Posts Tagged MPFS
By Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS
The 2013 Medicare Physician Fee Schedule (MPFS) final rule makes several changes to the Physician Quality Reporting System (PQRS). Providers who begin reporting now in accordance with these changes stand to gain incentive payments, while those who don’t will soon suffer economic consequences.
Incentives: The Good, the Bad, and the Ugly
The Good: Successful participation in the 2013 PQRS earns providers a 0.5 percent incentive on all original Medicare Part B allowed charges billed in the reporting period (whether six or 12 months). This incentive continues through 2014.
An additional 0.5 percent incentive is also available through 2014 for eligible providers (EPs) who submit data on quality measures through a Maintenance of Certification® (MOC) program operated by a specialty body of the American Board of Medical Specialties (ABMS). In addition to reporting PQRS data successfully for one year (submitted through a MOC program), the physician must participate in and successfully complete a MOC program. Board certification status may require more frequent reporting.
The Bad: Effective Jan. 1, 2015, EPs who do not successfully report PQRS quality measures will incur a negative 1.5 percent adjustment to all professional services reimbursed under the Medicare Part B fee schedule, based on 2013 program year data, per section 3002(b) of the Affordable Care Act (ACA).
The Ugly: Beginning in 2016, the negative adjustment to payments for nonparticipating EPs increases to 2 percent.
Subtle Changes to Traditional Reporting
The first step to successful PQRS participation is choosing “how” to report quality measures. An EP has two options: Either as an individual or as a group practice under the Group Practice Reporting Option (GPRO).
The 2013 MPFS final rule expands the definition of “group practice” from 25 or more EPs to two or more National Provider Identifiers (NPI) assigned to a single Tax Identification Number (TIN). Participation in the GPRO requires self-nomination. For 2013, GPRO reporters have until Oct. 15, 2013 to select and change their initial reporting method.
Individual EP Reporting of Individual Measures
EPs choosing to report as individuals must decide if they will report on individual measures or measures groups. Self-nomination is not required if an EP chooses individual reporting, regardless of the method of measure submission.
As shown in Table A on the next page, EPs choosing to report individual measures under their individual NPI may still choose from the following reporting mechanisms:
- Qualified direct electronic health record (EHR)
- Qualified EHR data submission vendor
Per the final rule, published in the Federal Register last Nov. 16, there are 259 measures for 2013, including 241 reportable through claims or registries.
Aligning Quality Initiatives
There are a number of quality improvement initiatives running concurrently that affect physician payments under Fee-for-Service Medicare, including the EHR incentive programs, Million Hearts Campaign, eRx program, Medicare Shared Savings Program (MSSP), and more. The 2013 MPFS final rule outlines PQRS changes intended to align quality-reporting requirements across these programs, thereby making it easier for EPs to earn incentives.
“We believe that alignment of CMS quality improvement programs will decrease the burden of participation on physicians and allow them to spend more time and resources caring for beneficiaries.”
— 2013 Medicare Physician Fee Schedule Final Rule
In 2012, the Centers for Medicare & Medicaid Services (CMS) began offering EPs attesting to meaningful EHR use the ability to “pilot” PQRS clinical quality measures reporting on the same sample of beneficiaries used for pursuing an EHR incentive payment. To participate in the EHR pilot program, EPs must indicate this intention through their meaningful use incentive program attestation.
As shown in Table B on the next page, EPs may choose to report the same six clinical quality measures for PQRS incentive purposes as they are reporting for meaningful EHR use. The six measures must include three core or alternate core EHR clinical quality measures and three additional EHR incentive program clinical quality measures. The clinical quality measures must be reported through direct EHR submission, or via a qualified data submission vendor. The pilot effectively allows “double dipping,” as EPs are able to capture one set of measures for use across two separate CMS quality incentive programs.
An EP choosing the EHR pilot must report on a full year of quality data and must be in his or her second year of meaningful use.
Individual EP Reporting of Measures Groups
EPs who opt for measures groups may submit through claims or a registry. A significant change to measures group reporting is the reduction of the patient sample threshold to 20 Medicare Part B FFS beneficiaries (down from 30).
