*Addendum A - Final OPPS APCs for CY 2020*Addendum B - Final OPPS Payment by HCPCS Codes for CY 2020
To access the CY 2020 OPPS Addenda click HERE or visit www.cms.gov https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient
In CY 2020, CMS is phasing in the second application of its reduction in payment for clinic visit service -HCPCS G0463 - in an effort to control unnecessary increases in the volume of the clinic visit service furnished in excepted off-campus provider-based departments (ie: departments that bill the modifier ‘‘PO’’ on claim lines).
Excepted off-campus provider-based department - a “department of a provider” that is located on the campus or within 250 yards from a “remote location of a hospital” that meets the requirements for provider based status. This definition also includes an off-campus department of a provider that was furnishing services prior to November 2, 2015 that were billed under the OPPS in accordance with timely filing limits.
at excepted off-campus provider-based outpatient departments• Modifier PN - Non-excepted service provided at an off-campus,
outpatient, provider - based department of a hospital
OFF-CAMPUS OUTPATIENT DEPARTMENTS
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Off-Campus PBD Payment Reduction - OPPS
250 YARDS
PHYSICIAN SUPERVISION REQUIREMENTS FOR PHYSICIAN ASSISTANTS
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Supervision Laws Changing
The CY 2020 MPFS Final Rule finalizes:1. PA must furnish their professional services in accordance with state law and state scope
of practice rules for PAs in the state in which the PA’s professional services are furnished.
2. In states with no explicit state law or scope of practice rules regarding physician supervision of PA services, physician supervision is: A process in which a PA has a working relationship with one or more physicians to supervise the delivery of their health care services. Such physician supervision is evidenced by documenting at the practice level the PA’s scope of practice and the working relationships the PA has with the supervising physicians when furnishing professional services.
The changed approach to the delivery of health care services involving PAs has resulted in changes to scope of practice laws in some states for PAs regarding physician supervision. Commenter’s from 20 states provided evidence of changes in their state laws or scope of practice rules to move away from references to “physician supervision” of PA’s, and in some cases replacing it with the term “Physician Collaboration” to describe the PA-Physician relationship.
CMS has reconsidered its interpretation of the statutory requirement that Physician Assistant (PA) services must be furnished under the supervision of a physician after receiving comments in response to CY 2018 MPFS Proposed Rule. These comments indicated PAs are now practicing more autonomously, like nurse practitioners (NPs) and clinical nurse specialists (CNSs), as members of medical teams that often consist of physicians, non-physician practitioners (NPPs) and other allied health professionals.
PRICE TRANSPARENCY
The CY 2020 OPPS/ASC Final Rule did not finalize expanded Price Transparency regulations as expected. On November 15, 2019, CMS finalized policies that follow directives in President Trump’s Executive Order entitled: “Improving Price and Quality Transparency in American Healthcare to Put Patients First”. CMS has issued the “CY 2020 OPPS/ASC Price Transparency Requirements for Hospitals to Make Standard Charges Public Final Rule”. Providers do get a reprieve in 2020 and will be able to use it in order to plan for what’s to come in 2021: a) Hospitals to make public a yearly list of their Standard Charges for items and services provided by the hospital and DRG. Standard Charge Criteria • Gross Charges related to the CDM • Discounted cash fees • Payer specific negotiated rates hospitals have negotiated with third-party payers • De-identified minimum negotiated charges for both the lowers and highest charge a hospital has negotiated
b) Hospitals are to display Shoppable Services Shoppable Services Guidelines i. Payer-specific negotiated charges ii. Discounted cash prices for at least 300 shoppable services 1) 70 CMS specified 2) 230 hospital selected iii. Include a plain-language description of each shoppable service. iv. Indicate when one or more of the CMS-specified shoppable services are not offered. v. Location shoppable service is provided. vi. Indicate if standard charge is an inpatient charge, an outpatient charge or both. vii. Shoppable services should be selected based on utilization (commonly provided) or billing rate. viii. Include charges for services customarily provided in conjunction with the primary service identified by a common billing code (e.g. HCPCS/CPT). ix. Display charges prominently on a publicly available webpage. x. Ensure data is easily accessible, without barriers: 1) Free of charge 2) Do not require user registration, password, or to submit PHI 3) Searchable by service description, billing code and payer xi. Update information at least annually and provide the last update date.
c) If a hospital maintains an internet-based price estimator tool that meets CMS requirements, CMS will deem it as having met the requirements for making public standard charges for 300 shoppable services in a consumer friendly manner.
d) Should CMS conclude a hospital is noncompliant with one or more of the requirements to make public standard charges, CMS may assess a monetary penalty of $300 per day.
