January 2019 Update of the Hospital Outpatient Prospective ...

[Pages:20]MLN Matters MM11099

Related CR 11099

January 2019 Update of the Hospital Outpatient Prospective Payment System (OPPS)

MLN Matters Number: MM11099 Revised

Related Change Request (CR) Number: 11099

Related CR Release Date: January 17, 2019 Related CR Transmittal Number: R4204CP

Effective Date: January 1, 2019 Implementation Date: January 7, 2019

Note: This article was revised on January 18, 2019, to reflect an updated Change Request (CR) that corrected the link to the list of drugs and biologicals with corrected payments rates in Section I.B.11.d of that CR. The transmittal number, CR release date and link to the transmittal also changed. All other information is unchanged

PROVIDER TYPES AFFECTED

This MLN Matters Article is intended for hospital outpatient facilities, physicians, providers and suppliers billing Medicare Administrative Contractors (MACs) for hospital outpatient services provided to Medicare beneficiaries.

PROVIDER ACTION NEEDED

CR 11099 describes changes to and billing instructions for various payment policies implemented in the January 2019 OPPS update. The January 2019 Integrated Outpatient Code Editor (I/OCE) will reflect the Healthcare Common Procedure Coding System (HCPCS), Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in CR 11099. Be sure your billing staffs are aware of these changes.

BACKGROUND

The January 2019 revisions to I/OCE data files, instructions, and specifications listed below are provided in CR 11068. (See the related article, MM11068, at .

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 more than 3 years. Section 1833(t)(6)(B)(ii)(IV) of the Act requires that the Centers for Medicare & Medicaid Services (CMS) create additional categories for transitional pass-through payment of new medical devices not described by existing or previously existing categories of devices.

CMS is establishing one new device pass-through category as of January 1, 2019. Table 1 provides a listing of new coding and payment information concerning the new device

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category for transitional pass-through payment.

Table 1 ? New Device Pass-Through Code Effective January 1, 2019

HCPCS Code

Effective Date

Status Indicator

(SI) APC

Short Descriptor

Long Descriptor

Device Offset from

Payment

Generator,

neurostimulator

Gen, neuro, (implantable), non-

C1823 01/01/2019

H

2993 trans

rechargeable, with $20,626.59

sen/stim

transvenous

sensing and

stimulation leads

1. b. Device Offset from Payment

Section 1833(t)(6)(D)(ii) of the Act requires that CMS deduct from pass-through payments for devices an amount that reflects the portion of the APC payment amount. CMS has determined that a portion of the APC payment amount associated with the cost of C1823 is reflected in APC 5464 (Level 4 Neurostimulator and Related Procedures). The C1823 device should always be billed with Current Procedural Terminology (CPT) Code 0424T (Insertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system (transvenous placement of right or left stimulation lead, sensing lead, implantable pulse generator)), which is assigned to APC 5464 for Calendar Year (CY) 2019. The device offset from payment represents a deduction from pass-through payments for the device in category C1823. Refer to for the most current device pass-through information.

1. c. Transitional Pass-Through Payments for Designated Devices

Certain designated new devices are assigned to APCs and identified by the 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. 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. CMS refers readers to Addendum P of the CY 2019 final rule with comment period for the most current OPPS HCPCS Offset file, available at .

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2. New Separately Payable Procedure Code

Effective January 1, 2019, new HCPCS codes C9751, C9752, C9753, C9754, and C9755 have been created as described in Table 2.

Table 2 ? New Separately Payable Procedure Codes Effective January 1, 2019

HCPCS Short Code Descriptor

Long Descriptor

APC SI

Bronchoscopy, rigid or flexible, transbronchial

ablation of lesion(s) by microwave energy,

including fluoroscopic guidance, when

performed, with computed tomography

Microwave acquisition(s) and 3-D rendering, computer-

C9751 bronch, 3D, assisted, image-guided navigation, and

1571 T

EBUS

endobronchial ultrasound (EBUS) guided

transtracheal and/or transbronchial sampling

(e.g., aspiration[s]/biopsy[ies]) and all

mediastinal and/or hilar lymph node stations

or structures and therapeutic intervention(s)

C9752

Intraosseous des lumb/sacrum

Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum

5115 J1

Destruction of intraosseous basivertebral

Intraosseous nerve, each additional vertebral body,

C9753 destruct

including imaging guidance (e.g.,

N/A

N

add'l

fluoroscopy), lumbar/sacrum (List separately

in addition to code for primary procedure)

Creation of arteriovenous fistula,

percutaneous; direct, any site, including all

Perc AV

imaging and radiologic supervision and

C9754 fistula, any interpretation, when performed and secondary 5193 J1

site

procedures to redirect blood flow (e.g.,

transluminal balloon angioplasty, coil

embolization, when performed)

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HCPCS Short Code Descriptor

Long Descriptor

APC SI

Creation of arteriovenous fistula,

percutaneous using magnetic-guided arterial

and venous catheters and radiofrequency

RF

energy, including flow-directing procedures

C9755

magneticguided AV

(e.g., vascular coil embolization with radiologic supervision and interpretation, when

