OPPS Proposed Rule for 2015

July 4th has come and gone, but we can still look for fireworks in next year’s OPPS proposed rule, which is now available on the CMS website.

CMS plans to continue expanding the packaging they began in 2014 by implementing comprehensive APCs and packaging of ancillary services.

Comprehensive APCs

In the 2014 final OPPS rule, CMS finalized their intent to create comprehensive APCs. These would provide payment for one device dependent APC, now called a comprehensive APC, and all other services on the claim (with a few exceptions, such as preventive services). CMS defines these as follows: “We are proposing to continue to define the services assigned to comprehensive APCs as primary services, and to define a comprehensive APC as a classification for the provision of a primary service and all adjunctive services and supplies provided to support the delivery of the primary service. We would continue to consider the entire hospital stay, defined as all services reported on the hospital claim reporting the primary service, to be one comprehensive service for the provision of a primary service into which all other services appearing on the claim would be packaged.” (OPPS Proposed for 2015, CMS-1613-P, p39)

With the 2015 proposed rule, CMS is making changes to the actual definitions and assignments. Twenty eight comprehensive APCs are being defined for 2015. This includes adding what previously was composite APC 8000, “Cardiac Electrophysiologic Evaluation and Ablation Composite,” as a comprehensive APC. Additionally, CMS is implementing a complexity adjustment when certain pairs of codes are present. Higher payment will result when such an adjustment is made. It’s an extensive revision to the APC logic, which makes it a more difficult to determine the impact of the new changes. At first, it might seem impossible without running claims through a grouper. However, there are ways to estimate the impact of the changes without an actual grouper using an approach such as the following:

  1. Identify the services, and their frequency, that would group into comprehensive APCs (by HCPCS or by the 2014 APC)
  2. Identify the 5 – 7 most frequent
  3. For those most frequently occurring, pull a “good” sampling of claims (good could be defined as volume, and how representative they are)
  4. Determine if there are any exceptions that would still be paid separately
  5. Estimate payment based on the comprehensive APC rates published in the proposed rule
  6. Compare this to what was paid under the 2014 rule
  7. Extrapolate to the total population for each comprehensive APC
  8. Apply this as an estimate for all 28 of the comprehensive APCs
  9. Although this will not be exact, it should give you an idea of the potential impact these comprehensive APCs will have on your organization.

Packaging of ancillary services

CMS initiated a significant effort in 2014 to increase the amount of packaging being performed in OPPS. They want OPPS to become “more like a prospective payment system” rather than a modified fee schedule. They are continuing this effort in 2015 by adding more items that are to be packaged:

  1. All add-on codes will be assigned a status indicator = N
  2. All DMEPOS supplies
  3. Ancillary services with a geometric mean cost < or = $100 (general guideline for 2015)

Also look for information on:

  • Status indicator X to be discontinued:

o  Some services packaged as noted above
o  Some services assigned SI=Q1 (21 HCPCS codes)
o  Some expensive services assigned SI=S

  •  Payment rate changes
  •  Conversion factor updated to $74.176, except for hospitals not participating in the OQR program
  •  Changes to some APC logic
  •  If additional drugs will be packaged in 2015
  •  Changes to outlier payments
  •  Changes to the ASC OPPS
  • And other changes

There will be something to discover in the proposed rule for all of us. Enjoy the fireworks!

Dave Fee is Outpatient Products Marketing Manager with 3M Health Information Systems.

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