HOPD Payment Changes Continue in 2014

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. However, HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The ultimate responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.   Our November/December 2013 Business Briefs column introduced hospital-based outpatient wound care departments (HOPDs) to “packaged” Medicare payments. Let’s review a few of the packaged items that we discussed in that column and then discuss some additional packaged items as well as some revised Medicare Ambulatory Payment Classification (APC) payments.

Packaged Add-On Debridement Codes

  Prior to 2014, add-on codes typically received separate payment based on APC assignment. Because add-on codes represent an extension or continuation of a primary procedure, they are typically supportive, dependent, or adjunctive to a primary surgical procedure. Effective Jan. 1, the Centers for Medicare & Medicaid Services (CMS) announced they are unconditionally packaging all procedures described by add-on codes in the Outpatient Prospective Payment System (OPPS) with the exception of add-on codes from drug-administration services and 2014 add-on codes assigned to device-dependent APCs.   The charts in the November/December column depict that, due to packaging of the add-on debridement codes, CMS allows the same APC payment rate for the debridement of a 120 sq cm wound as is allowed for debridement of a 10 sq cm wound. Many readers asked if they should still report the add-on codes. The answer is “yes.” Medicare’s Claims Processing Manual states: “Therefore, it is extremely important that hospitals report all Healthcare Common Procedure Coding System (HCPCS) codes consistent with their descriptors; Current Procedural Terminology and/or CMS instructions and correct coding principles, and all charges for all services they furnish, whether payment for the services is made separately or is packaged.”   Therefore, the HOPD should report the appropriate surgical or medical debridement base code for the first 20 sq cm debrided. If more than 20 sq cm is debrided, the HOPD should still report the appropriate add-on code(s) based on the total wound surface debrided. The HOPD will not be double paid by CMS because the Medicare Administrative Contractor (MAC) who processes claims has been informed never to pay for add-on codes. NOTE: CMS still allows payment for both the base code and appropriate add-on codes to qualified healthcare professionals (QHPs) who perform surgical or medical debridement. Packaging of add-on codes does not apply to QHPs.

Packaged Add-On Codes for Application of Cellular and/or Tissue-Based Products for Wounds (CTPs) [Old Term “Skin Substitutes”]

  The charts in the November/December column also depict that CMS packaged the add-on codes into the base codes for the application of CTPs. CMS does not always allow a higher APC payment for application of CTPs to larger wound surface areas. In fact, CMS allows the same APC payment for this work performed, regardless of wound surface area, on anatomic locations such as the foot. For the anatomic locations such as the leg, CMS allows 1 APC payment rate for wounds up to 100 sq cm and a higher APC payment rate for wounds 100 sq cm.

Packaged CTPs

  In addition to packaging the add-on codes for the application of CTPs, CMS is now packaging the payment for the products into the APC payment for the procedure based upon CMS’ designation of each product as either a “high cost” or a “low cost” product. As described previously, HOPDs should still report the appropriate add-on code(s) based on the total size of wound surface that received the application of the CTP. In addition, HOPDs should still report the “Q” code assigned to the product that was applied and should still report the number of sq cm applied, the appropriate charge, and any required modifiers. NOTE: This packaging of application of CTP add-on codes does not apply to QHPs. In addition, the packaging of the product in the application codes does not apply to QHPs who purchase CTPs and apply them in their offices. CMS still allows payment for both the base code and appropriate add-on codes to QHPs who apply CTPs. If the QHP purchases the CTP and applies it in his/her office, CMS still allows payment for the application and payment for the product if the product is covered by the MAC. Packaging of add-on codes and CTPs does not apply to QHPs.

Packaged Clinical Diagnostic Laboratory Tests

  Let’s now discuss CMS decision to package payment for clinical diagnostic laboratory tests. Since the launch of OPPS, CMS has excluded clinical diagnostic laboratory tests from the OPPS. Therefore, laboratory tests provided in HOPDs were paid separately at Clinical Laboratory Fee Schedule rates. Effective Jan. 1, CMS changed this policy when it was concluded that laboratory tests (other than molecular pathology tests) should be packaged when they are integral, ancillary, supportive, dependent, or adjunctive to a primary service or services provided in the hospital outpatient setting (ie, when they are provided on the same date of service as the primary service and when they are ordered by the same practitioner who ordered the primary service).   A laboratory test will not be packaged when the test is:     1. the only service provided to the Medicare beneficiary on that date of service, OR     2. conducted on the same date of service as the primary service but is ordered for a different purpose than the primary service by a practitioner different than the practitioner who ordered the primary service.   This may or may not be a common occurrence in your HOPD. One laboratory test that this author often sees ordered and performed in HOPDs is glucose blood tests (82962). Like the other CMS packaged procedures/products, HOPDs should continue coding for the packaged laboratory tests. You may view the laboratory test codes that are packaged in Addendum P of the 2014 OPPS Final Rule: www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1601-FC-.html

