Potential Impacts from OPPS Proposed Rule

On July 25, 2018, the Centers for Medicare and Medicaid Services (CMS) issued the proposed rule for the Hospital Outpatient Prospective Payment System (HOPPS) for CY 2019. The Proposed Rule was published in the Federal Register on July 31 and public comments are due by September 24. The Final Rule will be released by early November. See the OPPS Proposed Rule in its entirety at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-15958.pdf

Payment Rates

CMS is proposing an increase of payment rates under the Outpatient Department (OPD) fee schedule with a 1.25% increase to the conversion factor of CY 2018. The CY 2019 conversion factor is proposed to be $79.546; however, for hospitals that fail to meet the Hospital Outpatient Quality Reporting (OQR) Program requirements, CMS is proposing a conversion factor of $77.955.

Ambulatory Surgical Center (ASC) payments are proposed to increase by 1.3% that meet quality reporting under the ASCQR program.

Standardizing APC Payment Weights

CMS instructs providers to apply current procedure-to-procedure edits and then report all remaining services on the claim form. CMS will only pay for those services which are considered not packaged into another service.

CMS is proposing to continue using HCPCS code G0463 (Hospital outpatient clinic visit for assessment and management of a patient) in APC 5012 (Level 2 Examinations and Related Services) as the standardized code for the relative payment weights. A relative payment weight of 1.00 is proposed to be assigned to APC 5012 (code G0463).

Multiple Imaging Composite APC

For CY 2019 and subsequent years, CMS is proposing to continue to pay for all multiple imaging procedures within an imaging family performed on same date of service using multiple imaging composite APC payment methodology. Standard APC assignments will continue to apply for single imaging procedures and multiple imaging procedures performed across families. A single imaging session performed “with contrast” is part of a composite APC when at least one or more imaging procedures from the same family are also performed with contrast on same date of service.

The five multiple imaging composite APCs established in CY 2009 with CY 2019 proposed reimbursement rates are:

  • APC 8004 (Ultrasound Composite), proposed payment rate $302.05
  • APC 8005 (CT and CTA without Contrast Composite), proposed payment rate $268.50
  • APC 8006 (CT and CTA with Contrast Composite), proposed payment rate $489.03
  • APC 8007 (MRI and MRA without Contrast Composite), proposed payment rate $546.23
  • APC 8008 (MRI and MRA with Contrast Composite), proposed payment rate $860.89

2 Times Rule Exceptions

For CY 2019, CMS is proposing to make exceptions to all of the 2 times rule violation APCs, this meaning no adjustments or movement of codes to other APCs to balance the highest and lowest costing codes. There are four imaging APCs, which are proposed to be excluded from any change. APC 5521 Level 1 Imaging without Contrast, APC 5522 Level 2 Imaging without Contrast, APC 5523 Level 3 Imaging without Contrast and APC 5571 Level 1 Imaging with Contrast.

Cost allocation for CT and MRIs

In CY 2014, CMS finalized the policy to create new costs centers in relation to calculation of the cost-to-charge (CCR) ratio value assigned to each particular hospital specifically for implantable devices, MRIs, CTs and cardiac catheterizations. The CCR is a value used by CMS to convert charges to estimated costs as a means of determining the reimbursement for any particular APC.

CMS removed the data for those hospitals that used “square feet” as a means or calculating cost allocation. CMS is proposing to extend the practice of removing the cost data from the hospitals using “square feet” for CY 2019.

New HCPCS Code 0505T

CMS introduced a new HCPCS code effective July 1, 2018, category III code 0505T (Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion).

Code 0505T is proposed to be assigned to APC 5193 (Level 3 Endovascular Procedures) with a status indicator (SI) of J1. All ancillary services are still reported on the claim form, after applying edits, but only the primary code assigned J1 is paid. The other services are considered packaged into the primary service.

Imaging Procedures and Services (APCs 55215524 and 5571-5573)

In CY 2016, CMS conducted a comprehensive review and restructuring of APCs that contained imaging services. The purpose was to better allocate the resource cost and clinical characteristics of the imaging services within each APC. In CY 2017, there were additional adjustments made, in which 17 APCs were reduced to 7. Four of the APCs include imaging services without contrast and three include imaging services with contrast.

For CY 2019, CMS is proposing to maintain the seven APCs as finalized in CY 2017. CMS is not proposing to add another APC as was done for CY 2018 to account for high cost imaging procedures.

Clinical Families Services in Excepted Off-Campus Departments

Excepted off-campus provider-based departments (PBDs) are settings which were established and billing for services prior to November 2, 2015 and within the previously set distance of 35 miles and are paid at the HOPPS full established rate for each service and considered grandfathered into the payments under HOPPS even if the new distance threshold is not met.

For CY 2019 and subsequent years, CMS is proposing changes for excepted off-campus PBDs. If certain items or services from any of the clinical families were not furnished during the baseline of November 1, 2014 through November 1, 2015, the services are not considered covered under the excepted status and would instead be nonexcepted and paid under MPFS. However, if an excepted off-campus PBD furnishes new services or items from a clinical family for which other services were already provided as part of that family, these services would be considered excepted and paid under HOPPS, as it would not be considered a “service expansion.”

CMS is proposing to use the “families” of services and not limit to only the individual CPT® or HCPCS codes reported as this would allow for the expansion of services within the same family service line without the adjustment to reimbursement.

Site-Neutral Payments

For CY 2019, CMS is proposing a site-neutral method for controlling “unnecessary increases in the volume of covered outpatient department services.” For CY 2019, CMS has proposed to utilize a Medicare Physician Fee Schedule (MPFS) payment rate for code G0463 (Hospital outpatient clinic visit for assessment and management of a patient) when billed in excepted off-campus provider-based departments.

For CY 2019, CMS is proposing to reimburse outpatient clinic visits billed by excepted off-campus PBDs at the same rate that nonexcepted off-campus PBDs are paid. Only on-campus hospital outpatient departments would be reimbursed at the full HOPPS value for code G0463 in CY 2019. Excepted off-campus PBDs would continue to report G0463 with modifier PO, only the reimbursement would change from what is currently paid in CY 2018.

Radioisotopes Derived From Non-Highly Enriched Uranium Source

Hospitals report code Q9969 (Tc-99m from non-highly enriched uranium source, full cost recovery add-on per study dose) once per dose along with the diagnostic scan using the Tc-99m, with the caveat the hospital must be able to certify at least 95 percent of the Tc-99m dose is derived from non-HEU sources.

For CY 2019, CMS is proposing to continue to provide an additional $10 payment for radioisotopes produced by non-HEU sources. Once the conversion to non-HEU sources is closer to completion or has completed, CMS will reassess the payment policy.

Hospital Outpatient Quality Reporting (OQR) Program

For CY 2019, CMS is proposing to remove a total of ten Hospital Outpatient Quality Reporting Program (OQR) measures for CY 2020 and CY 2021 payment determinations.

CMS is clarifying the process for calculating the TCOV for measures PO-11 Thorax Computed Tomography (CT) – Use of Contrast Material (NQF #0513) and PO-14 Simultaneous Use of Brain Computed Tomography (CT) and Sinus CT (no NQF number). These two particular measures actually assess the rate of rare, undesired events for which a lower rate is preferred.

CMS is also proposing to remove OP-9 Mammography Follow-up Rates. The claims-based measure assesses the percentage of patients with mammography screening studies followed by a diagnostic mammography, ultrasound or MRI of the breast in an outpatient or office setting within 45 days.

- Article by Coding Strategies® Staff