Transcript APC/OPPS Update for CY2012

APCs: Issues & Answers
for CY2012
Sponsored By:
APCNow Web Site
www.APCNow.com
Presented By:
Duane C. Abbey, Ph.D., CFP
Abbey & Abbey, Consultants, Inc.
[email protected]
http://www.aaciweb.com
http://www.APCNow.com http://www.HIPAAMaster.com
Version 13.0 - Generic
Notes © 1994-2012, Abbey & Abbey, Consultants, Inc.
CPT® Codes – © 2011-2012 AMA
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 1
Presentation Faculty
Duane C. Abbey, Ph.D., CFP – Dr. Abbey is a healthcare consultant and educator with over 20
years of experience. He has worked with hospitals, clinics, physicians in various specialties,
home health agencies and other health care providers.
His primary work is with optimizing reimbursement under various Prospective Payment
Systems. He also works extensively with various compliance issues and performs
chargemaster reviews along with coding and billing audits.
Dr. Abbey is the President of Abbey & Abbey, Consultants, Inc. A wide range of consulting
services is provided across the country including charge master reviews, APC compliance
reviews, in-service training, physician training, and coding and billing reviews.
Dr. Abbey is the author of eleven books on health care, including:
•“Non-Physician Providers: Guide to Coding, Billing, and Reimbursement”
•“Emergency Department: Coding, Billing and Reimbursement”, and
•“Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance”.
His most recent books are:
“Compliance for Coding, Billing & Reimbursement A Systematic Approach to
Developing a Comprehensive Program”, “Introduction to Healthcare Payment
Systems”, and “The Medicare Recovery Audit Contractor Program” are available from
the CRC Press a Division of Taylor and Francis.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 2
Disclaimer
This workshop and other material provided are designed to provide accurate and
authoritative information. The authors, presenters and sponsors have made every
reasonable effort to ensure the accuracy of the information provided in this
workshop material. However, all appropriate sources should be verified for the
correct ICD-9-CM Codes, ICD-10-CM Diagnosis Codes, ICD-10-PCS Procedure
Codes, CPT/HCPCS Codes and Revenue Center Codes. The user is ultimately
responsible for correct coding and billing.
The author and presenters are not liable and make no guarantee or warranty;
either expressed or implied, that the information compiled or presented is errorfree. All users need to verify information with the Fiscal Intermediary, Carriers,
other third party payers, and the various directives and memorandums issued by
CMS, DOJ, OIG and associated state and federal governmental agencies. The
user assumes all risk and liability with the use and/or misuse of this information.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 3
OPPS Update for CY2012
Objectives
 To review the 2012 updates to the key features of the APC payment system.
 To appreciated the trends in modifications being made to APCs over the
years.
 To understand the complex nature of APCs and associated compliance
issues including RAC concerns.
 To appreciate the impact of proper coding and billing on APCs.
 To understand the impact of the 2012 changes on the chargemaster,
charges and the cost report for APCs.
 To review the 2012 update on high impact areas such as observation, the
Emergency Department, interventional radiology and associated areas.
 To review changes to the Provider-Based Rule (PBR) for 2012.
 To discuss anticipated future changes and directions for APCs.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 4
OPPS Update for CY2012
Acronyms/Terminology
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APCs – Ambulatory Payment Classifications
APGs – Ambulatory Patient Groups
ASC – Ambulatory Surgical Center
CAH – Critical Access Hospital
CCRs – Cost-to-Charge Ratios
CPT – Current Procedural Terminology
E/M – Evaluation and Management
FFS – Fee-for-Service
HCPCS – Healthcare Common Procedure Coding System
ICD-9-CM – International Classification of Diseases, Ninth Edition, Clinical
MAC – Medicare Administrative Contractor
MedPAC – Medicare Advisory Commission
MPFS – Medicare Physician Fee Schedule
NCCI – National Correct Coding Initiative
AWV – Annual Well Visit
PPPS – Personalized Preventive Plan Services
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 5
OPPS Update for CY2012
Acronyms/Terminology
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NCD/LCD – National/Local Coverage Decision
NTIOL –New Technology Intraocular Lens
OCE – Outpatient Code Editor
OPD – [Hospital] Outpatient Department
OPPS – [Hospital] Outpatient Prospective Payment System
PHP – Partial Hospitalization Program
PM – Program Memorandum
PPS – Prospective Payment System
QIO – Quality Improvement Organization
SI – Status Indicator
ASC – Ambulatory Surgical Center
RBRVS – Resource Based Relative Value System
MPFS – Medicare Physician Fee Schedule  Developed through RBRVS
VBP – Value Based Purchasing
PCR – Payment to Cost Ratio
 Note: The Federal Register entry has pages of acronyms!
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 6
OPPS Update for CY2012
General Comments
 APCs are becoming increasingly complex and more difficult to understand.
 Enormous Federal Register entries are now the norm.
 APCs represent a payment system that is out of control.
 Significantly increased bundling through packaging is still being added.
 APCs appear to be moving back toward APGs.
 There are wide variations in payments from year to year.
 Significant compliance concerns exist within the overall APC payment
system.
 In some cases these compliance concerns result because of lack of
explicit guidance from CMS.
 At some point the RAC auditors will become more involved in APCs.
 APCs and the underlying coding systems (i.e., CPT and HCPCS) generate
constant change and the need to update.
 Tracking and verifying that correct payment is received is difficult.
 It is critical to track adjudication and overall payment.
 Major issues with hospital charges, CCRs and the cost report are present.
 Federal Register Fanatics  Look for how many times the word
‘believe’ is used by CMS. What are you allowed to ‘believe’?
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 7
OPPS Update for CY2012
General Comments
 Note: All citations to the Federal Register are to the Examination Copy that
was released on November 1, 2011. The official Federal Register is
scheduled November 30, 2011. The examination copy is 2,552 pages long!!
 Official Title for this OPPS Update Federal Register:
 Hospital Outpatient Prospective Payment;
 Ambulatory Surgical Center Payment;
 Hospital Value-Based Purchasing Program;
 Physician Self-Referral; and
 Patient Notification Requirements in Provider Agreements.
• Note that there are even more topics addressed such as the
Provider-Based Rule (PBR), physician supervision requirements,
changes in observation, etc.
• All the contents of this FR should be carefully studied.
• Additional information is available at the CMS website:
 https://www.cms.gov/HospitalOutpatientPPS/
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 8
OPPS Update for CY2012
APC Background Information
 APC Fundamentals
 Encounter Driven System
• Some Exceptions – Example: Two separate blood transfusions on
the same day or two imaging services at different times on the
same day.
