2017 Proposed Rule Changes to the Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgery Payment System

Transcription

1 2017 Proposed Rule Changes to the Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgery Payment System Tuesday, August 16, 2016 (12:00 1:30 pm Pacific / 1:00 2:30 pm Mountain / 2:00 3:30 p.m. Central / 3:00 4:30 pm Eastern) Presented by: Mike Kovar Principal WeiserMazars LLP Taylor Pedone Manager WeiserMazars LLP

2 About the Presenters Mike Kovar is a Principal in the Health Care Advisory Services Practice of WeiserMazars LLP. He has over 25 years of experience in the health care industry focusing in the hospital provider areas. Mike has both operations and consulting experience focusing primarily in the regulatory, billing/coding, and compliance areas. Mike presents for HFMA nationally on a number of different revenue related topics including HFMA s Charge Master Essentials and Achieving Revenue Improvements through Charge Master & Charge Capture classes. Taylor Pedone is a Manager in the Health Care Advisory Services Practice of WeiserMazars LLP. Taylor s background includes assessment and implementation of process improvement initiatives across the revenue cycle including charge capture, patient financial services, denials, strategic and transparent pricing, and compliance. She is a Certified Professional Coder (CPC). 2

3 Learning Objectives for Today You will learn to: Identify the proposed OPPS and ASC changes that may have a significant impact on health system finances Prepare to address OPPS related issues within your organization s revenue cycle and other operational areas Describe potential compliance risks 3

4 2017 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Payment System (ASC) Proposed Rule Published in the Federal Register on July 14, 2016 Comments due to CMS by no later than 5pm EDT September 16, 2016 Complete proposed rule can be found on the CMS website under the Medicare tab and then home page for Hospital Outpatient Addenda to the rule can only be found only through the internet on the CMS website 4

5 Overall Impact of 2017 Proposed OPPS Changes 1.6% increase in Medicare payments in 2017 to all hospitals including cancer and children s hospitals and CMHCs (0.4% decrease in 2016) Estimated OPPS payments of $63 billion in 2017 $5.1 billion increase compared to 2016 estimated OPPS payments 5

6 Overall Impact of 2017 Proposed OPPS Changes Impacts on different hospital categories are as follows: urban hospitals 1.6% sole community rural hospitals 2.3% urban hospitals less than 100 beds 1.9% rural hospitals less than 50 beds 2.3% major teaching hospitals 1.2% non-teaching hospitals 1.9% governmental hospitals 1.5% proprietary hospitals 1.6% CMHCs -8.4% 6

7 Overall Impact of 2017 Proposed OPPS Changes (cont d) For CMHCs the 8.4% decrease can be attributed to APC consolidation APC 5851 and 5852 consolidated into a single APC 5853 for Partial Hospitalization-3 or more services Total beneficiary liability for copayments would decrease as an overall percentage of total payments 18.5% estimated in 2017 versus 19.3% in

8 Overall Impact of 2017 Proposed OPPS Changes CMS has a publicly available file to estimate the impact of the 2017 Proposed OPPS rule on it s website for every OPPS hospital OPPS NPRM Facility-Specific Impacts Disproportionate Share Patient Percentage Outpatient Cost-to- Charge Ratio Estimated 2017 Outlier Payment Provider Number CBSA Code Estimated 2016 OPPS Payment Estimated 2017 OPPS Payment % $32,335, $34,355, $39, % $22,231, $22,300, $3, % $16,654, $16,902, $13,

9 Overall Impact of 2017 Proposed OPPS Changes Top 10 CPT Code Winners-2017 Versus 2016 (Excludes J1, J2) HCPCS Code Short Descriptor CI SI APC 2017 Proposed Payment Rate 2016 July OPPS Payment 2017 OPPS Payment Variance 0100T Prosth retina receive&gen CH T 1906 $150, $95, $55, Repair defect of artery CH T 5183 $3, $2, $1, Repair defect of arm artery CH T 5183 $3, $2, $1, Repair blood vessel lesion CH T 5183 $3, $2, $1, Repair blood vessel lesion CH T 5183 $3, $2, $1, Repair blood vessel lesion CH T 5183 $3, $2, $1, Insertion of infusion pump CH T 5183 $3, $2, $1, Insert tunneled cv cath CH T 5183 $3, $2, $1, Insertion of cannula CH T 5183 $3, $2, $1, Insertion of cannula CH T 5183 $3, $2, $1,

