January 2020 Update of the Hospital Outpatient Prospective ...

MLN Matters MM11605

Related CR 11605

January 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS)

MLN Matters Number: MM11605 Revised

Related Change Request (CR) Number: 11605

Related CR Release Date: February 4, 2020

Effective Date: January 1, 2020

Related Transmittal Number: R4513CP & R267BP

Implementation Date: January 6, 2020

Note: We revised this article on February 4, 2020, due to an updated CR 11605. To reflect the updated CR in the article, we added Section 12.d. (Radiopharmaceuticals with Pass-Through Status as a Result of Division N, Title I, Subtitle A, Section 107(a) of the Further Consolidated Appropriations Act of 2020 (Public Law 116-94)) and Section 19 Extravascular Implantable Cardioverter Defibrillator (EV ICD). We renumbered existing Sections 12.d through 12.e. and changed Section 19 (Coverage Determinations) to Section 20. We also added Table 11 (Radiopharmaceuticals Receiving Pass-Through Status in Accordance with Public Law 116-94) and Table 14 (Extravascular Implantable Cardioverter Defibrillator (EV ICD) Effective January 1, 2020). We renumbered existing tables 11 through 13. The CR release date, transmittal numbers and link to the transmittals were also changed. All other information remains the same.

PROVIDER TYPE AFFECTED

This MLN Matters article is for institutional providers billing Medicare Administrative Contractors (MACs) for hospital outpatient services provided to Medicare beneficiaries.

PROVIDER ACTION NEEDED

CR 11605 describes changes to and billing instructions for various payment policies that Medicare is implementing in the January 2020 Outpatient Prospective Payment System (OPPS) update. Make sure your billing staffs are aware of these changes.

BACKGROUND

The January 2020 Integrated Outpatient Code Editor (I/OCE) will reflect the HCPCS, Ambulatory Payment Classification (APC), Status Indicator (SI), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in CR 11605. The CR identifies areas of key changes to billing instructions for various payment policies implemented in the January 2020 OPPS update. Those changes are as follows:

1. a. New Device Pass-Through Categories Section 1833(t)(6)(B) of the Social Security Act (the Act) requires that, under the OPPS, categories of devices be eligible for transitional pass-through payments for at least 2, but not

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more than 3 years. Section 1833(t)(6)(B)(ii)(IV) of the Act requires that we create additional categories for transitional pass-through payment of new medical devices not described by existing or previously existing categories of devices. The Centers for Medicare & Medicaid Services (CMS) is establishing five new device pass-through categories as of January 1, 2020. The following table provides a listing of new coding and payment information concerning the new device categories for transitional pass-through payment.

Table 1 ? New Device Pass-Through Codes Effective January 1, 2020

HCPCS Effectiv

Short

Code

e Date SI APC Descriptor

Long Descriptor

Orthopedic/device/d

rug matrix for

C1734

1/01/2020

H

2026

Orth/devic/drug bn/bn,tis/bn

opposing bone-tobone or soft tissue-

to bone

(implantable)

C1824

01/01/2020 H

2024

Generator, CCM, implant

Generator, cardiac contractility modulation (implantable)

Device Offset from Payment CPT 27870 -

$5,805.17

CPT 28705 $8,354.15

CPT 28715 ? $6,096.73

CPT 28725 ? $5,291.06

$13,019.03

C1839 01/01/2020 H 2028 Iris prosthesis

Iris prosthesis

C1982

01/01/2020 H

2025

Cath, pressure,valve-

occlu

Catheter, pressuregenerating, oneway valve, intermittently occlusive

C2596

01/01/2020 H

2027

Probe, robotic, water-jet

Probe, imageguided, robotic, waterjet ablation

$149.82 $2124.38

$0.00

b. Device Offset from Payment: Section 1833(t)(6)(D)(ii) of the Act requires that we deduct from pass-through payments for

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devices an amount that reflects the device portion of the APC payment amount. This deduction is known as the device offset, or the portion(s) of the APC amount that is associated with the cost of the pass-through device. The device offset from payment represents a deduction from pass-through payments for the applicable pass-through device. CMS has determined:

? The device offset amounts for APC 5115 (Level 5 Musculoskeletal Procedures) and APC 5116 (Level 6 Musculoskeletal Procedures) that are associated with the costs of the device category described by HCPCS code C1734 (Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)). The device in the category described by HCPCS code C1734 should always be billed with one of the following Current Procedural Terminology (CPT) codes: o CPT code 27870 (Arthrodesis, ankle, open) which is assigned to APC 5115 for Calendar Year (CY) 2020; o CPT code 28705 (Arthrodesis; pantalar) which is assigned to APC 5116 for Calendar Year (CY) 2020; o CPT code 28715 (Arthrodesis; triple) which is assigned to APC 5115 for Calendar Year (CY) 2020 or; o CPT code 28725 (Arthrodesis; subtalar) which is assigned to APC 5115 for Calendar Year (CY) 2020.