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PRICE TRANSPARENCY (continued)
Hospitals must make public their standard charges (both gross charges and payer-specific negotiated charges) for all items and services online in a machine-readable format.
Display payer-specific negotiated charges for at least 300 shoppable services, including 70 CMS-selected shoppable services and 230 hospital-selected shoppable services. If a hospital does not provide one or more of the 70 CMS selected shoppable services, the hospital must select additional shoppable services such that the total number of shoppable services is at least 300.
Include charges for services that the hospital customarily provides in conjunction with the primary service that is identified by a common billing code (e.g. Current Procedural Terminology (CPT)/ Healthcare Common Procedure Coding System (HCPCS)/ Diagnosis-Related Group (DRG)).
Display charge information prominently on a publicly available webpage and clearly identify the hospital (or hospital location); Charge information should be easily accessible and without barriers, and searchable.
Update the information at least annually
Should CMS conclude a hospital is noncompliant with one or more of the requirements to make public standard charges, CMS may assess a monetary penalty of $300 per day.
As of JAN 1st, 2019, per the 2019 IPPS Final Rule, providers have been posting their standard charges for all items / services online in a machine-readable format as well as their DRG price list.
JAN 1st, 2019 JUN 24th, 2019 CY 2020
The 2020 OPPS Proposed Rule, if finalized, would have expanded the current Price Transparency regulations in the ways outlined below.
On June 24, 2019 an Executive Order (EO) on Price Transparency was signed directing HHS to issue regulations requiring hospitals to post charge information, including “charges based on negotiated rates and for common shoppable items and services.”
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Price Transparency Key Event Timeline
Proposed Requirements for Making Public Consumer-Friendly “Standard Charges” for a Limited Set of ‘Shoppable Services’:
PRICE TRANSPARENCY (continued)
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Becker’s Hospital Review Webinar
Becker’s Hospital Review News Article
Click Here to listen to Julie Roberts and Emily Jones’ Webinar: https://www.youtube.com/watch?v=N9uhbYEafaI&feature=youtu.be
‘Revenue cycle is a team sport’ — 3 plays to get on the winning side of CMS’ price transparency ruleBy: Angie Stewart
Click Here to read the Becker’s Health Care Review Article: https://www.beckershospitalreview.com/payer-issues/revenue-cycle-is-a-team-sport-3-plays-to-get-on-the-winning-side-of-
Section 340B of the Public Health Service Act (340B) allows participating hospitals and other providers to purchase certain covered outpatient drugs at discounted prices from manufacturers.
Section 340B Program Changes
In the News
Additional Details
• Under the OPPS CMS pays ASP plus 6% for separately payable drugs and biologicals.
• Beginning January 1, 2018, Medicare adopted a policy to pay an adjusted amount of ASP minus 22.5 percent for certain separately payable drugs or biologicals that are acquired through the 340B Program.
• CMS will continue to adjust the payment rate for separately payable drugs and biologicals (other than drugs on pass through and vaccines) acquired under the 340B program to ASP minus 22.5%. *this will continue in CY2020.
CMS solicited comments in the event of an unfavorable decision on appeal to the case of “American Hospital Association et. al v. Azar et al” that ruled the Secretary exceeded his statutory authority by adjusting the Medicare payment rate for drugs acquired under the 340B Program.
CMS intends to conduct a survey to collect data for drug acquisition cost during CY2018 and CY2019. This data may be used to:• Set Medicare payment amount for 340B drugs going forward• Provide a remedy for years prior in the event of an adverse appeal decision
CY2020 proposed rule 340B remedies solicited for comment are as follows:• Rate of ASP + 3 percent for CY 2020 and for purposes of determining the remedy for CYs 2018 and 2019• CMS vetted possible remedies between a:
◦ Retrospective Remedy: made on a claim-by-claim basis ◦ Prospective Remedy: upward adjustment to 340B claims in the future
• Should there be another remedy mechanism that produces equitable results to non-340B hospitals while remaining budget neutral?
PRIOR AUTHORIZATION: 5 PROCEDURES IN OP DEPARTMENTS
New CY 2020 OP Procedures
What This Means For Providers
Implementation Deadline
CMS recently finalized 5 procedures which will require prior authorization in CY 2020 whenperformed in an Outpatient Department setting. After recognizing the utilization of services hadundergone a rapid increase, CMS began to question whether these procedures filed as therapeuticmay truly be cosmetic in nature, thus making them non-covered.
