying the Formula – ASC Payment 10080 - $ 89.59 10081 - $ 128.44. For Regular ASC Surgery – 65% of APC For 11044 - 65% * $438.32 = $284.91. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 52 APC Update for CY2008 APCs for ASCs New Organizational Model Have hospital contract with ASC for outpatient surgeries and then have hospital paid 100% of the APC payment versus 65% for the ASC. • Thoughts?? ASC Changes – Physician Impact For office-based procedures physicians will now be paid as if they performed the services in the hospital setting, that is, provider-based setting. Basically the same economic incentive is available as with hospitals and provider-based clinics. Only surgeries are considered as opposed to the more frequent E/M services. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 53 APC Update for CY2008 Injection, IV Therapy, Chemotherapy For CY2007 the implementation of the new hydration, infusion, IV injections and chemotherapy codes was probably (and still is) one of the greatest APC related challenges. New Coding Logic Encounter Driven • What do we do about observation? Must Determine Primary/Initial Service • IM/SQ/IA Injections Do Not Participate In This Logic Hierarchy of Services to Guide Coding (Policy?) • IV Infusion Chemotherapy • IV Push Chemotherapy • IV Infusion Non-Chemotherapy • IV Push Non-Chemotherapy • Hydration Application of Coding Logic Can Be a Challenge © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 54 APC Update for CY2008 Injection, IV Therapy, Chemotherapy New Coding Logic Coding May Be Through the Chargemaster By Nursing Personnel • Develop Cheat Sheet or Coding Template • Adjust Chargemaster Entries May be in distributed service areas. Revenue code choices? Extensive Policies and Procedures Should Be Developed Extensive, On-Going Training Must Be Conducted © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 55 APC Update for CY2008 Injection, IV Therapy, Chemotherapy APC Payment for Injections and Infusions APC Drug Admin CY2008 Pay CY2007 Pay Level I $16.21 $14.02 Level II $25.13 $25.71 Level III $51.22 $52.93 Level IV $105.38 $109.25 Level V $114.64 $116.62 Level VI $149.34 $155.27 Payment is generally holding steady. CMS is paying more for infusions and injections than they have in the past. • How do APGs treat injections? • Is there any possibility that CMS will want to package injections/infusions unless they are the only service provided? See New Injection Codes © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 56 APC Update for CY2008 Injection, IV Therapy, Chemotherapy Exercise – Compare payment from CY2006 through CY2008 for: • Two hours of hydration • Four hours of IV therapy • Nine hours of IV therapy • Two hours IV infusion chemotherapy followed by two IV push chemotherapy © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 57 APC Update for CY2008 Injection, IV Therapy, Chemotherapy There is a long list of P&P issues surrounding Hydration, Injections and Infusion Therapy Multiple Sites Vein Failure Separate Encounters Discontinue/Re-Establish Routine, Integral Part See Hospital Wide General Policy Multiple Injections, Same Drug General Injection, Hydration, Infusion Therapy Logic • • • • Primary/Initial vs. Secondary/Subsequent Concurrent Add-On Code Utilization CPT Guidance © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 58 APC Update for CY2008 Injection, IV Therapy, Chemotherapy Chemotherapy With the adoption of the new infusion, injection and chemotherapy codes, the long roller coaster ride for chemotherapy is coming to an end. Unless CMS decides to make some major change, which wouldn’t be that unusual, chemotherapy operations should become financial stable. Previous guidance from CMS supports the coding and billing of additional non-chemotherapy infusions and injections along with the chemotherapy as primary, of course. Questions surrounding nursing evaluation in the chemotherapy area continues to be somewhat problematic. CMS seems to indicate that these types of services are just a part of the chemotherapy services. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 59 APC Update for CY2008 Closed Fracture Care/Strapping This area is a major mess for APCs When APCs were developed, as with APGs, there were two categories within the closed fracture care and/or splinting: Low Level APC for Fingers, Toes, Trunk • Relatively inexpensive services for addressing fractured ribs, fingers, toes, etc. and/or strapping sprained/dislocated ribs, fingers, toes, etc. High Level APC for Everything Else • Relatively expensive services for arms, legs and other fracture/sprains, dislocations of other than finger, toe trunk What happened? We have only one APC for Closed Fracture Treatment We have only one APC for Strapping and Casting © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 60 APC Update for CY2008 Closed Fracture Care/Strapping Exercise – Sam present to ED after falling off horse. Complains of upper right chest pain. X-ray indicates a single, uncomplicated, non-displaced fracture of a rib. Nurse counsels patient on delimiting activities, proper breathing and the like. Patient discharged home with prescription for Tylenol #3. How to code and bill? Exercise – Stanley present to the ED with an injured right index finger. Xray indicates no fracture. Diagnosis is sprained finger. Physician orders nurse to apply a finger splint. A mild pain medication is prescribed. How to code and bill? Exercise – Susan presents to the ED with an injured toe. X-ray indicates a non-displaced fracture. Physician orders the toe to be ‘buddy-taped’. Susan is instructed to use acetaminophen as an analgesic. How to code and bill? • What should hospital be doing in this area? