2017 OPPS Update. Georgeann Edford RN, MBA, CCS-P Coding Compliance Solutions LLC

Transcription

1 2017 OPPS Update Georgeann Edford RN, MBA, CCS-P Coding Compliance Solutions LLC

2 Summary of Major Provisions Payment policies and rates for Outpatient Hospital and ASCs. I. Background II Summary of Adjustments III. Comprehensive APCs (C-APCs) IV. Outpatient Quality Reporting Changes V. Provider Based Departments 2 Georgeann Edford - Coding Compliance

3 Background Balanced Budget Act of 1997 added section 1833(t) to Title XVIII of the Social Security Act required annual review. Rate-per-service according to the APC group assigned to a service. Includes: Most outpatient hospital services Exclusions outlined in 42CFR Georgeann Edford - Coding Compliance

4 Restructuring APCs Annual review required of certain components of APCs to include: Revise groupings Relative payment weights Changes in medical practice and technologies and New cost data and other relevant information and factors. Changes to nine clinical families based on following: 1. Improved clinical homogeneity; 2. Improved resource homogeneity; 3. Reduce resource overlap in longstanding APCs; and 4. Greater simplicity and improved understandability of APC structure. Georgeann Edford - Coding Compliance Solutions 4

5 2017 UPDATES AFFECTING OPPS RATES 5 Georgeann Edford - Coding Compliance

6 OPPS Conversion Factor (70352) A budget neutrality adjustment factor of to ensure revisions made to the wage index and rural adjustment were made on a budget neutral. basis Estimated payments for outliers were maintained at 1.0 percent of total OPPS payments for CY 2017 Conversion Factor Updates 2017 Market Basket Update +2.7% Affordable Care Act Multifactor Productivity Reduction (MFP) -0.3% Affordable Care Act -0.75% Overall Net Update 1.65% National Unadjusted Payment Rate (Increased by 1.7%) $ Note: Hospitals that fail to meet the Hospital Outpatient Quality Reporting requirements will receive a 2.0% reduction resulting in a conversion factor of $ Georgeann Edford - Coding Compliance Solutions

7 Summary of Adjustments Partial Hospitalization: CMS performed analysis of claim and cost data for both outpatient hospital and CMHC Partial Hospitalization services which included coding practices. For 2017, combined Level 1 and 2 into a new APC for programs providing 3 or more services in a day. Cancer Hospitals: continue to provide additional payments needed to result in a payment-to-cost (PCR) equal to for each cancer hospital. Transitional pass-through payments: Temporary additional payments for at least 2 years but not more than 3 for certain for certain drugs, biological agents, brachytherapy devices used for the treatment of cancer, and categories of other medical devices Blood and Blood Products: Change from overall Hospital CCR to Blood-specific CCR. In absence of blood-specific, would apply average blood-specific CCR. Georgeann Edford - Coding Compliance Solutions 7

8 Summary of Adjustments Brachytherapy Sources: 2015 claims data was used to set 2017 rates for brachytherapy sources. Payment based on the geometric mean unit costs for each source which is consistent with other items and services paid under OPPS. (pages 86-96) Georgeann Edford - Coding Compliance Solutions 8

9 Summary of Adjustments Packaging Policies: Changing from date of service to claim level to capture all items and services during a hospital stay. (Page ) Laboratory Tests: Discontinuing use of the L1 modifier (used to identify unrelated lab tests on a claim). Expanding laboratory packaging exclusions that currently applies to molecular pathology to include lab tests that are designated as advanced diagnostic lab tests (ADLTs) that meet the criteria outlined in 1834A(d)(5)(A) of the Act. (Page ) Conditional Packaging: Several different conditional packaging status indicators. Q1, S, T V, Q2, T, Q4 and J1/J2. Change from date of service to claim; Q1 and Q2. (Pages ) Georgeann Edford - Coding Compliance Solutions 9

10 Summary of Adjustments - continued Chronic Care Management: Minor changes to certain CCM scope of service elements. See MPFS final rule for details, changes will be applied to hospital outpatients. Payment/HospitalOutpatientPPS/Downloads/Payment-Chronic- Care-Management-Services-FAQs.pdf Comprehensive APCs: (pages ) 25 C-APCs in 2015, 37 in 2016 and 25 new C-APCs added in 2017 for a total of 62 C-APCs for 1/1/2017. Georgeann Edford - Coding Compliance Solutions 10

