Updated on: February 18, 2017

The Big “opps” in the OPPS

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Original story posted on: November 21, 2016

Perhaps the biggest news out of the 2017 Outpatient Prospective Payment System (OPPS) final rule is something that didn’t happen. The proposed rule was going to prevent off-campus, provider-based entities from offering any new services that were not within a clinical family furnished and billed as of Nov. 2, 2015.  the Centers for Medicare & Medicaid Services (CMS) opted not to adopt that provision of the rule.

When the proposal came out, some consultants suggested that hospitals not offer any new services in off-campus locations. You could call that advice the OPPS “oops,” and it demonstrates why you don’t treat proposed rules as gospel.

While that particular proposal was rejected, the law does eliminate OPPS billing for most off-campus, provider-based locations that weren’t operating on Nov. 2, 2015. There is an exception for dedicated emergency departments. Even relocating or changing ownership of an off-campus location can trigger this. “Off campus” means the location is more than 250 yards from the hospital. 

Another significant change involves patient satisfaction and pain management. CMS is removing pain management from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores to address concerns that it encourages the over-prescription of opioids.

The rule also removes seven procedures from the inpatient-only list. Five are spine procedures as and two are laryngoplasty procedures. CMS also indicated that it will consider whether to remove total knee arthroplasty from the inpatient-only list, though it is not doing so now. 

The rules add 25 new Comprehensive Ambulatory Payment Classifications (C-APCs), which basically bundle a primary procedure with secondary services provided in conjunction with the primary procedure. They established three new clinical families to accommodate new C-APCs, including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures. Bone marrow transplants also get a C-APC designation, as well as a specific cost center. 

The rule changes the instructions for billing some related services as well. Rather than billing each service on the date it was provided, the entire package of related services will be billed jointly. 

There are also sections of the rule addressing partial hospitalization programs, value-based purchasing, EHR organ transplant, and quality reporting in Ambulatory Surgical Centers (ASCs). 

The changes to the physician fee schedule are a bit less dramatic than in most years. Some of the changes include:

 

  • Adding separate payments for existing non-face-to-face prolonged evaluation and management services.
  • Revaluing existing codes describing face-to-face prolonged services.
  • Creating and covering a code to describe the comprehensive assessment and care planning for patients with cognitive impairment (e.g., dementia).
  • Making separate payments using new codes to pay primary care practices that integrate care to treat patients with behavioral health conditions.

 

There are also several changes to chronic care management codes.

 

Other changes include tweaks to the valuation of moderate sedation services, providing coverage for telehealth related to (ESRD), advance care planning, and critical care consultations. 

 

CMS scaled back the collection of global surgical data. The original proposal would have collected data nationally. Now, only groups of more than 10 professionals who operate in Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island will be expected to report the data, starting July 1, 2017.   

In a change unlikely to affect too many readers, the rule prevents Medicare Advantage plans from contracting with a supplier unless the supplier is enrolled with Medicare. 

The rule also creates appropriate use criteria for advanced imaging focused on suspected or diagnosed coronary artery disease or lung cancer, suspected pulmonary embolism, headache, hip pain, lower back pain, shoulder pain, and cervical or neck pain.

Finally, there are some changes to the Accountable Care Organization (ACO) program.  Details to follow.

David M. Glaser, Esq.

David M. Glaser, Esq., is a shareholder in Fredrikson & Byron’s Health Law Group. David helps clinics, hospitals, and other healthcare entities negotiate the maze of healthcare regulations, providing advice about risk management, reimbursement, and business planning issues. He has considerable experience in healthcare regulation and litigation, including compliance, criminal and civil fraud investigations, and reimbursement disputes. David’s goal is to explain the government’s enforcement position and to analyze whether the law supports this position. David is a popular panelist on Monitor Mondays and a member of the RACmonitor editorial board.

 

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