Pulmonology Coding Alert
HCFA Launches Hospital OPPS
OPPS is an attempt to switch from a cost-based reimbursement system to one based on predetermined payment rates for outpatient services. The payments will be based on the ambulatory payment classification (APC) system, which divides all outpatient services included in the new payment schedule into 451 groups. The major thrust driving OPPS comes from the Balanced Budget Act of 1997, although a number of implementation adjustments resulted from the Balanced Budget Refinement Act of 1999.
OPPS will cover all Medicare-participating hospitals and community mental-health centers that provide partial hospital services to Medicare beneficiaries. As well, OPPS payments will be made for most hospital outpatient services and Medicare B services furnished to hospital inpatients who have no Part A coverage. Currently exempt are critical access and Indian Health Service hospitals as well as hospitals in Maryland.
HCFA, in its instructional material regarding OPPS and APCs to physicians, lists new technologies that might be reimbursable under OPPS as a matter of national policy. Of particular interest to pulmonologists are the following codes: G0125 (PET lung imaging of solitary pulmonary nodules, using 2-[fluorine-18]-fluoro-2-deoxy-d-glucose [FDG], following CT [71250/71260 or 71270]) and G0126 (PET lung imaging of solitary pulmonary nodules, using 2-[fluorine-18]-fluoro-2-deoxy-d-glucose[FDG], following CT [71250/71260 or 71270]; initial staging of pathologically diagnosed non-small cell lung cancer). These procedures currently are not eligible for coverage on a national basis, but HCFA expects OPPS to cover them when it finally becomes effective.
Editors note: Check http://www.hcfa.gov/, the HCFA internet site, for late-breaking news.
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