There are 22 measures groups for 2013, including a new measures group for oncology, focused on measurement of breast and colon cancer screening. The community acquired pneumonia (CAP) measures group was retired. The final measures groups are:
- Diabetes Mellitus
- Chronic Kidney Disease
- Coronary Artery Bypass Graft (CABG)
- Preventive Care
- Rheumatoid Arthritis
- Perioperative Care
- Back Pain
- Coronary Artery Disease (CAD)
- Heart Failure
- Ischemic Vascular Disease (IVD)
- Hepatitis C
- Chronic Obstructive Pulmonary Disease (COPD)
- Sleep Apnea
- Irritable Bowel Disease (IBD)
- Cardiovascular Prevention
CMS also finalized its intent to add Osteoporosis, Total Knee Replacement, Radiation Dose Optimization, and Preventive Cardiology as measures groups for reporting in 2014.
Group Practice Reporting
CMS finalized the proposal for groups of two or more NPIs to nominate and report under GPRO for 2013 quality reporting, providing greater opportunity for smaller clinics to participate in “system-based” reporting. Group practice size is determined during the active participation of reporting and not at the time of nomination.
Groups of two to 24 EPs looking to self-nominate under the GPRO must report on at least three measures through a registry on at least 80 percent of all Medicare FFS patients seen during the reporting period. The more common “web interface” reporting methodology associated with GPRO (more detail below) is not designed for smaller groups. CMS will not assign beneficiaries to groups of two to 24 that opt for GPRO reporting in 2013.
Registry reporting is a new reporting option for groups of 25-99 and 100+ EPs participating in GPRO for 2013. CMS will post a comprehensive list of quality registries on its website by summer 2013. When the registry reporting mechanism is selected, groups will choose three measures and report on 80 percent of all Medicare Part B FFS patients seen during the reporting period (Jan. 1, 2013 to Dec. 31, 2013).
Web interface is an alternative reporting mechanism with the number of assigned beneficiaries adjusted respective to group size. Groups of 25-99 will be assigned a Medicare patient sample of 218. Groups of 100 or more EPs will be assigned 411 patients. To continue alignment with other quality initiatives, CMS has adopted the Medicare Shared Saving Program (MSSP) method of patient assignment and sampling (For additional information on the MSSP program, go to www.federalregister.gov/articles/2011/11/02/2011-27461/medicare-program-
medicare-shared-savings-program-accountable-care-organizations). If either group fails to meet the sample threshold, they must report on 100 percent of the patient sample.
Regardless of size, if a group has chosen the web interface methodology, it must report on all 22 quality measures and seven disease modules: Care Coordination/Patient Safety, Preventive Care, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Hypertension, and Ischemic Vascular Disease.
If EPs are actively participating in a CMS Accountable Care Organization (ACO), they must report clinical quality measures through the GPRO web interface according to the ACO reporting criteria; they would not self-nominate for PQRS reporting through GPRO.
As CMS takes continued steps toward the public reporting of clinical quality data, EPs who actively report PQRS measures through the GPRO mechanism in 2013 will have their group level performance data posted on the Physician Compare website (www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/PhysicianReview-ICN904144.pdf).
There’s Still Time to Act
Through the final rule, CMS offers opportunities for EPs to successfully avoid the negative adjustment in 2015 and to prepare for the impact of the Value-based Payment Modifier, a provision of the ACA also mandated for implementation in 2015 (You can find additional information on the VBM at: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ValueBasedPaymentModifier.html).
Avoiding the PQRS Negative Adjustment
CMS is offering a temporary, less stringent data submission methodology for 2013, created to assist EPs in avoiding the 2015 PQRS negative adjustment. Unlike traditional clinical quality reporting, this methodology does not require EPs to submit any clinical quality data codes on Medicare Part B claims. Instead, CMS will analyze administrative claims data for 14 preventive and chronic care measures.
If EPs opt for the administrative claims methodology, they are required to self-nominate on the CMS website beginning summer 2013 (and no later than Oct. 15, 2013). Choosing the administrative claims option provides a mechanism for EPs to avoid the negative adjustment in 2015, but does not satisfy the reporting requirements for the PQRS incentive in 2013.
CMS provides EPs with three options for avoiding the 2015 PQRS payment adjustment:
- Satisfactorily report and earn the 2013 incentive of 0.5 percent.
