OPPS Update. Audio Seminar/Webinar. January 25, Practical Tools for Seminar Learning

Transcription

1 Audio eminar/webinar January 25, 2007 Practical Tools for eminar Learning Copyright 2007 American Health Information Management Association. All rights reserved.

2 Disclaimer The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. CPT five digit codes, nomenclature, and other data are copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in CPT. The AMA assumes no liability for the data contained herein. As a provider of continuing education, the American Health Information Management Association (AHIMA) must assure balance, independence, objectivity and scientific rigor in all of its endeavors. AHIMA is solely responsible for control of program objectives and content and the selection of presenters. All speakers and planning committee members are expected to disclose to the audience: 1) any significant financial interest or other relationships with the manufacturer(s) or provider(s) of any commercial product(s) or services(s) discussed in an educational presentation; 2) any significant financial interest or other relationship with any companies providing commercial support for the activity; and 3) if the presentation will include discussion of investigational or unlabeled uses of a product. The intent of this requirement is not to prevent a speaker with commercial affiliations from presenting, but rather to provide the participants with information from which they may make their own judgments. AHIMA 2007 Audio eminar eries i

3 Faculty Arlene F. Baril, M, RHIA Ms. Baril is Vice President of HIM & oftware ervices for United Audit ystems, Inc. based in Cincinnati, OH. he resides in Dallas and has over 26 years of experience specializing in APC auditing and rebilling services, Charge Description Master Reviews, Inpatient DRG and Outpatient HIM Coding Assessments, Physician Practice coding, and HIM Operations. Prior to joining UAI, Arlene was Director of HIM & Coding services for Pyramid/The HealthCare Financial Group. Arlene has also worked for Coopers & Lybrand/PricewaterhouseCoopers, LLP as a Regional Manager in their Healthcare Regulatory ervices Group based in Dallas, Texas. he had regional product-line responsibility for inpatient coding, outpatient coding, charge description master, MART coding compliance product and HIM operations. he also co-managed the compliance services product line. Ms. Baril has presented to many state HIM associations and for both the Healthcare Financial Management Association's and the American Health Information Management Association's national conferences. he has conducted APC seminars throughout the country. he serves on the editorial advisory board for Briefings on Coding Compliance and has authored articles on a variety of HIM and reimbursement topics. Ms. Baril has worked as a supervisor and a manager of coding, assistant director of medical records, director of medical records, and claims representative for a fiscal intermediary in New York tate. he possesses extensive knowledge of all aspects of coding and third party reimbursement issues. Cheryl D Amato, RHIT, CC Ms. D Amato is the director of health information management for the facility division of the provider solutions group at Ingenix. Ms. D Amato has over 20 years of experience in the healthcare industry, with expertise in implementing and managing utilization, quality assurance, and health information coding systems. he has been a frequent contributor and speaker for AHIMA continuing education programs. Carole Gammarino, RHIT Ms. Gammarino is a recruiting manager with Precyse olutions, HIM ervices. Ms. Gammarino is a frequent speaker and contributor to publications on APCs. he has over 10 years of experience in HIM, including extensive experience in Joint Commission preparation, tumor registry, medical staff coordinating services, unbilled accounts management, coding, and education and recruiting. AHIMA 2007 Audio eminar eries ii

4 Table of Contents Disclaimer... i Faculty...ii Overview of 2007 OPP... 1 Timeline for Updates... 2 Payment Rates... 2 Financial Updates... 3 Outliers... 4 New Drug HCPC Codes... 4 HCPC Codes... 5 Category III Codes... 5 pecial Packaged CPT Codes OPP tatus Indicators... 6 New Technology APCs... 7 tereotactic Radiosurgery... 8 MEG ervices... 9 Breast Brachytherapy...10 Reassignment of Other New Technology APCs...11 APC pecific Policies Blood and Blood Products...12 Observation ervices...12 Partial Hospitalization...13 Radiology Procedures...13 Nuclear Medicine Procedures...14 Complex Interstitial Radiation...15 Proton Beam Therapy...16 Other Nuclear Medicine Procedures...16 Cardiac and Vascular Procedures...17 GI and GU Procedures...18 Ocular Procedures...19 kin Procedures...20 Other Procedures...21 Treatment of Fracture/Dislocation...22 Medical ervices...23 Inpatient Only Procedures Moved to APCs...24 Use of CA Modifier...25 Brachytherapy ources...25 OPP Payment Changes for Devices Treatment of Device Dependent APCs...27 Devices Billed without Procedure...27 Devices that Require Procedure Code...28 Payment Policy...28 Use of FB Modifier...29 Table 21 Devices that Affect FB Modifier...29 Pass-Through Device Payment...30 OPP Drug Payment Changes Drugs, Pharmaceuticals and Biologicals...31 Pass-Throughs Expiring 12/31/ With Pass-Through tatus in Drugs with tatus Change...32 Payment Non Pass-Through tatus...33 CY2007 Payment Policy Radiopharmaceuticals...34 Other Policies Radiopharmaceuticals...34 Drug Administration...35 APC tructure...36 AHIMA 2007 Audio eminar eries

5 Table of Contents Hospital Coding and Payment for Visits Clinic Visits...39 Emergency Department...39 New ED G Codes...40 Critical Care ervices...40 CY2008 Visit Payment...41 Non Recurring Policy Changes CORF Changes...43 AAA creening Requirements...44 Critical Access Hospital Changes...44 AC Changes in What is a MAC?? Medicare Administrative Contractor...46 Quality Data Reporting Requirements under OPP Quality Data...48 Additional Quality Measures...49 Appendix...52 CE Certificate Instructions AHIMA 2007 Audio eminar eries

6 Final Rule 2007 OPP-Highlights 1 Overview of 2007 OPP Change Financial Updates New Technology APCs APC pecific Policies OPP Devices-Payment Changes OPP Drugs-Payment Changes Hospital Visit Changes Non-Recurring Policy Changes MACs Quality Reporting Requirements 2 AHIMA 2007 Audio eminar eries 1

7 Timeline of Updates April 7, 2000, final rule established requirements for The Outpatient Prospective Payment ystem (OPP) The OPP was first implemented for services provided on or after August 1, ince that time a number of rule-making changes have occurred Final rule published in the November 24, 2006 Federal Register outlines the OPP changes for CY Payment Rates The individual APC s RW (Relative Weight) multiplied by the CF (Conversion Factor) = the payment rate for that APC (Note: CF is $ for CY 2007) 4 AHIMA 2007 Audio eminar eries 2

8 Financial Updates The projected increase in overall payments to hospitals under OPP for 2007 is $32.5 billion. This is an average increase of 3% (market basket of 3.4%) Co-payment amounts for each APC may be found in Addendum A & B. For CY 2007, the OPP payment rates for HCPC codes G0105 and G0121 that describe screening colonoscopies will be set to equal the CY 2007 AC rate of $446 for these services. 5 Financial Updates Transitional outpatient payment (TOP) DRA ection 5105 reinstituted the hold harmless transitional outpatient payments (TOPs) for covered outpatient department services furnished on or after January 1, 2006, and before January 1, This change involves rural hospitals having 100 or fewer beds that are not CHs. Children s Hospitals and Cancer Centers will receive the transitional corridor payment permanently Financial impact in CY % Overall 2.9% large urban hospitals 3.2% other urban hospitals 2.7% rural hospitals 7.1% rural sole community hospitals 6 AHIMA 2007 Audio eminar eries 3