The five procedures were targeted as those representing or likely to be:a) Cosmetic surgical procedures in nature and/or directly related to cosmetic surgical procedures not covered by Medicareb) Procedures combined with or masqueraded as therapeutic services
• Prior to the service, documentation must be submitted by Hospital OP Departments proving services meet applicable Medicare coverage, coding and payment rules
• CMS is proposing providers may be exempt from the process of obtaining prior authorizations if they are able to achieve a provisional affirmation threshold of at least 90% during a semiannual assessment
• Providers who reach an exempt status may lose the exemption if their rate of non-payable claims become higher than 10% during the biannual assessment
• Blepharoplasty - eye lid lift• Botulinum toxin injections – migraines, or wrinkles• Panniculectomy – tummy tuck or excess skin removal• Rhinoplasty – nose job• Vein ablation
CMS believes implementing on July 1, 2020 is reasonable and provides Providers adequate time to educate and prepare.
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What is AUC?Criteria developed and endorsed by national professional medical specialty societies or other provider-led entities for advanced diagnostic imaging services provided to Medicare beneficiaries. This criteria was developed to enable ordering and furnishing professionals to make the most patient-appropriate treatment decisions. (Qualified Provider Led Entities (PLE) develop AUC).
Why is AUC needed?To enable ordering professionals the ability to order the most appropriate advanced diagnostic imaging services for their patients.
Who is subject to AUC?Clinicians ordering Medicare Part B advanced diagnostic imaging services such as PET Scans, Ultra Sound, Nuclear Medicine, CT Scants and MRI.
AUC Testing Period
How is AUC consulted?AUC criteria is accessed through a qualified Clinical Decision Support Mechanism (CDSM) - an interactive, electronic portal for clinicians that provides them with AUC information to make the most patient-appropriate treatment decision for their patient’s specific clinical condition.
The AUC program will operate in an Education and Operations Testing Period starting January 1, 2020.
During this period, claims will NOT be denied for failing to include AUC consultation information.
On January 1, 2021 the AUC program will be fully implemented and claims that fail to append AUC consultation information on professional and facility claims will not be paid.
A unique CDSM/AUC identifier is included on the order for the advanced diagnostic imaging test.
Use HCPCS G1000-G1100 to report CDSM. Use Modifiers and MA-MH & QQ to report AUC information.
APPROPRIATE USE CRITERIA (AUC)
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Proposed CY 2021 Future Changes
• Separate payment for the five levels of office/outpatient E/M visit CPT codes, as revised by the CPT Editorial Panel effective January 1, 2021 and resurveyed by the AMA RUC, with minor refinement.
• This would include deletion of CPT code 99201 (Level 1 new patient office/outpatient E/M visit) and adoption of the revised CPT code descriptors for CPT codes 99202-99215.
• Elimination of the use of history and/or physical exam to select among code levels.
• Choice of time or MDM to decide the level of office/outpatient E/M visit (using the revised CPT interpretive guidelines for MDM).
• Payment for prolonged office/outpatient E/M visits using the new CPT code 99xxx, deletion of HCPCS code GPRO1 (extended office/outpatient E/M visit) that was previously finalized for 2021, and no longer recognizing CPT codes 99358-9 for separate payment in association with office/outpatient E/M visits.
• Revise the descriptor for HCPCS code GPC1X and delete HCPCS code GCG0X.
• Increase in value for HCPCS code GCG1X and allow it to be reported with all office/outpatient E/M visit levels.
CY 2019 MPFS Propsed Rule CY 2020 MFPS Final Rule
CMS proposed and subsequently finalized in the CY 2019 PFS Final Rule updates to the 99201 through 99215 code set to reduce administrative burden and improve payment accuracy to better reflect the current practice of medicine effective January 1, 2021.
In the CY 2020 PFS Final Rule, CMS is finalizing changes to what was finalized in the CY 2019 PFS Final Rule for updates to the 99201 through 99215 code set to adopt the new coding, prefatory language, and interpretive guidance framework that has been issued by the AMA/CPT effective January 1, 2021.
2021 CHANGES FOR OFFICE/OUTPATIENT E/M VISITS
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The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) removes the geographic limitations for telehealth services furnished on or after July 1, 2019, for individuals diagnosed with a substance use disorder (SUD) for the purpose of treating the SUD or a co-occurring mental health disorder. The Support Act also allows telehealth services for treatment of a diagnosed SUD or co-occurring mental health disorder to be furnished to individuals at any telehealth originating site (other than a renal dialysis facility), including in a patient’s home.
