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PROPOSED 2006 OPPS RULE PUBLISHED
In the July 25, 2005 Federal Register the proposed rules for the Medicare OPPS
was published. Comments regarding the rule must be submitted to CMS by
September 16, 2005.
The payment rates for 2006 are based on the median charges from the 2004 claims
data. In this proposed rule, the beneficiary’s share of the outpatient bill is
estimated to be 30% in 2006, down from 32% in 2005.
This newsletter will publish just a few significant highlights:
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Observation Services
These changes are being proposed:
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Discontinue HCPCS codes G0244 (observation care), G0263 (direct admission with
CHF, chest pain or asthma) and G0264 (assessment other than CHF, chest pain or
asthma) and create 2 new HCPCS codes to be used by hospitals to report all
observation services whether separately payable or packaged.
GXXXX – Hospital observation services, per hour
GYYYY – Direct admission of patient for hospital observation care
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Shift the determination of whether the observation services are separately
payable under APC 339 from the hospital to OPPS claims processing logic.
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Multiple Diagnostic Imaging Procedures
Currently hospitals billing for diagnostic procedures receive full APC payments
for each imaging service on the claim regardless of how many procedures of the
body are studied in the same session. CMS has identified 11 families of imaging
procedures by modality (i.e., ultrasound, CT, CTA, MRI, MRA, etc.). It is
proposed that CMS pay a 50% reduction in OPPS payment for some second and
subsequent imaging procedures performed in the same session. The imaging
procedure reduction is proposed only to individual services described in 1
family, not across families. These procedures within 1 family must be performed
in the same session.
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Payment for Procedures with Modifiers -52, -73, -74
Each of these modifiers indicates that a procedure was terminated before
completion. Currently, hospitals are paid 50% of the APC payment for a
procedure with modifier -73 and 100% of the APC payment for procedures with
modifier -52 and -74.
CMS is proposing to pay 50% of the APC payment for a discontinued procedure that
does not require anesthesia, where modifier -52 is reported.
CMS is also proposing to pay 50% of the APC payment for a procedure when
modifier -74 (procedure discontinued after anesthesia is initiated) is
reported. However, CMS is seeking comment on the clinical circumstances in
which modifier -74 would be used to assist in their evaluation of this payment
reduction. In particular CMS is interested in obtaining information about
“when” during the procedure the decision to discontinue is made.
DME ORDERED IN THE HOSPITAL
CMS issued MedLearn Matters SE0507 on February 2, 2005. The article
states that when an orthotic/prosthetic is medically necessary for a Medicare
patient, ordered while the patient is still in the hospital but not delivered
to the patient until the beneficiary has been discharged, the hospital
(facility where the medical need occurred) is still responsible for the billing
of the device.
HIPAA COMPLIANCE
According to CMS MedLearn Matters MM3956, effective October 1, 2005
CMS is ending its contingency plan that has allowed providers to submit claims
format electronically that were not in the format required by HIPAA. All
providers must use the HIPAA compliant format for claims submitted to Medicare.
It is estimated that over 99% of claims submitted are already in HIPAA
compliant formats.
NOTICE OF COMPUTER MATCHING PROGRAM (CMP) IN OHIO
On July 25, 2005 in the Federal Register it was noted that CMS
filed a report of the CMP with the Chair of the House Committee on Government
Reform and Oversight as well as other government offices. The purpose of the
agreement will be to establish conditions, safeguards and procedures under
which CMS will conduct a computer matching program with ODJFS to study claims,
billings and eligibility information to detect suspected instances of fraud and
abuse in the State of Ohio.
Utilizing fraud detection software, the information will be used to
identify aberrant practices that may constitute fraud and abuse. The following
are examples of types of aberrant practices that may constitute fraud and abuse
and are expected to be identified in this matching program: billing for
provisions of more than 24 hours of services in 1 day, providing services and
treatment in ways more statistically significant than similar practice groups,
and upcoding and billing for services more expensive than those actually
performed.
The CMP will be effective no sooner than 40 days after the report
of the Matching Program is sent to Congress or 30 days after publication in the
Federal Register, whichever is later. The matching program will continue for 18
months from the effective date. It could be extended another 12 months.
JULY 2005 UPDATE FOR OPPS
The following drugs and biologicals have been designated as
eligible for pass-through status under the OPPS effective July 1, 2005.
| HCPCS |
APC |
SI |
Long Description |
| C9127 |
9127 |
G |
Injection, Paclitaxel Protein Bound Particles, per 1 mg |
| C9128 |
9128 |
G |
Injection, Pegaptiamib Sodium, per 0.3 mg |
| C9129 |
9129 |
G |
Injection, Clofarabine, per 1 mg |
| J8501* |
0868 |
G |
Aprepitant, oral, 5 mg |
*J8501 was approved for pass-through status effective April 6,
2005.
There are occasions when a hospital may furnish a device for
surgical insertion for which the hospital incurs no cost (i.e., devices
replaced under warranty, devices replaced due to recall, devices provided in a
clinical trial or devices provided as a sample). Under OPPS hospitals must
report a code for a device when reporting the procedure code for inserting the
device or an edit will not allow the claim to be processed for payment. In
those instances:
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Hospitals paid under the OPPS that surgically implant a device
furnished at no cost to the hospital shall report the appropriate HCPCS code
for the device on type of bill 13x.
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Hospitals paid under the OPPS that surgically implant a device
furnished at no cost to the hospital shall report a charge of zero for the
device, or if the hospital’s billing system requires that a charge be entered,
the hospital shall submit a token charge (e.g., $1.00) on the line with the
device code.
CMS recognizes that showing a charge for a device that has been
furnished without cost is not optimal, but showing a token charge in this
circumstance will allow claims for reasonable and necessary services that might
otherwise be denied due to OCE edits to be paid, and will ensure that
beneficiaries receive the care they need.
CHANGE REQUEST 3871, JULY 2005 OPPS SPECIFICATIONS
According to this Change Request, the following CPT/HCPCS codes
have been deleted as blood products effective July 1, 2005:
| 86890 |
Autologous blood processing |
| P9041 |
Albumin (human), %5, 50 ml |
| P9045 |
Albumin (human), 5%, 250 ml |
| P9046 |
Albumin (human), 5%, 20 ml |
Further clarification with AdminaStar Federal indicated these codes
should now be reported with revenue code 636.
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