ED Coding and Reimbursement Alert

OPPS conversion factor drops, but individual APC payments changes will vary.

The Centers for Medicare and Medicaid Services (CMS) released the Hospital Outpatient Prospective Payment System (OPPS) Final Rule on Nov. 30, 2015, effective for dates of service on and after Jan. 1, 2016. Check out our expert summary to see what’s relevant to emergency departments and clinics.

What’s The Big Picture, Will You Be Paid More Or Less In 2016?

For 2016, CMS finalized a payment rate decrease of -0.3 percent.  The negative update is primarily because of a 2 percent correction resulting from ”excess packaged payments” for laboratory tests that were excluded from packaging in the 2014 final OPPS rule.

CMS states net OPPS payments will decrease by 0.4 percent  in 2016 and estimates that after adjustments, total OPPS payments will decrease by approximately $133 million compared with 2015 payments, says Michael A. Granovsky, MD, FACEP, CPC, President of LogixHealth, a national ED coding and billing company based in Bedford, MA.

The conversion factor for 2016 will be $73.725, compared to the 2015 factor of $74.173. Hospitals that fail to meet quality reporting requirements will have a further reduction in their fee of 2 percent down to $72.251, Granovsky adds.

Check These Outpatient Visit Level Guidelines

CMS finalized its plan to continue the current clinic and ED visit coding policies for2016.  Hospitals should use the single HCPCS code, G0463, to report Medicare facility clinic visits, the CPT^® code range 99281-99285 for Type A ED visits and G0380 – G0384 for Type B ED visits.

CMS believes that additional analysis is still needed before changes are made to ED facility level coding guidelines and payments, so hospitals are instructed to continue to use their own guidelines to differentiate between the various levels of ED visits, advises Granovsky.

Watch For Renumbered Clinic Visits APCs

CMS reassigned the clinic HCPCS code G0463, currently in APC 0634, to a renumbered APC, 5012 —Level 2 examinations and related services.  The 2016 payment rate for APC 5012 and G0463 will be $102.12; the 2015 payment rate for G0463 was $96.25. The lack of distinction between new and established patient types for facility clinic visits will remain continue. 

The following is a comparison between 2015 and 2016 payments for Type A and Type B ED visits. Type A payments are generally slightly decreased and Type B payments are generally slightly higher, says Granovsky.

The payment rates in Addendum B and above have been determined by CMS based on 2014 Medicare claims data.

Critical Care APC Payment Increases, but Not with Trauma Activation

For 2016, CMS will continue to reimburse for critical care services reported with CPT^® code 99291 as in 2015. The 2016 payment rate will be $666.27. For comparison, the 2015 critical care payment rate was $656.69.

When you report ancillary services on the same date as critical care, such as chest x-rays, pulse oximetry, and transcutaneous pacing, expect those services to continue to be packaged.  Providers will report critical care in accordance with CPT^® guidelines except where CMS instructs otherwise, says Granovsky.

Critical care with trauma team activation, HCPCS code G0390, will be paid at a 2016 payment rate of $851.40. For comparison, the 2015 trauma activation payment rate was $888.97, he adds.

Use This New Status Indicator for Observation APC

CMS finalized its proposal to create a comprehensive APC for observation services, C-APC 8011, which replaces the current observation APC 8009. Most other services provided during the observation stay will be packaged and not separately paid as they are in 2015.

The primary service within C-APC 8011 will have a new status indicator J2. A service meeting the Observation requirements would trigger a single observation payment for claims containing the observation HCPCS code, G0378, and one of the following visit codes:

• any clinic visit HCPCS code G0463, any Type A ED visit (CPT^®  codes 99281 through 99285)
• any Type B ED visit (HCPCS codes G0380- G0384)
• a direct referral to observation (HCPCS code G0379) or critical care (CPT^®  code 99291) provided by a hospital in conjunction with observation services of substantial duration (8 or more hours of observation/8 units of HCPCS code G0378) (provided the observation was not furnished on the same day as surgery or post-operatively—no status indicator T on the same claim).

In addition, the observation claim must not contain any service with a J1 status indicator (a standard comprehensive APC service), Granovsky explains.

Observation will be packaged into any procedure with a status indicator T that is provided before or after an observation stay.  The T status procedure will be paid, observation will be packaged. The observation C-APC will not be paid if a major procedure is reported on the same claim.

HCPCS code, G0378, will continue to be reported by providers under C-APC 8011. With this comprehensive APC, beneficiaries will usually have a single copayment rather than one for each individual observation service provided. The 2016 C-APC 8011 observation payment rate will be a $2,174.14 compared with the 2015 payment rate of $1,234.22.

The Two-Midnight Rule will Continue to Define Observation vs.  Inpatient Stays

CMS revised the “two-midnight” inpatient rule somewhat to allow for greater flexibility in determining when an admission that does not meet the two-midnight definition would be payable by allowing a physician judgment exception.  CMS confirmed that payment for some inpatient stays shorter than two-midnights in duration would be allowed under certain circumstances; however, this change will be applied on a case by case basis as determined by the physician, and subject to medical review. CMS expects this to be another “rare and unusual” exception.

Two other exceptions to this rule include “inpatient–only” procedures and specific exceptions such as the one for new onset mechanical ventilation. Although many commenters had requested that CMS rescind the two-midnight rule altogether, it declined to do so. CMS did warn that it is aware of concerns related to providers unnecessarily prolonging the duration of hospital admissions, and that it will be monitoring for such patterns of systematic delays indicative of fraud or abuse, says Granovsky.

Don’t Hold Your Breath for Chronic Care Management and Advanced Care Planning Pay

CMS will reimburse facilities for Chronic Care Management Services (CCM), as defined by the code 99490 descriptor when at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, is provided.

Payment may be made for CCM services only if a long list of conditions are met, making it very unlikely this will be typically be reported in the ED. setting. Similarly, CMS  is conditionally packaging services described by code 99497 (Advanced care planning including the explanation and discussion of advance directives such as standard forms [with completion of such forms, when performed] by the physician or other qualified health care professional; first 30 minutes, face to face with the patient, family member[s], and/or a surrogate). 

This service will be paid if it is the only service provided and reported during the encounter, which is unlikely in the ED setting. The 2016 facility payment for 99497 will be $54.41. Code 99498, each additional 30 minutes is an add-on code and not paid under OPPS, says Granovsky.