 CPT/HCPCS Code Driven
• If the service is not coded with a CPT or HCPCS (and/or proper
modifiers), then there will be absolutely no payment!
 APC Grouper  Multiple APCs from Given Claim
 Inpatient-Only Procedures
• Surgery, if performed outpatient, will not be paid at all! (Patient
Liability?)
• How is this list determined?
 Covered, Non-Covered and Payment System Interfaces
• Example: Self-Administrable Drugs
 Pass-Through Payments – Directly Based on Charges Made – Covert
Charges to Costs How? (Hint: Cost-to-Charge Ratios)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 9
OPPS Update for CY2012
APC Background Information
 APC Weight, and Thus Payment, Determination
 Hospital Charges Converted to Costs
• How is this done?
• Do we charge for everything?
• Do we charge correctly for everything?
 Statistical Process Using the Costs
• Geometric Mean
• Mean Cost for Given APC/Mean Cost for All APCs = the APC Weight
 Variation of Costs Within a Given APC Category
• 2-Times Rule – “ … if the median cost of the highest cost item or
service within an APC group is more than 2 times greater than the
median of the lowest cost item or service within that same group.”
(Page 368 – CMS-1525-FC)
• 2-Times Rule Exception List
 Examples:
o APC=0080 Diagnostic Cardiac Catheterization
o APC=0604 Level 1 Hospital Clinic Visits
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 10
OPPS Update for CY2012
APC Background Information
 Use of Claims to Statistically Develop the APC Weights
 Because outpatient encounters often involve multiple services, the APC
grouping process often (if not a majority of the time) generates multiple
APCs.
 CMS can use only pure claims, that is, claims that group to a single
APC. These are called ‘singleton’ claims.
 CMS is trying very hard to get around this situation because most of
the claims filed by hospitals never get considered when the actual APC
weights are determined.
• Small Example: CPT=86891 – Intra- or Post-Operative Blood
Salvage
 A device is used to save blood, reprocess the blood and
generally re-infuse.
 Is it possible to have ONLY 86891 on a claim?
 What kind of payment do we have for 86891?
 What are the costs involved?
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 11
OPPS Update for CY2012
APC Background Information
 APC Cost Outliers
 Complicated Two-Tiered Formula
 Based on Excessive Costs - How are costs determined?
 Nationally, does CMS make full outlier payments?
 Provider-Based Rule (42 CFR §413.65)
 Provider-Based Clinics
 Provider-Based Clinical Services
 Potentially, two claim forms filed – CMS-1450 (UB-04) for technical
component and CMS-1500 (1500) for professional component.
 Reduction in payment for professional component
• Site-of-Service Differential in RBRVS (MPFS)
• Place-of-Service (POS) driven on CMS-1500
 Series of Criteria to Meet If to be Provider-Based
• On-Campus versus Off-Campus
• See Physician Supervision Developments  Important
 Changes in rules, regulations and interpretations.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 12
OPPS Update for CY2012
APC Background Information
 APC Advisory Panel
 CMS has developed an ever expanding APC Advisory Panel which they
are now extending to a super panel to determine appropriate
supervisory levels.
 “The Data Subcommittee is responsible for studying the data issues
confronting the APC Panel and for recommending options for resolving
them. The Visits and Observation Subcommittee reviews and makes
recommendations to the APC Panel on all technical issues pertaining to
observation services and hospital outpatient visits paid under the
OPPS (for example, APC configurations and APC payment weights).
The Subcommittee for APC Groups and SI Assignments advises the
Panel on the following issues: the appropriate SIs to be assigned to
HCPCS codes, including but not limited to whether a HCPCS code or a
category of codes should be packaged or separately paid; and the
appropriate APCs to be assigned to HCPCS codes regarding services
for which separate payment is made.” (Page 47 – CMS-1525-FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 13
OPPS Update for CY2012
APC Background Information
 ASCs – Ambulatory Surgical Centers
 In CY2008 CMS Started a Hybrid of APCs and RBRVS
 FR entries for APCs will now also be for ASCs
 ASC Surgery List
• Regular ASC Surgeries
• Office-Based Surgeries  New Additions
• Conditions for Coverage (CfCs)  New Acronym
• Additions and Deletions to Lists
 Payment Formula
• ASC Surgery  65% of APC
• Office-Based Surgeries – Lesser of:
 65% of APC or
 Non-Facility PE RVU from MPFS
• Physician Paid Facility MPFS (As With Hospitals)
 Separate Payment for Certain Ancillary Services
 Did all the features of APCs translate over?
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 14
OPPS Update for CY2012
By The Numbers
 Basically a 1.9% Market Basket Update  Several Factors Involved
 Conversion Factor = $70.016 versus $68.876 for CY2011 (1.655%)
 Assumes Quality Reporting  Further 2.0% reduction if not.
• Conversion Factor $66.059 in CY2009 to $67.439 for CY2010
 Wage Index Changes  See IPPS
 Statewide CCRs  See Table 11 – Interesting Just To Peruse
 SCHs  7.10% Increase on Budget Neutral Basis (Includes EACHs)
 Cost Outlier
 Fixed Threshold from $2,175.00 for CY2010 to $2,025.00 for CY2011 to
$1,900.00 for CY2012
• This is a fairly significant decrease. What is happening?
 Labor-Related Calculation  Remains the same.
 Co-Payment Amounts
 Still struggling to get to the target of a 20% coinsurance to calculate the
copayment amount.
 Drug Packaging Threshold
 $60.00 for CY2009 moved to $65.00 for CY2010 and $70.00 for CY2011
to $75.00 for CY2012
 Final ASC Conversion Factor - $42.627 ($42.627/$70.016= 60.88%)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 15
OPPS Update for CY2012
By The Numbers
 TOPs – Transitional Outpatient Payment
 “Effective for services provided on or after January 1, 2012, a rural
hospital with 100 or fewer beds that is not an SCH and an SCH
(including EACHs) will no longer be eligible for TOPs, in accordance
with section 108 of the MMEA.” (Page 286 – CMS-1525-FC)
 For SCHs (including EACHs), the 7.1% increase will continue.