9 Financial Updates-Outliers To be eligible in 2007, the cost of a service must be greater than 1.75 times the payment amount for the APC and greater than the APC payment amount plus the outlier threshold The outlier threshold is set at $1, for 2007 For these services, CM will pay 50% of the costs that exceed 1.75 times the APC payment rate. Multiplier remains the same (1.75) For CMHC s the outlier payment is calculated at 50% of the amount by which the cost exceeds 3.4 times the APC payment rate. 7 Table 5- New Drug HCPC Codes J Code Eff. 1/1/07 J2248 C Code Exp. 12/31/06 C9227 Description Injection, micafungin sodium, per 1 mg I G APC 9227 J3343 C9228 Injection, tigecycline, per 1 mg G 9228 J1740 C9229 Injection, ibandronate sodium, per 1 mg G 9229 J0129 C9230 Injection, abatacept, per 10 mg G AHIMA 2007 Audio eminar eries 4

10 New HCPC Codes Found in Addendum B with comment indicator NI The status indicator and/or APC assignments for all HCPC codes flagged with NI are subject to public comment CM is creating two Level II HCPC G-codes for implementation in CY 2007: G0392 (Transluminal balloon angioplasty, percutaneous, hemodialysis access fistula or graft; arterial) G0393 (Transluminal balloon angioplasty, percutaneous, hemodialysis access fistula or graft; venous). CM will provide payment for these G-codes at the same OPP rates as for CPT codes (Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel) and (Transluminal balloon angioplasty, percutaneous; venous) through APC 0081 (Non-Coronary Angioplasty or Atherectomy), with a CY 2007 final median cost of $2, CM will also assign both G-codes to payment group 9 for AC payment in CY Category III CPT Codes AMA issues Category III codes in January and July of each year July codes will become effective 1/1/07 These will be released in the regular quarterly OPP updates Mid-year Category III codes that go into effect on 1/1/07 are 0155T-0161T 10 AHIMA 2007 Audio eminar eries 5

11 pecial Packaged CPT Codes Table 3 p CPT Code Descriptor 2007 APC tatus Indicator Median APC $ Collect blood, venous access device 0624 $ Arterial puncture; withdrawal of blood for diagnosis 0035 T $ entinel node identification 0389 $ Venous sampling through cath; with or without angiography, radiological &I 0668 $ Pulse oximetry by continuous overnight monitoring 0443 X $ Irrigation of implanted access device 0624 $ OPP tatus Indicators (Complete List-Addendum D1) 12 AHIMA 2007 Audio eminar eries 6

12 New Technology APCs 13 New Technology APCs Nonmyocardial Positron Emission Tomography (PET) cans Positron emission tomography (PET) is a noninvasive diagnostic imaging procedure that assesses the level of metabolic activity and perfusion in various organ systems of the human body. CM will assign nonmyocardial PET scans, in particular, CPT codes 78608, 78811, 78812, and 78813, to new APC 0308 (Nonmyocardial PET Imaging). PET/Computed Tomography (CT) cans CM will assign PET/CT scans to New Technology APC 1511 (New Technology- Level XI ($900-$1000)) with a payment of $950 for CY 2007 to maintain the approximately $100 difference between payments for these services and nonmyocardial PET scans, which will be assigned to APC 0308 with a median cost of about $850 for CY AHIMA 2007 Audio eminar eries 7

13 New Technology APCs tereotactic Radiosurgery (R) Treatment Delivery ervices (APCs 0065, 0066, and 0067) CM will assign for CY 2007, HCPC codes G0173 and G0339 to clinical APC 0067, with a median cost of $3,872.87, HCPC code G0251 to clinical APC 0065, with a median cost of $1,241.89, and HCPC code G0340 to clinical APC 0066 with a median cost of $2, New Technology- tereotactic Radiosurgery tereotactic Radiosurgery (R) Treatment Delivery ervices (APCs 0065, 0066, and 0067) CM will assign for CY 2007 HCPC codes G0173 and G0339 to clinical APC 0067, with a median cost of $3, HCPC code G0251 to clinical APC 0065, with a median cost of $1, HCPC code G0340 to clinical APC 0066 with a median cost of $2, AHIMA 2007 Audio eminar eries 8

14 New Technology- R Treatment Delivery ervices HCPC Code hort Descriptor Final CY 2007 I Final CY 2007 APC Final CY 2007 APC Median Cost G0173 Linear acc stereo radsur com 0067 $3, G0251 Linear acc based stereo radio 0065 $1, G0339 Robot lin-radsurg com, first 0067 $3, G0340 Robt lin-radsurg fractx $2, New Technology- MEG ervices Magnetoencephalography (MEG) ervices (APCs 0038 and 0209) Magnetoencephalography (MEG) is a noninvasive diagnostic tool that assists surgeons in the pre-surgical period by measuring and mapping brain activity. It may be used for epilepsy and brain tumor patients. For CY 2007, CM is assigning CPT code to APC 0038, with a final CY 2007 median cost of $3, CPT codes and to APC 0209, with a final CY 2007 median cost of $ AHIMA 2007 Audio eminar eries 9

15 New Technology- MEG ervices HCPC Code CY 2007 Descriptor CY 2007 I CY 2007 APC CY 2007 Median Cost Meg, spontaneous 0038 $3, Meg, evoked, single 0209 $ Meg, evoked, each additional 0209 $ Breast Brachytherapy (Placement of radiotherapy after-loading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy) (Placement of radiotherapy after-loading balloon catheter into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy) Reassign CPT codes and from New Technology APCs to clinical APC 0648, retitled Level IV Breast Procedures, with a final CY 2007 median cost of $3, CM is also implementing appropriate procedure-todevice edits for both of these procedures. 20 AHIMA 2007 Audio eminar eries 10

