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 2
Final Payment Updates Market Basket 2.4% Multifactor Productivity (.5)% ACA (.2)% Packaged lab issue (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 5
OPPS CMS continues to revise the packaging "of items and services to make the system more prospective Rework: Composite APC logic In the 2016 OPPS rule change we continue to see CMS implementing changes to this ever-evolving complex payment system Addition to the new C-APC list Movement of certain APC weights Reclassification of current APC groups Changes and additions to APC status indicators 6
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 STATUS INDICATOR J1 This newest APC category recognizes an additional 10 clinical groups in 2016 7
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) 8
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) 9
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 10
C-APC Complexity Adjustments Examples Primary HCPC Code Primary Short Descriptor Primary SI Primary APC Assignment Secondary J1 or Add-on HCPC Code Secondary Short Descriptor Secondary SI Secondary APC Assignment Complexity Adjusted HCPC Assignment Complexity Adjusted APC Assignment 25607 Treat fx rad extra-articular J1 5123 25545 Treat fracture of ulna J1 5123 5607A 5124 26531 Revise knuckle with implant J1 5123 26531 Revise knuckle with implant J1 5123 6531A 5124 27726 Repair fibula nonunion J1 5123 27720 Repair of tibia J1 5123 7726A 5124 28300 Incision of heel bone J1 5123 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 11
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 12
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 13
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) 14
Status Indicators Affected by 2016 Updates ADDENDUM D1. - FINAL OPPS PAYMENT STATUS INDICATORS FOR CY 2016 Status Indicator Item/Code/Service OPPS Payment Status A Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS, for example: Ambulance Services Separately Payable Clinical Diagnostic Laboratory Services Separately Payable Non-Implantable Prosthetics and Orthotics Physical, Occupational, and Speech Therapy Diagnostic Mammography Screening Mammography 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. Not subject to deductible or coinsurance. C Inpatient Procedures Not paid under OPPS. Admit patient. Bill as inpatient. 15
Status Indicators Affected by 2016 Updates Status Indicator Q1 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. Q2 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. Q3 Q4 Codes that may be paid through a composite APC Conditionally packaged laboratory tests 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 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. Paid under OPPS or CLFS. 1. Packaged APC payment if billed on the same claim as a HCPCs code assigned published 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. 16
Status Indicators Affected by 2016 Updates Status Indicator J1 J2 Item/Code/Service Hospital Part B services paid through a comprehensive APC Hospital Part B services that may be paid through a comprehensive APC OPPS Payment Status 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. Paid under OPPS; Addendum B displays APC assignments when 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. 17
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. 18
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 19
Major Restructuring of APC Groupings 766 APC in 2015 663 APC for 2016 With 200+ APC reassigned to new APC number 20
Other Changes 21
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 22
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 23
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 24
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 25
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 26
Questions or Comments 27
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 28