PROVIDER-BASED CHANGES AND OPPS: MORE RULEMAKING AND CHANGES IN 2019Scott Treida, MT(ASCP), CPC, CRCR | Director

2019 OPPS FINAL RULE

Final CY2019 payment rule for the Medicare Outpatient Prospective Payment System (OPPS) was released on November 2, 2018.

Correction notices An online version of the rule is available at

https://www.federalregister.gov/d/2018-24243

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https://www.federalregister.gov/d/2018-24243

OPPS RATE INCREASE

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OPPS ESTIMATED IMPACT

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OPPS ESTIMATED IMPACT

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KENTUCKY SPECIFIC IMPACTS

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*Kentucky Hospitals with Total Payments > $100,000

ADDENDUM B

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ADDENDUM D1

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SECTION X NONRECURRING POLICY CHANGES

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1. Controlling Unnecessary Increases in the Volume of Outpatient Services

Off-Campus Provider-Based Emergency Departments

2. Expansion of Clinical Families of Services at Excepted Off-Campus

Departments of Provider Off-Campus Provider-Based Emergency Departments

3. 340B Drug Payment Policy to Non-excepted Off-Campus Departments

of a Hospital

4. ASCs and Off-Campus Provider-Based Emergency Departments

OFF-CAMPUS HOSPITAL OUTPATIENT DEPARTMENT (HOPD)

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HOSPITAL OUTPATIENT DEPARTMENT (HOPD) REGULATIONS AND REFERENCES

42 CFR 413.65 42 CFR 485.610 (e) CMS Manual Pub 100.07, Chapter 2, Section 2256G, 2256H Section 603 of the Bipartisan Budget Act of 2015

Known as the November 2, 2015 Rule

Sections 16001 and 16002 of the 21st Century Cures Act CY2017 OPPS Final Rule CY2018 OPPS Final Rule CY2019 OPPS Final Rule

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WHY IS CMS FOCUSED ON HOPD SERVICES?

Source: https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf12

Fun Fact:Roughly 10,000 Baby Boomers will turn 65 today, and about 10,000 more will cross that threshold every day for the next 10 years.

- Pew Research

https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf

OFF-CAMPUS HOPDs: CMSs VIEW

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Source: https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf Pages 59008 & 59009

Reduction in payments is not budget neutral

CMS identifies its intent is to lower costs and utilization

Federal Register / Vol. 83, No. 225 / Wednesday, November 21, 2018 / Rules and Regulations

https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf

OFF-CAMPUS HOPDs: CMSs VIEW

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Source: https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf Pages 59017 & 59021

Federal Register / Vol. 83, No. 225 / Wednesday, November 21, 2018 / Rules and Regulations

https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf

OFF-CAMPUS HOPDs

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Increasing Choices and Encouraging Site Neutrality Bipartisan Budget Act of 2015; enacted Nov. 2, 2015

See CMS guidelines for special considerations: mid-build (21st Century Cures Act), relocation, change of ownership, service line expansion, etc. Campus and provider-based guidelines (42CFR413.65, etc.)

Non-exceptedOff-campus HOPDs

New HOPD Billing OPPS services on or

after Nov. 2, 2015

Paid under MPFS Jan. 1, 2017, implemented

PFS relativity adjuster: 40% of OPPS

HCPCS modifier PN

Excepted Off-campus HOPDs

Old HOPD Billing OPPS services prior to

Nov. 2, 2015 Dedicated ED

42 CFR 489.24 Remote location of a hospital

42 CFR 413.65 Paid under OPPS

Full rates

HCPCS modifier PO

OPPS SITE NEUTRAL PAYMENT

CMS is making payments for clinic visits site-neutral by reducing the payment rate for hospital outpatient clinic visits provided at off-campus provider-based departments by 60%. Based on a two-year phase-in of this policy, half of the total reduction will apply in 2019.

The estimated impact for individual hospitals depends on the volume of clinic visits provided at off-campus hospital outpatient departments.

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OFF-CAMPUS HOPDs: CLINIC VISITS

CMS is expanding OPPS payment reduction to EXCEPTED off-campus PBDs, for HCPCS code G0463 Hospital outpatient clinic visit for assessment and management of a patient.

Excepted off-campus HOPDs will see payments for G0463 reduced to 70% of OPPS for 2019, and then reduced to 40% of OPPS for 2020 and subsequent years.

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*Payment amounts are unadjusted.

Insider Tip: G0463 may appear in some CDMs as 99201-99205; 99211-99215.

On-campusHOPD

Off-campusHOPD

Excepted

Off-campusHOPD

Non-exceptedCY 2018 $ 114 $ 114 $ 45 CY 2019* $ 116 $ 81 $ 46 CY 2020* $ 117 $ 47 $ 47 HCPCS Code G0463 G0463 G0463 HCPCS Modifier N/A PO PN

OFF-CAMPUS HOPDs: EXPANDED SERVICES

CMS is concerned about service expansion at excepted (grandfathered) PBDs.

