Health Information Management

OPPS final rule serves as sign of things to come

APCs Insider, December 6, 2013

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CMS may not have finalized all of its sweeping proposals in the 2014 OPPS Final Rule released November 27, but it did serve warning to hospitals that it will continue to increase the number of packaged services, and will revisit consolidating ED E/M level codes, as soon as next year.

CMS could have used the Thanksgiving eve release date to usher in dramatic proposed OPPS changes, such as replacing 20 E/M CPT® codes for new and established patient clinic visits, Type A ED visits, and HCPCS G-codes for Type B ED visits with three new HCPCS G-codes—one for all clinic visits, one for all Type A ED visits, and one for all Type B ED visits.

Providers were concerned that CMS was not budging on its effective date of January 1, 2014, for the rule, despite releasing it nearly a month later than usual.

Instead, CMS chose to only replace existing E/M CPT clinic visit codes into a single HCPCS G-code, meaning coders will report the HCPCS G-code to Medicare for all clinic visits and CMS will make a single APC payment.

In the rule, CMS said it will look at the ED E/M coding again next year, but noted provider concerns about the consolidation. “We received several comments that a single payment for an ED visit might underrepresent resources required to treat the most complex patients, such as trauma patients. We find this to be a compelling issue, for which an alternative payment structure, possibly including more than one payment level, may be warranted,” CMS stated in the rule.

CMS also proposed creating 29 new device-dependent comprehensive APCs, which would act like a mini-DRG, with a single APC payment made despite all of the separate services reported. CMS admitted that due to the operational complexity of the proposal, this would be an administrative burden to implement in 2014. Instead, it will be refined for 2015 before implementation, at least giving providers more time to prepare.

CMS also finalized five new categories of packaged services, including:
  • 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
  • Device removal procedures

The packaging of procedures described by add-on codes also does not include drug administration add-on codes, another aspect of the rule where CMS listened to commenters. 

CMS had proposed packaging the following categories as well, but did not finalize any changes, so they will continue to be separately payable under OPPS in 2014:

  • Ancillary services (currently assigned status indicator "X"); proposal to reassign all services to status indicator Q1
  • Diagnostic tests on the bypass list

However, it’s likely that these will be revisited in 2015, again giving providers some time to prepare.

In the end, after an unprecedented year that saw radical proposed changes, delays, and a short implementation window, the release of the final rule may have unexpectedly ended on a positive note. CMS did not push through many of the most disruptive changes and clearly listened to commenter input about the viability of others, highlighting the importance of participation in the process. 

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