Revenue Cycle

Determine how Bipartisan Budget Act impacts off-campus departments, modifier -PO

HIM Briefings, June 1, 2016

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to HIM Briefings.

The new modifier -PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments [PBD]) and the alternative payment provisions under the Bipartisan Budget Act Section 603 are both related to off-campus PBDs but define "off-campus PBD" slightly differently.

CMS recently published FAQs on modifier -PO, giving providers valuable guidance on how the modifier will apply to hospital services. Last week, CMS also indicated that it will wait until the CY 2017 OPPS proposed rule provides further guidance on Section 603. Nevertheless, some of the guidance related to modifier -PO seems to indicate that CMS is trying to bring the requirements in line with off-campus PBDs covered by Section 603, rather than simply relying on preexisting regulatory definitions of off-campus departments.

Modifier -PO was adopted January 1, 2015, with a required use date of January 1, 2016. It was originally adopted as a modifier to track statistics and information related to hospitals' off-campus PBDs. The modifier nominally applies to all items and services provided in an off-campus PBD, according to the Medicare Claims Processing Manual, but there are some significant exceptions.

The recent FAQs make it clear that modifier -PO does not apply to non-OPPS services. These services include therapy and a few other services still paid on other fee schedules, noted with a status indicator A under the OPPS, as well as dialysis, which is paid under the ESRD PPS. This guidance would dovetail with Section 603, which arguably only applies to services that would otherwise be payable under OPPS, exempting them from OPPS and providing alternative payment. Additionally, because critical access hospital (CAH) services are not paid under the OPPS, the modifier will also not apply to any services at PBDs of a CAH.

Similarly, the FAQs and other guidance indicate modifier -PO is not used for off-campus emergency departments. This guidance is in line with Section 603, which excludes the off-campus alternative payment methodology from items and services furnished at dedicated emergency departments.

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to HIM Briefings.

Most Popular