- Report one valid measure or measures group using a traditional reporting methodology of claims, registry, or EHR.
- Self-nominate for analysis by CMS under the administrative claims-based reporting methodology.
The Push for Better Care and Outcomes
CMS has moved again to better align quality-reporting requirements in an effort to minimize duplication and administrative burden and, ultimately, to increase participation rates. CMS will continue to modify and evolve quality initiatives like PQRS to collect accurate and meaningful data that will empower physicians, health care systems, and patients through information for the purpose of affecting overall care delivery and outcomes, and to influence the shift of paying for “value” vs. “volume.”
Penny Osmon Bahr, BA, CPC, CPC-I, CHC, PCS, is director of health care solutions and specializes in health care reimbursement and practice management. She has more than 18 years of health care experience with a strong background in Medicare compliance, coding and billing, regulatory interpretation, curriculum development, and health information management (HIM). Ms. Osmon Bahr provides strategic guidance and solutions for revenue cycle, ICD-10, risk management, and HIM for health care clients throughout Wisconsin and the Midwest, emphasizing waste reduction, risk mitigation, and quality improvement. She is an author and speaker. Ms. Osmon Bahr is a founding member of the Wisconsin ICD-10 task force (WICD-10), sits on the HIMSS national ICD-10 Task Force, and is a member of the Medical Group Management Association.
April 1st, 2013
A physical therapy (PT) operation in Tennessee has agreed to pay the federal government for medically unnecessary services.
Therapists have struggled with payment policies over the last three decades as legislative efforts have employed methods that “supposedly” aim to bring the cost of services down by paying for the quality, rather than quantity, of care. Lynn S. Berry, PT, CPC, said “Therapists must juggle clinical concerns with documentation burdens to meet the challenge” of reimbursement.
While most therapists are meeting these challenges, a few have bent under the pressure of lowered payments. For example, Grace Healthcare, LLC and its affiliate Grace Ancillary Services, LLC (Grace) in Chattanooga, Tenn. On March 8, the Department of Justice (DOJ) and Office of Inspector General (OIG) announced that Grace’s therapy providers agreed to pay $2.7 million, plus interest, to resolve allegations of false billing for medically unnecessary therapy services.
According to the DOJ press release:
“The settlement resolves claims that in ten nursing home facilities in which Grace provided physical, occupational, and speech therapy for periods ranging from 2007 through June of 2011, Grace pressured therapists to increase the amount of therapy provided to patients in order to meet targets for Medicare revenue that were set without regard to patients’ individual therapy needs and could only be achieved by billing for a large amount of therapy per patient.”
Don’t let this happen to you. While waiting for more positive changes in the reimbursement system, there are things therapists can do to improve the current situation.
Properly Document when Using New G Codes and Severity Modifiers
To ensure you are compliant when rendering PT services, Berry’s recommendation is to “provide an audit trail by documenting in the medical record the G codes and severity modifiers, their rationale for use, and the pertinent tests provided. After the primary impairment goal is reached, a secondary impairment may be noted and treatment continued until the goal for that impairment is met or final discharge occurs. The G codes and modifiers apply to all claims in which Medicare is the primary or secondary payer.” The G codes and severity modifiers for PT, occupational therapy, and speech-language pathology are noted in the 2013 Medicare Physician Fee Schedule (MPFS) Final Rule.
Will Payment Challenges Get Better for PTs?
There is positive action taking place on the horizon. According to Berry:
“For PT, the American Physical Therapy Association (APTA) is already working on a new payment system. Their draft of an Alternative Payment System (APS), or the Physical Therapy Classification and Payment System (PTCPS), was released to members for comment March 15, 2012. The CPT® Editorial Panel in Memphis, Tenn., Oct. 2-3, 2012, fully supported their efforts. A workgroup will be started that is open to all advisors to rewrite the Physical Medicine and Rehabilitation Section of CPT®. This is a two-part, per session payment system: One set of codes for evaluations, and another set of per-session codes for treatments. Each combines consideration of the complexity of the visit and the severity or complexity of the patient’s condition. APTA expects this system to begin Jan. 1, 2015.”
