Corporate Compliance

Note from the instructor: CY 2015 OPPS Proposed Rule contains Significant Policies

Medicare Insider, July 8, 2014

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This week’s note from the instructor is written by Kimberly Anderwood Hoy Baker, JD, CPC,regulatory specialist for HCPro.

On July 3, CMS posted the display copy of the CY 2015 OPPS Proposed Rule with proposed payment and policy changes for hospital outpatient and ambulatory surgery center services. Notably, the rule contains refinements to the Comprehensive Ambulatory Payment Classification (APC) policy (adopted in the CY 2014 OPPS Final Rule for implementation in CY 2015) and significant increased packaging of ancillary services. The rule also included a very significant proposal on inpatient certification, eliminating the onerous requirement for most hospital inpatient stays.
CMS made several adjustments to the policy for payment of Comprehensive APCs. Most significantly they proposed a “complexity adjustment”. The complexity adjustment applies when a primary procedure assigned to a Comprehensive APC is reported with other specified procedures also assigned to Comprehensive APCs or with a specified packaged add-on code. When one of these combinations are reported, the payable APC is increased to the next highest APC in the clinical group (i.e., from level II to level III). New Addendum J has details of the code combinations subject to this complexity adjustment and the APC that will be paid when one of the combinations is reported. Also included in Addendum J is the ranking of procedure codes for determining the primary procedure that will control the APC assigned when multiple procedures assigned to Comprehensive APCs are reported.
Another significant refinement to the policy relates to the services excluded from the Comprehensive APC payment. The rule contains new Table 6, listing 10 categories of services not subject to packaging to the Comprehensive APCs. There are two significant changes from the policy articulated in the CY 2014 OPPS Final Rule. Self-administered drugs that are not treated as supplies to the procedure will be excluded from packaging and are still billable to the patient. The prior rule implied these drugs would be packaged to the Comprehensive APC. However, CMS proposes excluding them based on their statutory exclusion from coverage under Part B. 
They have also proposed to exclude therapy services that are reported on separate facility claims “for recurring services” from packaging to Comprehensive APCs. CMS refers to them as “recurring” services in the proposed rule, but they are presumably referring to services the Claims Manual defines as “repetitive services”, which are required to be billed on a separate monthly claim. They also proposed to exclude ambulance service; brachytherapy; mammography; preventative services; pass-through drugs, biologicals and devices; and services paid on a reasonable cost basis.
The proposed rule also makes another significant packaging proposal related to ancillary services with costs of $100 or less. CMS is proposing to conditionally package services with a mean cost of $100 or less, eliminating status indicator “X” and reassigning these codes to status indicator “Q1” (STV Packaged). Table 11 has the list of APCs that will be packaged under the new rule, including level I and II x-rays, level I ultrasounds, ECGs, and many other ancillary procedures and diagnostic tests. The proposal would exclude preventative services, certain psychiatry and counseling services, and drug administration services from the new policy. Services that formerly had a status indicator “X” but are not subject to packaging (i.e., they have a cost greater than $100) will be reassigned to status indicator “S”.
One of the most significant proposals in the rule did not relate to outpatient services at all, but rather to the inpatient certification requirement. In the CY 2014 IPPS Final Rule, CMS adopted revised certification requirements for all inpatient admissions. Because all elements of the new certification had to be signed by the physician prior to discharge, this requirement has created a great deal of difficulty for hospitals and arguably required the most extensive change to computerized documentation systems of all the changes in 2014. 
The proposal would modify the regulation on certification to only require the certification for outlier cases and long-stays, defined as stays 20 days or longer. The requirements for the new certification are similar to the requirements under the current rule: reason for continued hospitalization or special and unusual circumstances for outliers, estimated time the patient will remain in the hospital, and plans for post-hospital care. CMS is careful to note that the order requirements also adopted in the CY 2014 IPPS Final Rule are not proposed to change and an order complying with the new order requirements is still necessary to demonstrate the patient is considered an inpatient during this stay.
The rule contains other proposals including payment updates, a proposal for a new modifier to identify off-campus provider based department services, an increase to the outlier threshold, and quality proposals. As always, providers are encouraged to read the rule for policies significant to their operations and submit comments on proposals that will unduly or negative affect them. The comment deadline was not set in the display copy of the rule, but the rule is set to be published in the Federal Register on July 14 and the comment period is normally 60 days from the publication date.

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