Clinic Visits – 1 OPPS Payment

  Now, let’s discuss how CMS implemented a similar payment change for HOPD clinic visits. Prior to 2014, HOPDs were required to use the 5 “new patient” clinic visit codes (99201-99205) and the 5 “established patient” clinic visit codes (99211-99215). Each HOPD was required to develop a resource-based mapping system that converted resources consumed into a single “new patient” or “established patient” clinic visit code. In addition, each HOPD was required to write a policy and procedure that could be used to educate existing staff, new employees, auditors, etc. on how to use their unique clinic visit mapping system.   It should not surprise anyone that 2014 is the year that CMS has decided to change the way payment is made for HOPD clinic visits. CMS eliminated the APC allowable payment rates for the 10 “new patient” and “established patient” clinic visit codes. Instead, CMS will allow only 1 APC payment rate for HOPD clinic visits. To accomplish this, CMS created a new HCPCS code (G0463 Hospital outpatient clinic visit for assessment and management of a patient) for HOPDs to use to report clinic visits to CMS. In addition, CMS has ceased recognizing a distinction of “new patient” and “established patient” clinic visits. See Table 1 for a comparison of the 2013 APC allowable clinic visit rates versus the 2014 APC allowable payment rate for G0463.   Now, you are probably wondering if you should keep your clinic visit mapping system. Because HOPDs will most likely need to continue reporting the 99201-99205 and 99211-99215 clinic visit codes to non-Medicare payers, this author suspects most HOPDs will continue using their clinic visit mapping system. Then they will most likely set up their coding and billing system by:     1. Entering into their charging system either G0463 for Medicare-covered patients or 99201-99205/99211-99215 for non-Medicare-covered patients, OR     2. Entering into their charging system 99201-99205/99211-99215 for all patients. The billing system will then convert Medicare-covered patients to G0463.   HOPDs should have a meeting with their hospital’s charge description master (CDM), coding staff, and billing personnel to determine the clinic visit coding and billing system that will work best for their facilities. NOTE: QHPs still use 99201-99205 and 99211-99215 to code for their evaluation and management services performed in HOPDs. The G0463 HCPCS code does not pertain to QHPs.

Noninvasive Vascular Diagnostic Studies APC Payment

  Many HOPDs have inquired whether noninvasive vascular diagnostic studies have been packaged for Medicare payment. The answer is “no.” CMS still pays HOPDs separately for both single-level (93922) and multiple-level (93923) vascular diagnostic studies. In fact, the 2014 APC payment rate increased for both studies. See Table 2.

Non-Ophthalmic Fluorescent Vascular Angiography APC Payment

  Finally, let’s look at the changes for non-ophthalmic fluorescent vascular angiography when it is used by QHPs who work in HOPDs.   As we discussed in the June/July 2013 Business Briefs column, CMS established (in April 2012) a temporary pass-through code (C9733) for the procedure. CMS originally assigned the new pass-through code to APC group 0397. Effective Jan. 1, CMS discontinued APC Group 0397 and reassigned C9733 to APC Group 0263. Therefore, C9733 continues to be separately payable by CMS when the procedure is deemed medically necessary. Please note that CMS assigned the “Q2” status indicator to APC group 0263. The “Q2” status indicator means that no separate payment is provided when C9733 is billed with other procedures that are assigned a “T” status indicator. See Table 3.

Summary

  HOPD program directors, CDM directors, coders, and billers should be communicating and cooperating to make the appropriate coding and charging changes in their paper and/or electronic systems. Once the changes are made, HOPDs should confirm that the changes are working correctly by processing test claims. Kathleen D. Schaum is president and founder of Kathleen D. Schaum & Associates Inc., Lake Worth, FL. She may be reached for questions and consultations at 561-964-2470 or kathleendschaum@bellsouth.net.