11 C- APC CY 2017 C-APCs CY 2017 APC Title Clinical New Family C-APC 5072 Level 2 Excision/ Biopsy/ Incision and EBIDX * 5073 Level 3 Excision/ Biopsy/ Incision and EBIDX * 5091 Level 1 Breast/Lymphatic Surgery and BREAS * Related Procedures 5092 Level 2 Breast/Lymphatic Surgery and Related BREAS * Procedures 5093 Level 3 Breast/Lymphatic Surgery & Related BREAS Procedures 5094 Level 4 Breast/Lymphatic Surgery & Related BREAS Procedures 5112 Level 2 Musculoskeletal Procedures ORTHO * 5113 Level 3 Musculoskeletal Procedures Level 4 Musculoskeletal Procedures ORTHO ORTHO * 5115 Level 5 Musculoskeletal Procedures ORTHO 5116 Level 6 Musculoskeletal Procedures ORTHO 11 Georgeann Edford - Coding Compliance

12 CY 2017 C-APCs C- APC CY 2017 APC Title Clinical New C Level 3 Airway Endoscopy AENDO * 5154 Level 4 Airway Endoscopy AENDO * 5155 Level 5 Airway Endoscopy AENDO * 5164 Level 4 ENT Procedures ENTXX * 5165 Level 5 ENT Procedures ENTXX 5166 Cochlear Implant Procedure COCHL 5191 Level 1 Endovascular Procedures VASCX * 5192 Level 2 Endovascular Procedures VASCX 5193 Level 3 Endovascular Procedures VASCX 5194 Level 4 Endovascular Procedures VASCX 5200 Implantation Wireless PA Pressure Monitor WPMXX * 5211 Level 1 Electrophysiologic Procedures EPHYS 5212 Level 2 Electrophysiologic Procedures EPHYS 5213 Level 3 Electrophysiologic Procedures EPHYS 5222 Level 2 Pacemaker and Similar Procedures AICDP 5223 Level 3 Pacemaker and Similar Procedures AICDP 5224 Level 4 Pacemaker and Similar Procedures AICDP 5231 Level 1 ICD and Similar Procedures AICDP 5232 Level 2 ICD and Similar Procedures AICDP 12 Georgeann Edford - Coding Compliance

13 CY 2017 C-APCs C- APC CY 2017 APC Title Clinical Family New C- APC 5302 Level 2 Upper GI Procedures GIXXX * 5303 Level 3 Upper GI Procedures GIXXX * 5313 Level 3 Lower GI Procedures GIXXX * 5331 Complex GI Procedures GIXXX 5341 Abdominal/Peritoneal/Biliary and Related GIXXX * Procedures 5361 Level 1 Laparoscopy & Related Services LAPXX 5362 Level 2 Laparoscopy & Related Services LAPXX 5373 Level 3 Urology & Related Services UROX * 5374 Level 4 Urology & Related Services UROX * 5375 Level 5 Urology & Related Services UROX 5376 Level 6 Urology & Related Services UROX 5377 Level 7 Urology & Related Services UROX 5414 Level 4 Gynecologic Procedures GYNX * 5415 Level 5 Gynecologic Procedures GYNX 5416 Level 6 Gynecologic Procedures GYNX 13 Georgeann Edford - Coding Compliance

14 CY 2017 C-APCs C- APC CY 2017 APC Title Clinical New C-APC 5431 Level 1 Nerve Procedures NERVE * 5432 Level 2 Nerve Procedures NERVE * 5462 Level 2 Neurostimulator & Related Procedures NSTIM 5463 Level 3 Neurostimulator & Related Procedures NSTIM 5464 Level 4 Neurostimulator & Related Procedures NSTIM 5471 Implantation of Drug Infusion Device PUMPS 5491 Level 1 Intraocular Procedures INEYE * 5492 Level 2 Intraocular Procedures INEYE 5493 Level 3 Intraocular Procedures INEYE 5494 Level 4 Intraocular Procedures INEYE 5495 Level 5 Intraocular Procedures INEYE 5503 Level 3 Extraocular, Repair, and Plastic Eye EXEYE * Procedures 5504 Level 4 Extraocular, Repair, and Plastic Eye EXEYE * Procedures 5627 Level 7 Radiation Therapy RADT 5881 Ancillary Outpatient Services When Patient Dies N/A 8011 Comprehensive Observation Services N/A 14 Georgeann Edford - Coding Compliance