Also, believes new services (started on or after Nov. 5, 2015) should not be paid OPPS rates.

Proposed: 19 clinical families Payment at OPPS rates for items and services in each of the 19

proposed clinical families if that PBD furnished and billed for a service in that clinical family of services prior to November 2, 2015.

2019 CMS did not finalize the proposed policy. Excepted PBDs will continue to receive full payments under OPPS as

long as it remains excepted (but for clinic visits). CMS will monitor the volume of services at excepted locations to

determine if future rulemaking is necessary for service expansions.

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OFF-CAMPUS HOPDs: 340B

CMS finalized its proposal to extend the ASP 22.5% payment rate to 340B drugs (excluding vaccines and drugs on pass-through payment status) provided at non-excepted off-campus HOPDs.

Providers excluded:

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Critical access hospitals

Rural sole community

hospitals

Childrens hospitals

PPS-exempt cancer

hospitals

OFF-CAMPUS HOPDs: 340B

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HospitalOn-campus

Off-campusHOPDExcepted

Off-campusHOPDNon-excepted Rural SCH

HospitalOn-campus

HospitalOff-campusExcepted

Off-campusHOPDNon-excepted Rural SCH

Drugs and Biologicals Separately payable (K) ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6%

Pass through status (G) ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6% ASP+6%

Separately payable vaccines (F, L) Cost Cost Cost Cost Cost Cost Cost Cost

Packaged (N) - - - - - - - -

340 Acquired Drugs and BiologicalsSeparately payable (K) ASP-22.5%

JGASP-22.5%JG & PO

ASP+6%TB & PN

ASP+6%TB

ASP-22.5%JG

ASP-22.5%JG & PO

ASP-22.5%JG & PN

ASP+6%TB

Pass through status (G) ASP+6%TB

ASP+6%TB & PO

ASP+6%TB & PN

ASP+6%TB

ASP+6%TB

ASP+6%TB & PO

ASP+6%TB & PN

ASP+6%TB

Separately payable vaccines (F, L) Cost Cost Cost Cost Cost Cost Cost Cost

Packaged (N) - - - - - - - -

2018 2019

JG - Drug or biological acquired with 340B drug pricing program discount. TB - Drug or biological acquired with 340B drug pricing program discount, informational purposes. CMS article, Billing 340B Modifiers under the Hospital OPPS, dated April 2, 2018.

Sheet1

20182019

HospitalOn-campusOff-campusHOPDExceptedOff-campusHOPDNon-exceptedRural SCHHospitalOn-campusHospitalOff-campusExceptedOff-campusHOPDNon-exceptedRural SCH

Drugs and Biologicals

Separately payable (K)ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%

Pass through status (G)ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%ASP+6%

Separately payable vaccines (F, L)CostCostCostCostCostCostCostCost

Packaged (N)--------

340 Acquired Drugs and Biologicals

Separately payable (K)ASP-22.5%JGASP-22.5%JG & POASP+6%TB & PNASP+6%TBASP-22.5%JGASP-22.5%JG & POASP-22.5%JG & PNASP+6%TB

Pass through status (G)ASP+6%TBASP+6%TB & POASP+6%TB & PNASP+6%TBASP+6%TBASP+6%TB & POASP+6%TB & PNASP+6%TB

Separately payable vaccines (F, L)CostCostCostCostCostCostCostCost

Packaged (N)--------

ASC SERVICES

Final rule added 17 procedures relating to cardiac catheterization to the list of ASC Covered Surgical Procedures.

Growing trend of cardiac procedures being transitioned from an inpatient to an outpatient setting.

States that currently prohibit cardiac catheterization procedures at outpatient facilities may decide to adopt changes to allow certain procedures that have been deemed acceptable by CMS to be performed at facilities without on-site inpatient services, including ASCs.

CMS is updating ASC rates by 2.1% for CY 2019. Impact for hospital providers?

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ASC SERVICES

https://www.medicare.gov/procedure-price-lookup/

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https://www.medicare.gov/procedure-price-lookup/

OFF-CAMPUS EMERGENCY DEPARTMENTS

CMS agreed with MedPACs recommendation to develop data to assess the extent to which OPPS services are shifting to off-campus provider-based emergency departments.

New modifier effective January 1, 2019. Modifier ER (Items and services furnished by a

provider-based off-campus emergency department)

Reported with every claim line of the UB-04 for outpatient hospital services furnished in an off-campus provider-based emergency department.

Critical access hospitals are exempt.

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LABORATORY PAYMENT REPORTING

Protecting Access to Medicare Act (PAMA): CMS implemented market-based Lab Fee Schedule

in CY2018. Applicable laboratories required to report private

payer payment data to CMS. Private payer payment rates for outreach

business, by HCPCS code with volumes. CMS website includes FAQ article and format

for data submission. In the past, most hospital laboratories were excluded.

