Health Information Management

Voice your opinion on OPPS changes

APCs Insider, August 16, 2013

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By Steven Andrews

Coders may often feel like CMS imposes major changes on rules and regulations without listening to the concerns of those who will be affected, but for the next three weeks, you have a chance to make an impact.

When CMS released its 2014 OPPS proposed rule July 5, it opened a window for comments from stakeholders that could influence the final rule, which is to be released in early November. CMS has set a September 6 deadline for comments, suggestions, and concerns that professionals may have, and will respond to all submissions when the final rule is released.

Though it may seem unlikely CMS would change its policy based on those submissions, there is recent precedent with its publication of the IPPS final rule. One proposed change involved the criteria for inpatient admissions, which now must span two midnights instead of simply 24 hours. Based on comments, CMS amended the final rule to include observation time in the two midnight period.

Multiple dramatic changes in the proposed OPPS rule could spur comments from providers. One of the major revisions is to the evaluation and management (E/M) coding and reimbursement.

Currently, hospitals report five different levels of E/M CPT® codes for new patient clinic visits, established patient clinic visits, and Type A ED visits, and HCPCS G-codes for Type B ED visits. Under the proposal, CMS would replace all of these codes with three new HCPCS G-codes. This proposal could greatly simplify and standardize reporting for E/M services and reduce inconsistencies that coders may face when trying to determine the extent of services.

The proposed rule also introduces many new packaged services in an attempt to reduce some of the fee-for-service aspects of the system.

CMS proposes packaging the following seven new categories of supporting items and services:

  • Drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure
  • Drugs and biologicals that function as supplies or devices when used in a surgical procedure
  • Clinical diagnostic laboratory tests (except molecular pathology) when provided on the same date of service as another service
  • Procedures described by add-on codes
  • Ancillary services (currently assigned status indicator “X”); proposal to reassign all services to status indicator Q1
  • Diagnostic tests on the bypass list
  • Device removal procedures

The 718-page document offers many more proposals, including:

  • Keeping the payment level for separately payable drugs, biologicals, and therapeutic radiopharmaceuticals at average sales price plus 6%
  • Increasing the drug packaging threshold to $90
  • Continuing to apply the 7.1% adjustment to OPPS payments to certain rural sole community hospitals, including essential access community hospitals
  • Beginning to enforce physician supervision requirements for critical access hospitals
  • Removing various edits like device-to-procedure edits and nuclear medicine and radiopharmaceutical edits

In order to submit a commit, go to and search for “2014 OPPS.”

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