15 C-APC Clinical Family Descriptor Key: AENDO = Airway Endoscopy AICDP = Automatic Implantable Cardiac Defibrillators, Pacemakers, and Related Devices. BREAS = Breast Surgery COCHL = Cochlear Implant EBIDX = Excision/ Biopsy/ Incision and Drainage ENTXX = ENT Procedures EPHYS = Cardiac Electrophysiology EXEYE = Extraocular Ophthalmic Surgery GIXXX = Gastrointestinal Procedures GYNXX = Gynecologic Procedures INEYE = Intraocular Surgery LAPXX = Laparoscopic Procedures NERVE = Nerve Procedures NSTIM = Neurostimulators ORTHO = Orthopedic Surgery PUMPS = Implantable Drug Delivery Systems RADTX = Radiation Oncology SCTXX = Stem Cell Transplant UROXX = Urologic Procedures VASCX = Vascular Procedures WPMXX = Wireless PA Pressure Monitor 15 Georgeann Edford - Coding Compliance

16 Device Dependent Comprehensive APCs ( ) In CY 2014, 39 device dependent APCs were identified. For CY 2015, the device dependent APCs were consolidated into 26 of the available 28 C-APCs. Three (3) device dependent APCs remain. For CY 2016, followed the same process. CY 2017 no longer recognize device dependent APCs and instead recognize device intensive procedures based on individual HCPCS code-level device offset being greater than 40%. Established 3 criteria: 1. All procedures must involve implantable devices that would be reported if device insertion procedures were performed; 2. the required devices must be surgically inserted or implanted devices that remain in the patient s body after the conclusion of the procedure (at least temporarily); and 3. the procedure must be device-intensive; that is, the device offset amount must be significant, which is defined as exceeding 40 percent of the procedure s mean cost. Georgeann Edford - Coding Compliance Solutions 16

17 Summary of Adjustments - continued Device-Intensive Procedures: Finalized 2 policy changes for Methodology for assignment of device intensive status from the APC level to the HCPCS code level so that the status is appropriately assigned to those procedures that exceed the 40 percent threshold. 2. Payment is changing for those APCs with <100 claims from geometric mean cost of median mean cost. Calculation methodology is also changing from APC level to HCPCS code level. (Pages ) Payment Modifier for X-ray films: For all radiology services performed on or after January 1, 2017 that involved the use of x-ray film, CMS is requiring the use of the FX modifier be used to report that service. Payment for the technical portion of any radiology service involving film, that is reported appropriately with the modifier, will be reduced by 20%. (Pages ) Georgeann Edford - Coding Compliance Solutions 17

18 Summary of Adjustments - continued Inpatient Only (IPO): Procedures that are only paid if patient status is inpatient. Requires patient be admitted as an inpatient before the procedure is performed. In 2017, seven procedure removed from IPO list: 5 spine procedures 2 laryngoplasty (Pages ) Total knee arthroplasty is being considered and will most likely be taken off list next year. (Pages ) C-APC for Bone Marrow Transplants (BMT): The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself. (Pages ) Georgeann Edford - Coding Compliance Solutions 18

19 Two-midnight Rule 2016 OPPS Final Rule amended the two-midnight rule to allow the treating physician or other practitioner to use his or her judgement to make exceptions to the two-midnight rule requirement, subject to medical review by a QIO (Quality Improvement Organization) rather than a recovery audit contractor (RAC). CMS notes that stays less than 24 hours should rarely be considered inpatient stays. Medicare Outpatient Observation Notice: Requires hospitals and CAH to provide the individual patient s receiving outpatient observation services for more than 24 hours both a written notice and an oral explanation that the individual is an outpatient receiving observation services and the implication of that status. Georgeann Edford - Coding Compliance Solutions 19

20 Recalibration of APC Weights CMS goal to use the most appropriate cost information in setting the APC relative payment weights Claims Data (1/1/15 1/1/16) Construction of database. Rates for 2017 calculated using claims data from calendar year 2015 adjudicated & resolved Established the geometric mean natural cost of a single procedure claim was $55 Created pseudo single procedure claims Certain services (codes) on bypass list 194 HCPCS codes Revenue code to cost center crosswalk Hospital Specific Cost to Charge Ratios (CCR) Addendum N HCPCS codes in effect OPPS Relative Weights Composite APCs Single and Pseudo single claims Most recent cost report data Section II.A.3 20 Georgeann Edford - Coding Compliance