New CMS HCPCS G Codes Three new codes added describing new bundled services for treatment of opioid use disorders.
• HCPCS code G2086: Office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month.
• HCPCS code G2087: Office-based treatment for opioid use disorder, including care coordination, individual therapy, group therapy and counseling; at least 60 minutes in a subsequent calendar month.
• HCPCS code G2088: Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (List separately in addition to code for primary procedure).
The list of telehealth services can be located on the CMS website HERE!https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.html
Did You Know?For CY 2020, the payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is 80 percent of the lesser of the actual charge or $26.65.
CMS established a general principle to allow the Physician, the Physician Assistant, or the Advanced Practice Registered Nurse who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team.
This principle would apply across the spectrum of all Medicare-covered services paid under the PFS. This new flexibility for medical record documentation requirements is for professional services furnished by physicians, Physician Assistants and Advanced Practice Registered Nurses in all settings.
When furnishing their professional services, the clinician may review and verify (sign/date) notes in a patient’s medical record made by other physicians, residents, nurses, students, or other members of the medical team, including notes documenting the practitioner’s presence and participation in the services, rather than fully re-documenting the information.
Important ClarificationThese changes would not modify the scope of, or standards for, the documentation needed in the medical record to demonstrate medical necessity of services, or otherwise for purposes of appropriate medical record keeping.
REVIEW AND VERIFICATION OF MEDICAL RECORD DOCUMENTATION
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CMS Strengthening Therapy Services Requirements. Claims for outpatient therapy services furnished in whole or in part by a therapy assistant must include the modifiers below, effective for dates of service beginning on January 1, 2020.
CMS did not finalize the proposed documentation requirement to explain in the treatment note, the application or non-application of the therapy assistant modifier for each therapy services furnished; nor did they finalize a requirement that the therapist and therapy assistant minutes be included in the documentation.
• CQ Modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant.
• CO Modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.
PHYSICAL AND OCCUPATIONAL THERAPY ASSISTANT MODIFIERS
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• CQ and CO modifiers will trigger a reduced payment rate and they are required when applicable for services furnished on or after January 1, 2020, on the claim line alongside the respective GP or GO therapy modifier.
CMS finalized a de minimis standard under which a service is considered to be furnished in whole or in part by a PTA or OTA when more than 10% of the service is furnished by the PTA or OTA. Only the minutes that the PTA/OTA spends independent of the therapist will count towards the 10% de minimis standard.
Important ClarificationFor services furnished on or after January 1, 2022, payment for outpatient physical and occupational therapy services which are furnished in whole or in part by a therapy assistant will be paid at 85% of the amount that is otherwise applicable. The reduced payment rate is not applicable to outpatient therapy services furnished by CAHs.
Break Through Devices Program Updates
Required Criteria
Other CMS Technology Updates
CMS finalized an alternative new technology add-on payment pathway for a medical device that receives FDA marketing authorization as part of the Breakthrough Devices Program.
CMS considers the product new and not substantially similar to an existing technology for purposes of the IPPS new technology add-on payment. It is not subject to the substantial clinical improvement criterion.
This change begins with applications received for new technology add-on payments for FY 2021.
An add-on payment is made for discharges involving approved new technologies, if the total covered costs of the discharge exceed the DRG payment for the case (including adjustments for indirect medical education (IME) and disproportionate share hospitals (DSH) but excluding outlier payments). Technologies eligible for add-on payments are identified based on the applicable ICD-10-CM codes. Claims submitted with an ICD code indicating new technology was involved in the treatment of the patient are eligible for add-on payments.
Technologies approved for new technology add-on payments for FY 2020 are projected to increase approximately $162 million as compared to FY 2019.
• CMS finalized the proposed modification to the current payment amount to increase the maximum add-on payment amount from 50% to 65% of the costs of the new technology or medical service (except with respect to a medical product designated by the FDA as a QIDP).
• CMS is finalizing an increase to the add-on payment, from 50% to 75% for Qualified Infectious Disease Products (QIDPs) e.g. antimicrobials.
Click HERE for a list of items eligible for new-technology add on payments in CY2020! (Page 5, Section E)
In general, payment for ambulance services based on 101% of reasonable costs is higher than payment made under the Ambulance Fee Schedule. This higher payment is intended to provide a CAH with enough payment to sustain their own ambulance services when no other ambulance services are available in their service area.
