Health Information Management

CMS proposes C-APC for observation services in 2016

APCs Insider, July 24, 2015

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By Steven Andrews

CMS did not propose making any radical changes to comprehensive APCs (C-APC) methodology, such as how complexity adjustments are calculated, in the 2016 OPPS proposed rule, but the agency did propose to expand the system.
CMS proposes adding nine new C-APCs:
  • 5165, Level 5 ENT Procedures
  • 5492, Level 2 Intraocular Procedures
  • 5416, Level 6 Gynecologic Procedures
  • 5361, Level 1 Laparoscopy
  • 5362, Level 2 Laparoscopy
  • 5123, Level 3 Musculoskeletal Procedures
  • 5375, Level 5 Urology and Related Services
  • 5881, Ancillary Outpatient Services When Patient Expires
  • 8011, Comprehensive Observation Services
As part of the C-APC for observation services, CMS proposes creating status indicator J2 to identify specific combinations of services. When those services are performed together and reported on a single Part B claim, CMS would deem all other OPPS services and items to be adjunctive. This would create a single payment for comprehensive services based on the costs of all reported services on the claim.
CMS will make C-APC payments for claims for comprehensive observation services that meet the following criteria:
  • The claims do not contain a HCPCS code with status indicator T reported on the same day or one day prior to the date of service associated with HCPCS code G0378 (observation services per hour)
  • The claims contain eight or more units of services described by G0378
  • The claims contain one of the following codes:

o   HCPCS code G0379 (direct referral of patient for hospital observation care) on the same date of service as G0378

o   CPT® code 99284 (level 4 ED visit)

o   CPT code 99285 (level 5 ED visit) or HCPCS code G0384 (Type B ED visit Level 5)

o   CPT code 99291 (critical care, E/M of the critically ill or critically injured patient; first 30–74 minutes)

o   HCPCS code G0463 (hospital outpatient clinic visit for assessment and management of a patient) provided on the same date of service or one day before the date of service for  G0378

  • The claims do not contain a HCPCS code with status indicator J1 (outpatient services paid through a C-APC)
CMS is proposing a 2016 geometric mean cost resulting from this methodology of $2,111 for C-APC 8011, based on more than 1 million previous claims. By establishing the new C-APC, CMS proposes deleting APC 8009 that previously reporting extended assessment and management.
Read more on CMS’ proposed changes on Jugna Shah, MPH, and Valerie A. Rinkle, MPA, will analyze the 2016 OPPS proposed 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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