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 61 APC Update for CY2008 Wound Care Wound Care Therapy-Only Codes • “-GP”, “-GO”, “-GN” • Therapy Plan of Care When hospital outpatients receive wound care services by individuals outside of a certified therapy plan of care, the hospital reports the appropriate CPT code and nontherapy revenue code and is paid under the OPPS. When these services are provided to hospital outpatients by a qualified therapist under a therapy plan of care and reported using either one of the appropriate therapy modifiers, the therapy revenue code series (42X, 43X, or 44X), or both, hospitals are paid based on the MPFS. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 62 APC Update for CY2008 Hyperbaric Oxygen Hyperbaric Oxygen Therapy C1300 reimbursement has created significant discussion over the past several years. CMS Maintains Everything Is Appropriate • As stated in the proposed rule (72 FR 42706), we believe that this adjustment through use of the hospitals' overall CCRs is all that is necessary to yield a valid median cost for establishing a scaled weight for HBOT services. Therefore, for CY 2008, we proposed to continue to use the same methodology that we have used since CY 2005 to estimate payment for HBOT. Page 590 Examination Copy November 27, 2007 Federal Register © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 63 APC Update for CY2008 2 Times Rule 0033 - Partial Hospitalization 0043 - Closed Treatment Fracture Finger/ Toe/Trunk 0060 - Manipulation Therapy 0080 - Diagnostic Cardiac Catheterization 0093 - Vascular Reconstruction/Fistula Repair without Device 0105 - Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices 0106 - Insertion/Replacement of Pacemaker Leads and/or Electrodes 0109 - Removal/Repair of Implanted Devices 0235 - Level I Posterior Segment Eye Procedures 0251 - Level I ENT Procedures 0260 - Level I Plain Film Except Teeth 0278 - Diagnostic Urography 0282 - Miscellaneous Computed Axial Tomography 0303 - Treatment Device Construction © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 64 APC Update for CY2008 2 Times Rule 0323 - Extended Individual Psychotherapy 0330 - Dental Procedures 0340 - Minor Ancillary Procedures 0368 - Level II Pulmonary Tests 0381 - Single Allergy Tests 0409 - Red Blood Cell Tests 0432 - Health and Behavior Services 0438 - Level III Drug Administration 0604 - Level 1 Hospital Clinic Visits 0664 - Level I Proton Beam Radiation Therapy 0688 - Revision/Removal of Neurostimulator Pulse Generator Receiver Question: For how many years can an APC be on this list? • This is supposed to be an exceptional process, that is, exempting an APC from being divided into several parts in order to reduce the variation. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 65 APC Update for CY2008 Chargemaster Related Issues Establishing Hospital Charges Cost-to-Charge Ratios (CCRs) Cost Report Development Interface Charge-Compression • Tiered Supply Charge Formulas • Tiered Drug Charge Formulas This has become a major issue for DRGs because the formula for calculating the DRG weights is being changes to the same formula that is used for APCs. Major Issue for Hospitals • Transparent Pricing • Strategic Pricing • Comparative Pricing • Rational Pricing What impact does all of this have on APCs? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 66 APC Update for CY2008 Chargemaster Related Issues Bundling Charges CMS and CPT Guidance Fitting the Pieces Together • Distinguish Between: Charging Separately Charging Separately Billing Separately Reporting • Examples: CPT Guidance – Infusions & Injections o IV Infusion Supplies Not To Be Reported Separately CPT Guidance – Conscious Sedation o Procedures Annotated with “ʘ” Should Not Report Conscious Sedation Separately © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 67 APC Update for CY2008 Chargemaster Related Issues Bundling Charges CMS and CPT Guidance Fitting the Pieces Together • Supply Categorization Ancillary vs. Non-Ancillary Supply Items Stock Items IV Solutions Supply Categorization Issues o See Position Paper from AACI which is in its 10th version. • Status Indicator = “N” Items To Bill or Not To Bill Charge Development Examples: o Subsequent Hours of Critical Care o Concurrent Infusions Number of SI=“N” Services Will Increase In Future © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 68 APC Update for CY2008 Policy Issues Outpatient Hospital Services and Supplies Incident to a Physician Service Changes to 42 CFR §§ 410.27(a)(1)(iii) and (f) • Language relating to designation of provider-based status. “This proposed deletion of the reference in §§ 410.27(a)(1)(iii) and (f) to CMS ‘‘designating’’ a department of a provider under § 413.65 would make those sections consistent with the 2002 amendments to the provider-based rules, in that under the amended provider-based rules, a main provider is no longer required to ask CMS to make a determination that a facility or organization is provider-based before the main provider can bill for services of the facility as if the facility were provider-based, or before the main provider can