Health Information Management

OPPS guessing game continues

APCs Insider, November 1, 2013

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It’s November 1, which should mark an important day for the healthcare industry. No, it’s not (only) for gathering in the break room to pick over leftover Halloween candy brought in by coworkers, but also the date CMS usually targets to release the OPPS final rule.

That’s unlikely to happen this year, as the road to the final rule has been unusually complicated. When CMS released its proposed rule in July, it included what Jugna Shah, MPH, president and founder of Nimitt Consulting of Washington, D.C., called some of the most sweeping changes in OPPS history. These changes include:

  • Replacing the current 20 outpatient visit CPT® codes with three HCPCS G codes
  • Expanding packaging to include seven new categories with more than 2,400 codes that will either be unconditionally or conditionally packaged
  • Replacing existing device-dependent APCs with 29 new comprehensive APCs

All of the changes had providers working to conduct data analyses to see what the impact of these rules might be before the 60-day comment period ended. However, CMS was forced to release updated data for the proposed rule just a week before the comment period ended after hearing from numerous providers about difficulties replicating the rule.

CMS ended up extending the comment period for sections affected by the new data for 10 days, but many providers were still left with inadequate data or time to offer sufficient comments.

When the government shutdown struck, CMS furloughed 65% of its workforce and all regulatory timelines were thrown into doubt. With the 16-day shutdown over, CMS gave an update last week of its plan for upcoming releases.

“Although we are still assessing the impact of the partial government shutdown on completion of the calendar year 2014 Medicare fee for service payment regulations, we intend to issue the final rules on or before November 27, 2013, generally to be effective on January 1, 2014,” CMS said.

The impacted regulations include:
  • Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (CMS-1526-F)
  • CY 2014 Changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System (CMS-1601-FC)
  • CY 2014 Home Health Prospective Payment System Final Rule (CMS-1450-F)
  • Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2014 Final Rule with Comment Period (CMS-1600-FC)

The vague wording of CMS’ statement leaves the actual release and enforcement dates for OPPS and other rules up in the air. Typically, CMS gives 60 days between the release of a final rule and the date of implementation. There may be, at most, about a month given this year if the rule is not released until November 27.

CMS did provide some wiggle room in its answer, however, by saying regulations would “generally” be effective January 1. With the recent IPPS final rule, CMS delayed auditor enforcement of the controversial 2-midnight rule for three months after the rule was implemented. CMS also began requiring functional G codes for therapy services Jan. 1, 2013, but gave providers a 6-month grace period to implement the change.

CMS could conceivably enforce the OPPS changes in a piecemeal manner, but like most other aspects of the rule this year, it’s almost impossible to predict what—or when—CMS will decide.



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