When that system goes into effect, “therapists can then move forward to provide efficient, effective care for their patients and meet the challenge of high quality care at reasonable cost,” said Berry.
For more information on capturing proper reimbursement for therapy services, read the articles “Therapy Services: The Uphill Climb to Better Codes and Reimbursement” and “PTs Rise to 2013 G code Challenge” in March 2013 Cutting Edge.
March 14th, 2013
Follow physical therapy service requirements for new G code and modifier reporting.
By Lynn S. Berry, PT, CPC
A new, claims-based collections system implemented through the 2013 Medicare Physician Fee Schedule (MPFS) Final Rule calls for adding non-payable G codes with additional severity modifiers on each therapy claim—along with the normal charges and therapy modifiers and applicable Physician Quality Reporting System (PQRS) codes and modifiers.
Rule of Thumb for G Code Use
In the final rule, the Centers for Medicare & Medicaid Services (CMS) instructs us to use G codes and severity modifiers during:
- The initial treatment
- Defined progress periods
- Any subsequent evaluation or re-evaluation
- The end of care (or discharge)
- When reporting of the primary functional limitation has ended with further therapy required
- When reporting begins on a different or subsequent functional limitation
G codes signify the patient’s primary impairment as determined by the therapist. The therapist determines the severity by using a standard set of functional outcome measures denoted by a severity modifier added to the G codes. A G code with a severity modifier is also required for the projected outcome of the patient (the patient’s goal).
The measures for both the goal and the initial level of impairment should be noted in the patient’s plan of care; the goal and current level of impairment should be noted in progress reports no later than every 10 treatment days (a new definition of progress report time frames); and the goal and final level of impairment should be noted in the discharge note or when the goal is reached. For most claims, two G codes are required, with two exceptions:
- When therapy services are under multiple plans of care (physical therapy (PT), occupational therapy (OT), and/or speech-language pathology (SLP)) from the same therapy provider; or
- When it is a one-time visit and all three G codes (current status, goal status, and discharge status) must be reported.
Know Therapy G Codes and Severity Modifier Requirements
To provide an audit trail, the G codes and severity modifiers, their rationale for use, and the pertinent tests provided need to be documented in the medical record. After the primary impairment goal is reached, secondary impairments may be noted and treatment continued until the goal for that impairment is met or final discharge occurs. The G codes and modifiers apply to all claims in which Medicare is the primary or secondary payer. The G codes and severity modifiers for PT, OT, and SLP are noted in the final rule (and shown in Table A).
Select only one impairment as primary. If a specific category does not apply, or if using a composite functional measurement tool, select the “other” category. Each impairment category has three applicable codes.
Note: The SLP G codes are aligned with their functional reporting system, the National Outcomes Measurement System (NOMS). For SLP, the “other” category is used for any of the eight remaining NOMS categories not specified in the rule.
Table A: G codes for 2013
||Mobility: Walking and Moving Around
||Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals
||Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
||Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting
||Changing and Maintaining Body Position
||Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals
||Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
||Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting
||Carrying, Moving, and Handling Objects
||Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals
||Carrying, moving & handling objects functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
||Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting
||Self care functional limitation, current status, at therapy outset and at reporting intervals
||Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
||Self care functional limitation, discharge status, at discharge from therapy or to end reporting
||Other PT/OT Primary Functional Limitation
||Other physical or occupational primary functional limitation, current status, at therapy episode outset and at reporting intervals
||Other physical or occupational primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
||Other physical or occupational primary functional limitation, discharge status, at discharge from therapy or to end reporting
||Other PT/OT Subsequent Functional Limitation
||Other physical or occupational subsequent functional limitation, current status, at therapy episode outset and at reporting intervals
||Other physical or occupational subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
||Other physical or occupational subsequent functional limitation, discharge status, at discharge from therapy or to end reporting
||Swallowing functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
||Swallowing functional limitation, projected goal status, at initial therapy treatment/outset and at discharge from therapy
||Swallowing functional limitation, discharge status, at discharge from therapy/end of reporting on limitation
||Motor speech functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
||Motor speech functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy
||Motor speech functional limitation, discharge status at discharge from therapy/end of reporting on limitation