 See also, Children’s Hospitals and Cancer Hospitals
• Extensive Cost Studies for Cancer Hospitals – See PCR – Paymentto-Cost Ratio
 Wage Index
 “In addition to the changes required by the Affordable Care Act, we
note that the FY 2012 IPPS wage indices continue to reflect a number of
adjustments implemented over the past few years, including, but not
limited to, reclassification of hospitals to different geographic areas,
the rural floor provisions, an adjustment for occupational mix, and an
adjustment to the wage index based on commuting patterns of
employees (the out-migration adjustment).Reclassifications Under
Section 508 – Highly specialized situations. See FY2010 IPPS/LTCH
PPS Federal Register dated June 2, 2010.” (Page 266 – CMS-1525-FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 16
OPPS Update for CY2012
By The Numbers
 Wage Index – Continued
 “… our longstanding policy for OPPS has been to adopt the final wage
index used in IPPS. Therefore, for calculating OPPS payments in CY
2012, we used the FY 2012 IPPS wage indices.” (Page 268 – CMS-1525FC)
 “For the OPPS, using the IPPS wage index as the source of an
adjustment factor for geographic wage differences has, in the past,
been both reasonable and logical, given the inseparable, subordinate
status of the outpatient department within the hospital overall.” (Page
269 – CMS-1525-FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 17
OPPS Update for CY2012
Recalibration of APC Relative Weights
 Recalibration and Rebasing Process
 OPPS Update Federal Registers – Typically Long Discussions
 Calculation of Median Costs Within APC Categories
 Single Procedure Claims versus Multiple Procedure Claims
• Methodology Carried Over From DRGs – Doesn’t Really Work
• Pseudo Single Procedure Claims
• Bypass Codes
 CCRs – Cost-to-Charge Ratios from Cost Reports
• See Revenue Code-to-Cost Center Crosswalk
• CT & MRI Equipment – Major Moveable vs. Building Equipment
Device Dependent APCs – Expensive Implant or Supply Item Is
Larger than Payment for Service
 Blood and Blood Products  Still Equalizing Payments Due To
Incorrect CCRs
 Updated CPT/HCPCS Codes
 Updated Status Indicators Affecting Packaging
• See Also – Packaged Revenue Codes – Table 2
 Payment Variations  See 2-Times Rule + Payment Change Limitations
 Composite APCs  Observation, Pulmonary Rehab, Etc.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 18
OPPS Update for CY2012
Recalibration of APC Relative Weights
 Recalibration and Rebasing Process
 New Codes – CPT and HCPCS
• CMS discusses new codes implemented throughout the year along
with addressing new CPT/HCPCS codes.
• See also assignment or reassignment of Status Indicator codes.
 Multiple Imaging Families – Started in CY2009
• Significant Concerns By Hospitals
• Continue with the Composite APCs (8004-8008)
 Packaging Services
• See SI=“Q1”, “Q2”, and “Q3”
• Dependent and Independent Methodology
• CPT=19295 – Localization Clip, Breast  SI=“Q1” – APC=0340 $46.23 for CY2011
• Other Specific CPT/HCPCS Codes – Including SI=“N”
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 19
OPPS Update for CY2012
CPT/HCPCS Changes For CY2012
 As usual there are hundreds of changes for both CPT and HCPCS. With
the exception of laboratory codes, the rate of change for 2012 is in a fairly
normal range.
 However, some of the CPT changes have a significant impact on APC
grouping and the logic in the I/OCE (Integrated Outpatient Coded Editor).
 Integumentary System
• 15271-15278 – Skin Substitute Grafts
 Whole New Sequence of Codes – Anatomical/Size
• 15777 – Implantation of biologic implant
 Musculoskeletal System
• 22633-22634 – Arthrodesis
• 29582-29584 – Application Multi-Layer Compression System
 Respiratory System
• 32096-32098 – Thoracotomy – Diagnostic
• 32505-32507 – Thoracotomy – Therapeutic
• 32607-32609 – Thoracoscopy – Diagnostic
• 32666-32674 – Thoracoscopy - Therapeutic
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 20
OPPS Update for CY2012
CPT/HCPCS Changes For CY2012
 CPT Changes for CY2012
 Cardiovascular
• 33227-33229 – Pacemaker Removal
• 33230-33231 – Insertion Pacemaker
• 33262-33264 – Removal and Insertion Pacemaker
• Vascular Injection Procedures
 Extensive Coding Guideline Additions
• 37191-37193 – Insertion/Repositioning/Removal Vena Cava Filters
 Digestive System
• 49082-49084 – Abdominal paracentesis
 Nervous System
• 64633-64636 – Destruction by neurolytic agent
 Radiology
• 77424-77425 – Intraoperative radiation treatment delivery
• 78226-78227 – Hepatobiliary system imaging
• 78579-78598 – Pulmonary ventilation and Quantitative differential
 Laboratory – Molecular Pathology  Guidance and all new codes in the
81000 sequences
 Hydration, Injections, Infusions  See changed coding guidance.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 21
OPPS Update for CY2012
CPT/HCPCS Changes For CY2012
 CPT Changes
 New Modifiers
• Two new modifiers for physicians, none for hospitals.
• “-33” – Preventative Services
• “-92” Alternative Laboratory Platform Testing
 Category II Codes
• Quite a few additions. Tracking Codes – Patient Management
 Category III Codes
• Added about 31 new codes. These are temporary codes (up to five
years) that generally receive Category I status over time. Be certain
to check for applicability to HOPPS.
 HCPCS Changes
 As usual there are quite a few HCPCS additions
 One new modifier, “-PD” that is used by physicians when billing in a
hospital owned or operated clinic for a service in the 3-Day Payment
Window. (The modifier invokes the site-of-service differential.)
 Quite a few new G-Codes that describe patient conditions.
 Just a few L-Codes and DME items.
 Relatively few new J-Codes for pharmaceutical items.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 22
OPPS Update for CY2012
Composite APCs – Issues and Changes
 Composite APCs
 Observation – APC=8002 and APC=8003
• See Minor Surgery – Status Indicator “T” Bundling Issue
 Issue has been presented and noted in the Federal Register.
Next year??
• APC 8002  $393.15/$394.22/$381.34
• APC 8003  $720.64/$714.33/$705.27
 LDR Prostate Brachytherapy – APC=8001
• CPT=55875+77778
• CY2012  $3,339.98; CY2011  $3,229.24; CY2010  $3,112.61
 Electrophysiology Studies – APC=8000
• APC 8000  $11,311.28/$10,787.46/$10,118.25
• Problematic Area – High variability of services, thus costs.
 Mental Health Services – APC=0034
• See Payment Limit for APC=0176 (Full Day Partial Hospitalization)
• APC 0034 - $191.13/$238.33/$210.89  Wow, significant decrease!
 Multiple Imaging – APCs – 8004, 8005, 8006, 8007, 8008
• See new CPT Sequence 74176-74178
 Cardiac Resynchronization Therapy Composite APC (APCs 0108, 0418,
0655, and 8009)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 23
OPPS Update for CY2012
On-Going APC Issues
 Variation Within APC Categories
 2-Times Rule  Statistical Measure of Too Much Variation
• “… the median cost of the highest cost item or service within an
APC group is more than 2 times greater than the median of the
lowest cost item or service within that same group.” (Page 395 –
CMS-1504-FC)
• Question: How many years can an APC be repeatedly on the list?