? The device offset amount for APC 5231 (Level 1 Implantable Cardioverter-Defibrillator (ICD) and Similar Procedures) that is associated with the cost of the device category described by HCPCS code C1824 (Generator, cardiac contractility modulation (implantable)). The device in the category described by HCPCS code C1824 should always be billed with CPT code 0408T (Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes) which is assigned to APC 5231 for Calendar Year (CY) 2020.

? The device offset amount for APC 5491 (Level 1Intraocular Procedures) that is associated with the cost of the device category described by HCPCS code C1839 (Iris prosthesis). The device in the category described by HCPCS code C1839 should always be billed with CPT code 66999 (Unlisted procedure, anterior segment of eye), which is assigned to APC 5491 for Calendar Year (CY) 2020.

? The device offset amount for APC 5193 (Level 3 Endovascular Procedures) that is associated with the cost of the device category described by HCPCS code C1982 (Catheter, pressure-generating, one-way valve, intermittently occlusive). The device in the category described by HCPCS code C1982 should always be billed with CPT Code 37243 (Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction), which is assigned to APC 5193 for Calendar Year (CY) 2020.

? The device offset amount for APC 5376 (Level 6 Urology and Related Services) that is associated with the cost of the device category described by HCPCS code C2596 (Probe, image-guided, robotic, waterjet ablation). The device in the category described by HCPCS code C2596 should always be billed with CPT code 0421T (Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including

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ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed)), which is assigned to APC 5376 for Calendar Year (CY) 2020.

Refer to for the most current device passthrough information.

c. Transitional Pass-Through Payments for Designated Devices Certain designated new devices are assigned to APCs and identified by the I/OCE as eligible for payment based on the reasonable cost of the new device reduced by the amount included in the APC for the procedure that reflects the packaged payment for device(s) used in the procedure. The I/OCE will determine the proper payment amount for these APCs as well as the coinsurance and any applicable deductible. All related payment calculations will be returned on the same APC line and identified as a designated new device. Refer to Addendum P of the CY 2020 final rule with comment period for the most current OPPS HCPCS Offset file. Addendum P is available via the Internet on the CMS website.

d. Alternative Pathway for Devices That Have a Food and Drug Administration (FDA) Breakthrough Designation For devices that have received FDA marketing authorization and a Breakthrough Device designation from the FDA, CMS provided an alternative pathway to qualify for device passthrough payment status, under which devices would not be evaluated in terms of the current substantial clinical improvement criterion for the purposes of determining device pass-through payment status. The devices would still need to meet the other criteria for pass-through status. This applies to devices that receive pass-through payment status effective on or after January 1, 2020.

2. New Separately Payable Procedure Codes a. Medical Procedures Effective January 1, 2020, new HCPCS codes C9757 and C9758 have been created as described in the following table:

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Table 2 ? New Separately Payable Procedure Codes for Medical Procedures Effective January 1, 2020

HCPCS Short Code Descriptor

Long Descriptor

APC SI

C9757 Spine/lumbar Laminotomy (hemilaminectomy), with

5115 J1

disk surgery decompression of nerve root(s), including

partial facetectomy, foraminotomy and

excision of herniated intervertebral disc, and

repair of annular defect with implantation of

bone anchored annular closure device,

including annular defect measurement,

alignment and sizing assessment, and image

guidance; 1 interspace, lumbar

Interatrial C9758 shunt ide

Blinded procedure for nyha class iii/iv heart failure; transcatheter implantation of interatrial shunt or placebo control, including right heart catheterization, trans-esophageal echocardiography (tee)/intracardiac echocardiography (ice), and all imaging with 1589 T or without guidance (e.g., ultrasound, fluoroscopy), performed in an approved investigational device exemption (ide) study

b. Blood Products

Effective January 1, 2020, new HCPCS code P9099 has been created as described in the following table:

Table 3 ? New Procedure Codes for Blood Products Effective January 1, 2020

HCPCS Code

Short Descriptor

Long Descriptor

APC SI

P9099

Blood component/product noc

Blood component or product not otherwise classified

N/A

E2

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3. Billing for Devices Under the OPPS

Effective for dates of service beginning on or after January 1, 2019, providers may bypass the claims processing edit that requires a device HCPCS for the procedure. For certain deviceintensive procedures that describe situations in which a device may not be required, providers may bypass the claims processing edits that require a device by reporting modifier "CG". In light of this policy change, we are modifying section 61.2 of chapter 4 of the Medical Claims Processing Manual, publicatioin100-04. The modified manual section is part of CR11605.

4. Comprehensive APCs (C-APCs)

a. Two New Comprehensive APCs (C-APCs) Effective January 1, 2020

Comprehensive APCs provide a single payment for a primary service, and payment for all adjunctive services reported on the same claim is packaged into payment for the primary service. With a few exceptions, all other services reported on a hospital outpatient claim in combination with the primary service are considered to be related to the delivery of the primary service and packaged into the single payment for the primary service.

Each year, in accordance with section 1833(t)(9)(A) of the Act, we review and revise the services within each APC group and the APC assignments under the OPPS. As stated in the CY 2020 OPPS/ASC final rule with comment period, as a result of our annual review of the services and the APC assignments under the OPPS, we finalized the addition of two new CAPCs under the existing C-APC payment policy effective January 1, 2020. The new C-APCs that are effective January 1, 2020, include:

? C-APC 5182 (Level 2 Vascular Procedures) and

? C-APC 5461 (Level 1 Neurostimulator and Related Procedures).