||Spoken Language Comprehension
||Spoken language comprehension functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
||Spoken language comprehension functional limitation, projected goal status at initial therapy treatment/outset and at discharge
||Spoken language comprehension functional limitation, discharge status at discharge from therapy/end of reporting on limitation
||Spoken Language Expression
||Spoken language expression functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
||Spoken language expression functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy
||Spoken language expression functional limitation, discharge status at discharge from therapy/end of reporting on limitation
||Attention functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
||Attention functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy
||Attention functional limitation, discharge status at discharge from therapy/end of reporting on limitation
||Memory functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
||Memory functional limitation, projected goal status at initial therapy treatment/outset and at discharge
||Memory functional limitation, discharge status at discharge from therapy/end of reporting on limitation
||Voice functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
||Voice functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy
||Voice functional limitation, discharge status at discharge from therapy/end of reporting on limitation
||Other SLP Functional Limitation
||Other speech language pathology functional limitation, current status at time of initial therapy treatment/episode outset and reporting intervals
||Other speech language pathology functional limitation, projected goal status at initial therapy treatment/outset and at discharge from therapy
||Other speech language pathology functional limitation, discharge status at discharge from therapy/end of reporting on limitation
Table B: Severity modifiers for reporting therapy G codes
||Impairment Limitation Restriction
||0 percent impaired, limited or restricted
||At least 1 percent but less than 20 percent impaired, limited or restricted
||At least 20 percent but less than 40 percent impaired, limited or restricted
||At least 40 percent but less than 60 percent impaired, limited or restricted
||At least 60 percent but less than 80 percent impaired, limited or restricted
||At least 80 percent but less than 100 percent impaired, limited or restricted
||100 percent impaired, limited or restricted
The severity/complexity modifiers for reporting each functional G code on the claim are shown in Table B.
Here is an example of how to use G codes on a claim:
A 66-year-old patient presents at the clinic and receives a full initial evaluation, including specific impairment and functional measures testing and administration of three PQRS outcome measures: falls, body mass index, and pain level. A plan of care is developed (with specific goals based on the patient’s impairments, co-complexities, and severity) to submit to the physician for certification. Treatment is initiated as specified in the plan. Documentation is completed, and includes all of the tests and measures used and the rationale for the treatment and severity modifier chosen. G codes and modifiers are added to the documentation. The claim is filed for the patient for the date of service with the following entries:
97001 GP X1 $XX.00
97112 GP X1 XX.00
97116 GP X1 XX.00
G8978 GPCL 0.00
G8979 GPCI 0.00
Note: Modifier GP Services delivered under an outpatient physical therapy plan of care (or “other therapy” modifier) must be added to the data codes because they are always therapy codes. The order does not matter when assigning the therapy or severity modifier. Therapy modifiers are not required to be added to PQRS codes. Neither modifier KX Requirements specified in the medical policy have been met nor modifier 59 Distinct procedural service can be used with these G codes. These codes are not only added for 2013, but CMS notes they will continue to require data code submission until a new payment system is developed.
Lynn Berry, PT, CPC, had over 35 years of clinical and management experience before beginning a new career as a coder and auditor and later becoming a provider representative for a Medicare carrier. She now has her own consulting firm, LSB HealthCare Consultants, LLC, furnishing consulting and education to diverse providers, and is a senior coder and auditor for the Coding Network. Berry has held a variety of offices for her local AAPC chapter and continues as one of the directors of the St. Louis West Chapter.
March 1st, 2013
By Denise Williams, RN, CPC-H
CMS estimates an “overall” rate increase, but changes cost methodology.
In the 2013 Outpatient Prospective Payment System (OPPS) final rule, the Centers for Medicare & Medicaid Services (CMS) bases payments on claims data submitted by hospital providers during 2011. CMS is changing the calculation based on median cost to geometric mean cost, citing this methodology will result in payment rates more accurately reflecting the cost of providing services. CMS believes this means improved data under the OPPS, and improved payment policy. CMS notes there will be some fluctuation in the relative weights used for calculating payment, but as the costs are realigned, the fluctuations should stabilize over time.
Understand the Master Plan
CMS estimates payments under the OPPS will increase overall by 1.8 percent compared to 2012 (see Chart A for a six-year conversion factor history); however, there continue to be other factors involved that will affect payments. Payments to community mental health centers (CMHC) will decrease by 3.9 percent due to the relative weight being based on geometric mean cost rather than median cost.
