Author Archives: Dave Fee

OPPS Proposed Rule for 2016

I hope the publication of the 2016 OPPS proposed rule on July 1st did not dampen anyone’s July 4th celebration. The new rule continues the migration CMS began in 2014 to a more “prospective payment” type system. That means that there continues to be more packaging and fewer APCs.

A few specifics: Continue reading

Do You have Questions About Edits 71 and 77?

I live in the Salt Lake City area, but last week I ventured east for the public Hospital Outpatient Payment (HOP) Panel meeting at CMS. As I listened to the testimony, I thought about some of the emails I have received about OCE edits 71 (Claim Lacks required device code) and 77 (Claim Lacks allowed procedure code). I have been asked a number of questions about these edits along with requests to talk to CMS to see if they would reinstate them, or as a last resort, have 3M create similar edits. Continue reading

Comprehensive APCs: 4 Steps for Review

It’s already two months into 2015 and I can’t help but think of the changes coming to the outpatient prospective payment system (OPPS) and APCs. CMS introduced APCs and OPPS in 2000. Since then, they have been working to slowly increase packaging within the system.

In 2014, significant increases in packaging were introduced. This year, they have continued to make major changes that will have an impact on every hospital that is subject to the Medicare OPPS and APCs. I am specifically thinking about: Continue reading

Complexity Adjustment: CMS Updates I/OCE Specifications and Software

Last week, CMS published updated I/OCE specifications and software. The changes revolved around calculations of the complexity adjustment for the comprehensive APCs (C-APCs).

Bypassing the code pair ranking

The specific language change in the specifications is in Appendix L where there is a note added: “In some instances, code pair combinations specified for complexity-adjustment may have a secondary procedure with a higher rank than the primary procedure. In these cases, the rank is ignored and the complexity-adjusted APC remains assigned to the primary procedure of the code pair.” Continue reading

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.

Continue reading

Regulatory Updates: Changes to Billing for Laboratory Services

It is the Ides of May (not quite as famous as the Ides of March), but a good time to think about changes to billing for laboratory services and what to expect in the CMS July 2014 OPPS update. It has been a topic of discussion since the beginning of the year, and continues to create questions given what we know will be coming this summer.

Before this year, clinical laboratory services were assigned a status indicator of A and paid based on the clinical laboratory fee schedule whenever they were present on a claim, even if there was a medical visit APC or a procedure APC also present on the claim. This changed with the January 2014 update to OPPS. CMS decided to package clinical laboratory, with two major exceptions. Meaning, if a lab service is billed with a medical visit APC or with a procedure APC on the claim, it will be packaged (not paid separately). The exceptions are: Continue reading

OPPS Proposed Rules: Implications of the Government Shutdown

Well, the federal government is back to work after two and a half weeks off. I will refrain from any political comments. However, I would like to discuss the implications it might have on the OPPS changes for 2014.

All comments on the proposed rule were due about the middle of September. Normally CMS would have six to eight weeks to review the comments and publish the final rule on November 1st. However, with the government shutdown, there is not going to be anywhere close to six weeks, let alone eight weeks, to review the comments and publish a final rule.

Our government teams are back, and now the question: What is going to happen with the final rule? Continue reading

OPPS Proposed Rules: Big Change in Hospital Payment

Wow, the last couple weeks have been busy, considering the 2014 Outpatient Prospective Payment System (OPPS) proposed rules . Every year CMS publishes an OPPS proposed rule with a 60 day comment period, giving affected parties a chance to review it. CMS includes descriptions of changes to grouping logic, updated packaging policies, modifications to payment rules, and other pertinent topics affecting OPPS. The final rule is usually published on or about November 1st. The 2014 proposed rule was published July 8th with a comment period set for September 6th. This rule represents the largest change in hospital payment since OPPS was introduced in August 2000. Continue reading

Highlights from the CMS July APC Update

The July APC update is out, and I’m sure many of you have already installed it and find the changes 3M made valuable for you.

With this update out, we now get to look ahead to 2014. This week CMS published the proposed rules for the Hospital Outpatient Prospective Payment for next year. There seem to be a number of notable changes coming up for hospitals in 2014. I would like to highlight a couple of them. Continue reading

Setting the Record Straight on Therapy Functional Reporting G-Codes

No one likes feeling like they are making a mistake, especially when dealing with something as important as accurate coding. Recently, a certain set of codes (the Therapy Functional Reporting G-Codes [non-payable]) and the way some hospitals’ billing systems process them have left many coders scratching their heads. Here, I’ll do my best to set the record straight.

In January 2013, CMS introduced 42 Therapy Functional Reporting G-codes (non-payable). These G codes are to be reported in conjunction with therapy services (physical, occupational, and speech). CMS also introduced seven complexity/severity modifiers to be used with these G codes. Continue reading