16 APC Reassignment of Other New Technology APCs (Table 10) 21 APC pecific Policies 22 AHIMA 2007 Audio eminar eries 11

17 Blood and Blood Products Payment for Blood and Blood Products For the CY 2007 OPP, CM is finalizing its proposal to establish payment rates for blood and blood products by using the same simulation methodology described in the November 15, 2004 final rule. However, for CY 2007 CM is providing a payment transition for those blood products for which the difference between their CY 2006 adjusted median cost and their CY 2007 simulated median cost is greater than 25 percent. pecifically, CM is setting the CY 2007 median costs upon which payments for blood and blood products are based at the higher of the CY 2007 unadjusted simulated median cost or 75 percent of the CY 2006 adjusted median cost on which the CY 2006 payment is based. This results in adjustment to the simulated median costs for CY 2007 for 7 of the 34 blood products. 23 Observation ervices Observation services reported using HCPC code G0378 (Hospital observation services, per hour) that are eligible for separate payment map to APC 0339 (Observation). The CY 2007 payment rate for APC 0339 is $ For CY 2007, CM will continue to apply the criteria for separate payment for observation services and the coding and payment methodology for observation services that were implemented in CY 2006, with one exception. CM is making final changes in APC assignments and payments for clinic and emergency department visits. As part of those changes, low level clinic visits are being moved from APC 0600 (Low Level Clinic Visits) to APC 0604 (Level 1 Clinic Visits), with a final CY 2007 median cost of $ Under the circumstances where direct admission to observation is separately payable, CM is finalizing its assignment of HCPC code G0379 to APC 0604, consistent with its CY 2006 placement in the APC for Low Level Clinic Visits. Diagnoses requirements are unchanged for AHIMA 2007 Audio eminar eries 12

18 Partial Hospitalization Partial Hospitalization is paid on a per diem rate under APC 0033 The final rate for CY2007 is $ The beneficiary co-pay is $46.95 A PHP bill must still have at least 3 partial hospitalization HCPC codes for each day of service, one of which must be a psychotherapy HCPC code (except brief psychotherapy) 25 Radiology Procedures Radiology Procedures (APCs 0333, 0662, and Other Imaging APCs) CM is adopting its proposal to defer implementation of a multiple imaging procedure payment reduction for CY 2007, without modification. CM is finalizing its proposal for payment of APCs 0333 and 0662 based on their median costs established according to the standard OPP methodology, without modification. Computerized Reconstruction (APC 0417) CM proposed to assign HCPC code G0288 (Reconstruction, computed tomographic angiography of aorta for surgical planning for vascular surgery) to APC 0417 (Computerized Reconstruction) for CY 2007, with a proposed median cost of $ CM is finalizing its CY 2007 payment rate for APC 0417 based on a median cost of $ AHIMA 2007 Audio eminar eries 13

19 Radiology Procedures Cardiac Computed Tomography and Computed Tomographic Angiography (APCs 0282, 0376, 0377, and 0398) CM is finalizing its proposal without modification to assign CPT codes 0144T through 0151T to APCs 0282, 0376, 0377, and 0398, all with status indicator code. Radiologic Evaluation of Central Venous Access Device (APC 0340) CM is maintaining the assignment of CPT code to APC 0340 for CY 2007 and will reevaluate that assignment when data become available. 27 Nuclear Medicine Procedures Myocardial Positron Emission Tomography (PET) cans (APC 0307) For CY 2007, CM proposed to assign CPT codes 78459, 78491, and to a single APC, specifically, APC CM is finalizing the APC assignments for the myocardial PET procedures as shown in the following table without modification. 28 AHIMA 2007 Audio eminar eries 14

20 Nuclear Medicine Procedures HCPC Code hort Descriptor CY 2007 I CY 2007 APC CY 2007 Median Cost CY 2007 Final APC 0307 Median Cost Heart muscle imaging (PET) 0307 $ $ Heart image (PET), single 0307 $1, $ Heart image (PET), multiple 0307 $ $ Complex Interstitial Radiation ource Application (APC 651) APC 0651 (Complex Interstitial Radiation ource Application), contains only one CPT code (Complex interstitial application of brachytherapy sources). According to CM, the coding, APC assignment, median cost, and resulting payment rate for CPT code have not been stable since the inception of the OPP, and that instability has been a source of concern to hospitals that furnish the service and to specialty societies. CM proposed to use the median cost of $1,028.93, as derived from all single bills for APC 0651 to establish the median for the APC. CM now says that the median cost for APC 0651 calculated using CY 2005 claims data as updated for this final rule is $1, Together with the median cost for APC 0163 of $2,134.32, and separate payment for each source applied, CM says that the OPP will make appropriate payment for brachytherapy services in CY AHIMA 2007 Audio eminar eries 15

21 Proton Beam Therapy APCs 0664 and 0667 CM proposed to pay for the following four CPT codes that describe proton beam therapy: (Proton treatment delivery; simple, without compensation) (Proton treatment delivery; simple, with compensation) (Proton treatment delivery; intermediate) (Proton treatment delivery; complex) CM proposed to assign the simple proton beam therapy procedures to APC 0664 (Level I Proton Beam Radiation Therapy), with a proposed median cost of $1,141, and the intermediate and complex proton beam therapy procedures to APC 0667 (Level II Proton Beam Radiation Therapy), with a proposed median cost of $1,365 CM is finalizing without modification its CY 2007 proposal to provide payment for proton beam therapy through APCs 0664 and 0667, with their payment rates based on the final APC median costs of $1,154 and $1,381, respectively. 31 Other Nuclear Medicine Procedures Urinary Bladder Residual tudy (APC 0340) CM is finalizing its proposal to assign CPT code to APC 0340 for CY 2007, with a median cost of $ Hyperthermia Treatment (APC 0314) CM is finalizing the CY 2007 payment rate for APC 0314 based on its median cost of $204, calculated using CY 2005 claims data as proposed. Unlisted Procedure for Clinical Brachytherapy (APC 0312) CM is finalizing the CY 2007 proposal for the assignment of CPT code to APC 0312, without modification. 32 AHIMA 2007 Audio eminar eries 16

22 Cardiac and Vascular Procedures Electrophysiologic Recording/Mapping (APC 0087) CM proposed that CPT codes 93609, 93613, and remain assigned to APC 0087 for CY CM is adopting the CY 2007 proposal as final without modification. Endovenous Laser Ablation Procedures (APC 0092) CM is finalizing its proposal to assign CPT codes and to APC 0092 for CY Cardiac and Vascular Procedures Repair/Repositioning of Defibrillator Leads (APC 0106) CM is finalizing the CY 2007 proposal with modification to reassign CPT codes and from APC 0106 to APC CM is modifying the titles of these APCs to reflect their new composition. APC 0106 is retitled Insertion/Replacement of Pacemaker Leads and/or Electrodes. APC 0105 is retitled Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices. The final median cost of APC 0106 is $3,596.87, and the final median cost of APC 0105 is $1, Thrombectomy Procedures (APCs 0103 and 0653) CM is finalizing its proposal for the APC assignments of CPT codes 37184, 37185, 37186, 37187, and with modification. All five procedures are assigned to APC 0088 for CY AHIMA 2007 Audio eminar eries 17

23 GI and GU Procedures Insertion of Mesh or Other Prosthesis (APC 0195) CM proposed to reassign CPT code from APC code 0154 to APC 0195 (Level IX Female Reproductive Procedures), with status indicator T for CY The proposed median cost of APC 0195 was $1,777 for CY CM is finalizing the proposal without modification. 35 GI and GU Procedures Percutaneous Renal Cryoablation (APC 0423) CM proposed to accept the APC Panel s recommendation to reassign CPT code 0135T from APC 0163 to APC 0423 for CY CM says that it believes that assignment of CPT code 0135T to APC 0423 is clinically appropriate, and that the CY 2007 median cost of APC 0423 of $2,410 is reasonably close to the expectations regarding the resource requirements for the renal cryoablation procedure. CM is reassigning CPT code 0135T to APC 0423, as proposed, without modification. However, the final APC 0423 median cost is $2, Ultrasound Ablation of Uterine Fibroids with Magnetic Resonance Guidance (MRgFU) (APCs 0195 and 0202) CM is finalizing the proposed CY 2007 APC assignments of CPT codes 0071T and 0072T, without modification. 36 AHIMA 2007 Audio eminar eries 18

