Corporate Compliance

Note from the instructor: CMS issues quarterly OPPS and I/OCE updates

Medicare Insider, March 24, 2015

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This week’s note from the instructor is written by Judith L. Kares, JD, regulatory specialist for HCPro.  
CMS recently issued the April 2015 quarterly updates to the OPPS (Claims Processing Transmittal 3217) and the I/OCE (Claims Processing Transmittal 3218). Last week we focused on the discussion in the quarterly OPPS update regarding CMS’ decision to allow payment for certain preadmission inpatient only procedures bundled into a subsequent inpatient claim under the so-called three- (or one-) day window rules. This week we will review the other key changes set out in the April OPPS and I/OCE updates.
Summary of additional key OPPS and I/OCE changes
Addition of one new pass-through device category: Effective April 1, 2015, CMS has created one new pass-through device category identified by HCPCS code C2623. Reimbursement for C2623 is cost based, subject to an offset amount equal to the policy-packaged portion of the APC to which the procedure utilizing the device is assigned. The policy-packaged portion of the applicable APC payment is the portion of the payment that was designed to cover the predecessor device used with that procedure.
Addition of six new pass-through drugs and biologicals: Effective April 1, 2015, CMS has approved six new pass-through drugs/biologicals. These pass-throughs—C9445, C9448, C9449, C94502, C9451, and C9452—are reimbursed based upon average sales price (ASP) + 6%, updated on a quarterly basis. If ASP data is not yet available, reimbursement is based on wholesale average cost (WAC) + 6%. If WAC data is not yet available, reimbursement is based on 95% of average wholesale price (AWP); however, as soon as ASP data is available, ASP + 6% is the basis for payment. 
Other changes to drugs and biologicals: CMSreleased updated April 1, 2015, ASP data, as well as retroactive ASP updates for certain prior quarters. In particular, hospitals should review these updates to determine whether to submit adjustment claims for prior quarters.
Effective April 1, 2015, CMS also made the following changes:
  • Changed the status indicators (SIs) for the following two drugs:
o   J0365—changed from SI of “K” to “E” (not recognized by Medicare)
o   J7180—changed from SI of “N” to “K” (separately payable under OPPS)
  • Reassigned two skin substitute products—Q4150 and Q4153—from low cost to high cost status
  • Replaced HCPCS code Q9975, Factor VIII FC Fusion Recomb, with HCPCS code C9136, Factor viii (Eloctate)
Finally, CMS is correcting coinsurance (initially set at 20%) for the following two drugs, as set out below:
  • For HCPCS code J7315, effective January 1, 2014, through March 31, 2015; and
  •  For HCPCS Code C9447, effective January 1, 2015, through March 31 2015
Implementation of the “PO” HCPCS modifier. In keeping with its finalized instructions in the CY 2015 OPPS final rule, CMS emphasized that the “PO” HCPCS modifier should be reported with every code for outpatient hospital services furnished in an off-campus hospital provider-based department (PBD), beginning with dates of services on and after January 1, 2016. In preparation, hospitals may begin voluntarily reporting this new modifier during CY 2015.
The “PO” modifier, however, should not be reported for remote locations of a hospital, satellite facilities of a hospital, or for services furnished in an emergency department. In response to an informal query regarding whether critical access hospitals (CAHs) are also subject to the mandatory reporting of the “PO” modifier, one CMS representative has indicated that CAHs are not required to do so. CAHs may want to seek further confirmation by contacting their MACs or raising this issue during an open door forum call.
Two billing clarifications. CMS also provided clarification on the following two services:
  • Hospitals may report C2625 (Stent, non-coronary, temporary, with delivery system) when utilizing the Propel™ and Propel Mini™ drug eluting sinus implants by Intersect ENT; and
  •  Hospitals are reminded to report two claim lines when billing for cystoscopy procedures using Cysview® (hexaminolevulinate hydrochloride):
o   One claim line with an appropriate cystoscopy procedure code; and
o   A separate claim line with HCPCS code C9275 (Injection, Hexaminolevulinate Hydrochloride, 100 mg, per study dose)
I/OCE processing of inpatient-only procedure, subject to emergency exception. In the April 2015 I/OCE update, CMS clarified the processing of an inpatient-only procedure performed emergently in the outpatient setting in the following circumstances:
  • The patient died prior to being admitted to the inpatient setting; and
  • On the same date of service, the hospital performed another procedure (SI of “J1”) for the same patient that would otherwise qualify for payment under a comprehensive APC
In these circumstances, CMS stated the hospital should follow the rules applying to the emergency exception to the inpatient only rules. Under the inpatient-only rules, Medicare generally denies payment not only for the inpatient-only procedure performed in the outpatient setting, but for all other outpatient services performed for that patient on the same date of service, including those services otherwise payable under the OPPS. 
The emergency exception applies when an inpatient-only procedure is performed emergently, but the patient dies before he or she can be admitted. Under this exception, Medicare will pay for a single inpatient-only procedure under APC 0375, and all other outpatient services performed for the patient on the same date of service are packaged. To trigger the applicability of the emergency exception, the hospital must attach the CA modifier to the inpatient-only procedure and report patient status code 20 (patient expired) in FL 17 on the UB-04.
In the April I/OCE update, CMS clarified by stating the emergency exception rules should be followed even when a procedure with a SI of “J1” is reported on the same claim with the same date of service as the inpatient-only procedure. The specified inpatient-only procedure APC (0375) will be assigned as the payable APC. The comprehensive APC procedure will be assigned to its comprehensive APC; however, the comprehensive APC will be packaged with SI = N, along with all other lines on the claim.
Additional resources on this topic
Medicare Claims Processing Transmittal 3217
Medicare Matters Article MM9097
Medicare Claims Processing Transmittal 3218
Medicare Matters Article MM9107

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