• How is this affecting you?
 0057 Bunion Procedures
 0058 Level I Strapping and Cast Application
 0060 Manipulation Therapy
 0076 Level I Endoscopy Lower Airway
 0080 Diagnostic Cardiac Catheterization
 0135 Level III Skin Repair
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 24
OPPS Update for CY2012
On-Going APC Issues
 Variation Within APC Categories
 0148 Level I Anal/Rectal Procedures
 0235 Level I Posterior Segment Eye Procedures
 0262 Plain Film of Teeth
 0317 Level II Miscellaneous Radiology Procedures
 0330 Dental Procedures
 0340 Minor Ancillary Procedures
 0341 Skin Tests
 0347 Level III Transfusion Laboratory Procedures
 0367 Level I Pulmonary Test
 0369 Level III Pulmonary Tests
 0403 Level I Nervous System Imaging
 0409 Red Blood Cell Tests
 0436 Level I Drug Administration
 0604 Level 1 Hospital Clinic Visits
 0607 Level 4 Hospital Clinic Visits
 0660 Level II Otorhinolaryngologic Function Tests
 0667 Level II Proton Beam Radiation Therapy
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 25
OPPS Update for CY2012
On-Going APC Issues
 New Technologies
 CMS provides a generalized discussion of the goals and objectives for
the new technology payments. CMS makes it fairly clear that they have
no intention of paying for expensive capital equipment that may have
low utilization during the startup years for a new, high technology,
service.
 Movement from New Technologies to Clinical APCs
• G0417-G0418  Surgical pathology prostate needle saturation
 Low Volume – Reassigned within the New Technology Area
 Device Payment
 Pass-Through Expiration Dates
 See FB and FC Modifiers
 See Table 30 for Offsets
 See Table 31 for Listing of Affected Devices
 Device Dependent APCs
 No Cost/Full Credit and Partial Credit
 Hospitals, overall, tend to undercharge for devices. See issues such as
charge compression.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 26
OPPS Update for CY2012
On-Going APC Issues
 Specific APC Categories – Payment and Code Mappings (Examples)
 Cardiovascular Computed Tomography (CCT) (APC 0340 and 0383)
 Cardiac Imaging (APC 0377)
 Insertion/Replacement/Repair of AICD Leads, Generator, and Pacing
Electrodes (APC 0108)
 Implantable Loop Recorder Monitoring (APC 0690)
 Echocardiography (APCs 0128, 0269, 0270, and 0697)
 Upper Gastrointestinal (GI) Services (APCs 0141, 0419, and 0422)
 Laser Lithotripsy (APC 0163)
 Revision/Removal of Neurostimulator Electrodes (APCs 0040 and 0687)
 Transcranial Magnetic Stimulation Therapy (TMS) (APC 0218)
 Placement of Amniotic Membrane (APCs 0233 and 0244)
 Insertion of Anterior Segment Aqueous Drainage Device (APC 0673)
 Closed Treatment Fracture of Finger, Toe, and Trunk (APCs 0129, 0138,
and 0139)
 Stereotactic Radiosurgery (SRS) Treatment Delivery Services (APCs
0065, 0066, 0067, and 0127)
 Device Construction for Intensity Modulated Radiation Therapy (IMRT)
(APC 0305)
 Skin Repair (APCs 0133, 0134, and 0135)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 27
OPPS Update for CY2012
On-Going APC Issues
 Drugs, Biological, and Radiopharmaceuticals
 Transitional Pass-Through Payment Process
• Drugs Expiring – See Table 32
• New Drugs on the List – See Table 33
• Nuclear Medicine Concerns
• Contrast Agent Offset
 Packaging Criteria
 Packaging Threshold - $75.00 versus the $80.00 Proposed
• See Table 36
 CMS Posting Offset Amounts for All Affected APCs
 Policy-Packaged Drugs and Devices
 340B Hospitals – Data Considerations
 ASP+4 vs. ASP+6 and Redistribution for Overhead Costs
• See Table 38
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 28
OPPS Update for CY2012
On-Going APC Issues
 Drugs, Biological, and Radiopharmaceuticals
 “We note that although it is CMS’ longstanding policy under the OPPS
to refrain from instructing hospitals on the appropriate revenue code to
use to charge for specific services, we continue to encourage hospitals
to bill all drugs and biologicals with HCPCS codes, regardless of
whether they are separately payable or packaged, and to ensure that
drug costs are completely reported, using appropriate revenue codes.
We also note that we make packaging determinations for drugs and
biologicals annually based on cost information reported under HCPCS
codes, and the OPPS ratesetting is best served when hospitals report
charges for all items and services with HCPCS codes when they are
available, whether or not Medicare makes separate payment for the
items and services.” (Page 701 – CMS-1525-FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 29
OPPS Update for CY2012
On-Going APC Issues
 Brachytherapy Sources – See Various A-Codes and C-Codes
 Congressional Mandate – Pay Separately
• Otherwise CMS would probably package these sources into the
associated service.
 Pass-Through Payment (Sort Of) Up To CY2009 – SI=“H”  “K”  “U”
• CMS’s interpretation of ‘charges adjusted to cost’ is interesting.
 CMS Has Developed a Discrete ‘Mini’ APC System for Sources
 “After consideration of the public comments we received, we are
finalizing our proposal to pay for brachytherapy sources at prospective
payment rates based on their source-specific median costs for CY
2012.” (Page 165 – CMS-1525-FC)
 “Consistent with our policy regarding APC payments made on a
prospective basis, we are finalizing our proposal to subject the cost of
brachytherapy sources to the outlier provision of section 1833(t)(5) of
the Act, and also to subject brachytherapy source payment weights to
scaling for purposes of budget neutrality.” (Page 165-166 – CMS-1525FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 30
OPPS Update for CY2012
On-Going APC Issues
 APC Cost Outliers
 “Currently, the OPPS provides outlier payments on a service-by-service
basis. For CY 2011, the outlier threshold is met when the cost of
furnishing a service or procedure by a hospital exceeds 1.75 times the
APC payment amount and exceeds the APC payment rate plus a $2,025
fixed-dollar threshold.” (Page 316 – CMS-1525-FC)
 “For CY 2012, based on updated data, we have established a fixeddollar threshold of $1,900 which, together with a multiple threshold of
1.75, will enable us to meet our target outlier payment of 1 percent of
total OPPS spending.” (Page 322 – CMS-1525-FC)
• 1.75  1.75
• $2,025.00  $1,900.00
 See also the discussion of cost outliers for PHP and CMHCs.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 31
OPPS Update for CY2012
On-Going APC Issues
 Drug Administration Services
 An area of considerable changes over the last several years.