The payment adjustment for dedicated cancer centers will continue for calendar year 2013. Because these centers provide cutting edge therapies and procedures, their cost is higher on average than other facilities. CMS recognizes this, and the adjustment is to offset their higher-than-usual cost. Since the OPPS contains a budget neutral requirement, CMS must shift monies from other facilities to the cancer centers to make the adjustment.
CMS reviewed comments regarding intraoperative radiation therapy (IORT) services represented by CPT® codes 77424 Intraoperative radiation treatment delivery, X-ray, single treatment session and 77425 Intraoperative radiation treatment delivery, electrons, single treatment session. These services are not the typical intraoperative services considered integral to or dependent on the surgical procedure because these are actual radiation therapy services provided while a patient is in the operative suite. These services will no longer be packaged for 2013 and are assigned to Ambulatory Payment Classification (APC) 0412.
It appears CMS has abandoned the establishment of national guidelines for reporting visits under the OPPS. The final rule notes, “it would be disruptive and administratively burdensome” to require hospitals that have successfully implemented internal guidelines to implement new national guidelines. CMS acknowledges new guidelines would have to be implemented by thousands of hospitals and inevitably create new problems that would need to be addressed.
You can download the CMS display copy of the rule and all addenda. Select CMS-1589-FC to download the final rule: “Hospital Outpatient Prospective Payment – Final Rule with Comment Period and CY 2013 Payment Rates.”
Composite APCs Remain the Same
No new composite APCs were created for 2013; however, new CPT® codes have been established to combine electrophysiological (EP) evaluations with ablations and have been assigned to the composite APC. Previously, composite payment was triggered when an EP evaluation and ablation were reported on the same date of service, so the cost for both studies was included in the payment calculation. Assigning new CPT® codes for the combination services to the composite APC should maintain consistent payment rates.
Outlier Fixed-dollar Thresholds Updated
CMS annually updates the formula for calculating outlier payments. Consistent with prior years, for 2013 an outlier payment will be triggered when costs for providing a service or procedure exceed both:
- 1.75 times the APC payment amount; and
- APC payment plus the $2,025 fixed-dollar threshold (increased $125 from 2012).
Two-times Rule Violations: Resolutions and Exemptions
During the Hospital Outpatient Payment (HOP) Panel’s (formerly called the APC Panel) February 2012 meeting, information was presented regarding the resource expenditures involved in a direct referral for observation services. CMS analyzed claims data and agreed with the information presented: The resources involved with HCPCS Level II G0379 (*Direct referral for observation services) are very similar to the resources expended for CPT® 99205 (**Level 5 outpatient visit). Based on this data, CMS has reassigned G0379 to APC 0608; this change also resolves the longstanding “two times rule” violation. This change will also provide more appropriate payment when the criteria for composite APC 8002 are not met.
Seventeen APCs have been deemed exemptions from the two-times rule for 2013, based on meeting CMS’ criteria for exceptions (resource homogeneity; clinical homogeneity; hospital outpatient setting utilization; volume of services; opportunity for upcoding and code fragments). A complete discussion of these criteria can be found in the April 7, 2000 OPPS final rule (65 FR 18457 and 18458).
Radioisotope Add-on Payment
The U.S. government and the International Atomic Energy Agency (IAEA) are promoting the conversion of all medical radioisotope production to non-highly enriched uranium (non-HEU) fueled nuclear reactors. This transition is expected to be completed in five years. Alternative methods for producing Tc-99m, such as in cyclotrons, are expected to apply costs in the OPPS that are not accounted for in current or previous claims data. Suppliers of these radioisotopes are expected to pass on the full impact of these costs to hospitals. CMS believes this will create significant payment discrepancies for hospitals due to factors that are over and above the norm.
CMS has created a new HCPCS Level II code, Q9969 Tc-99m from non-highly enriched uranium source, full cost recovery add-on per study dose, to provide an add-on payment to cover additional cost as these sources become available, rather than waiting until the cost is reflected in the claims data. The add-on payment will change as the use becomes more widespread and is included in the rate setting claims data. As these isotopes become more widely used, the cost will fold into the procedure, just as costs for established radiopharmaceutical sources do currently.