5193

J1

fistula

performed) and fistulogram(s), angiography,

venography, and/or ultrasound, with radiologic

supervision and interpretation, when

performed

3. Device Intensive Procedures Effective January 1, 2019, CMS is modifying the device-intensive criteria to lower the device offset percentage threshold from greater than 40 percent to greater than 30 percent and to allow procedures that involve single-use devices, regardless of whether or not they remain in the body after the conclusion of the procedure, to qualify as device-intensive procedures. Accordingly, effective January 1, 2019, all new procedures requiring the insertion of an implantable medical device will be assigned a default device offset percentage of at least 31 percent (previously at least 41 percent), and thereby assigned device intensive status, until claims data are available. In certain rare instances, CMS may temporarily assign a higher offset percentage if warranted by additional information. In light of this policy change, CMS is modifying the Medical Claims Processing Manual, chapter 4, section 20.6.4.

4. New HCPCS Code C1890 For When No Device Is Used in ASCs for Device-Intensive Procedures Effective January 1, 2019

In the CY2019 OPPS/ASC Final Rule, CMS finalized its policy to apply the ASC deviceintensive procedure payment methodology to device-intensive procedures under the ASC payment system, when the device intensive procedure is furnished with a surgically inserted or implanted device (including single use medical devices). Because devices are packaged into the procedure payment for device-intensive procedures, and ASCs do not report packaged codes, it is necessary to implement a mechanism to report when an ASC performs a deviceintensive procedure without an implantable or inserted medical device. To implement this policy, CMS is establishing a new C-code that ASCs must report, specifically, HCPCS C1890, along with the device-intensive procedure code, to signify that the device was not furnished with the device-intensive procedure. This code is payable in the ASC setting only, and should not be reported on institutional claims by hospital outpatient department providers. Therefore, HCPCS code C1890 is assigned to SI=E1 (Not paid by Medicare when submitted on outpatient claims (any outpatient bill type)) under the OPPS. Since this HCPCS code is not included on the current 2019 Alphanumeric HCPCS release, MACs will add this code to their system. The C1890 short descriptor is: No device w/dev-

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intensive px. The long descriptor is: No implantable/insertable device used with deviceintensive procedures.

5. Three New Comprehensive APCs (C-APCs) Effective January 1, 2019

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 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, CMS reviews and revises the services within each APC group and the APC assignments under the OPPS. As stated in the CY 2019 OPPS/ASC final rule with comment period, as a result of this annual review of the services and the APC assignments under the OPPS, CMS finalized the addition of three new CAPCs under the existing C-APC payment policy, effective January 1, 2019.

The new C-APCs include: C-APC 5163 (Level 3 Ear, Nose, and Throat (ENT) Procedures), CAPC 5183 (Level 3 Vascular Procedures), and C-APC 5184 (Level 4 Vascular Procedures). A list of these new C-APCs is in the following table.

Table 3 -- New Comprehensive C-APCs for CY 2019

CY 2019 C-APC 5163 5183 5184

CY 2019 C-APC Descriptor

Level 3 ENT Procedures Level 3 Vascular Procedures Level 4 Vascular Procedures

The addition of these new C-APCs increases the total number of C-APCs to 65 for CY 2019. CMS notes that Addendum J to the CY 2019 OPPS/ASC final rule with comment period contains all of the data related to the C-APC payment policy methodology, including the list of complexity adjustments and other information for CY 2019. In addition, CMS notes that HCPCS codes assigned to comprehensive APCs are designated with status indicator J1 in the latest OPPS Addendum B, available at

6. Changes to the Inpatient-Only List (IPO) for CY 2019

The Medicare Inpatient-Only (IPO) list includes procedures that are typically only provided in the inpatient setting and therefore are not paid under the OPPS. For CY 2019, CMS is removing four procedures from the IPO list. CMS is also adding one procedure to the IPO list. The changes to the IPO list for CY 2019 are included in Table 4.

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Table 4 -- Changes to the IPO list for CY 2019

CY 2019 CPT Code

CY 2019 Long Descriptor

Action

CY 2019 OPPS APC Assignment

CY 2019 OPPS SI

31241

Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery

Removed

5153

J1

01402

Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty

Removed

N/A

N

Implantation or replacement of carotid sinus

baroreflex activation device; total system (includes

0266T generator placement, unilateral or bilateral lead

Removed

5463

J1

placement, intra-operative interrogation,

programming, and repositioning, when performed).

Anesthesia for extensive spine and spinal cord

00670 procedures (e.g., spinal instrumentation or vascular Removed

N/A

N

procedures)

Percutaneous transluminal revascularization of

acute total/subtotal occlusion during acute

myocardial infarction, coronary artery or coronary

C9606 artery bypass graft, any combination of drug-eluting Added

N/A

C

intracoronary stent, atherectomy and angioplasty,

including aspiration thrombectomy when

performed, single vessel

7. Modifier "ER"

Effective January 1, 2019, hospitals are required to report new HCPCS modifier "ER" (Items and services furnished by a provider-based off-campus emergency department) with every claim line for outpatient hospital services furnished in an off-campus provider-based emergency department. Modifier ER would be reported on the UB?04 form (CMS Form 1450) for hospital outpatient services. Critical Access Hospitals (CAHs) would not be required to report this modifier.