 Coding and Charge Capture Difficulties
 APC Panel Recommendation – Pay separately for CPT 96368 and 93676,
that is, concurrent infusion and additional pushes.
• CMS has rejected this recommendation and will continue with the
five level APC structure for injections and infusions.
 See also slight changes in guidance from CPT.
APC
CY2012
CY2011
CY2010
CY2009
0436
$24.82
$26.35
$25.67
$25.03
0437
$34.81
$36.88
$37.44
$36.66
0438
$72.73
$75.58
$75.69
$74.32
0439
$126.71
$128.44
$126.78
$126.80
0440
$207.80
$205.86
$219.96
$191.06
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 32
OPPS Update for CY2012
On-Going APC Issues
 Partial Hospitalization Services
 Hospitals vs. CMHCs
• Two Tiered Costs Structure – Cost Report Data HCRIS
• Two Sets of APCs – Status Indicator “P”
 APC=0172/0173  Level I and II at CMHC
 APC=0175/0176  Level I and II at Hospital
APC
CY2012
CY2011
CY2010
0172
$97.63
$129.64
$149.84
0173
$113.81
$164.43
$210.89
0175
$160.71
$204.89
[$149.84]
0176
$238.33
[$210.89]
$191.13
 “… we have decided to provide a 2-year transition to CMHC rates based
solely on CMHC data for the two CMHC PHP APC per diem rates. For
CY 2011, the CMHC PHP APC Level I and Level II rates will be
calculated by taking 50 percent of the difference between the CY 2010
final hospital-based medians and the CY 2011 final CMHC medians and
adding that number to the CY 2011 final CMHC medians.” (Page 768)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 33
OPPS Update for CY2012
On-Going APC Issues
 Partial Hospitalization Services
 Cost Report Data for CMHCs Through HCRIS
• Note the significant difference in reimbursement (determined via
costs) between hospitals and CMHCs.
• “A few commenters expressed concerns that the technical data on
which CMS relies during the rate setting process are fundamentally
flawed, in that the data do not reflect the full scope of CMHC costs.
These commenters also stated that, due to insufficient cost
reporting instructions for CMHCs, they continue to incorrectly
exclude owner’s salary costs from their cost reports, contributing
to their low median costs.” (Page 797 – CMS-1525-FC)
 Separate Cost Outlier Payments to CMHCs
• “Specifically, we proposed to establish that if a CMHC's cost for
partial hospitalization services, paid under either APC 0172 or APC
0173, exceeds 3.40 times the payment for APC 0173, the outlier
payment would be calculated as 50 percent of the amount by which
the cost exceeds 3.40 times the APC 0173 payment rate.” (Pages
800-801 – CMS-1525-FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 34
OPPS Update for CY2012
On-Going APC Issues
 Inpatient-Only Procedures
 “The inpatient list specifies those services for which the hospital will be
paid only when provided in the inpatient setting because of the nature
of the procedure, the underlying physical condition of the patient, or
the need for at least 24 hours of postoperative recovery time or
monitoring before the patient can be safely discharged.” (Page 8902 –
CMS-1525-FC)
 Commenters continue to recommend doing away with this list.
• “Many commenters suggested that the inpatient only list be
eliminated in its entirety. The commenters indicated that hospitals
already meet minimum safety standards through Joint Commission
accreditation and the Medicare hospital conditions of participation.
Commenters suggested that, if the inpatient only list cannot be
eliminated in its entirety, an appeals process be developed.
Commenters believed that an appeal process would give the
hospital the opportunity to submit documentation on the
physician’s intent, the patient’s clinical condition, and the
circumstances that enabled the patient to be sent home safely
without an inpatient stay.” (Page 810 – CMS-1525-FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 35
OPPS Update for CY2012
On-Going APC Issues
 Inpatient-Only Procedures
 Deletions from the List
• 0184T Excision of rectal tumor APC= 0149 SI=“T”
• 20930 Allograft, morselized, SI=“N”
• 20931 Allograft, structural, SI=“N”
• 21346 Open treatment nasomaxillary complex fx APC=0254 SI=“T”
• 22551 Arthrodesis, anterior APC=0208 SI=“T”
• 22554 Arthrodesis, anterior interbody technique APC=0208 SI=“T”
• 35045 Direct repair of aneurysm APC=0093 SI=“T”
• 43281 Laparoscopy, surgical, repair hernia, APC=0132 SI=“T”
• 43770 Laparoscopy, surgical, gastric restrictive APC=0131 SI=“T”
• 54650 Orchiopexy, abdominal approach APC=0154 SI=“T”
 There were more than 40 other procedures that commenters requested
to be removed. CMS rejected these codes.
 Note that the procedures on the list are determined in part on a
statistical basis and not purely on a clinical basis. For non-Medicare
patients there are procedures on this list that are performed in the
outpatient setting and paid by private third-party payers.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 36
OPPS Update for CY2012
On-Going APC Issues
 “-CA” Modifier – APC=0375
 APC 0375 - Ancillary Outpatient Services When Patient Expires
• Example: Patient rushed to hospital ED, taken to surgery and then
expires without being admitted to hospital.
• Blanket payment for various types of procedures.
 Better Database and Proper Utilization
• CY2012  $6,038.66
• CY2011  $6,372.10
• CY2010 $5,965.94
• CY2009  $4,770.52
• CY2008  $5,006.13
 Question: Why don’t we use a process similar to the “-CA” modifier for
inpatient only procedures that are inadvertently performed on an
outpatient basis?
• We could do away with the inpatient-only list, and at least there
would be a default average payment for such services instead of
making then the patient’s liability.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 37
OPPS Update for CY2012
Physician Supervision Changes
 Starting in CY2008 the Issue of Physician Supervision Took On A Life Of Its
Own
 Previous guidance was provided in April 7, 2000 Federal Register
relative to direct physician supervision at off-campus provider-based
clinics.
 In CY2008 CMS started clarifying their guidance on this requirement as
part of the Provider-Based Rule (PBR).
 From CY2008 to the present there has been significant discussions in
the Federal Registers and changes to the CMS manuals.
 Distinguish
• Diagnostic vs. Therapeutic Supervision
• Off-Campus vs. On-Campus (Out-of-Hospital) vs. In-Hospital
• General vs. Direct vs. Personal Supervision
 General Application of “Incident-To” From the SSA
 CAH Issue – Differences in requirement from the CAH CoPs and the
PBR Supervision requirements.
