ED Coding and Reimbursement Alert

Assigned status indicator will determine what will be paid separately

CMS has again increased packaging in support of its strategic goal of using larger payment bundles in the OPPS to maximize hospitals’ incentives to provide care in the most efficient manner. Packaging will include payments for items and services that are typically integral, ancillary, supportive, dependent, or adjunctive to a primary service, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company based in Bedford, MA. 

For 2016, CMS will increase the set of conditionally packaged services by three APCs:

Level 4 minor procedures are commonly performed in the ED and include such services as 11720 (nail debridements), 29125 and 29126 (forearm splints), 30300 (removal of nasal foreign body), 30901 (control of nosebleeds), 41250 (repair of tongue laceration), 51701 (bladder catheterization), and foreign body removals from the eye and other locations. While many procedures will still be paid, these level 4 procedures will be packaged when reported on the same claim with another service or procedure with a status indicator of S (procedure or service not discounted when multiple), T (procedure or service multiple procedure reduction applies), or V (clinic or ED visit), Granovsky explains.

Your 2016 Packages Include These 2 Things

• Ancillary services including certain diagnostic procedures, lab and diagnostic tests.

o The packaging of ancillary services is currently applied only when a service is performed with another service; separate payment will continue to be made when these ancillary services are performed and reported as the only service on a claim.

o A new status indicator, Q4, has been established for conditionally packaged lab tests. There will be no separate payment if the lab test is reported on a claim with another service having a status indicator of J1, J2, S, T, V, Q1, Q2, or Q3.  The lab test may be paid if it is “unrelated” to the primary service; providers will report the lab test with an L1 modifier indicating that it is unrelated.

o CMS assigned many conditionally packaged services the status indicator “Q1,” which indicates that the service is separately payable only when not billed on the same date of service as a service assigned status indicator “S,” “T,” or “V.” In the ED many procedures have a status indicator of Q1 and will not be separately paid, including laceration repairs —CPT^® 12001-12018 and EKGs — CPT^® 93005.
o For 2015, ancillary service packaging is applied to services that have a mean cost of less than or equal to $100. For 2016, CMS will eliminate this dollar threshold for most ancillary services, stating that there are some services with a mean cost of over $100 where packaging is appropriate.

• Clinical diagnostic tests that have the new Q4 status indicator (conditionally packaged when reported with codes having a status indicator of J1, J2, S, T, V, Q1, Q2, or Q3) will be packaged and not separately paid unless they are ordered for a different diagnosis by a different practitioner (using L1 modifier for unrelated tests). CMS will add ten new C-APCs in 2016 to the 25 comprehensive APCs (C-APCs) created in 2015. Other than the C-APC for Observation, the remainder of these C-APCs includes mostly Ambulatory Surgery Center procedures such as device-dependent procedures, says Granovsky.