Modifier ER is required to be reported in provider-based off-campus emergency departments that meet the definition of a "dedicated emergency department" as defined in 42 Code of Federal Regulations (CFR) 489.24 under the Emergency Medical Treatment and Labor Act (EMTALA) regulations. Per 42 CFR 489.24, a "dedicated emergency department" means any department or facility of the hospital, regardless of whether it is located on or off the main

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hospital campus, that meets at least one of the following requirements:

a. It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department;

b. It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or

c. During the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.

In light of this policy change, CMS is creating a new section in the Medical Claims Processing Manual, chapter 4, section 20.6.18. This new manual section is attached to CR 11099.

8. Method to Control for Unnecessary Increases in Utilization of Outpatient Services/G0463 with modifier PO

For CY 2019, CMS is finalizing a policy to use its authority under section 1833(t)(2)(F) of the Act to apply an amount equal to the site-specific Physician Fee Schedule (PFS) payment rate for nonexcepted items and services furnished by a nonexcepted off-campus Provider-Based Department (PBD) (the PFS payment rate) for the clinic visit service, as described by HCPCS code G0463, when provided at an off-campus PBD excepted from section 1833(t)(21) of the Act (departments that bill the modifier "PO" on claim lines).

The PFS-equivalent amount paid to nonexcepted off-campus PBDs is 40 percent of OPPS payment (that is, 60 percent less than the OPPS rate) for CY 2019. CMS is phasing this policy in over a two-year period. Specifically, half of the total 60-percent payment reduction, a 30percent reduction, will apply in CY 2019. In other words, these departments will be paid 70 percent of the OPPS rate (100 percent of the OPPS rate minus the 30-percent payment reduction that applies in CY 2019) for the clinic visit service in CY 2019.

9. Partial Hospitalization Program (PHP)

a. Technical Change to the OPPS Revenue-Code-to-Cost-Center Crosswalk

For CY 2019 and subsequent years, hospitalbased PHPs will follow a new PHP-only RevenueCode-to-CostCenter crosswalk, which maps all PHP revenue codes to cost center 93.99 "Partial Hospitalization Program" as the primary source for the Cost-to-Charge Ratios (CCR) used in hospital-based PHP rate setting. Cost center 93.99 ("Partial Hospitalization Program") is for recording costs providing partial hospitalization programs, and became effective for hospital cost reporting periods ending on or after September 30, 2017.

The new PHP-only Revenue-Code-to-Cost Center crosswalk is available online at in the CY 2019 OPPS/ASC final rule with comment period.

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b. Updates to PHP Allowable HCPCS Codes

In the CY 2019 OPPS/ASC final rule with comment period, CMS proposed to delete six existing PHP allowable HCPCS codes (96101, 96102, 96103, 96118, 96119, 96120) and to replace them with 9 new PHP allowable codes (96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146) for APCs 5853 and 5863, as of January 1, 2019, as detailed in Table 5.

Table 5 -- Proposed CY 2019 Changes to the Allowable HCPCS Codes for PHP APCs 5853 and 5863

Existing Code 96101

96102

96103

96118

96119

96120

Proposed CY 2019 Action Delete

Delete

Delete

Delete

Delete

Delete

Proposed CY 2019 Replacement(s) Codes 96130, 96131, and may also include 96136, 96137,

96138, 96139, 96146 96130, 96131, and may also include 96136, 96137,

96138, 96139, 96146 96130, 96131, and may also include 96136 96137,

96138, 96139, 96146 96132, 96133, and may also include 96136, 96137,

96138, 96139, 96146 96132, 96133, and may also include 96136, 96137,

96138, 96139, 96146 96132, 96133, and may also include 96136, 96137,

96138, 96139, 96146

Proposed CY 2019 APC Action

Add

Add

Add

Add

Add

Add

10. Payment Adjustment for Certain Cancer Hospitals Beginning CY 2019

For certain cancer hospitals that receive interim monthly payments associated with the cancer hospital adjustment at 42 CFR 419.43(i), Section 16002(b) of the 21st Century Cures Act requires that, for CY 2018 and subsequent calendar years, the target Payment-to-Cost Ratio (PCR) that should be used in the calculation of the interim monthly payments and at final cost report settlement is reduced by 0.01. For CY 2019, the target PCR, after including the reduction required by Section 16002(b), is 0.88.

11. Drugs, Biologicals, and Radiopharmaceuticals

a. New CY 2019 HCPCS Codes and Dosage Descriptors for Certain Drugs, Biologicals, and Radiopharmaceuticals

For CY 2019, several new HCPCS codes have been created for reporting drugs and biologicals in the hospital outpatient setting, where there have not previously been specific codes available. These new codes are listed in Table 6.

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