24 GI and GU Procedures Laser Vaporization of Prostate (APC 0429) CM is finalizing the CY 2007 proposal to assign CPT code to APC 0429 for CY The CY 2007 final median cost of APC 0429 is $2, Gastrointestinal Procedures with tents (APC 0384) CM is finalizing the CY 2007 proposal for APC 0384 without modification. The final median cost for APC 0384 is $1, Endoscopy with Thermal Energy to phincter (APC 0422) CM is finalizing the proposal for assignment of CPT code to APC 0422 for CY 2007, with a median cost of $1, Ocular Procedures Keratoprosthesis (APC 0293) CPT code is a surgical procedure for implantation of a keratoprosthesis, an artificial cornea. CM proposed to create a new APC 0293 (Level V Anterior egment Eye Procedures) with a median cost of $3, and to move CPT code into that APC in order to more appropriately pay for the procedure and the related device. CM is adopting its proposal without modification, with a median cost of $3, for CY CM is also assigning a procedure-to-device edit for CPT code with APC AHIMA 2007 Audio eminar eries 19

25 Ocular Procedures Eye Procedures (APCs 0232, 0235, and 0241) CM is finalizing the CY 2007 proposal for APCs 0232, 0235, and 0241 without modification, with final median costs of $370.77, $240.36, and $1,543.32, respectively. Amniotic Membrane for Ocular urface Reconstruction CM is finalizing the proposed CY 2007 payment policies without modification for HCPC codes V2785 and V2790 as reflected in their assigned status indicators. 39 kin Procedures kin Replacement urgery and kin ubstitutes (APC 0025) For CY 2006, the American Medical Association (AMA) made comprehensive changes, including code additions, deletions, and revisions, accompanied by new and revised introductory language, parenthetical notes, subheadings and cross-references, to the Integumentary, Repair (Closure) subsection of surgery in the CPT book to facilitate more accurate reporting of skin grafts, skin replacements, skin substitutes, and local wound care. 40 AHIMA 2007 Audio eminar eries 20

26 CY 2007 kin ubstitutes and Replacement Procedures 41 Other Procedures continued Complex kin Repair (APC 0024) In the CY 2007 OPP proposed rule, CM proposed to assign CPT code (Repair, complex, eyelids, nose, ears and/or lip, 1.1 cm to 2.5 cm, to APC 0024 (Level I kin Repair) with a payment rate of $ CM now says that CPT code would be more appropriately assigned to APC 0025 and is making that reassignment effective January 1, Insertion of Posterior pinous Process Distraction Device CM is accepting the APC Panel s recommendation and assigning CPT codes 0171T and 0172T to APC 0050 with status indicator T for CY These assignments are interim final, and, therefore, open to comment in this final rule with comment period 42 AHIMA 2007 Audio eminar eries 21

27 Treatment of Fracture/Dislocation (APCs 0062, 0063, and 0064) APC 0046 is a large clinical APC to which many procedures related to the percutaneous or open treatment of fractures and dislocations are assigned for CY Most of the approximately 100 procedures in the APC are relatively low volume, with even fewer single bills available for rate setting. CM proposed to split APC 0046 into three new APCs: APC 0062 (Level I Treatment Fracture/ Dislocation) APC 0063 (Level II Treatment Fracture/Dislocation) APC 0064 (Level III Treatment Fracture/Dislocation) 43 Treatment of Fracture/Dislocation (APCs 0062, 0063, and 0064) One code, CPT (Radical resection of tumor (e.g., malignant neoplasm), soft tissue of leg or ankle area), is not clinically coherent with the other procedures in APC 0046, and CM proposed to reassign this procedure outside of the Fracture/Dislocation series to APC 0050 (Level II Musculoskeletal Procedures Except Hand and Foot) for CY CM is finalizing its proposal without modification to reconfigure CY 2006 APC 0046 for fracture and dislocation procedures into three new APCs for CY 2007 APCs 0062, 0063, and 0064 reassign CPT code to APC AHIMA 2007 Audio eminar eries 22

28 Medical ervices Medication Therapy Management ervices CM is continuing to assign status indicator B to CPT codes 0115T, 0116T, and 0117T for CY 2007 and is finalizing its proposed policy without modification. ingle Allergy Tests (APC 0381) CM proposed to continue differentiating single allergy tests ( per test ) from multiple allergy tests ( per visit ) by assigning these services to two different APCs to provide accurate payments for these tests in CY The final CY 2007 APC 0381 median cost calculated based upon 382 single claims, using the methodology as proposed, is $ Medical ervices Hyperbaric Oxygen Therapy (APC 0659) CM is finalizing its proposed methodology for estimating a per unit median cost for HCPC code C1300, assigned to APC 0659, without modification for CY The final median cost for APC 0659 is ($97.20 per unit). Guidance for Chemodenervation (APC 0215) CM is finalizing its proposal to assign CPT codes and to APC 0215 for CY 2007, without modification. Pathology ervices (APC 0344) CM is finalizing the APC 0344 structure as proposed without modification. The final CY 2007 median cost of APC 0344 is $ AHIMA 2007 Audio eminar eries 23

29 Inpatient Only Procedures- Moved to APCs Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s) 0202 T Vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s), with repair of enterocele 0202 T Vaginal hysterectomy, for uterus greater than 250 grams; with repair of enterocele T Parathyroidectomy or exploration of thyroid(s); reexploration 0256 T Thymectomy, partial or total; transcervical approach 0256 T Creation of lesion by stereotactic method, including burr holes and localizing and recording techniques, single of multiple stages; globus pallidus or thalamus 0221 T Elevation of depressed skull fracture; simple extradural 0254 T ympathectomy, cervicothoracic 0220 T 47 Inpatient Only Procedures- Moved to APCs Escharotomy; initial incision 0016 T Reconstruction by contouring of benign tumor of cranial bones, extracranial 0254 T Apply spine prosth device 0049 T Colpopexy, vaginal; extra-peritoneal approach (sacrospinous, iliococcygeus) 0202 T Colpopexy, vaginal; intra-peritoneal approach (uterosacral, levator myorrhaphy) 0202 T Construction of artificial vagina; with graft Vaginoplasty for intersex state T T Vaginal hysterectromy, for uterus 250 grams or less 0195 T Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s) 0195 T Vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s), and/or ovary(s), with repair of enterocele 0195 T Vaginal hysterectomy, for uterus 250 grams or less; with repair of enterocele 0195 T Vaginal hysterectomy, for uterus greater than 250 grams 0202 T 48 AHIMA 2007 Audio eminar eries 24

