Hospital outpatient and ASU policy and payment changes for

2015Robin Ingalls-Fitzgerald, CCS, CPC, FCS,

CEDC, CEMC

Definitions Off-campus, and data collection Modifiers Policy and Payment Changes

Overview

A hospital department/clinic Physician and/or non-physician practitioner ( NPP) employed by the hospital(2010)

Operational requirements for PBE as listed in 42 CFR 413.65 such as:

PBE may be on campus or located within 35 miles of the main campus

Operates under the main provider license (hospital) Physician and staff working within the clinic are under the same

reporting structure as all other departments of the hospital Signage, name badges, business cards, letterheads, logos, etc.,

identify the department as a part of the hospital Patients are registered as hospital patients

Provider Based (PBE)

On campus: physical area immediately adjacent to the main provider (hospital); other structures within 250 yards of main hospital buildings.

Off-campus: means a department that is either created by, or acquired by, a hospital that is the main provider for the purpose of furnishing outpatient hospital services under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of this section.A remote location of a hospital comprises both the specific physical facility that serves as the site of services for which separate payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. The entity is located within a 35-mile radius of the campus of the provider.

PBE Clinic

CMS proposes to begin collecting data on services furnished in off-campus provider-based departments beginning in 2015 by requiring hospitals and physicians to report a modifier for those services furnished in an off-campus provider-based department on both hospital and physician claims.

Off-Campus Provider-Based Departments

Citing the trend toward hospital acquisition of physician offices and subsequent treatment of those locations as off-campus provider-based outpatient departments, CMS has determined that a better understanding is needed of how this trend is affecting Medicare. Toward that end, CMS is proposing to collect information on the type and frequency of physicians’ services and outpatient hospital services furnished in off-campus provider-based departments (facility located more than 250 yards from the main hospital building),  beginning Jan. 1, 2015. CMS proposes to create a HCPCS modifier that will be reported with every code for physicians’ services and outpatient hospital services furnished in an off-campus provider-based department of a hospital. Presumably, CMS would use the data it collects to justify any future site-neutral payment policies.

Collection of Data Off-Campus Provider

CMS believes the most efficient and equitable means of gathering information across two different payment systems would be to create a HCPCS modifier to be reported with every code for physicians’ services and outpatient hospital services furnished in an off-campus provider based department of a hospital on both the CMS-1500 claim form for physicians’ services and the UB-04 form (CMS Form 1450) for hospital outpatient services. CMS hopes to collect information on the type and frequency of physicians’ services and outpatient hospital services furnished in off campus provider based departments beginning January 1, 2015

Collection of Data Off-Campus Provider

What are modifiers?Two character codes that add value to the description of the service providedTell a story / exhibitionists – bring attention to a code for reimbursement Usage must always be supported by documentation / medical record

Common usageTwo procedures were appropriately performed even though generally not provided in the same encounterPatient returned for a second procedure to treat a complication performed earlier in the same dayReport similar but different procedures on different body parts or at different encountersOffice visit and a procedure were performed on the same day

Modifiers and Reimbursement

Significant, separately identifiable E/M Same patient, same day encounter

If a procedure and a significant and separately identifiable E/M service occur during the same visit, both may be billed

Documentation supports the scenario Reimbursement for proper usage

Payment consideration for each code identified

Modifier -25

Bilateral proceduresUsed to report procedures conducted on

opposite sides of the bodyModifier -50 is restricted to surgical

procedures Reimbursement for proper usage

150% of fee schedule

Modifier -50

Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances.

Appropriate UsageDocumentation indicates two separate

procedures performed on the same day by the same physician

Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury)

Modifier -59

New coding requirements related to Healthcare Common Procedure Coding System (HCPCS) modifier -59 could impact your reimbursement.

Change Request (CR) 8863notifies MACs and providers that the Centers for Medicare & Medicaid Services (CMS) is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.”

Make sure your billing staffs are aware of the coding modifier changes

Modifier -59 new for 2015

XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure

XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner

XU Unusual Non Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service

Four new HCPCS modifiers

These modifiers, collectively referred to as X{EPSU} modifiers, define specific subsets of the 59 modifier. CMS will not stop recognizing the 59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. CMS will continue to recognize the-59 modifier in many instances but may selectively require a more specific -X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of the 59 modifier so it would be incorrect to include both modifiers on the same line

Modifier -59 new for 2015

Comprehensive-APCsIn the CY 2014 OPPS/ASC final rule, CMS adopted a Comprehensive-APC policy to

expand the categories of related items and services packaged into a single payment for a comprehensive primary service under the OPPS, in order to make the OPPS more consistent with a prospective payment system.  CMS created Comprehensive-APCs to prospectively pay under the OPPS for high cost device dependent services in 29 device dependent APCs using a single payment for the hospital stay, CMS delayed implementation of this policy to CY 2015 to provide CMS and hospitals with more time to evaluate and comment further on the policy.

