Health Information Management

CMS’ proposed ’complexity adjustment’ introduces new concept to OPPS

APCs Insider, July 11, 2014

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After last year's OPPS proposed rule debacle, which included a later-than-usual release, data errors that required corrections and a comment extension, and radical changes to E/M, the 2015 OPPS proposed rule released by CMS last week seems relatively benign.
At less than 700 pages, it's also shorter than most proposed rules, but does include a new concept to the OPPS in the form of "complexity adjustments" for Comprehensive APCs.
As promised, CMS reintroduced the concept of Comprehensive APCs for device-dependent APCs first seen in last year's proposed rule. With Comprehensive APCs, a single payment will be made rather than separate, individual APC payments.
CMS has refined the concept to include some lower-cost device-dependent APCs and two new APCs for other procedures and technologies that are either largely device dependent or represent single session services with multiple components. CMS is now proposing 28 Comprehensive APCs for 2015 after consolidating and restructuring the 29 proposed last year.
The most significant change to the policy is a proposed "complexity adjustment." The adjustment is applied 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 the facility reports one of these combinations, CMS will increase the payable APC to the next higher APC in the clinical group, similar to DRGs on the inpatient side.
"This is the first time in OPPS history where we have something like severity adjustment," says Kimberly Anderwood Hoy Baker, JD, director of Medicare and Compliance for HCPro, a division of BLR, in Danvers, Massachusetts.
CMS lists the services it is proposing to assign to each Comprehensive APC for 2015, along with cost statistics, in Addendum J.
To read about more of the changes proposed in the rule, including requirements related to inpatient physician certification and data collection for off-campus provider-based hospital departments, see For more analysis of the rule, and strategies to determine the financial impact of the proposals, listen to HCPro's popular, annual webcast with experts Jugna Shah, MPH,andValerie A. Rinkle, MPA.
CMS will accept comments on the proposed rule until September 2, 2014, and will respond to comments in a final rule to be issued on or around November 1, 2014. The proposed rule will appear in the July 14 issue of the Federal Register.

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