Inpatient Facility Coding & Compliance Alert

Take a sneak peek at the three codes that concern you. 

 In 2015, you can wipe two cervical and lumber hemilaminectomy codes off your inpatient-only code list.

Here’s why: On Nov. 10, CMS released its final rule with comment period that revises Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2015. This final rule will be effective from January 1, 2015.

Background: CMS designates a set of procedures as inpatient-only, meaning CMS will only pay for the procedure when it is performed in the inpatient setting. The agency reviews the list each year and makes changes based on provider requests and its own medical experts’ recommendations. 

“While the existence of this listing is sometime challenged, CMS is adamant in maintaining the listing”, says Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA.. He further adds that “the main argument against this listing is that the decision to perform a given procedure on an inpatient basis is really a clinical decision that should not be driven through payment restrictions.”

The changes: For 2015, CMS removed these procedures from the inpatient-only list:

• 63043 – Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure)

• 63044 – Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure)
  

Rationale: The committee of experts believes that 63043 and 63044 “can be safely performed in the outpatient setting. Therefore, we are removing CPT® codes 63043 and 63044 from the inpatient only list. Because CPT® codes 63043 and 63044 are add-on codes, they are being assigned status indicator ‘N’ for CY 2015,” per the Federal Register, Vol. 29, No. 217. 

Moreover, 63044 will find its place in to the ASC list of covered surgical procedures for CY 2015. The final rule states that “procedure described by CPT® code 63044 would not be expected to pose a significant risk to beneficiary safety when performed in an ASC, and would not be expected to require active medical monitoring and care of the beneficiary at midnight following the procedure.”

Plus: As for 63043, the final rule mentions that a “beneficiary would generally require active medical monitoring and care at midnight following the procedure, so we are not adding it to the list of ASC covered surgical procedures.”

CMS added CPT® code 22222 (Osteotomy of spine, including discectomy, anterior approach, single vertebral segment; thoracic) to the inpatient-only list beginning Jan. 1, 2015.

Procedures on the inpatient-only list are exempt from CMS’ 2-midnight rule. CMS does not mandate any length of stay for these procedures, only that the patient was admitted and met medical necessity.

Give your feedback: You may submit your comments on above till Dec. 30th, 2014, 5 p.m. on http://www.regulations.gov.

You can refer to the OPPS final rule 2015 in the federal register available at the U.S. Government Printing Office website (www.gpo.gov/fdsys/pkg/FR-2014-11-10/pdf/2014-26146.pdf)