OPPS Proposed Updates Released July 8, 2013

Just in case you haven’t had a chance to get into the Federal Register and review the proposed changes; here are a couple of the highlights. The Centers for Medicare & Medicaid Services (CMS) are proposing a collapse of hospital outpatient clinic and ED visit codes instead of recognizing the current five levels of clinic and Ed visit codes. The proposal includes creation of three new HCPCS Level II codes to describe these services, with the strategic goal of using larger payment bundles to maximize hospital incentives to only provide care that is medically necessary.

From 2002 to present there has not been a set of national guidelines for Evaluation and Management leveling. CMS had advised for hospitals to create their own internal policies and guidelines and to design them to reasonably relate the intensity of hospital resources to the different levels of codes. Since CMS has evaluated the intent to develop guidelines, it has proven to be consistent, that there is not a single approach that could accurately capture hospitals relative costs across the country, therefore, it is not feasible to adopt a national set of guidelines.

Proposed Creation of New Codes and APC’s:
New APC’s will be assigned to the new code sets if published to the final rule.

The collapse would include the following codes: Clinic visits 99201-99215 would all be delegated to new APC 0634 and HCPCS Level II code GXXXC.

Type A Emergency Department visit CPT codes 99281-99285 would be delegated to new APC 0635 HCPCS code GXXXA, while Type B Emergency Department visits would be assigned APC 0636 and HCPCS code GXXXB. Also, the distinction between new and established patient clinic visits will no longer be recognized with this new code set. Previous years 2011 or 2012 claims data will be reviewed to set the total means cost to the new code set.

Another area that I found very interesting relates to the status indicator proposal. CMS is proposing that status indicator X be reassigned to either SI “Q1” or SI “S” with a creation of new “J1” status indicator to identify codes with comprehensive APC’s. Payment for services assigned to these status indicators will be subject to the reduction of the national unadjusted payment rates for applicable hospitals, with the exception of services assigned to New Technology APCs with assigned status indicator “S” or “T”.  Reference the CY 2009 OPPS/ASC final rule with comment period (73 FR 68770) for a discussion of this policy.

New Addendum P on the CMS website lists all of the codes involved in CMS’s new packaging system, however these codes will be paid a separate payment if the code is reported alone on the claim.

It is going to be interesting to see how this will all shake out in the final rule which is due to be released November 1, 2013 following the comment period.