30 Use of CA modifier Hospitals are instructed to continue reporting modifier CA only under circumstances described in section VI of Transmittal A , which provided specific billing guidance for the use of modifier CA. In addition, CM will continue to make one payment under APC 0375 for the services that meet the specific conditions discussed in previous rules for using modifier CA, based on calculation of the relative payment weight for APC 0375 as described above. The CY 2007 proposed APC 0375 median cost was $3,539, significantly increased from the $2,527 median cost in the CY 2006 proposed rule and the CY 2006 final median cost of $2,717. The CY 2007 final APC 0375 median cost is $3, Brachytherapy ources AHIMA 2007 Audio eminar eries 25

31 Brachytherapy ources OPP Payment Changes For Devices 52 AHIMA 2007 Audio eminar eries 26

32 Treatment of Device-Dependent APCs CY 2007 Payment Policy Device-dependent APCs are populated by HCPC codes that usually, but not always, require that a device be implanted or used to perform the procedure. CM is finalizing its proposed payment policies for device-dependent APCs for CY The CY 2007 payment rates for device-dependent APCs are based on their median costs calculated from CY 2005 non-token claims that passed the device edits, without application of a maximum payment reduction floor in comparison with CY 2006 payment medians. 53 Devices Billed Without Procedure Devices Billed in the Absence of an Appropriate Procedure Code CM notes that it has identified circumstances in which hospitals billed a device code but failed to also bill any procedure code with which the device could be used correctly. These errors in billing have led to the costs of the device being packaged with an incorrect procedure code and also have caused the hospital to be paid incorrectly for the service furnished if the device was appropriately reported. CM will implement edits effective with the January 2007 outpatient code editor (OCE). The edits are posted on the OPP Web site at: 54 AHIMA 2007 Audio eminar eries 27

33 Devices that Require Procedure Code Device Description C1721 AICD, dual chamber C1722 AICD, single chamber C1767 Generator, neuro non-recharg C1777 Lead, AICD, endo single coil C1778 Lead, neurostimulator C1779 Lead, pmkr, transvenous VDD C1785 Pmkr, dual, rate-resp C1786 Pmkr, single, rate-resp C1820 Generator, neuro rechg bat sys C1882 AICD, other than sing/dual C1895 Lead, AICD, endo dual coil C1896 Lead, AICD, non sing/dual C1897 Lead, neurostim test kit C1898 Lead, pmkr, other than trans C1899 Lead, pmkr/aicd combination C1900 Lead, coronary venous C2619 Pmkr, dual, non rate-resp C2620 Pmkr, single, non rate-resp C2621 Pmkr, other than sing/dual 55 Payment Policy - Replaced Devices with No Cost or Credit CM proposed, effective for services furnished on or after 1/01/07, to reduce the APC payment and beneficiary co-payment for selected APCs in cases in which an implanted device is replaced without cost to the hospital or with full credit for the removed device. CM will limit the adjustment to identified APCs, but only when the purpose of the procedure is to replace a device that is reported by a HCPC code that was furnished without cost or at full credit by the manufacturer. CM proposed that the following 3 criteria must be met for an APC to be subject to the adjustment. That all procedures assigned to the selected APCs must require implantable devices that would be reported if device replacement procedures were performed. That the required devices must be surgically inserted or implanted devices that remain in the patient s body after the conclusion of the procedures, at least temporarily. That the offset percent for the APC (that is, the median cost of the APC without device costs divided by the median cost of the APC with devices) must be significant. For this purpose, CM is defining a significant offset percent as exceeding 40 percent. 56 AHIMA 2007 Audio eminar eries 28

34 Use of FB Modifier Effective January 1, 2007, the definition of the FB modifier will read: Item Provided Without Cost to Provider, upplier, or Practitioner or credit received for replaced device (Examples, but not limited to: Covered under warranty, replaced due to defect, free sample). Hospitals will be instructed to append the modifier to the HCPC code for the procedure in which the device was inserted on claims when the device that was replaced under warranty, recall or field action is one of the devices in Table 21. Claims containing the FB modifier will not be accepted unless the modifier is on a procedure code with status indicator, T, V or X. In cases in which the device being replaced is replaced without cost, the provider will report a token device charge. In cases in which the device being inserted is an upgrade (either of the same type of device or to a different type of device), the provider will report as the device charge the difference between its usual charge for the device being replaced and the credit for the replacement device. CM will be able to identify whether the device was replaced without cost by the presence of the token charge. Where there is not a token charge for the device but there is an FB modifier on a HCPC code, CM will assume that an upgrade occurred. 57 Table 21 Devices That Affect FB Modifier 58 AHIMA 2007 Audio eminar eries 29

35 Pass-Through Device Payment Expiration of Transitional Pass-Through Payments for Certain Devices For CY 2007, CM proposed to continue to make payment under the passthrough provisions for category C1820. This category would expire from pass-through payment after December 31, CM is finalizing its proposal to expire category C1820, Generator, neurostimulator (implantable), with rechargeable battery and charging system, from pass-through payment after 12/31/07 without modification. Provisions for Reducing Transitional Pass-Through Payments to Offset Costs Packaged into APC Groups After the CY 2007 proposed OPP rule was published and prior to the publication of this final rule, CM is announcing that it has established two new device categories for transitional pass-through payment. CM has established device categories L8690 (Auditory osseointegrated device, external sound processor, replacement) and C1821 (Interspinous process distraction device (implantable)) for pass-through payment, effective 1/01/07. CM says it cannot identify device-related costs in the procedural APCs that are expected to be billed with either of the new categories L8690 or C1821, that is, in APC 0256 or APC 0050, respectively. Therefore, the offset amount for CY 2007 is $0 for device categories L8690 and C OPP Drug Payment Changes 60 AHIMA 2007 Audio eminar eries 30

36 OPP Changes - Drugs, Pharmaceuticals and Biologicals Transitional Pass-Through Payment for Additional Costs of Drugs and Biologicals ection 1833(t)(6)(C)(i) of the ocial ecurity Act specifies that the duration of transitional pass-through payments for drugs and biologicals must be no less than 2 years and no longer than 3 years. Drugs and Biologicals with Expiring Pass-Through tatus in CY 2006 CM proposed to delete HCPC code C9221 and instruct hospitals to use HCPC code J7344 (Nonmetabolic active tissue) for services furnished on or after January 1, CM is finalizing the proposal without modification. ince the publication of the proposed rule, CM has determined that HCPC code J7319 (odium hyaluronate injection) appropriately describes the product reported under HCPC code C9220, and that HCPC code J7346 (Injectable human tissue) appropriately describes the product reported under HCPC code C9222. Therefore, CM is deleting HCPC codes C9220 and C9222, and instructing hospitals to use HCPC codes J7319 and J7346, respectively, for services furnished on or after January 1, CM is finalizing its proposal to discontinue pass-through status as of December 31, 2006, for the 12 drugs and biologicals shown in the table on the next slide. 61 Pass-Throughs Expiring 12/31/06 62 AHIMA 2007 Audio eminar eries 31