21 Complexity Adjustments Qualifying J1 code combinations or combinations of J1 services and certain add-on codes that are subsequent to the primary code from the originating C-APC, will receive a complexity adjustment. The complexity adjustment arises when the code combination represents a complex, costly form or version of the primary service according to the following criteria: Frequency of 25 or more claims reporting the code combination (frequency threshold); and Violation of the 2 times rule (cost threshold). Therefore, the highest payment for any code combination for services assigned to a C-APC would be the highest paying C-APC in the clinical family. Georgeann Edford - Coding Compliance Solutions 21

22 Complexity Adjustment Process Pairs of procedure codes with SI J1 meet the complexity adjustment requirement of commonly occurring and exhibiting materially greater resource requirements. If a pair of procedure codes did not meet the requirement for a materially greater resource requirement or did not occur commonly, then the pair of procedure codes were not considered to be complex, and primary service claims with that combination of procedure codes are not reassigned. All pairs of procedures described by HCPCS codes assigned to status indicator J1 for each primary service are similarly evaluated. Georgeann Edford - Coding Compliance Solutions 22

23 Complexity Adjustment The list of codes that qualify for complexity adjustments can be found in Addendum J Addendum B provides a complete listing of the CPT codes, the APC assigned and the applicable status indicator. Georgeann Edford - Coding Compliance Solutions 23

24 Outlier Payment Thresholds CY 2014 fixed-dollar threshold of $2,900 CY 2015 fixed-dollar threshold of $2,775 CY 2016 fixed-dollar threshold of $3,250 CY 2017 fixed-dollar threshold of $3,825 (page ) Georgeann Edford - Coding Compliance Solutions 24

25 Hospital Outpatient Quality Reporting (OQR) 42CFR (f)(1) outlines the process for participating in the OQR and 42 CFR (e)(2) CMS is establishing measures and policies for the CY 2018, the CY 2019 and the CY 2020 payment determination and subsequent years. Hospital results will be publicly displayed on the Hospital Compare Web site, or CMS Web site, as soon as possible after measure data have been submitted to CMS Hospitals will generally have approximately 30 days to preview their data The minimum threshold is 75%. Georgeann Edford - Coding Compliance Solutions 25

26 Hospital Outpatient Quality Reporting (OQR) For CY 2020 and subsequent years, there are a total of 7 measures: two claims-based measures 1) OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy and 2) OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687). five Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey-based measures: 1) OP-37a: OAS CAHPS - About Facilities and Staff; 2) OP-37b: OAS CAHPS - Communication About Procedure; 3) OP-37c: OAS CAHPS - Preparation for Discharge and Recovery; 4) OP-37d: OAS CAHPS - Overall Rating of Facility; and 5) OP-37e: OAS CAHPS - Recommendation of Facility Georgeann Edford - Coding Compliance Solutions 26

27 Ambulatory Surgery Centers (ASC) ASC payment update: payment increased by 1.9% for ASCs that meet the quality reporting requirements under the ASCQR. Revised process for assigning ASC payment indicators for Category I and III CPT codes by assigning the ASC payment indicator before they are used for payment purposes. ASC Quality Reporting (ASCQR) CMS will publicly display data on the Hospital Compare Web site, or other CMS Web site, as soon as possible after measure data have been submitted to CMS. ASCs will generally have approximately 30 days to preview their data The minimum threshold is 75%. Georgeann Edford - Coding Compliance Solutions 27

28 ASC Quality Reporting (ASCQR) A total of seven measures: two measures collected via a CMS Web-based tool and five Outpatient and Ambulatory Surgery Consumer Assessment of CMS-1656-FC/IFC 56 Healthcare Providers and Systems (OAS CAHPS) Survey-based measures. The two measures that are submitted directly to CMS via a CMS Web-based tool are: ASC-13: Normothermia Outcome and \ASC-14: Unplanned Anterior Vitrectomy. The five survey-based measures are: ASC-15a: OAS CAHPS About Facilities and Staff; ASC-15b: OAS CAHPS Communication About Procedure; ASC-15c: OAS CAHPS Preparation for Discharge and Recovery; ASC-15d:OAS CAHPS Overall Rating of Facility; and ASC-15e: OAS CAHPS Recommendation of Facility. Georgeann Edford - Coding Compliance Solutions 28

29 Hospital Value-Based Purchasing (VBP) Program By law, CMS is required to establish a VBP under which value-based incentive payments are made in a fiscal year to hospitals based on their performance on measures established for a performance period for such fiscal year. CMS removed the HCAHPS Pain Management dimension from the Hospital VBP Program, beginning with the FY 2018 program year. Georgeann Edford - Coding Compliance Solutions 29