 Note: At issue is a significant compliance concern. If auditors were to
determine that proper physician supervision was not provided, then
recoupments could be demanded.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 38
OPPS Update for CY2012
Physician Supervision Changes
 Physician Supervision Discussions
 For 2011: “The definition of direct supervision will be revised simply to
require immediate availability, meaning physically present,
interruptible, and able to furnish assistance and direction throughout
the performance of the procedure but without reference to any
particular physical boundary. Since the new definition will now apply
equally in the hospital or in on-campus or off-campus PBDs, we are
removing paragraphs (a)(1)(iv)(A) and (B) of §410.27 altogether. The
new definition of direct supervision under §410.27(a)(1)(iv) will now
state, “For services furnished in the hospital or CAH or in an outpatient
department of the hospital or CAH, both on- and off-campus, as defined
in section 413.65 of this subchapter, ‘direct supervision’ means that the
physician or nonphysician practitioner must be immediately available
to furnish assistance and direction throughout the performance of the
procedure. It does not mean that the physician or nonphysician
practitioner must be present in the room when the procedure is
performed.” (Page 828, CMS-1504-FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 39
OPPS Update for CY2012
Physician Supervision Changes
 Physician Supervision Discussions
 From 2012 Update: “Therefore, in the CY 2009 OPPS/ASC proposed rule
and final rule with comment period (73 FR 41518 through 41519 and 73
FR 68702 through 68704, respectively), we clarified and restated the
various supervision requirements for outpatient hospital therapeutic
and diagnostic services. We clarified that outpatient therapeutic
services furnished in the hospital and in all PBDs of the hospital,
specifically both on-campus and off-campus PBDs, must be provided
under the direct supervision of physicians. We also reiterated that all
outpatient diagnostic services furnished in PBDs, whether on or off the
hospital’s main campus, should be supervised according to the levels
assigned for the individual tests under the MPFS. (Page 825 – CMS1525-FC)
 Note also that CMS is recognizing all three supervision levels:
Personal, Direct and General on the outpatient therapeutic side as well
as on the diagnostic side (see MPFS).
• Question: With the above language, do the supervision requirement
apply to in the hospital PBDs and well as PBDs on the campus but
outside the hospital?
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 40
OPPS Update for CY2012
Physician Supervision Changes
 Physician Supervision Discussions
 “Specifically, for these services we redefined direct supervision to
remove all requirements that the supervisory practitioner remain
present within a particular physical boundary, although we continued
to require immediate availability. We also established a new category of
services, “nonsurgical extended duration therapeutic services”
(extended duration services), which have a substantial monitoring
component. We specified that direct supervision is required for these
services during an initiation period, but once the supervising physician
or NPP has determined that the patient is stable, the service can
continue under general supervision.” (Page 829 – CMS-1525-FC)
 Cardiac Rehabilitation and Pulmonary Rehabilitation – Only physicians
may meet the physician supervision requirements.
 CAHs and Small Rural Hospitals (Less than 100 beds) have been
exempted from the supervision requirements now through 2012.
 The key phrase “immediately available” remains undefined.
• CMS has given some counterexamples. For instance, a supervising
physician must be interruptible.
• How can a physician/practitioner be immediately available and not
on campus??
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 41
OPPS Update for CY2012
Physician Supervision Changes
 Physician Supervision Discussions
 CMS has decided to establishing an independent advisory review
process.
• Note: This is a standard bureaucratic approach when difficult
decisions must be made. See ‘share-the-blame’ concept.
 CMS intends to use the APC Advisory Panel
• But this panel addresses only APCs, that is, HOPPS
• Need to include representatives for CAHs and small rural hospitals.
• Qualifications of panel members.
 Clinicians vs. Non-Clinicians vs. Non-Physician Practitioner vs.
Nursing Staff
• Scope of authority limited to supervision issues.
 Keep in mind that this panel has only advisory capabilities.
CMS can still do whatever they want to do.
• Process and criteria for determining which services require what
level of supervision. Subregulatory Process – Not in the manuals.
• Services Not Described by CPT Codes
• Starting Agenda
 Extension Beyond “Incident-To” Services
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 42
OPPS Update for CY2012
Physician Supervision Changes
 Physician Supervision Discussions
 “We stated in the proposed rule and continue to believe that, while the
statute does not explicitly mandate direct supervision, direct
supervision is the most appropriate level of supervision for most
hospital outpatient services that are authorized for payment as
“incident to” physicians’ services. We believe that the “incident to”
nature of hospital outpatient therapeutic services under the law permits
us to recognize specific circumstances in which general supervision is
appropriate, as we have for extended duration services, and that CMS
has authority to accept a recommendation by the review entity of
general supervision for a given service. However, we continue to
believe that direct supervision is the most appropriate level of
supervision for the majority of hospital outpatient therapeutic services
and, as such, it is the default supervision standard.” (Page 847 – CMS1525-FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 43
OPPS Update for CY2012
Physician Supervision Changes
 Physician Supervision Discussions
 OK, So What Does All This Mean to Hospitals?
 For 2012 the actual rules and regulations concerning physician
supervision are not being substantively changed.
• Some issues are clarified, for example, three levels of supervision
on the therapeutic side.
 The hold-harmless for CAHs and small rural hospitals is being
continued.
 However, for most hospitals, the direct physician supervision
requirement will need to be attained for virtually all outpatient services
regardless of location. See off-campus vs. on-campus vs. in the
hospital.
 The advisory panel/committee is being established with all the
bureaucratic trappings.
• How long will it take for this panel to actually produce meaningful
resutlts?
• And, will CMS accept the recommendations?
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 44
OPPS Update for CY2012
Hospital Outpatient Visits
 Hospital Outpatient Visits – A Continuing Area of Challenge
 New vs. Established Patients – Registration within 3 years.
• Commenters indicated that using the old definition of having a
medical record number was easier to use that the registration as an
inpatient or outpatient definition.
• Comments also recommended that a single set of E/M codes be
used for outpatient visits.
• “We stated in the CY 2012 OPPS/ASC proposed rule (76 FR 42269)
that we continue to believe that defining new or established patient
status based on whether the patient has been registered as an
inpatient or outpatient of the hospital within the 3 years prior to a
visit will reduce hospitals’ administrative burden associated with
reporting appropriate clinic visit CPT codes, …” (Page 752 – CMS1525-FC)
• While this whole issue is discussed in some detail, CMS continues
to find statistically significant differences in costs (from charges
converted to costs) between the current established vs. new patient
categories.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 45
OPPS Update for CY2012
Hospital Outpatient Visits
 Hospital Outpatient Visits – A Continuing Area of Challenge
 Direct Admits to Observation – G0379
• Comments recommended assignment to higher level APC.