37 Drugs/Biologicals with Pass-Through tatus in Drugs with tatus Change 64 AHIMA 2007 Audio eminar eries 32

38 Payment - Non Pass-Through tatus ection 1833(t)(16)(B) of the ocial ecurity Act requires that the threshold for establishing separate APCs for drugs and biologicals be set at $50 per administration for CYs 2005 and CM proposed that for each year beginning with CY 2007, the agency would adjust the packaging threshold by the Producer Price Index (PPI) for prescription drugs, and the adjusted dollar amount would be rounded to the nearest $5 increment in order to determine the new threshold. The adjusted amount for CY 2007 was calculated to be $55.99, which CM is rounding down to $55. Therefore, for CY 2007, CM proposed to pay separately for drugs, biologicals, and radiopharmaceuticals whose per day cost exceeds $55 and packaging the costs of drugs, biologicals, and radiopharmaceuticals whose per day cost is less than or equal to $55 into the procedures with which they are billed. For CY 2007, CM also proposed to continue the policy of exempting the oral and injectable 5HT3 anti-emetic products from the packaging rule, thereby making separate payment for all of the 5HT3 anti-emetic products (J1260, J1626, J2405, J2469, Q0166, Q0179, Q0180) CM is finalizing its proposal to calculate an annual update to the OPP packaging threshold using the proposed methodology without modification. 65 Non Pass-Through Non Packaged Drugs - Payment CM is not finalizing its proposal to pay for drugs and biologicals at AP+5 percent. Instead, after carefully considering all comments and the recommendations of the APC Panel, CM will continue to pay for separately payable drugs, biologicals and their associated pharmacy handling in the hospital outpatient department for CY 2007 at a combined rate of AP+6 percent. Medicare will temporarily allow a separate payment in CY 2007 for each day of intravenous immune globulin (IVIG) administration to physicians and hospital outpatient departments that administer IVIG to Medicare beneficiaries. This pre-administration-related service payment will continue to be billed under the same HCPC code as in 2006: G0332 (Pre-administrationrelated services for intravenous infusion of immunoglobulin, per infusion encounter). CM will continue its CY 2006 placement of HCPC code G0332 in New Technology APC 1502 (status indicator ) with a payment rate of $75 at this time. The payment for pre-administration-related services is in addition to the separate payments Medicare makes for the IVIG product itself and its administration. 66 AHIMA 2007 Audio eminar eries 33

39 CY 2007 Payment Policy - Radiopharmaceuticals Radiopharmaceuticals are classified under the OPP as specified covered outpatient drugs (CODs). Accordingly, payments for radiopharmaceuticals are to be made at average acquisition cost as determined by the ecretary and subject to any adjustment for overhead costs. Radiopharmaceuticals are also subject to the policies affecting all similarly classified OPP drugs and biologicals, such as passthrough payments and packaging determinations. At this time, CM says it believes that there is sufficient reason to extend the temporary policy of paying for radiopharmaceuticals at charges reduced to cost for one additional year as the best proxy for radiopharmaceutical acquisition and overhead costs, consistent with the August 2006 recommendation of the APC Panel. CM is placing hospitals on notice to correct any charge issues in CM says that it expects that for the CY 2008 OPP update, hospitals will have adapted to the CY 2006 coding changes and responded to our instructions to include their charges for radiopharmaceutical handling in their charges for the radiopharmaceutical products. 67 Other Policies - Radiopharmaceuticals CY 2007 Proposed and Final Payment Policy for Radiopharmaceuticals with HCPC Codes, But without OPP Hospital Claims Data For CY 2007, hospitals will receive payment for non pass-through radiopharmaceuticals without hospital claims data that have been assigned HCPC codes as of January 1, 2007, at the hospital s charge for the radiopharmaceutical adjusted to cost, using the hospital s overall cost-to-charge ratio. This methodology will provide payment for nonpass-through radiopharmaceuticals using the same payment methodology that CM has finalized for pass-through radiopharmaceuticals CM finalized its policy for drugs and biologicals that have HCPC codes but do not have pass-through status, and those that do not have CY 2005 hospital claims data as follows: Items with a per administration cost of less than or equal to $55 will be packaged Items with an estimated per administration cost greater than $55 will receive separate payment. 68 AHIMA 2007 Audio eminar eries 34

40 Other Policies - Radiopharmaceuticals CY 2007 Proposed and Final Payment Policy for Drugs and Biologicals with HCPC Codes, But without OPP Hospital Claims Data For CY 2007, CM proposed to continue payment for new drugs and biologicals with HCPC codes as of January 1, 2007, but without passthrough status, at a rate that is equivalent to the payment they would receive in the physician office setting, unless the drug or biological was also covered under the Part B drug CAP. 69 Drug Administration Coding and Payment Changes CM will use only CPT codes for the reporting of drug administration services for the CY 2007 OPP. The following table lists drug administration HCPC codes, associated status indicators, and CY 2007 APC assignments, where applicable, for CPT codes that will be newly recognized under the OPP for reporting drug administration services provided in hospital outpatient departments on or after January 1, C8957 is the only HCPC code that is reportable in CY 2007 (prolonged infusion requiring the use of portable or implantable pump) A transmittal detailing OPP-specific guidance for hospital outpatient departments providing drug administration services will be released in AHIMA 2007 Audio eminar eries 35

41 2007 CPT Code 2007 Description 2007 APC CY 07 I Intravenous Infusion, hydration; initial, up to one hour Intravenous Infusion, hydration; each additional hour (list separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); initial, up to one hour Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); each additional hour (List separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure) Intravenous infusion, for therapy, prophylaxis, or diagnosis, (specify substance or drug); concurrent infusion (List separately in addition to code for primary procedure) - N Therapeutic, prophylactic or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) Chemotherapy administration; intravenous, push technique, single or initial substance/drug Chemotherapy administration; intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug Chemotherapy administration, intravenous infusion technique; each additional hour (List separately in addition to code for primary procedure) Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour CY 2007 Drug Administration APC tructure Final CY 2007 APC Final APC tatus Indicator Final CY 2007 APC Median Cost CPT/HCPC Code Description Immunization admin, each add Immune admin oral/nasal 0436 $ Immune admin oral/nasal addl Ther/prop/diag inj/inf proc Immunotherapy, one injection Chemotherapy, unspecified 0437 $ Immunization admin Hydrate iv infusion, add-on Ther/proph/dg iv inf, add-on Tx/proph/dg addl seq iv inf Ther/proph/diag inj, sc/im Immunotherapy injections Antigen therapy services 72 AHIMA 2007 Audio eminar eries 36

