Health Information Management

OPPS delay means no holiday for outpatient facilities

APCs Insider, November 22, 2013

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For many, this is the time of year when the latest updated rules, regulations, and payment rates are being calculated and finalized in order to determine the financial impact that can be expected. But for outpatient facilities, a critical piece of the puzzle is still missing.

Despite traditionally being released by November 1, this year’s OPPS final rule remains in limbo. CMS still intends to release it by November 27, the day before Thanksgiving. It’s safe to say that few will be giving thanks this year for the sweeping proposed changes, incorrect data released by CMS that extended the comment period, and delay caused by the government shutdown that led to this unprecedented wait.

Facilities will only have approximately one month—which will include Thanksgiving, Christmas, and New Year’s—to implement CMS’ changes this year, which could be a strain even in a normal year. In the 2014 OPPS proposed rule, however, CMS proposed changes that 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

These changes may not require extreme operational reorganization to implement—which is helpful, since CMS says the final rule’s regulations will still “generally” be implemented by January 1, 2014—but they could have vast financial implications for years to come.

The impact of collapsing 20 E/M codes into three G codes is largely unknown since this wasn’t something providers requested or anticipated. The impact will vary by facility, depending on their distribution and what CMS sets as the payment rate. Meanwhile, the expanded packaging may not have an immediate impact on reimbursement, but could in a few years when CMS is calculating rates for these services. In the past, hospitals have not consistently reported packaged services separately, so CMS cannot collect accurate data on the cost and frequency of the packaged services. If providers don’t supply this data, CMS can’t use it to set payment rates.

It’s possible that CMS won’t institute any of these changes or will delay implementation of some of them deeper into 2014. But for those tasked with figuring out how the puzzle will fit together, the fact these questions still remain is the biggest problem of all.


Note: APCs Insider will not publish next week due to Thanksgiving. Enjoy the holiday and look for the next edition Friday, December 6!

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