• “Therefore, we are finalizing our proposal to continue to assign
HCPCS code G0379 to APC 0604 and composite APC 8002.” (Page
757 – CMS-1525-FC)
 ED Coding and Payment
• “Since CY 2007, we have recognized two different types of
emergency departments for payment purposes under the OPPS—
Type A emergency departments and Type B emergency
departments. As described in greater detail below, by providing
payment for two types of emergency departments, we recognize, for
OPPS payment purposes, both the CPT definition of an emergency
department, which requires the facility to be available 24 hours a
day, and the requirements for emergency departments specified in
the provisions of the Emergency Medical Treatment and Labor Act
(EMTALA) …” (Page 758 – CMS-1525-FC)
• While there is an extended discussion, no real changes in
approach.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 46
OPPS Update for CY2012
Hospital Outpatient Visits
 Critical Care Coding, Billing and Reimbursement
 Critical Care Codes – CPT Changes
• For 2011, CPT changed instructions for certain ancillary services
provided. CMS’s response:
 “…, and we will implement claims processing edits that will
conditionally package payment for the ancillary services that
are reported on the same date of service as critical care
services in order to avoid overpayment.” (Page 750 – CMS1504-FC)
• “We believe all services provided in conjunction with critical care,
as part of a single clinical encounter, are included in the critical
care period and, therefore, do not support the commenters’
recommendation that a modifier be implemented to allow the
identification of ancillary services provided to critical care patients
during the same date of service as critical care services, but
outside the critical care period. Hospitals may use HCPCS modifier
“-59” to indicate when an ancillary procedure or service is distinct
or independent from critical care when performed on the same day
but during a different encounter.” (Page 757 – CMS-1525-FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 47
OPPS Update for CY2012
Hospital Outpatient Visits
 Hospital Visit Coding Guidelines
 From 2011 - “We agree with the commenters that national guidelines
should be clear, concise, and specific with little or no room for varying
interpretations, and that hospitals should have at least 1 year to
prepare for the transition. If the AMA were to create facility specific CPT
codes for reporting visits provided in HOPDs, we would certainly
consider such codes for OPPS use.” (Page 756 – CMS-1504-FC)
 For 2012 – “Based on public comments, as well as our own knowledge
of how clinics operate, it seemed unlikely that one set of
straightforward national guidelines could apply to the reporting of
visits in all hospitals and specialty clinics.” (Page 770 – CMS-1504-FC)
 CMS has noted a slight shift to the Level 4 and Level 5 at the national
aggregated level.
• What could be causing this shift.
• What do your hospital’s E/M frequencies look like? Normal bell
shaped curve?
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 48
OPPS Update for CY2012
Hospital Outpatient Visits
 Hospital Visit Coding Guidelines
 One of the greatest concerns on the part of hospitals is whether or not
their mappings are appropriate. Even with the CY2008 principles,
guidance, at best, is very general.
 “In contrast, many commenters urged CMS to move forward with the
implementation of national guidelines for hospitals to report visits,
asserting that CMS has poor data upon which to calculate visit APC
payment rates because there are no standard definitions, and citing the
challenges of having different guidelines in place by different payers.
The commenters recommended that, in the absence of national
guidelines for hospital visit reporting, CMS support a request to the
American Medical Association CPT Editorial Panel to create unique
CPT codes for hospital reporting of emergency department and clinic
visits based on internally developed guidelines.” (Page 773 – CMS1525-FC)
• Coding Issues – Example: Minimal fracture care. Separate code or
place in the E/M levels.
• Design Issues: Point System, Narrative System, Hybrid, Diagnoses
• What incentive does the AMA have for getting into this area?
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 49
OPPS Update for CY2012
Hospital Outpatient Visits
 Hospital Visit Coding Guidelines
 Commenters are very concerned about contractor audits of the hospital
developed coding guidelines.
• “In addition, some commenters expressed their appreciation for
CMS’ encouragement of its contractors to use a hospital’s own
guidelines when auditing and evaluating the appropriateness of
codes assigned, but requested that hospitals be exempt from audits
of visit billing until national guidelines are implemented.” (Page 773
– CMS-1525-FC)
• CMS’ Response: “We continue to encourage fiscal intermediaries
and MACs to review a hospital’s internal guidelines when an audit
occurs, as indicated in the CY 2008 OPPS/ASC final rule with
comment period (72 FR 66806).” (Page 774 – CMS-1525-FC)
 Exercise: Analyze this response relative to the eventual entry of
the RACs (Recovery Audit Contractors) into this area including
the use of statistical extrapolation.
 Bottom-Line – CMS is making no changes as such in this area. They
will continue to monitor their national level aggregate data for possible
aberrations.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 50
OPPS Update for CY2012
Hospital Outpatient Visits
 Outpatient Visit Payment Changes – Clinic Visits and ED Visits
APC
Description
0604
Clinic Lev 1
0605
CY2011
CY2010
$53.84
$52.36
$57.92
Clinic Lev 2
$72.19
$75.13
$69.68
0606
Clinic Lev 3
$95.14
$99.71
$89.12
0607
Clinic Lev 4
$130.56
$128.48
$113.44
0608
Clinic Lev 5
$176.70
$168.92
$167.52
CPT
APC
99281
0609
99282
CY2012
2011
Pay
2010
Pay
SI
$50.28
$51.77
$53.16
V
0613
$86.51
$87.25
$87.85
V
99283
0614
$140.18
V
99284
0615
$136.16 $139.14
$218.99 $222.58
$223.17
Q3
99285
0616
$323.14 $329.54
$329.73
Q3
© 1999-2012 Abbey & Abbey, Consultants, Inc.
2012
Pay
Slide # 51
OPPS Update for CY2012
Ambulatory Surgical Centers
 ASC Payment Process
 Now a hybrid of APCs and MPFS.
 Calculation of ASC Payments Depends on Lists of Surgical Procedures
• Office-Based vs. OP Hospital vs. IP Hospital
• ASCs Surgical Procedures Include Office-Based and Certain OP
Hospital Surgeries  The process for determining these lists is allimportant for ASCs.
 Concerns for excluding surgeries from ASCs.
 Treatment of new codes.
 Determination of covered services, drugs, biologics, etc.
 Transitional Payment Rate Are No Longer In Use
 Many issues that are present for OPPS in general (e.g., “-FB” and “-FC”
modifiers, preventive services, etc.) are present for ASCs also.
