PROVIDER-BASED CHANGES AND OPPS: MORE RULEMAKING AND CHANGES IN 2019Scott Treida, MT(ASCP), CPC, CRCR | Director
2019 OPPS FINAL RULE
Final CY2019 payment rule for the Medicare Outpatient Prospective Payment System (OPPS) was released on November 2, 2018.
Correction notices An online version of the rule is available at
https://www.federalregister.gov/d/2018-24243
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https://www.federalregister.gov/d/2018-24243
OPPS RATE INCREASE
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OPPS ESTIMATED IMPACT
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OPPS ESTIMATED IMPACT
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KENTUCKY SPECIFIC IMPACTS
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*Kentucky Hospitals with Total Payments > $100,000
ADDENDUM B
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ADDENDUM D1
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SECTION X NONRECURRING POLICY CHANGES
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1. Controlling Unnecessary Increases in the Volume of Outpatient Services
Off-Campus Provider-Based Emergency Departments
2. Expansion of Clinical Families of Services at Excepted Off-Campus
Departments of Provider Off-Campus Provider-Based Emergency Departments
3. 340B Drug Payment Policy to Non-excepted Off-Campus Departments
of a Hospital
4. ASCs and Off-Campus Provider-Based Emergency Departments
OFF-CAMPUS HOSPITAL OUTPATIENT DEPARTMENT (HOPD)
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HOSPITAL OUTPATIENT DEPARTMENT (HOPD) REGULATIONS AND REFERENCES
42 CFR 413.65 42 CFR 485.610 (e) CMS Manual Pub 100.07, Chapter 2, Section 2256G, 2256H Section 603 of the Bipartisan Budget Act of 2015
Known as the November 2, 2015 Rule
Sections 16001 and 16002 of the 21st Century Cures Act CY2017 OPPS Final Rule CY2018 OPPS Final Rule CY2019 OPPS Final Rule
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WHY IS CMS FOCUSED ON HOPD SERVICES?
Source: https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf12
Fun Fact:Roughly 10,000 Baby Boomers will turn 65 today, and about 10,000 more will cross that threshold every day for the next 10 years.
- Pew Research
https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf
OFF-CAMPUS HOPDs: CMSs VIEW
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Source: https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf Pages 59008 & 59009
Reduction in payments is not budget neutral
CMS identifies its intent is to lower costs and utilization
Federal Register / Vol. 83, No. 225 / Wednesday, November 21, 2018 / Rules and Regulations
https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf
OFF-CAMPUS HOPDs: CMSs VIEW
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Source: https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf Pages 59017 & 59021
Federal Register / Vol. 83, No. 225 / Wednesday, November 21, 2018 / Rules and Regulations
https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf
OFF-CAMPUS HOPDs
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Increasing Choices and Encouraging Site Neutrality Bipartisan Budget Act of 2015; enacted Nov. 2, 2015
See CMS guidelines for special considerations: mid-build (21st Century Cures Act), relocation, change of ownership, service line expansion, etc. Campus and provider-based guidelines (42CFR413.65, etc.)
Non-exceptedOff-campus HOPDs
New HOPD Billing OPPS services on or
after Nov. 2, 2015
Paid under MPFS Jan. 1, 2017, implemented
PFS relativity adjuster: 40% of OPPS
HCPCS modifier PN
Excepted Off-campus HOPDs
Old HOPD Billing OPPS services prior to
Nov. 2, 2015 Dedicated ED
42 CFR 489.24 Remote location of a hospital
42 CFR 413.65 Paid under OPPS
Full rates
HCPCS modifier PO
OPPS SITE NEUTRAL PAYMENT
CMS is making payments for clinic visits site-neutral by reducing the payment rate for hospital outpatient clinic visits provided at off-campus provider-based departments by 60%. Based on a two-year phase-in of this policy, half of the total reduction will apply in 2019.
The estimated impact for individual hospitals depends on the volume of clinic visits provided at off-campus hospital outpatient departments.
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OFF-CAMPUS HOPDs: CLINIC VISITS
CMS is expanding OPPS payment reduction to EXCEPTED off-campus PBDs, for HCPCS code G0463 Hospital outpatient clinic visit for assessment and management of a patient.
Excepted off-campus HOPDs will see payments for G0463 reduced to 70% of OPPS for 2019, and then reduced to 40% of OPPS for 2020 and subsequent years.
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*Payment amounts are unadjusted.
Insider Tip: G0463 may appear in some CDMs as 99201-99205; 99211-99215.
On-campusHOPD
Off-campusHOPD
Excepted
Off-campusHOPD
Non-exceptedCY 2018 $ 114 $ 114 $ 45 CY 2019* $ 116 $ 81 $ 46 CY 2020* $ 117 $ 47 $ 47 HCPCS Code G0463 G0463 G0463 HCPCS Modifier N/A PO PN
OFF-CAMPUS HOPDs: EXPANDED SERVICES
CMS is concerned about service expansion at excepted (grandfathered) PBDs.
