Health Information Management

2016 OPPS proposed rule: CMS looks to extensively reconfigure and consolidate APCs

APCs Insider, July 10, 2015

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By Steven Andrews
CMS appeared to give providers a break with this year’s OPPS proposed rule, released July 1. The rule came out a couple days before the holiday weekend at a relatively short 697 pages.
However, the rule contains a number of proposals that pack a lot of information into deceptively short passages, according to Jugna Shah, MPH, president and founder of Nimitt Consulting, based in Washington, D.C., and Spicer, Minnesota.
In fact, CMS reviews the code assignments and structure of APCs each year, but is proposing extensive changes for 2016. Last year, the agency finalized changes to reconfigure and consolidate ophthalmology and gynecology APCs, but is proposing to expand that to nine new clinical families for 2016:
  • Diagnostic tests and related services
  • Endoscopy procedures
  • Gastrointestinal procedures
  • Imaging services (specifically diagnostic radiology and nuclear medicine)
  • Incision and drainage and excision/biopsy procedures
  • Orthopedic procedures
  • Skin-related procedure (combining debridement and destruction with skin procedure APCs)
  • Urology and related procedures
  • Vascular procedures
“This may be the single largest restructuring of APC groups since the inception of OPPS,” says Shah. “And it’s likely just the beginning.” A crosswalk of the 2015 APCs and proposed 2016 APCs is available in Addendum Q.
Part of the reconfiguration is simply to renumber APCs to give consecutive numbers to APC levels within a clinical family. For example, urology procedures would be numbered APC 5371 (Level 1 Urology and Related Services), APC 5372 (Level 2 Urology and Related Services), etc., up through Level 7.
But the changes for some clinical families go far beyond the cosmetic. The current APCs for diagnostic tests and related services are divided by organ system or physiologic test type. CMS determined these groups are unnecessarily narrow for a prospective payment system and proposes reducing 19 non-imaging diagnostic APCs into four general levels. The procedures assigned to each APC are available in Addendum B of the proposed rule.
These are just a small sample of the changes CMS is proposing for APC reconfiguration, and providers need to thoroughly review the changes to assess potential impact, Shah says. CMS encourages comments on all of its proposals and specifically requests comments on its APC changes. Providers have until August 31 to comment, and CMS will respond to comments in a final rule expected to be issued on or around November 1.
For more on the changes CMS proposed, see Shah and Valerie A. Rinkle, MPA, will analyze the rule and give a comprehensive overview of the changes and what providers may want to comment on in HCPro’s annual OPPS proposed rule webcast from 1-2:30 p.m. (Eastern) Tuesday, August 18. Look for more in-depth coverage of the 2016 OPPS proposed rule in the September 2016 issue of Briefings on APCs, scheduled to publish August 13.

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