Health Information Management

Proposed 2004 OPPS rule

APCs Insider, August 27, 2003

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August 8, 2003
Vol. 4, No. 31


Rule Pool results

The proposed 2004 OPPS rule is posted on the CMS web site, and is due to be published in the Federal Register Tuesday, August 12. Unfortunately, there were no winners in the Rule Pool of July 25. This week's question:

How many printed pages in the proposed 2004 OPPS rule document?

The answer will appear in next week's APC Weekly Monitor, or be one of the first five to e-mail the correct answer and win a 3-month free trial to one of our APC newsletters!

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

Andrea Clark
Health Revenue Assurance Associates

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

Julie Downey,
ambulatory coding coordinator, HIM
University Colorado Hospital

Carole Gammarino,

Julia R. Palmer
president, Health Information Management Division

Valerie Rinkle, MPA,
revenue cycle director
Asante Health System




Proposed 2004 OPPS rule posted

Take a deep breath and relax. The proposed 2004 OPPS rule is out, and there are no new national E/M guidelines yet. CMS posted the proposed rule on its Web site, and it is scheduled to be published in the Federal Register Tuesday, August 12.

However, CMS is requesting feedback concerning the guidelines, recommended by a panel headed by the American Hospital Association (AHA) and American Health Information Management Association (AHIMA).You should send comments to CMS no later than Oct. 6, 2003.

You don't need to stress about APC observations changes, either, because there are none. Just make sure you understand the changes set in PM 01-02-129 in January.

The proposed rule may have significatn financial and operational impact on hospitals. To determine how the new proposed rule will affect your facility financially, identify your high volume services, and compare the changes in rates in Addendum B. The impact will be different for every facility, because it is dependent on the services provided.

For more information on the proposed rule including an analysis from Jugna Shah, MPH, check out

Sign up for our "2004 OPPS Proposed Rule: Understanding and Implementing the Changes," audioconference on August 19, 1 p.m. Eastern to get ahead of the changes. Speakers Jugna Shah, MPH, and Gloryanne Bryant, RHIT, CCS, will help you begin the transition to 2004 OPPS. To register, Click here or call our customer service team at 800/650-6787.

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 Each week, our team of experts answers a question that will appeal to the majority of readers. The elected question and the corresponding answer are delivered to your inbox every Friday.

TODAY'S TOPIC: Pump coding

Question: How should we code facility charges for services related to an implantable infusion pump that was implanted at another hospital? The patient is in our outpatient department for refilling and reprogramming the pump. Could you give the revenue codes to be used for the following CPT codes: 96530, 62368, J0475. Also, is it ever appropriate to bill an E/M code in conjunction with these codes?

Answer: Assuming that this is either an intrathecal or epidural pump, CPT code 62368, "analyze spine infusion pump," includes reprogramming. It carries a status indicator of S, compacts to APC 0691, and is reimbursed at $152.10.

Unless documentation can support a separately identifiable E/M service on the same day as the procedure, it should not be reported. The narrative of 62368 states it is a comprehensive service to include electronic analysis, evaluation of reservoir status, alarm status, and drug prescription. One would be hard pressed to have additional documentation to support E/M service, however, it is still a possibility.

Depending where the service is provided, possible revenue codes are: 360, 361, 761, 510, 490, 514 pain clinic,and 940. However, Medicare discourages revenue code 514.

J0475 is a packaged drug. Depending on facility policy, some hospitals will report revenue code 250, and others will use 636. If we adhere to CMS reporting requirements, payable detailed drugs are reported with 636. We are aware that some hospitals are reporting all J codes payable (or not) with 636, due to other third party payers accepting J codes of all kinds.

CPT Assistant changes for 2003 shows that 95990, "spin/brain pump refill and maintenance," was developed to report refilling and maintenance of implantable pumps or reservoirs for spinal and brain drug delivery. Definitive skills and knowledge are needed due to the risks and severity of potential complications. 95990 carries a status indicator of T, compacts to APC 0125, and pays $107.63.

Code 96530 should be reported for an implanted infusion pump for chemotherapy or insulin.

We checked version 9.1 Correct Coding Initiative to see if modifier -59 was needed. A modifier is not required with this version.

TIP OF THE WEEK: Bill endoscopies correctly

Coding and Compliance Feature Article of the Month: Use official coding guidelines for general rules, create facility-specific guidelines for consistency

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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