Pass-through Payment Changes
Three devices are eligible for pass-through payment in 2013: HCPCS Level II codes C1830 Powered bone marrow biopsy needle; C1840 Lens, intraocular (telescopic); and C1886 Catheter, extravascular tissue ablation, any modality (insertable). Edits will continue for device/procedure reporting and radiopharmaceutical/nuclear medicine procedures.
Reporting of modifiers FB Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples) and FC Partial credit received for replaced device continues to be mandated by CMS for 2013. These modifiers indicate a device was received at no cost or at a discounted cost from the manufacturer and triggers a reduced APC payment. The APCs for which these modifiers apply are listed in Tables 29 and 30 of the OPPS final rule.
Pass-through status for 23 drugs and biologicals expired Dec. 31, 2012. These are listed in Table 31 of the final rule. The cost of two of these drugs is above the packaging threshold, which is $80 for 2013, and separate payment will continue. There are 26 drugs and biologicals designated for pass-through status for 2013. These drugs are listed in Table 32. There are HCPCS Level II code changes for several of these drugs; for example, C9289 is replaced by J9019 Injection, asparaginase (erwinaze), 1000 iu beginning Jan. 1, 2013.
Payment for all separately-payable drugs (with or without pass-trhough status) for 2013 will be made at average sales price (ASP) plus 6 percent. The packaging threshold applies to all classes of drugs, including anticancer therapies.
Number of Inpatient-only Procedures Reduced by One
Despite commenters’ requests that 39 procedures be removed from the list for 2013, only one procedure—CPT® 22856 Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), single interspace, cervical—was removed from the inpatient-only list. CMS noted the procedures not removed from the list were reviewed, and safe performance can be accomplished only in the inpatient setting. Table 45 provides the specifics regarding the single procedure removed, its corresponding CPT® code, and APC assignment.
Supervision for Outpatient Therapeutic Services
CMS extended through 2013 the enforcement of direct supervision for therapeutic services provided in critical access hospitals (CAHs) and small rural hospitals with 100 beds or fewer. In the final rule, CMS notes this will be the final year for the extension.
The HOP Panel received requests for change in supervision levels at both meetings held during 2012. The latest requests were reviewed during the August 2012 meeting and recommendations were made to CMS. Comments were accepted and are in the review process. The final decision will be issued prior to January 2013. The final decisions for change in supervision levels can be found on the CMS website.
Hospital Quality Reporting Program
No new quality measures were established for 2013, and one was removed. CMS policy of reducing payment to hospitals that fail to meet quality reporting requirements will continue at 2 percent for 2013. This reduction extends to the beneficiary and secondary payer payments, as well. CMS will again use a separate conversion factor to apply these reduced payments.
Short Stay Billing Under Part B – Demonstration Project
A new demonstration project has been initiated and is expected to last over the next three years. Titled the “Medicare Part A to Part B Rebilling (AB Rebilling) Demonstration,” this project is in response to hospital comments that staffing restrictions prevent all short stay admissions from being reviewed while the patient is still in-house. Based on the requirements for reporting Condition Code 44, if the patient has been discharged, the hospital has no means to change the status from inpatient to outpatient. Under the demonstration project, when the recovery audit contractor (RAC), Medicare audit contractor (MAC), or Comprehensive Error Rate Testing (CERT) contractor denies the short stay claim on the basis that an inpatient admission was not reasonable and necessary, participating hospitals can rebill the claims under Part B and receive 90 percent of allowable Part B payment for these Part A short stays. Medicare beneficiaries are protected from any adverse impacts based on Part B rebilling.
CMS published updates for therapy services in the 2013 Medicare Physician Fee Schedule final rule. Over the past couple of years, CMS has noted they are required to implement a claims-based methodology for therapy services to reform the payment system in the future. To move in that direction, the new guidance initiates the capture of data that has never been reported via a claim. New HCPCS Level II G codes and modifiers have been created to reflect the complexity of service and severity of illness related to beneficiary condition, services furnished, and final outcome. It is imperative that therapy departments review the requirements. Documentation and correct reporting of services are crucial.