• See NTIOLs relative to cataract surgery.
• Significant discussions for cataract surgeries at ASCs.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 52
OPPS Update for CY2012
Reporting Quality Data
 Quality Reporting for Hospital Outpatient Services
 There is an extensive discussion in the Federal Register addressing
Quality Data Reporting.
 Quality Reporting In Multiple Settings
• “CMS has implemented quality measure reporting programs for
multiple settings of care. These programs promote higher quality,
more efficient health care for Medicare beneficiaries. The quality
data reporting program for hospital outpatient care, known as the
Hospital Outpatient Quality Reporting (Hospital OQR) Program,
formerly known as the Hospital Outpatient Quality Data Reporting
Program (HOP QDRP), has been generally modeled after the quality
data reporting program for hospital inpatient services known as the
Hospital Inpatient Quality Reporting (Hospital IQR) Program
(formerly known as the Reporting Hospital Quality Data for Annual
Payment Update (RHQDAPU) Program).” (Page 1096 – CMS-1525FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 53
OPPS Update for CY2012
Reporting Quality Data
 HOP QDRP Quality Measures
 Expansion for CY2012, CY2013 and CY2014
• “We refer readers to the following OPPS/ASC final rules with
comment periods for a history of measures adopted for the Hospital
OQR Program, including lists of: 11 measures adopted for the CY
2011 payment determination (74 FR 60637); 15 measures adopted
for the CY 2012 payment determination (75 FR 72083 through
72084); 23 measures adopted for the CY 2013 payment
determination (75 FR 72090); and 23 measures adopted for the CY
2014 payment determination (75 FR 72094).” (Page 1081)
• For CY2012:
 OP-12: The Ability for Providers with HIT to Receive Laboratory
Data Electronically Directly into their Qualified/Certified EHR
System as Discrete Searchable Data
 OP-13: Cardiac Imaging for Preoperative Risk Assessment for
Non-Cardiac Low-Risk Surgery
 OP-14: Simultaneous Use of Brain Computed Tomography (CT)
and Sinus Computed Tomography (CT)
 OP-15: Use of Brain Computed Tomography (CT) in the
Emergency Department for Atraumatic Headache
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 54
OPPS Update for CY2012
Reporting Quality Data
 HOP QDRP Quality Measures
 Expansion for CY2012, CY2013 and CY2014
• CY2013
 OP-16: Troponin Results for Emergency Department acute
myocardial infarction (AMI) patients or chest pain patients (with
Probable Cardiac Chest Pain) Received Within 60 minutes of
Arrival
 OP-17: Tracking Clinical Results between Visits
 OP-18: Median Time from ED Arrival to ED Departure for
Discharged ED Patients
 OP-19: Transition Record with Specified Elements Received by
Discharged Patients
 OP-20: Door to Diagnostic Evaluation by a Qualified Medical
Professional
 OP-21: ED- Median Time to Pain Management for Long Bone
Fracture
 OP-22: ED- Patient Left Before Being Seen
 OP-23: ED- Head CT Scan Results for Acute Ischemic Stroke or
Hemorrhagic Stroke who Received Head CT Scan Interpretation
Within 45 minutes of Arrival
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 55
OPPS Update for CY2012
Reporting Quality Data
 HOP QDRP Quality Measures
 Expansion for CY2012, CY2013 and CY2014
• CY2014
 “After consideration of the public comments we received, we
are finalizing the retention of the 23 measures adopted for the
CY 2013 payment determination, but are not at this time
adopting any of the new measures proposed for the CY 2014
payment determination. As of now, a total of 23 measures will
be used for the CY 2014 payment determination.” (Page 1169 –
CMS-1504-FC)
 Beyond CY2014, CMS Is considering a number of other measures
number 35 as listed in the Federal Register.
• Heart Failure – 12 Measures
• Emergency Department – 7 Measures
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 56
OPPS Update for CY2012
Additional Issues
 Additional Issues Discussed in the November 30, 2011 OPPS Update
Federal Register. Interestingly most of these do not relate to APCs or the
OPPS as such.
 Changes to Whole Hospital and Rural Provider Exceptions to the
Physician Self-Referral Prohibition: Exception for Expansion of Facility
Capacity
 Changes to Provider Agreement Regulations on Patient Notification
Requirements
 Value-Based Purchasing
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 57
OPPS Update for CY2012
CCRs and Implantable Devices
 “In preparation for the FY 2012 IPPS proposed rule and the CY 2012 OPPS
proposed rule, we assessed the availability of data in the “Implantable
Devices Charged to Patients” cost center. In order to develop a robust
analysis regarding the use of cost data from the “Implantable Devices
Charged to Patients” cost center, we believe that it is necessary to have a
critical mass of cost reports filed with data in this cost center. The cost
center for “Implantable Devices Charged to Patients” is effective for cost
reporting periods beginning on or after May 1, 2009. We checked the
availability of CY 2009 cost reports in the December 31, 2010 quarter
ending update of HCRIS, which is the latest upload of CY 2009 cost report
data that we could use for the proposed rule. We determined that there
were only 437 hospitals that had completed the “Implantable Devices
Charged to Patients” cost center (out of approximately 3,500 IPPS
hospitals). We stated in the proposed rule that we do not believe this is a
sufficient amount of data from which to generate a meaningful analysis.
Therefore, we did not propose to use data from the “Implantable Devices
Charged to Patients” cost center to create a distinct CCR for Implantable
Devices Charged to Patients for use in calculating the OPPS relative
weights for CY 2012.” (Page 73 – CMS-1525-FC)
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 58
OPPS Update for CY2012
Summary and Conclusions
 APCs Represent CMS’s Most Complex Prospective Payment System
 The Federal Register Entries Are Becoming Enormous
 We are into the Eleventh Year (Depending on how you count) of APCs –
 The variation in payments continues to be a roller coaster although
there appears to be a little more stability.
 Significant policy changes continue to be developed, specifically
increased packaging and more composite APCs.
 Apparently there will no national guidelines for technical component
E/M coding for the ED and provider-based clinics. (AMA Develop?)
 Physician supervision within the Provider-Based Rule has become a
major issue due to CMS clarifying guidance.
 The cost report and appropriate CCRs have become an issue although
this problem has been evident since APCs were implemented.
 While there continue to be areas of difficulty (e.g., singleton claims for
weight development), CMS is whittling away at issues.
 Hospitals should anticipate that APCs will continue to change at a rapid
pace during the coming years.
© 1999-2012 Abbey & Abbey, Consultants, Inc.
Slide # 59