30 NEW CPT AND LEVEL II HCPCS CODES 30 Georgeann Edford - Coding Compliance

31 New Code Process CPT codes (Category I and III) are established by the American Medical Association (AMA). Level II HCPCS codes are established by the CMS HCPCS Workgroup. Code changes that affect payment are updated annual rule making and are published quarterly through OPPS Change Requests(CR). Codes published in the quarterly update appear in Addendum B with the status indicator of N1 Category I CPT Codes Category III CPT Codes Level II HCPCS Codes Georgeann Edford - Coding Compliance Solutions 31

32 APC Assignment to New Codes New CPT and Level II HCPCS codes are assigned to interim status indicator (SI) and APC assignments. These interim assignments are finalized in the OPPS/ASC final rules according to the following timeframe. ASC Quarterly Update CR October 1, 2016 January 1, 2017 Type of Code Level II HCPCS Codes Effective Date October 1, 2016 Level II HCPCS Codes January 1, 2017 Category I and III CPT Codes January 1, 2017 Comments Sought CY 2017 OPPS/ASC final rule with comment period CY 2017 OPPS/ASC final rule with comment period CY 2017 OPPS/ASC proposed rule When Finalized CY 2018 OPPS/ASC final rule CY 2018 OPPS/ASC final rule CY 2017 OPPS/ASC final rule Georgeann Edford - Coding Compliance Solutions 32

33 New CPT Codes For new codes that describe wholly new services, versus revised codes that describe services for which APC and status indicator assignments are already established, CMS does not receive the new codes in time to propose payment rates in the proposed rule published in July. For the new and revised CPT codes that are publicly available and provided in time for evaluation in the CY 2017 OPPS/ASC proposed rule, APCs and SO will be assigned. For new codes that are not received in time for the proposed 2017 OPPS/ASC proposed rule, G codes, interim APCs and SI would be and the new CPT codes would be implemented the following year (2018). Georgeann Edford - Coding Compliance Solutions 33

34 Provider Based Departments PAGES Georgeann Edford - Coding Compliance

35 Background When a Medicare beneficiary receives services in an off-campus department of a hospital, there are two claims submitted to Medicare; a facility claim and a professional claim The total payment amount for the services made by Medicare is generally higher than the total payment amount made by Medicare when the beneficiary receives those same services in a physicians office. One claim is paid under the OPPS for the institutional services and one under the MPFS for the professional services furnished by a physician or other practitioner. Medicare beneficiaries are responsible for the cost-sharing liability, if any, for both of these claims, often resulting in higher total beneficiary costsharing than if the service had been furnished in a physician s office Georgeann Edford - Coding Compliance Solutions 35

36 Background Section 603 of Pub. L made two amendments to section 1833(t) of the Act one amending paragraph (1)(B) and the other adding new paragraph. The first provision adds a new clause which excludes from the definition of covered OPD services applicable items and services. The second provision defines the term applicable items and services furnished by certain off-campus providerbased departments of a provider and requires the Secretary of HHS to make payments for such applicable items and services under an applicable payment system (other than OPPS). (81 FR 45681) Georgeann Edford - Coding Compliance Solutions 36

37 CY 2017 Proposed Rule CMS proposed to do three things to implement the provision outlined by the Act: 1. Define applicable items and services for the purpose of determining whether such items and services are covered OPD services under section 2. Define off-campus PBD 3. Establish policies that would define where certain items and services furnished by a given off-campus PBD were under excepted status and describe the applicable payment system for non-excepted items and services. Georgeann Edford - Coding Compliance Solutions 37

38 DEFINING PBD STATUS 38 Georgeann Edford - Coding Compliance

39 Statutory Definitions Definitions related to provider-based status are found at 42 CFR (a)(2): Campus: means the physical area immediately adjacent to the provider s main buildings, other areas and structures that are not strictly contiguous to the main buildings, but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider s campus. Georgeann Edford - Coding Compliance Solutions 39

40 Statutory Definitions - continued Department of a provider: means a facility or organization that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of the same type as those furnished by the main provider under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of this section. A department of a provider comprises both the specific physical facility that serves as the site of services of a type for which payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. A department of a provider may not itself be qualified to participate in Medicare as a provider under of this chapter, and the Medicare conditions of participation do not apply to a department as an independent entity. For purposes of this part, the term department of a provider does not include an RHC or, except as specified in paragraph (n) of this section, an FQHC. Georgeann Edford - Coding Compliance Solutions 40

