OPPS Proposed Rule Significantly Affects Coding

Michelle Leppert, for HealthLeaders Media , July 10, 2013

Extended Assessment and Management Services

CMS proposed a related change to the Extended Assessment and Management Services (EAM) APCs as well. Currently, two EAM Composite APCS exist, APC 8002 and APC 8003. Under the proposal, CMS would pay for the entire visit through the proposed new EAM Composite APC 8009 when observation care is provided and criteria is met. Since CMS has proposed to replace existing E/M codes with new G-codes, the new EAM will not specify a certain level of E/M, but rather just the presence of one of the G-codes, critical care, or direct referral G-code.

The proposed payment rate for the new composite is $1,343 which is significantly higher than today's APC rate for either APC 8002 or 8003. This may allow hospitals to be more appropriately paid for Extended Assessment and Management but this still needs to be carefully evaluated, Shah says.

Packaged services

CMS proposed major changes to which services are packaged and how, in an effort to make OPPS more "PPS-like" and less "fee-for-service like," Shah says.

CMS proposes packaging the following seven new categories of supporting items and services:

  • Drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure
  • Drugs and biologicals that function as supplies or devices when used in a surgical procedure
  • Clinical diagnostic laboratory tests (except molecular pathology) when provided on the same date of service as another service
  • Procedures described by add-on codes
  • Ancillary services (currently assigned status indicator "X"); proposal to reassign all services to status indicator Q1
  • Diagnostic tests on the bypass list
  • Device removal procedures

New Addendum P on the CMS website lists all of the codes involved in CMS' new packaging proposals (approximately 2149 codes).

For many of these services, CMS will continue to make a separate payment if they are reported alone on a claim.

"This is a very extensive proposed change," Shah says and one that is likely to have long-term impacts that we may not even be aware of today."

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