42 CY 2007 Drug Administration APC tructure 0438 $ Antigen therapy services Antigen therapy services Antigen therapy services Antigen therapy services Antigen therapy services Antigen therapy services Antigen therapy services Ther/proph/diag inj, ia Ther/proph/diag inj, iv push Ther/proph/diag inj add-on Chemo, anti-neopl, sq/im Chemo hormon antineopl sq/im Chemo intralesional, up to Chemo intralesional over Chemo, iv infusion, addl hr Chemo iv infus each addl seq Chemo ia infuse each addl hr Chemotherapy injection 73 CY 2007 Drug Administration APC tructure Chemo, iv push, sngl drug 0439 $ Chemo, iv push, addl drug Chemo, ia, push technique Hydration iv infusion, init Ther/proph/diag iv inf, init 0440 $ Refill/maint, portable pump Refill/maint pump/resvr syst 74 AHIMA 2007 Audio eminar eries 37

43 CY 2007 Drug Administration APC tructure Chemo, iv infusion, 1 hr Chemo prolong infuse w/pump Chemo ia infusion up to 1 hr 0441 $ Chemotherapy, infusion method Chemotherapy, intracavitary Chemotherapy, intracavitary Chemotherapy, into CN C8957 Prolonged IV inf, req pump 75 Hospital Coding and Payment For Visits 76 AHIMA 2007 Audio eminar eries 38

44 Clinic Visits A. Clinic Visits For clinic visits, CM proposed five new codes, to replace hospitals reporting of the CPT clinic visit E/M codes for new and established patients and consultations. In response to the numerous comments related to creation of G-codes, CM is postponing finalizing G-codes for clinic visits until national guidelines have been established. Providers should continue to use CPT codes to bill for clinic visits. The CPT codes for new and established visits and consultations will continue to be payable under the OPP. 77 Emergency Department Visits B. Emergency Department Visits To determine whether visits to emergency departments or facilities (referred to as Type B emergency departments) that incur EMTALA obligations but do not meet more prescriptive expectations that are consistent with the CPT definition of an emergency department (referred to as Type A emergency departments) have different resource costs than visits to either clinics or Type A emergency departments, CM proposed to establish a set of five G-codes for use by all entities that meet the definition of a DED under the EMTALA regulations in ection but that are not Type A emergency departments. For CY 2007, CM is finalizing its proposal with modification. CM will not adopt the G-codes in Type A emergency departments, but will adopt the G-codes for Type B emergency departments. A Type A emergency department is defined as a hospital-based facility or department that must be open 24 hours a day, 7 days a week and meet the EMTALA definition of DED (dedicated Emergency Department). A satellite facility or an area carved out of a facility ED that is not open 24/7 is billed as a Type B Emergency Visit. 78 AHIMA 2007 Audio eminar eries 39

45 New ED G Codes Type B Emergency Departments The hospital emergency department visit provided in a Type B emergency department. (The ED must meet at least one of the following requirements) It is licensed by the tate in which it is located under applicable tate law as an emergency room or emergency department It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment During the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment The code ranges are: G0380-Level 1 hospital type B ED visit G0381-Level 2 G0382-Level 3 G0383-Level 4 G0384-Level 5 79 Critical Care ervices CM will continue to instruct providers to bill CPT codes and for critical care. In addition, CM is creating one new G-code, G0390 (Trauma response team activation associated with hospital critical care service), effective January 1, 2007, which is assigned to APC 0618 (Critical Care with Trauma Response), with a median cost of $ When critical care is provided without trauma activation, the hospital will bill CPT code (and 99292, if appropriate) as usual, and receive payment for APC 0617 (Critical Care), which has a median cost of $402.67, calculated from that subset of single claims for CPT code without revenue code 68x reported on the same day. 80 AHIMA 2007 Audio eminar eries 40

46 CY 2007 Visit Payment CY 2007 APC Title CY 2007 APC HCPC Code hort Descriptor Eye exam established pat Office/outpatient visit, new (Level I) Office/outpatient visit, est (Level I) Level 1 Hospital Clinic Visits 0604 G0101 G0245 CA screen; pelvic/breast exam Initial foot exam pt lops Office consultation (Level I) Confirmatory consultation (Level I) G0264 Assessment Other, CHF, Chest Pain, Asthma 81 CY 2007 Visit Payment Eye exam, new patient Eye exam and treatment Office/outpatient visit, new (Level II) Office/outpatient visit, est (Level II) Level 2 Hospital Clinic Visits Office consultation (Level III) Office Consultation (Level II) Confirmatory consultation (Level III) Confirmatory consultation (Level II) Initial care, normal newborn G0246 Follow-up evaluation of foot pt lop G0344 Initial preventive exam 82 AHIMA 2007 Audio eminar eries 41

47 CY 2007 Visit Payment Eye exam, new patient Office/outpatient visit, new (Level III) Level 3 Hospital Clinic Visits Office/outpatient visit, est (Level IV) Confirmatory consultation (Level IV) Office consultation (Level IV) 83 CY 2007 Visit Payment Office/outpatient visit, new (Level IV) Level 4 Hospital Clinic Visits Office/outpatient visit, est (Level V) Office consultation (Level V) Confirmatory consultation (Level V) Level 5 Hospital Clinic Visits G0175 Office/outpatient visit, new (Level V) OPP service, sched team conf Level 1 Emergency Visits Emergency dept visit (Level I) Level 2 Emergency Visits Emergency dept visit (Level II) Level 3 Emergency Visits Emergency dept visit (Level III) Level 4 Emergency Visits Emergency dept visit (Level IV) Level 5 Emergency Visits Emergency dept visit (Level V) 84 AHIMA 2007 Audio eminar eries 42

48 Non Recurring Policy Changes 85 CORF Changes New HCPC for AAA creening Removal of Comprehensive Outpatient Rehabilitation Facility (CORF) ervices from the List of ervices Paid under the OPP CM is adopting as final, without modification, the technical change to regulation ection (d) to remove from the list of services paid under the OPP certain services furnished by a CORF when they are provided outside the patient s plan of care (for example, hepatitis B vaccine). Proposed Assignment of New HCPC Code for Payment of Ultrasound creening for Abdominal Aortic Aneurysm (AAA) (ection 5112) DRA ection 5112 provides for coverage under Medicare Part B of ultrasound screening for abdominal aortic aneurysms (AAAs), effective for services furnished on or after January 1, 2007, subject to certain eligibility and other limitations. CM is assigning code G0389 to APC 0266 with a median cost of $95.37 for CY Consistent with the statute, no Medicare beneficiary deductible will be applied to payment for this AAA screening service. 86 AHIMA 2007 Audio eminar eries 43