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LABORATORY PAYMENT REPORTING

Physician Fee Schedule Final rule, published Nov. 23, 2018: CMS essentially created a new entity (hospital

outreach laboratory) that meets the definition of an applicable laboratory.

Applicable laboratory expanded to include clinical laboratories that receive at least $12,500 of Medicare revenues from the CLFS for claims submitted using the CMS 1450 14X bill type, which is used by some hospital outreach laboratories to bill for laboratory services provided to non-patients.

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LABORATORY PAYMENT REPORTING

Civil monetary penalties (up to $10,000 per day), for each failure to report, misrepresentation, or omission of data.

Specific directions on data collection and data reporting: 2019 PFS Final Rule MLN Matters: MM1076 revised, January 17, 2019, CY

2019 Update for Clinical Laboratory Fee Schedule. https://www.cms.gov/Medicare/Medicare-Fee-for-

Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html

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Data collection period (payments received) January-June 2019Window to validate collected data July-December 2019Report data to CMS January March 2020Updated Lab fee schedule January 2021

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.htmlhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA-Regulations.html

DEVICE CREDITS

For 2019, CMS lowered the device offset percentage threshold from greater than 40% to greater than 30% 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.

361 device intensive procedures. OPPS Final Rule, addendum P.

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HCPCS Short Descriptor SI APCFinal CY2019 APC

Payment Rate

Device Offset

Percentage

Device Offset

Amount33206 Insert heart pm atrial J1 5223 $9,879.34 59.97% $5,924.64

DEVICE CREDITS

2018 OIG: Hospitals Did Not Comply With Medicare Requirements for Reporting Certain Cardiac Device Credits

Medicare incorrectly paid hospitals $7.7M for cardiac device replacement claims, resulting in potential overpayments of $4.4M.

Manufacturers issued reportable credits to hospitals for recalled cardiac medical devices, but the hospitals did not adjust the claims with the proper condition codes, value codes (FD), or modifiers to reduce payment as required.

Guidelines: Chapter 4, Section 61.3.5 Medicare Claims Processing Manual O/P Chapter 3, Section 100.8 Medicare Claims Processing Manual I/P CMS MLN Fact Sheet: Medicare Billing for Cardiac Device Credits

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PRICE TRANSPARENCY

CMS new hospital price transparency policy went into effect January 1, 2019.

Hospitals must make available a list of their current standard charges via the internet in a machine readable format and update this information at least annually, or more often as appropriate.

All items and services Standard charges by DRG

No hospitals are exempt. CMS FAQs articles includes clarifying information:

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/FAQs-Req-Hospital-Public-List-Standard-Charges.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/Downloads/Additional-Frequently-Asked-Questions-Regarding-Requirements-for-Hospitals-To-Make-Public-a-List-of-Their-Standard-Charges-via-the-Internet.pdf

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https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/FAQs-Req-Hospital-Public-List-Standard-Charges.pdfhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/Downloads/Additional-Frequently-Asked-Questions-Regarding-Requirements-for-Hospitals-To-Make-Public-a-List-of-Their-Standard-Charges-via-the-Internet.pdf

QUESTIONS

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PRESENTER

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SCOTT TREIDA, MT(ASCP), CPC, CRCR | Director, Blue & Co., LLC317.713.7950 | streida@blueandco.com

Mr. Treida is a Director with Blue & Co., LLC. Scott started consultingwith Blue & Co. 20 years ago. He is responsible for coordinating andperforming detailed work related to Blue & Co.s revenue cyclemanagement services; concentrating on chargemaster (CDM) andcoding quality reviews, regulatory compliance, and revenue cycle teamdevelopment. Scott is a frequent presenter at local and nationalprofessional associations.

Scott is a graduate of Indiana University and Indiana University - PurdueUniversity Indianapolis with degrees in Biology and Medical Technology.He is a certified professional coder (CPC), and Medical Technologist withboard certification by the American Society for Clinical Pathology(ASCP). He enjoys running and resides in Indianapolis, Indiana with hiswife and kids.

Provider-Based Changes and OPPS: More Rulemaking and Changes in 20192019 OPPS Final ruleOPPS RATE INCREASEOpps Estimated ImpactOPPS ESTIMATED IMPACTKentucky specific impactsAddendum bAddendum d1Section X Nonrecurring Policy ChangesOff-campus hospital outpatient department (HOPD)hospital outpatient department (HOPD) REGULATIONS AND ReferencesWhy is cms focused on hopd services?Off-campus HOPDs: CMSs VIEWOff-campus HOPDs: CMSs VIEWOff-campus HOPDsOPPS SITE Neutral PAYMENTOff-campus HOPDs: CLINIC VISITSoff-campus HOPDs: EXPANDED SERVICESoff-campus HOPDs: 340Boff-campus HOPDs: 340BASC ServicesASC ServicesOff-campus emergency departmentsLaboratory payment reportingLaboratory payment reportingLaboratory payment reportingdevice creditsdevice creditsPrice transparencyQUESTIONSpresenter