Also, believes new services (started on or after Nov. 5, 2015) should not be paid OPPS rates.
Proposed: 19 clinical families Payment at OPPS rates for items and services in each of the 19
proposed clinical families if that PBD furnished and billed for a service in that clinical family of services prior to November 2, 2015.
2019 CMS did not finalize the proposed policy. Excepted PBDs will continue to receive full payments under OPPS as
long as it remains excepted (but for clinic visits). CMS will monitor the volume of services at excepted locations to
determine if future rulemaking is necessary for service expansions.
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OFF-CAMPUS HOPDs: 340B
CMS finalized its proposal to extend the ASP 22.5% payment rate to 340B drugs (excluding vaccines and drugs on pass-through payment status) provided at non-excepted off-campus HOPDs.
Providers excluded:
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Critical access hospitals
Rural sole community
hospitals
Childrens hospitals
PPS-exempt cancer
hospitals
OFF-CAMPUS HOPDs: 340B
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HospitalOn-campus
Off-campusHOPDExcepted
Off-campusHOPDNon-excepted Rural SCH
HospitalOn-campus
HospitalOff-campusExcepted
Off-campusHOPDNon-excepted Rural SCH
Drugs and Biologicals Separately payable (K) ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6%
Pass through status (G) ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6%
Separately payable vaccines (F, L) Cost Cost Cost Cost Cost Cost Cost Cost
Packaged (N) - - - - - - - -
340 Acquired Drugs and BiologicalsSeparately payable (K) ASP-22.5%
JGASP-22.5%JG & PO
ASP+6%TB & PN
ASP+6%TB
ASP-22.5%JG
ASP-22.5%JG & PO
ASP-22.5%JG & PN
ASP+6%TB
Pass through status (G) ASP+6%TB
ASP+6%TB & PO
ASP+6%TB & PN
ASP+6%TB
ASP+6%TB
ASP+6%TB & PO
ASP+6%TB & PN
ASP+6%TB
Separately payable vaccines (F, L) Cost Cost Cost Cost Cost Cost Cost Cost
Packaged (N) - - - - - - - -
2018 2019
JG - Drug or biological acquired with 340B drug pricing program discount. TB - Drug or biological acquired with 340B drug pricing program discount, informational purposes. CMS article, Billing 340B Modifiers under the Hospital OPPS, dated April 2, 2018.
Sheet1
20182019
HospitalOn-campusOff-campusHOPDExceptedOff-campusHOPDNon-exceptedRural SCHHospitalOn-campusHospitalOff-campusExceptedOff-campusHOPDNon-exceptedRural SCH
Drugs and Biologicals
Separately payable (K)ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%
Pass through status (G)ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%
Separately payable vaccines (F, L)CostCostCostCostCostCostCostCost
Packaged (N)--------
340 Acquired Drugs and Biologicals
Separately payable (K)ASP-22.5%JGASP-22.5%JG & POASP+6%TB & PNASP+6%TBASP-22.5%JGASP-22.5%JG & POASP-22.5%JG & PNASP+6%TB
Pass through status (G)ASP+6%TBASP+6%TB & POASP+6%TB & PNASP+6%TBASP+6%TBASP+6%TB & POASP+6%TB & PNASP+6%TB
Separately payable vaccines (F, L)CostCostCostCostCostCostCostCost
Packaged (N)--------
ASC SERVICES
Final rule added 17 procedures relating to cardiac catheterization to the list of ASC Covered Surgical Procedures.
Growing trend of cardiac procedures being transitioned from an inpatient to an outpatient setting.
States that currently prohibit cardiac catheterization procedures at outpatient facilities may decide to adopt changes to allow certain procedures that have been deemed acceptable by CMS to be performed at facilities without on-site inpatient services, including ASCs.
CMS is updating ASC rates by 2.1% for CY 2019. Impact for hospital providers?
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ASC SERVICES
https://www.medicare.gov/procedure-price-lookup/
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https://www.medicare.gov/procedure-price-lookup/
OFF-CAMPUS EMERGENCY DEPARTMENTS
CMS agreed with MedPACs recommendation to develop data to assess the extent to which OPPS services are shifting to off-campus provider-based emergency departments.
New modifier effective January 1, 2019. Modifier ER (Items and services furnished by a
provider-based off-campus emergency department)
Reported with every claim line of the UB-04 for outpatient hospital services furnished in an off-campus provider-based emergency department.
Critical access hospitals are exempt.
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LABORATORY PAYMENT REPORTING
Protecting Access to Medicare Act (PAMA): CMS implemented market-based Lab Fee Schedule
in CY2018. Applicable laboratories required to report private
payer payment data to CMS. Private payer payment rates for outreach
business, by HCPCS code with volumes. CMS website includes FAQ article and format
for data submission. In the past, most hospital laboratories were excluded.
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LABORATORY PAYMENT REPORTING
Physician Fee Schedule Final rule, published Nov. 23, 2018: CMS essentially created a new entity (hospital
outreach laboratory) that meets the definition of an applicable laboratory.