include the costs of those services in its cost report.” Page 42771 © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 69 APC Update for CY2008 Policy Issues Outpatient Hospital Services and Supplies Incident to a Physician Service Changes to 42 CFR §§ 410.27(a)(1)(iii) and (f) • “Section 410.27(a)(1) currently states that Medicare Part B pays for hospital services and supplies furnished incident to a physician service to outpatients, including drugs and biologicals that cannot be self-administered, if they are furnished by or under arrangements made by a participating hospital, except in the case of a resident of a skilled nursing facility as provided in § 411.15(p); as an integral though incidental part of a physician’s services; and in the hospital or at a location (other than a rural health clinic or a Federally qualified health center) that CMS designates as a department of a provider under § 413.65.” Page 42772 Hospitals establishing relationships with ASC relative to incident-to services may not qualify under the provider-based rule. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 70 APC Update for CY2008 Policy Issues Outpatient Hospital Services and Supplies Incident to a Physician Service Changes to 42 CFR §§ 410.27(a)(1)(iii) and (f) • “With regard to potential for ASCs to provide ‘‘incident to’’ services under arrangements with HOPDs, we note that the provider-based rules set forth at § 413.65 do not apply to ASCs. In addition, our longstanding policy codified at § 416.30(f) for ASCs operated by hospitals requires that ‘‘the ASC participates and is paid only as an ASC, without the option of converting to or being paid as a hospital outpatient department, unless CMS determines there is good cause to do otherwise.’’ We do not believe good cause exists such that a Medicare-certified ASC would be able to provide ‘‘incident to’’ services under arrangement to hospital outpatients under § 410.27.” What is going on here? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 71 APC Update for CY2008 Policy Issues Interrupted Procedures - 42 CFR §419.44 “Currently, when a procedure is interrupted after its initiation or the administration of anesthesia, hospitals append modifier 74 (Discontinued outpatient procedure after anesthesia administration) to the interrupted procedure, and the full OPPS payment for the procedure is made. In addition, when a procedure requiring anesthesia is discontinued after the beneficiary is prepared for the procedure and taken to the room where the procedure is to be performed, but before the administration of anesthesia, hospitals currently append modifier 73 (Discontinued outpatient procedure prior to anesthesia administration) to the discontinued procedure and receive 50 percent of the OPPS payment for the planned procedure. Hospitals also report modifier 52 to signify that a service that did not require anesthesia was partially reduced or discontinued at the physician’s discretion. Modifier 52 is reported under the OPPS for a variety of types of interrupted services, such as radiology services. Under the OPPS, we apply a 50percent reduction to the facility payment for interrupted procedures and services reported with modifier 52.” Page 42772 Proposed FR Entry © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 72 APC Update for CY2008 Policy Issues Reporting Wound Care Services “For CY 2008, we are proposing to revise the list of therapy revenue codes that may be reported with CPT codes 97597, 97598, 97602, 97605, and 97606 to designate them as services that are performed by a qualified therapist under a certified therapy plan of care, and thus payable under the MPFS, to be consistent with the current billing practices of hospitals and to ensure that we are making separate payment under the OPPS only in appropriate situations.” Page 42773 • What is going on here? Cardiac Rehabilitation Status Indicator Change G-Codes Bone Marrow Stem Cell Technical Coding/Grouping Changes Sole Community Hospitals 7.1% Bonus (?) © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 73 APC Update for CY2008 Odds and Ends Exercise – Stephanie, a physical therapist at the Apex Medical Center, has been called to the ED to fabricate and apply a splint. This is for a badly sprained leg. Discuss how this service should be coded and billed. • Will this service be paid under APCs or under the Rehabilitation Fee Schedule (MPFS)? What is happening with the APC coinsurance percentage. Supposed to be 20%. Where are we? How soon will we get there? © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 74 APC Update for CY2008 Summary and Conclusions APCs Represent CMS’s Most Complex Prospective Payment System As We Enter the Ninth Year of APCs – The variation in payments continues to be a roller coaster Significant policy changes continue to be developed, specifically increased packaging Hospital charging structures are now in the limelight both from the public as well as how they impact APC weight development Proper chargemaster construction along with proper coding interfaces and charge capture are of great importance Correct CPT/HCPCS coding along with proper use of modifiers continues to paramount Significant, additional guidance from CMS is needed in a number of difficult areas Hospitals should anticipate that APCs will continue to change at a rapid pace during the coming years. © 1999-2008 Abbey & Abbey, Consultants, Inc. Slide # 75