* The definition provided in this article for G0379 is not the HCPCS Level II definition, “Direct admission of patient for hospital observation care.” The definition “Direct referral for observation services” was used purposefully because CMS has repeatedly noted that observation is an OP service and “admission” infers IP admission. CMS has publically stated that “referral” is more appropriate.
** The definition provided in this article for CPT® 99205 is the short definition that hospitals use and will recognize. The full definition is for physicians, not hospitals.
Denise Williams, RN, CPC-H, is the senior vice president for Health Revenue Assurance Associates, Inc. She has been involved with APCs since their initiation. Ms. Williams has worked as corporate chargemaster manager for two health care systems and is heavily involved in compliance and coding/billing edits and issues.
January 1st, 2013
By G. J. Verhovshek, MA, CPC
You’ve probably heard of the “multiple procedure rule,” which reduces Medicare payment by 50 percent for the second and subsequent procedures provided to a single patient by the same physician on the same day. But did you know that a modified version of the multiple procedure rule may apply when reporting two or more endoscopic procedures?
All in the Family
CPT® and the Centers for Medicare & Medicaid Services (CMS) classify endoscopic procedure codes by “family,” where each family is comprised of related services. Each family has a “parent” code—called the endoscopic base code—representing the most basic version of that endoscopic service.
Usually, the base code is the first-listed code within a sequence of codes in CPT®. For example, consider this partial code family:
45300 Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
45303 with dilation (eg, balloon, guide wire, bougie)
45305 with biopsy, single or multiple
45307 with removal of foreign body
In this case, 45300 describes the most basic version of the service. Codes 45303, 45305, 45307, etc., include the work of 45300, plus any additional work in the code descriptor.
A no fail way to find the endoscopic base code within each family is to consult the most recent Medicare Physician Fee Schedule (MPFS) Relative Value File. This file is updated at least annually (and often several times per year), and can be downloaded from the CMS website.
The column labeled “ENDO BASE” will tell you the parent code for every endoscopic procedure. If there is no code in the “ENDO BASE” column, the code in column “A” is the base code (or the code in column “A” is not an endoscopic procedure). You can confirm the multiple-scope rule applies to a given code if you find a “3” in the “MULT PROC” column.
Apply Multiple Scope Rule
At its most basic, the multiple scope rule requires you to always bundle diagnostic endoscopy with any surgical endoscopy within the same family. For example, if a surgeon performs diagnostic sigmoidoscopy (45330 Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)) followed by sigmoidoscopy with control of bleeding (45334 Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)), you may report only 45334 because the endoscopic control of bleeding includes the work of a diagnostic endoscopy, 45330.
When a physician performs two endoscopic procedures in the same family, and neither procedure represents the base procedure, you may report both codes. Medicare payers will reimburse the most extensive (i.e., highest-valued) endoscopy at full value, and will reimburse any additional endoscopies in the same family by subtracting the value of the base endoscopy and paying the difference.
As an example, a surgeon performs sigmoidoscopy with tumor removal by hot forceps (45333 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery), followed by medically-necessary removal of polyps by snare technique (45338 Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique). Because neither endoscope is the base procedure, you may report both procedures. Medicare will reimburse the more extensive procedure (45338, with 9.66 fully implemented non-facility relative value units (RVUs)) at full value. Medicare will also pay the value of the second scope, minus the value of the base procedure. In this case, the secondary scope, 45333, has 9.0 RVUs, from which we must subtract the 4.23 RVUs assigned to the endoscopic base code 45330.
No Relation = No Multiple Scope Deduction
The multiple endoscopy rule applies only when the physician performs two or more endoscopies in the same family. You don’t need to worry about the rule if the physician performs multiple endoscopies from different code families. For example, if a surgeon performs flexible sigmoidoscopy with single biopsy (45331 Sigmoidoscopy, flexible; with biopsy, single or multiple) and esophagoscopy with biopsy (43202 Esophagoscopy, rigid or flexible; with biopsy, single or multiple) during the same session, you may report each separately without payment reduction because these scopes are not part of the same code family (the base code for 45331 is 45330, while the base code for 43202 is 43200 Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)).
G.J. Verhovshek, MA, CPC, is managing editor at AAPC.
December 1st, 2012
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