CMS recognized there are instances where a provider or supplier of ambulance services not owned or operated by the CAH may be located within a 35-mile drive of the CAH, but not legally authorized to furnish ambulance services, thus necessitating the CAH ambulance service.
In this instance, the CAH ambulance service would NOT be paid 101% of the reasonable cost.
To remove artificial reimbursement barriers to regional health care delivery and to improve access to care for individuals living in remote and rural areas, CMS has revised their interpretation of the Act to exclude consideration of ambulance providers or suppliers that are not legally authorized to furnish ambulance services to transport individuals either to or from a CAH.
Generally, payment to ambulance providers and suppliers for ambulance services is made under the Ambulance Fee Schedule. The Affordable Care Act increased payment for ambulance services furnished by Critical Access Hospitals (CAH) or entities owned and operated by a CAH to 101% of the reasonable costs.
In the 2012 IPPS Final Rule, CMS revised the regulation to state payment for ambulance services is 101% of reasonable cost only if the CAH is the only provider or supplier of ambulance services located within a 35-mile drive of the CAH.
CRITICAL ACCESS HOSPITALS: PAYMENT FOR AMBULANCE SERVICES
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The History of Ambulance Services Reimbursement
CY 2020 IPPS Final Rule
Summary
Beginning with discharges on or after October 1, 2008, CMS reduces Medicare payment when a replacement device is received by the hospital at a reduced cost or with a credit that is 50% or greater than the cost of the device, and when the assigned MS-DRG for the claim is one of the MS-DRGs applied to this policy.
New DRGs subject to the above regulation:
Click HERE for the full list of DRGs subject to this policy! (Pages 121-122)https://www.govinfo.gov/content/pkg/FR-2019-08-16/pdf/2019-16762.pdf
References:MS-DRG 319 (Other Endovascular Cardiac Valve Procedures with MCC)MS-DRG 320 (Other Endovascular Cardiac Valve Procedures without MCC)
• CMS generally maps new MS–DRGs onto the list when they are formed from procedures previously assigned to MS–DRGs that are already on the list. Currently, MS–DRGs 216 through 221 are on the list of MS–DRGs subject to the policy for payment under the IPPS for replaced devices offered without cost or with a credit as shown in the table below.
• A subset of the procedures currently assigned to MS–DRGs 216 through 221 was assigned to new MS–DRGs 319 and 320. Therefore, CMS is adding new MS–DRGs 319 and 320 to the list of MS–DRGs subject to the policy for payment under the IPPS for replaced devices offered without cost or with a credit.
Per Diem RateFor transfers from an IPPS hospital to a hospital or unit excluded from IPPS with a DRG that is subject to the post-acute care transfer policy, the transferring hospital is paid based upon a per diem rate.
The per diem rate paid to a transferring hospital is calculated by dividing the full MS–DRG payment by the geometric mean length of stay for the MS–DRG.
Special Payment MethodologyTo account for MS–DRGs subject to the post-acute care policy that exhibit exceptionally higher shares of costs very early in the hospital stay, a special payment methodology is in place:
Hospitals receive 50% of the full MS–DRG payment, plus the single per diem payment, for the first day of the stay, as well as a per diem payment for subsequent days.
FY 2020 MS-DRGs RemovedThe changes to MS-DRGs for FY 2020 have been evaluated against the general post-acute care transfer policy criteria using the FY 2018 MedPAR data. As a result of this review, no new MS-DRGs will be added to the list of MS-DRGs subject to the post-acute care transfer policy. However, MS-DRGs 273 and 274 were removed from the list of MS-DRGs that are subject to the post-acute care transfer policy and the special payment policy.
Click HERE for a listing of MS-DRGs and Special Pay MS-DRGs (Table 5) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2020-IPPS-Final-Rule-Home
CY 2019 IPPS Final Rulehttps://www.govinfo.gov/content/pkg/FR-2018-08-17/pdf/2018-1676pdf
CMS Appropriate Use Criteria Program websitehttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Pro-gram/index.html
Off-Campus Provider Based Department “PO” Modifier Frequently Asked Questionshttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/PO-Modifi-er-FAQ-1-19-201pdf
“CY 2020 CPT-HCPCS Code Summary Final Rule” VitalWare file
Health Resources & Services Administration websitehttps://www.hrsa.gov/opa/index.html
FY 2020 Final Rule and Correction Notice Tableshttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2020-IPPS-Final-Rule-Home-Page-Items/FY2020-IPPS-Final-Rule-Tables.html?DLPage=1&DLEntries=10&DLSort=0&DLSortDir=ascending