In the CY 2015 OPPS/ASC proposed rule, CMS is proposing several additional Comprehensive-APCs, including some lower cost device dependent APCs not proposed last year and 2 new APCs for other procedures and technologies that are either largely device dependent or represent single session services with multiple components.  CMS is also proposing the restructuring and consolidation of some of the current device dependent APCs with similar costs based on the 2013 claims data.  After the APC consolidation and restructuring we are proposing a total of 28 Comprehensive-APCs for 2015 versus the 29 Comprehensive-APCs that were described in the CY 2014 final rule.

Ambulatory Surgical Centers policy and payment changes for 2015

CMS is proposing to restructure and consolidate two comprehensive APCs that represent single session services with multiple components.

These two new comprehensive APCs are C-APC 0067 for single-session cranial stereotactic radiosurgery (SRS) and C-APC 0351 for intraocular telescope implantation. In addition, they are proposing to reassign CPT codes 77424 and 77425 that describe intraoperative radiation therapy treatment (IORT) to C-APC 0648 (Level IV Breast and Skin Surgery)

Ambulatory Surgical Centers example

For the endovascular clinical family (renamed Vascular Procedures, VASCX), CMS is proposing to combine C-APCs 0082, 0083, 0104, 0229, 0319, and 0656 to form three proposed levels of comprehensive endovascular procedure APCs:

1) C-APC 0083 (Level I Endovascular Procedures); 2)C-APC 0229 (Level II Endovascular Procedures);

and 3)C-APC 0319 (Level IV Endovascular

Procedures).

Ambulatory Surgical Centers example

CMS is also proposing three new clinical families: Gastrointestinal Procedures (GIXXX) for gastrointestinal stents, Tube/Catheter Changes (CATHX) for insertion of various catheters, and Radiation Oncology (RADTX), which would include C-APC 0067 for single session cranial SRS. As a result of the proposed CY 2015 comprehensive APC policy, the device-dependent APCs would no longer exist in CY 2015 because these APCs will have all been converted to comprehensive APCs. CMS is proposing to create claims processing edits that require any of the device codes used in the previous device-to-procedure edits to be present on the claim for all procedures assigned to any of the 26 proposed comprehensive APCs (of a total of 28 proposed comprehensive APCs).

More CMS fun

APC APC Title

0039 Level III Neurostimulator0061 Level II Neurostimulator0083 Level I Endovascular 0084 Level I EP0085 Level II EP0086 Level III EP0089 Level III Pacemaker0090 Level II Pacemaker0107 Level I ICD0108 Level II ICD0202 Level V Female Reproductive0227 Level Implantation of Drug Infusion0229 Level II Endovascular 0259 Level VII ENT Procedures0293 Level IV Intraocular

PROPOSED APCs THAT WILL REQUIRE A DEVICE CODE ON A CLAIM WHEN A PROCEDURE ASSIGNED TO ONE OF

THESE APCs IS REPORTED

APC APC Title

0318 Level IV Neurostimulator

0319 Level IV Endovascular

0384 GI Procedures with Stents

0385 Level I Urogenital

0386 Level II Urogenital

0435 Level V Musculoskeletal

0427 Level II Tube/Catheter

0622 Level II Vascular Access

0648 Level IV Breast Surgery

0652 Insertion of IP/Pl catheter

0655 Level IV Pacemaker

CMS is also proposing to conditionally package ancillary services which are usually billed with a primary service and have a geometric mean cost equal or less than $100. These ancillary services primarily include minor diagnostic tests. CMS will continue to pay for these services separately in those instances where hospitals provide such services alone and without another primary service during the same encounter. CMS proposes that preventive services will continue to be paid separately.

CMS is proposing to delete status indicator “X” and assign ancillary services that are currently assigned status indicator “X” to either status indicator “Q1” or “S” (significant procedures that don’t receive a multiple procedure reduction). The specific codes for the diagnostic tests on the bypass list that CMS is proposing to be conditionally package are listed in Addendum P of this proposed rule.

Diagnostic Tests on the Bypass List and Changes to the Status Indicator

Questions comments

Questions or Comments?

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r57soma.pdf

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-07-03-4.html

http://www.ofr.gov/OFRUpload/OFRData/2014-26183_PI.pdf

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf

websites

Robin Ingalls-Fitzgerald, CCS, CPC, FCS, CEDC, CEMCCEO/President robin@mrsnh.com

Medical Reimbursement Specialists, LLC Codeaid LLCPO BOX 486 266 A Summer StBristol, NH 03222Office PHONE: (603) 217-0006 Cell Phone (603) 236-9465FAX: (603)-947-1458

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