The following table lists these new C-APCs:

Table 4 -- New Comprehensive APCs for CY 2020

CY 2020 APC

5182 5461

CY 2020 APC Descriptor

Level 2 Vascular Procedures Level 1 Neurostimulator and Related Procedures

The addition of these new C-APCs increases the total number of C-APCs to 67 for CY 2020. We note that Addendum J to the CY 2020 OPPS/ASC final rule with comment period contains all the data related to the C?APC payment policy methodology, including the list of complexity adjustments and other information for CY 2019. In addition, we note that HCPCS codes assigned to comprehensive APCs are designated with status indicator "J1" in the latest OPPS Addendum B, which is available at .

b. Exclusion of Procedures Assigned to New Technology APCs from the C-APC Policy

For CY 2020, we finalized a policy to continue to exclude payment for any procedure that is assigned to a New Technology APC from being packaged when included on a claim with a "J1"

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service assigned to a C-APC. We also finalized a policy to exclude payment for any procedures that are assigned to a New Technology APC from being packaged into the payment for comprehensive observation services (C-APC 8011) assigned to status indicator "J2" when the New Technology procedures are included on a claim with "J2" procedures. We note that HCPCS codes assigned to comprehensive APCs are designated with status indicator "J1" or "J2" in the latest OPPS Addendum B, which are available at . Further information on C-APC 8011 (Comprehensive Observation Services) is in the CY 2020 OPPS/ASC final rule with comment period.

5. Changes to the Inpatient ? Only list (IPO) for CY 2020

The Medicare IPO list includes procedures that are typically only provided in the inpatient setting and therefore are not paid under the OPPS. For CY 2020, CMS is removing 11 procedures from the IPO list. The changes to the IPO list for CY 2020 are in Table 5.

Table 5 -- Changes to the IPO list for CY 2020

CY 2020 CPT Code 27130

22633

22634

CY 2020 Long Descriptor

Final Action

CY 2020 OPPS APC Assignment

Arthroplasty, acetabular and proximal femoral

Remove

prosthetic replacement (total hip arthroplasty) with or from the

without autograft or allograft

IPO

Arthrodesis, combined posterior or posterolateral

technique with posterior interbody technique including Remove

laminectomy and/ or discectomy sufficient to prepare from the

interspace (other than for decompression), single

IPO

interspace and segment; lumbar;

Arthrodesis, combined posterior or posterolateral

technique with posterior interbody technique including

laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; each additional interspace and segment (list separately in addition to code for

Remove for the

IPO

primary procedure)

5115 5115

N/A

CY 2020 OPPS Status

Indicator J1

J1

N

63265

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical

Remove from the

IPO

5114

J1

63266

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic

Remove from the

IPO

5114

J1

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CY 2020 CPT Code 63267

63268

00802

00865

00944

01214

CY 2020 Long Descriptor

Final Action

CY 2020 OPPS APC Assignment

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar

Remove from the

IPO

Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral

Remove from the

IPO

Anesthesia for procedures on lower anterior abdominal wall; panniculectomy

Remove from the

IPO

Anesthesia for extraperitoneal procedures in lower Remove

abdomen, including urinary tract; radical

from the

prostatectomy (suprapubic, retropubic)

IPO

Anesthesia for vaginal procedures (including biopsy of Remove

labia, vagina, cervix or endometrium); vaginal

from the

hysterectomy

IPO

Anesthesia for open procedures involving hip joint; total hip arthroplasty

Remove from the

IPO

5114 5114 N/A N/A N/A N/A

CY 2020 OPPS Status

Indicator J1

J1

N

N

N

N

6. Changes to Medical Review for Certain Inpatient Hospital Admissions under Medicare

Part A

For CY 2020 and subsequent years, we finalized a policy to exempt procedures that have been removed from the IPO list from certain medical review activities related to compliance with the 2-midnight rule, which states that generally services are considered appropriate for inpatient hospital admission and payment under Medicare Part A when the physician expects the patient to require a stay that crosses at least 2 midnights and admits the patient to the hospital based upon that expectation (78 FR 50913 through 50954).

Specifically, procedures that have been removed from the IPO list are not eligible for referral to Recovery Audit Contractors (RACs) for noncompliance with the 2-midnight rule within the 2calendar years following their removal from the IPO list. These procedures will not be considered by the Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs) in determining whether a provider exhibits persistent noncompliance with the 2midnight rule for purposes of referral to the RAC nor will these procedures be reviewed by RACs for "patient status" within the 2-calendar years following their removal from the IPO list. During this 2-year period, BFCC-QIOs will have the opportunity to review claims for procedures that have been recently removed from the IPO list in order to provide education for practitioners and providers regarding compliance with the 2-midnight rule, but claims identified as noncompliant with the 2-midnight rule will not be denied with respect to the site-of-service under Medicare Part A.

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