49 AAA creening Requirements The provision will apply to individuals (a) who receive a referral for such an ultrasound screening as a result of an initial preventive physical examination; who have not been previously furnished with an ultrasound screening under Medicare who have a family history of abdominal aortic aneurysm or manifest risk factors included in a beneficiary category recommended for screening (as determined by the United tates Preventive ervices Task Force). Ultrasound screening for abdominal aortic aneurysm will be included in the initial preventive physical examination. ection 5112 also added ultrasound screening for abdominal aortic aneurysm to the list of services for which the beneficiary deductible does not apply. 87 Critical Access Hospital Changes Emergency Medical creening in Critical Access Hospitals (CAHs) CM proposed to revise the current CAH Conditions of Participation to align the emergency medical screening requirements in CAHs with those applicable to acute care hospitals. The proposed change would allow registered nurses, in addition to the personnel currently required to serve as qualified medical personnel to screen individuals who present to the CAH emergency room if the nature of the patient s request is within the registered nurse s scope of practice under tate law and such screening is permitted by the CAH's bylaws. The proposed change would effectively eliminate the need for a doctor or mid-level practitioner to report to the emergency department to attend to a non-emergent request for medical care if a registered nurse is on site at the CAH and has made a determination that the care needed is of a non-emergent nature. CM is adopting the proposed change to regulation ection (d), with minor change. 88 AHIMA 2007 Audio eminar eries 44

50 AC Changes in Procedures Added to AC List CPT hort Descriptor Repair wound/lesion add-on Repair wound/lesion add-on Repair wound/lesion add-on Place breast cath for rad Treat cheek bone fracture Percutaneous vertebroplasty, thor Percutaneous vertebroplasty, lumb Percutaneous vertebroplasty, add l AV fuse, upper arm, cephalic Reposition gastrostomy tube Ligation of hemorrhoids AC Payment Additional AC Procedures Added ince Proposed Rule HCPC G0392 G T 0177T hort descriptor Repair wound/lesion add-on Place breast clip, percut Endobronchial us add-on Upper gi scope w/thrml txmnt Insert mesh/pelvic flr add-on Brain surgery using computer AV fistula or graft arterial AV fistula or graft venous Aqu canal dilat w/o retent Acq canal dilat w retent Payment Group AHIMA 2007 Audio eminar eries 45

51 What is a MAC???? 91 Medicare Administrative Contractor MMA ection 911 amended Title XVIII of the ocial ecurity Act to add section 1874A, Contracts with Medicare Administrative Contractors (MACs). ection 1874A of the Act replaces the prior Medicare intermediary and carrier contracting authorities. Using competitive procedures, CM will replace its current claims payment contractors (intermediaries and carriers) with new contract entities, MACs. MMA requires that CM compete and transition all Medicare claims processing workloads to MACs by October 1, In 2006, there are 20 intermediaries and 18 carriers that process FF claims. MACs will perform all core claims processing operations for both Medicare Part A and Part B. The Part A and Part B MACs will operate in distinct, non overlapping geographic jurisdictions, which will form the basis of the Medicare claims processing operations. 92 AHIMA 2007 Audio eminar eries 46

52 Medicare Administrative Contractor Based on the authority provided in ections 1874A(a) through (d) of the ocial ecurity Act, CM is establishing regulations pertaining to MACs in a new ubpart E of 42 CFR Part 421. CM notes that each of the former provider nomination provisions is repealed As a general rule, Medicare providers and suppliers will be assigned to the MAC that is contracted to administer the types of services (benefits) billed by the provider or supplier within the geographic locale in which the provider or supplier is physically located or furnishes health care services. One significant exception to this general rule pertains to suppliers of durable medical equipment, prosthetics, orthotics, and supplies. CM will continue to allow these suppliers to bill to the contractor assigned to the locale in which the beneficiary receiving the items or supplies resides. 93 Medicare Administrative Contractor CM is finalizing it proposed rules-- Providers will generally be assigned to the MAC with claims processing jurisdiction over the geographic locale in which the provider is physically located. Large chain providers comprised of individual providers that were formerly permitted by CM to nominate an intermediary, which the agency refers to as qualified chain providers, will be permitted to request opportunity to consolidate their Medicare billing activities to the MAC with jurisdiction over the geographic locale in which the chain s home office is located. Qualified chain providers that were formerly granted single intermediary status do not need to re-request such privileges on behalf of the entire chain at this time. CM may grant other exceptions to the general rule for assigning providers to MACs, but only based on a finding that such an exception will support the implementation of the MACs or if CM deems the exception to be in the compelling interest of the Medicare program. 94 AHIMA 2007 Audio eminar eries 47

53 Quality Data Reporting Requirements under OPP 95 Quality Data Reporting In the CY 2007 OPP proposed rule, CM proposed to employ its equitable adjustment authority to adapt the quality improvement mechanism provided by the IPP RHQDAPU program for use in the OPP effective with Hospitals that are required to report quality data under the IPP RHQDAPU program in order to receive IPP FY 2007 update, and fail to meet the requirements for receiving the full FY 2007 IPP payment update, would have received an update to the CY 2007 OPP conversion factor that would have been reduced by 2.0 percentage points. CM has now concluded that the most appropriate course at this point is to implement a separate OPP quality update reporting program based on measures specifically developed to characterize the quality of hospital outpatient care. CM says the process will require 2 years before quality measure data are available. Given concerns about increasing growth in OPP spending without concern for the value of the services, CM does not believe it would appropriate to delay focusing on the quality of hospital outpatient services beyond the minimum of 2 years required for the development and implementation of these measures. CM also says it agrees with those who pointed out that implementation of the OPP RHQDAPU program as proposed for CY 2007 would mean that hospitals could not have made decisions regarding their participation in IPP quality reporting program with full knowledge of the effects of their participation on their OPP update. 96 AHIMA 2007 Audio eminar eries 48

54 Additional Quality Measures and Procedures for Hospital Reporting of Quality Data for the FY 2008 IPP Annual Payment Update CM is using this rulemaking in addition to the IPP rulemaking to establish additional quality measures in order to give hospitals advance notice and lead time to learn about the collection requirements of the new measures before linking them to payment. In the CY 2007 OPP proposed rule, CM proposed to add the following categories to the FY 2008 IPP RHQDAPU program measure set: HCAHP urvey HCAHP is also known as Hospital CAHP or the CAHP Hospital urvey. 97 Any Questions??? Thank you for your participation! Arlene Baril, M, RHIA (972) voice/fax Cheryl D Amato, RHIT, CC cheryl.damato@ingenix.com 98 AHIMA 2007 Audio eminar eries 49

55 Audio eminar Discussion Following today s live seminar Available to AHIMA members at Click on Communities of Practice (CoP) icon on top right AHIMA Member ID number and password required for members only Join the Coding Community from your Personal Page Under Community Discussions, choose the Audio eminar Forum You will be able to: Discuss seminar topics Network with other AHIMA members Enhance your learning experience AHIMA Audio eminars Visit our Web site for information on the 2007 seminar schedule. While online, you can also register for seminars or order CDs and pre-recorded Webcasts of past seminars. AHIMA 2007 Audio eminar eries 50

56 Upcoming Audio eminars Present on Admission Reporting February 1, 2007 CPT: urgery Coding Guidelines February 8, 2007 Thank you for joining us today! Remember sign on to the AHIMA Audio eminars Web site to complete your evaluation form and receive your CE Certificate online at: Each person seeking CE credit must complete the sign-in form and evaluation in order to view and print their CE certificate Certificates will be awarded for AHIMA and ANCC Continuing Education Credit AHIMA 2007 Audio eminar eries 51