OPPS Update: Soothe Your Facility's Wallet With a 4 Percent Payment Increase

2005 final rule offers more dough for vaccines

Think you can't get paid for preventive physical exams? According to the OPPS final rule for 2005, you can. The rule gives you no less than four new codes to describe - and get reimbursed for - those services.
The whole of the changes to the outpatient prospective payment system (OPPS) that CMS implemented Jan. 1, 2005, means an average 4.0 percent increase in Medicare payments. Keep in mind that the government tweaks the increase based on geography (your state and whether you're a rural or urban facility), so the hike for your hospital may be higher or lower than 4.0 percent.
MMA Changes Shift Your Bottom Line
Thanks to the Medicare Modernization Act (MMA), you can now earn reimbursement for preventive physical exams using these new G codes: G0344 (Initial preventive exam), G0366 (Electrocardiogram [EKG] for initial preventive exam), G0367 (EKG tracing for initial preventive exam), and G0368 (EKG interpretation and report for preventive exam). When reporting these services, make sure that the physician performs the exam within the first six months of the patient's coverage. If you can't tell whether the six-month period has passed, make sure you give the patient an advance beneficiary notice (ABN).
Tip: Don't forget to add the CPT or HCPCS codes for other procedures the physician performs alongside the preventive exam.
But where CMS giveth, they also taketh away. Mammographies, both screening and diagnostic, are no longer covered under the OPPS, says Sarah L. Goodman, MBA, CPC-H, CCP, president of SLG Inc. in Raleigh, N.C. A provision in the MMA requires payments for diagnostic mammograms to be moved from OPPS to the Physician Fee Schedule (PFS), Goodman says. CMS expects this move to increase payment rates for mammograms by almost 40 percent.
Kiss 5 Pass-Through Device Categories Goodbye
As of Dec. 31, 2004, a handful of pass-through periods expire, which means that the new year brings only packaged reimbursement for these five devices:

  C1783 - Ocular implant, aqueous drainage assist device
  C1884 - Embolization protective system
  C1888 - Endovascular noncardiac ablation catheter
  C1900 - Lead, left ventricular coronary venous system
  C2614 - Probe, percutaneous lumbar discectomy.
Open the Packaging Rule
If you received separate payment for a drug or biological in 2004, you'll probably still receive separate payment for it in 2005. The item must have median costs per day less than $50 (based on the hospital claims data CMS is using for the 2005 final rule) to receive separate payment in 2005.
But those drugs and biologicals that were packaged in 2004 and that have median costs per day of less than $50 (again, based on the [...]

- Published on 2005-01-22