41 Statutory Definitions - continued Remote location of a hospital: means a facility or organization that is either created by, or acquired by, a hospital that is the main provider for the purpose of furnishing inpatient hospital services under the name, ownership, and financial and administrative control of the main provider, in accordance with the provisions of this section. A remote location of a hospital comprises both the specific physical facility that serves as the site of services for which separate payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. The Medicare conditions of participation do not apply to a remote location of a hospital as an independent entity. For purposes of this part, the term remote location of a hospital does not include a satellite facility as defined in (h)(1) and (e)(1) of this chapter. Georgeann Edford - Coding Compliance Solutions 41

42 Statutory Definitions - continued Provider-based entity: means a provider of health care services, or a RHC as defined in (b) of this chapter, that is either created or acquired by the main provider for the purpose of furnishing health care services of a different type from those of the main provider under which the ownership and administrative and financial control of the main provider, in accordance with the provisions of this section. A provider-based entity comprises both the specific physical facility that serves as the site of services of a type for which payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at the facility. A provider-based entity may, by itself, be qualified to participate as a provider under 489.2, and the Medicare conditions of participation do apply to a provider-based entity as an independent entity. Georgeann Edford - Coding Compliance Solutions 42

43 Statutory Definitions - continued Provider-based status: means the relationship between a main provider and a provider based entity or a department of a provider, remote location of a hospital, or a satellite facility, that complies with the provisions of this section. Georgeann Edford - Coding Compliance Solutions 43

44 November 2, 2015 Under Section 603 of the Bipartisan Budge Act of 2015, effective January1, 2017, most hospital off-campus provider-based departments (off- campus PBDs) that began furnishing services on or after November 2, 2015, (date of enactment of Section 603) will no longer be eligible to be paid under OPPS. Generally, applicable items and services furnished by certain off-campus outpatient departments of a provider on or after January 1, 2017, will not be considered covered OPD services for purposes of payment under the OPPS and will instead be paid under Medicare Part B if the requirements for such payment are otherwise met. Georgeann Edford - Coding Compliance Solutions 44

45 Exemptions Applicable Items and Services 1. Dedicated Emergency Departments 2. On-Campus locations 3. Furnished at a location that was billing as an outpatient department of a hospital prior to November 2, Locations, items and services with the scope of these grandfathered exceptions are referred to by CMS as excepted locations, items and services. Georgeann Edford - Coding Compliance Solutions 45

46 Excepted Status Applies to off-campus PBDs as they existed at the time of enactment and excepts those items and services that were being furnished and billed by off-campus PBDs prior to November 2, Adopting an exceptions process to our relocation proposal that is limited to extraordinary circumstances outside a hospital s control. CMS is preparing a proposed policy on relocation, with modification to allow excepted off-campus PBDs to relocate temporarily or permanently, without loss of excepted status, for extraordinary circumstances outside of the hospital s control, such as natural disasters, significant seismic building code requirements, or significant public health and public safety issues. Georgeann Edford - Coding Compliance Solutions 46

47 Expansion of Services at PBD Excepted off-campus PBDs and the items and services that are furnished by such PBDs that were being furnished on November 2, 2015 would continue to be paid under OPPS. OPPS payment would be limited to the provision of items and services that were being furnished prior to the November 2, Items and services that are not part of a clinical family of services furnished and billed by the excepted off-campus PBD would not payable under the OPPS. Excepted locations that add new services according to groups of clinical families as defined by APC classifications would be unable to receive OPPS payments for such new services. Georgeann Edford - Coding Compliance Solutions 47

48 Expansion of Services CMS decided not to limit expansions of services at excepted locations for Currently, there is no limit on a grandfathered facility s ability to expand beyond those furnished as of November 2, CMS noted that it will instruct its Medicare Administrative Contractors to update their systems to identify all offcampus PBDs by address and the date the location was added to the hospital s enrollment record. Georgeann Edford - Coding Compliance Solutions 48

49 Conclusion & Take Aways Read the CY 2017 OPPS Final Rule with comment period Other changes include: Organ procurement and reporting New technology EHR incentive program Appropriate Use Criteria Comment Indicators Supervision rules E&M Services ASC CY 2017 Medicare Physician Fee Schedule with comments Georgeann Edford - Coding Compliance Solutions 49