Health Information Management

CMS February 10 changes to OPPS

APCs Insider, March 28, 2003

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THE MONITOR'S ADVISORY BOARD

Keith Siddel,
MBA, PhD (c),
president, CEO
HRM, Hospital Resource Management

Cheryl D'Amato,
RHIT, CCS,
director health information management
HSS, Inc.

Julie Downey,
CPC, CPC-H,
ambulatory coding coordinator, HIM
University Colorado Hospital

Carole Gammarino,
RHIT, CPUR,
professional services consultant
Precyse Solutions

Julia R. Palmer
MBA, RHIA, CCS,
president
Health Information Management Division of HRM

Valerie Rinkle, MPA,
revenue cycle director
Asante Health System


On Himinfo.com

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ASK THE EXPERT

HIM VENDOR BUSINESS DIRECTORY

CMS changes Final Rule again

CMS has made more changes to the November 1, 2002 final rule, and if you blinked on February 10, you might have missed it. CMS published six pages of corrections in the Federal Register, without first publishing a notice of proposed rule making or employing the 30-day delay for the effective date.

"Without a program memo or the 30-day delay date, some people easily could miss this information," says Diane R Jepsky, RN, MHA, LNC, executive vice president of coding and compliance at CodeCorrect, Inc., Yakima, WA.

CMS says waiting 30 days would just delay the corrections, and facilities would have that much longer to be underpaid. Therefore, the changes are effective January 1, 2003.

The changes are all corrections to errors, including incorrect responses and descriptions, typographical errors, omissions, and miscalculations. In some cases where miscalculations were made, the corrections greatly increase the reimbursement.

"CMS has recalculated a lot of the APC payments (in the February 10 Federal Register), because it failed to do so after moving CPT and HCPCS codes into or out of an APC," Jepsky says.

For example, in the November 1, 2002 final rule:

  • on page 66821, under APC 2616, and on page 66961, under HCPCS code C2616, CMS inserted incorrect values for Brachytx seed, Yttrium-90.
  • Instead of the $460.86 payment first published in Addendum B in November, the corrected payment rate is $6,485.37.
  • This more than $6,000 miscalculation is one of the largest; the majority of recalculated payment rates increased around $200, says Jepsky.

Make these changes immediately to your chargemaster, Jepsky says, or money can be lost daily. Many of the changes will have to be handcoded, while others will be made automatically in software programs.

For more details, check out the April issue of Briefings on APCs, or the Federal Register for February 10, 2003.

  • Check out the March issue of Briefings on APCs for information on new modifiers, how to overcome OPPS hurdles, and new clinical trial codes.

Your "APCs Weekly Monitor," is a free weekly e-zine from HCPro, publisher of "Briefings on APCs," the monthly newsletter devoted entirely to managing under APCs, and the newsletter, "APC Answer Letter," with answers to readers' questions about coding for APCs.

The "Monitor" is a complimentary companion publication, with a specific mission: to provide answers to your tough questions about the APC regulations.

If you have a question about APC coding that you would like addressed in the "Monitor," post it on our Web site at himinfo.com. Each week, our team of experts answers questions that will appeal to the majority of readers. The elected questions and their corresponding answers are delivered to your inbox every Friday.


TODAY'S TOPICS:
Ophthalmology clinics set own coding guidelines

ASK THE EXPERT

The deletion of the C codes took effect January 1, and our facility had to delete them from the chargemaster. Yet our local BlueCross has just moved and started accepting the C codes for reimbursement. How are other facilities handling this situation in their chargemasters?

We had to enter in our chargemaster a subclass that will pull these codes for all BlueCross claims. This creates more of an opportunity for mistakes and denied claims. How are other facilities handling this situation? Will the upcoming Health Insurance Portability and Accountability Act of 1996 (HIPAA) electronic data interchange (EDI) standards solve our problem?

PAY PER VIEW

Unique structure at Florida hospital increases coder recognition

If you look for the Charge Capture and Coding (CC&C) unit at Mayo Clinic/St. Luke's Hospital in Jacksonville, FL, you won't find it in the medical records department. This team of 53 works in a separate building as part of the patient financial services (PFS) department.

To read more, click here. The cost is $10. Briefings on Coding Compliance Strategies subscribers have free access via their online subscriptions.


Question:

Do you know of any specific coding guidelines for hospital-based ophthalmology clinics? I code and bill the hospital side of our eye clinic and have found most of the coding information in this area refers to physician billing.

Answer:

Unfortunately, CMS does not have specific ophthalmology guidelines beyond the general E/M requirements stated below. For ophthalmology procedures, be sure that all CPT/HCPCS codes with APCs are set up to bill when performed in the clinic.

CMS has not provided clear guidance for coding facility E/M levels, instead it has left it up to each facility to develop its own system for reporting E/M levels. The system must be based upon resource utilization and the facility E/M criteria can include time, but time should not be used exclusively.

The criteria should not include any other separately billable service.

CMS also says that facilities can disregard the word "physician" in the CPT book when used in a facility setting. This information is in Hospital Manual Section 442.


Questions from readers are answered by a team of experts working in the APC area within the health care industry. Their answers are provided as advice. Readers should consult the federal regulations governing OPPS, related CMS sources, and with their local fiscal intermediary before making any decisions regarding the application of OPPS to their particular situations.


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