Applicable laboratory expanded to include clinical laboratories that receive at least $12,500 of Medicare revenues from the CLFS for claims submitted using the CMS 1450 14X bill type, which is used by some hospital outreach laboratories to bill for laboratory services provided to non-patients.
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LABORATORY PAYMENT REPORTING
Civil monetary penalties (up to $10,000 per day), for each failure to report, misrepresentation, or omission of data.
Specific directions on data collection and data reporting: 2019 PFS Final Rule MLN Matters: MM1076 revised, January 17, 2019, CY
2019 Update for Clinical Laboratory Fee Schedule. https://www.cms.gov/Medicare/Medicare-Fee-for-
Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html
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Data collection period (payments received) January-June 2019Window to validate collected data July-December 2019Report data to CMS January March 2020Updated Lab fee schedule January 2021
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html
DEVICE CREDITS
For 2019, CMS lowered the device offset percentage threshold from greater than 40% to greater than 30% and to allow procedures that involve single-use devices, regardless of whether or not they remain in the body after the conclusion of the procedure, to qualify as device-intensive procedures.
361 device intensive procedures. OPPS Final Rule, addendum P.
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HCPCS Short Descriptor SI APCFinal CY2019 APC
Payment Rate
Device Offset
Percentage
Device Offset
Amount33206 Insert heart pm atrial J1 5223 $9,879.34 59.97% $5,924.64
DEVICE CREDITS
2018 OIG: Hospitals Did Not Comply With Medicare Requirements for Reporting Certain Cardiac Device Credits
Medicare incorrectly paid hospitals $7.7M for cardiac device replacement claims, resulting in potential overpayments of $4.4M.
Manufacturers issued reportable credits to hospitals for recalled cardiac medical devices, but the hospitals did not adjust the claims with the proper condition codes, value codes (FD), or modifiers to reduce payment as required.
Guidelines: Chapter 4, Section 61.3.5 Medicare Claims Processing Manual O/P Chapter 3, Section 100.8 Medicare Claims Processing Manual I/P CMS MLN Fact Sheet: Medicare Billing for Cardiac Device Credits
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PRICE TRANSPARENCY
CMS new hospital price transparency policy went into effect January 1, 2019.
Hospitals must make available a list of their current standard charges via the internet in a machine readable format and update this information at least annually, or more often as appropriate.
All items and services Standard charges by DRG
No hospitals are exempt. CMS FAQs articles includes clarifying information:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/FAQs-Req-Hospital-Public-List-Standard-Charges.pdf
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/Downloads/Additional-Frequently-Asked-Questions-Regarding-Requirements-for-Hospitals-To-Make-Public-a-List-of-Their-Standard-Charges-via-the-Internet.pdf
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https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/FAQs-Req-Hospital-Public-List-Standard-Charges.pdfhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/Downloads/Additional-Frequently-Asked-Questions-Regarding-Requirements-for-Hospitals-To-Make-Public-a-List-of-Their-Standard-Charges-via-the-Internet.pdf
QUESTIONS
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PRESENTER
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SCOTT TREIDA, MT(ASCP), CPC, CRCR | Director, Blue & Co., LLC317.713.7950 | [email protected]
Mr. Treida is a Director with Blue & Co., LLC. Scott started consultingwith Blue & Co. 20 years ago. He is responsible for coordinating andperforming detailed work related to Blue & Co.s revenue cyclemanagement services; concentrating on chargemaster (CDM) andcoding quality reviews, regulatory compliance, and revenue cycle teamdevelopment. Scott is a frequent presenter at local and nationalprofessional associations.
Scott is a graduate of Indiana University and Indiana University - PurdueUniversity Indianapolis with degrees in Biology and Medical Technology.He is a certified professional coder (CPC), and Medical Technologist withboard certification by the American Society for Clinical Pathology(ASCP). He enjoys running and resides in Indianapolis, Indiana with hiswife and kids.
Provider-Based Changes and OPPS: More Rulemaking and Changes in 20192019 OPPS Final ruleOPPS RATE INCREASEOpps Estimated ImpactOPPS ESTIMATED IMPACTKentucky specific impactsAddendum bAddendum d1Section X Nonrecurring Policy ChangesOff-campus hospital outpatient department (HOPD)hospital outpatient department (HOPD) REGULATIONS AND ReferencesWhy is cms focused on hopd services?Off-campus HOPDs: CMSs VIEWOff-campus HOPDs: CMSs VIEWOff-campus HOPDsOPPS SITE Neutral PAYMENTOff-campus HOPDs: CLINIC VISITSoff-campus HOPDs: EXPANDED SERVICESoff-campus HOPDs: 340Boff-campus HOPDs: 340BASC ServicesASC ServicesOff-campus emergency departmentsLaboratory payment reportingLaboratory payment reportingLaboratory payment reportingdevice creditsdevice creditsPrice transparencyQUESTIONSpresenter