Health Information Management

OPPS proposed rule out this summer

APCs Insider, June 6, 2003

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CMS says OPPS proposed rule out "this summer"

CMS officials are hoping to get the OPPS proposed rule out "earlier rather than later," but it is anyone's guess when it will actually appear.

In an Open Door Forum held in Massachusetts this week, CMS said it expects to get the rule out this summer.

Don't look for it before June 21, our experts say, but CMS will strive to issue it before September. The sooner the proposed rule comes out, the easier it is for facilities to implement changes, but an early issue date could have its drawbacks.

"I'd like to see the proposed rule earlier so that the comment period is longer. But I also don't want CMS to rush the process and create more problems with the rule than normal,"says Diane R. Jepsky, RN, MHA, LNC, executive vice president of coding and compliance at CodeCorrect, Inc.,Yakima, WA.

Since OPPS was instituted in August 2000, the proposed rules have been issued on November 13, 2000, August 2, 2001, and August 9, 2002.


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TODAY'S TOPIC: Coding infusion and IV push together

Question: We are getting denials from Medicare on Q0081 with 90784, when a drug is pushed into the IV. If there is heparin in the infusion (Q0081) and the patient is given a morphine IV push, is it appropriate to code both or just the morphine? Are we suppose to be adding modifier -59 when one is a push and one is infused over time?

Answer: A recent informal query to CMS on this issue received the following reply:

Effective 1/1/2003 CMS created a mutually exclusive edit for the diagnostic injection code (90784) with the infusion therapy code (Q0081)and the chemotherapy administration (Q0083-Q0085) codes.

Basically CMS said that an injection procedure could never be done at the same time as an infusion therapy or chemotherapy administration — the patient would only receive one of these procedures at one session. If the patient did have an injection in the morning and chemotherapy in the afternoon, then the provider could bill the code with modifier -59 to indicate that the procedures were performed at different sessions in one day. This edit went into effect on January 1, 2003 in the OCE.

CMS's response was informal and it stated it is continuing to research this issue based upon obvious objections to this significant policy change in APC payment. Therefore, we recommend that you seek advice immediately from your fiscal intermediary (FI). In the absence of FI advice, use the definition of modifier -59 which says "different site." Since an IV injection is a different route than the infusion of a different therapeutic drug from the one injected, modifier -59 seems appropriate.

We also recommend you submit comments to CMS as this edit appears to contradict APC packaging rules where payment for the infused drugs/solution is packaged into Q0081 and payment for the separate injected drugs is packaged into 90784.

This edit results in significant payment reduction to hospitals, particularly in Emergency Department cases.


ASK THE EXPERT: Are the codes for the magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) being replaced by new CPT codes?

PAY PER VIEW: PMs issued in April bring more changes

Program Memorandum (PM) A-03-020 announced new codes, pass-through devices and drugs, plus changes to changes already made in February 10 Federal Register that were already changes to changes in the January 3 PM A-02-129, that were originally changes to the 2003 final rule issued in November 2002. Study these PMs and know them before the 2004 OPPS changes hit you!

Read more here. The cost is $10. Briefings on APCs subscribers have free access via their online subscriptions.

Coding and Compliance Feature Article of the Month: Interventional procedures cause coding confusion


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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