10 Overall Impact of 2017 Proposed OPPS Changes Top 10 CPT Code Losers-2017 Versus 2016 HCPCS Code Short Descriptor CI SI APC 2017 Proposed Payment Rate 2016 July OPPS Payment 2017 OPPS Payment Variance Ligation of neck artery CH T 5181 $ $3, $2, J9226 Supprelin la implant K 1142 $24, $26, $2, Rsv mab im 50mg CH M $1, $1, Unlisted px small intestine CH T 5301 $ $2, $1, Abdomen surgery procedure CH T 5301 $ $2, $1, Bone marrow harvest allogen CH S 5242 $1, $3, $1, Transplt autol hct/donor CH S 5242 $1, $3, $1, Mri brain w/o & w/dye CH T 5181 $ $2, $1, Artery x-rays adrenal gland CH Q $ $2, $1, Artery x-rays lung CH Q $ $2, $1,

11 Summary of 2017 Proposed Rule Proposed updates affecting OPPS payments including: Proposed Additional Comprehensive APCs Proposed packaging policy changes for 2017 Proposed OPPS APC group policy changes Proposed APC consolidations Proposed payment changes for devices Proposed payment changes for drugs, biologicals, and radiopharmaceuticals Proposed OPPS payment for Hospital outpatient visits and Critical Care services 11

12 Summary of 2017 Proposed Rule (cont d) Proposed payment changes for partial hospitalization services Proposed procedures that will be paid only as inpatient procedures Proposed OPPS payment status changes and comment indicators Proposed nonrecurring policy changes 603 implementation relating to payment of certain items and services furnished by certain off-campus departments of a provider 12

13 Summary of 2017 Proposed Rule (cont d) Proposed update of the Ambulatory Surgery Center (ASC) payment system Proposed hospital outpatient quality reporting program updates Proposed ASC quality reporting program updates What will not be addressed today: Transplant Outcomes proposed policy changes Proposed changes to Medicare and Medicaid EHR incentive program Proposed additional Hospital VBP program policy changes 2 13

14 OPPS Background Outpatient Prospective Payment System (OPPS) was first implemented on August 1, 2000 Medicare pays for hospital outpatient services on a rate-per-service basis that varies based on the ambulatory payment classification (APC) assigned to the service Healthcare Common Procedure Coding System (HCPCS) is used to identify and group services in an APC HCPCS includes both CPT and HCPCS Level II Codes Payment is based on status indicators (See Addendum D1) All services within an APC are comparable clinically and relative to resource use. Service are not considered comparable relative to resource use if the highest mean cost for an item or service in an APC is more than 2 times greater than the lowest mean cost of an item or service in the same APC. 14

15 OPPS Background Hospitals excluded from OPPS: Maryland hospitals for services paid under the cost containment waiver Critical access hospitals Hospitals outside the 50 states, the District of Columbia, and Puerto Rico Indian Health Service hospitals 15

16 Updates Affecting Proposed OPPS Payments Approximately 163 million final action claims for services provided in a hospital outpatient setting from January 1, 2015 through December 31, 2015 were used to calculate the 2017 rates Single/ pseudo claims process used in previous years was again used for 2017 rate setting purposes Medicare lists bypassed HCPCS Codes to determine single claims in Addendum N 16

17 Updates Affecting Proposed OPPS Payments Hospital-specific overall ancillary and department cost-to-charge ratios (CCRs) used to convert charges to estimated costs through application of a revenue code-to-cost center crosswalk Most recent submitted, in most cases, cost reports beginning in CY 2014 used to calculate CCRs (cost-to-charge ratio) to be used to calculate costs for the CY 2017 OPPS payment rates To calculate APC costs, Medicare calculated hospital specific overall ancillary CCRs and hospital-specific departmental CCRs for each hospital with 2015 claims data 17

18 Updates Affecting Proposed OPPS Payments CMS is requesting public comments on P-codes used for billing of blood products Adequacy and necessity of current level of granularity of current descriptors used for P-codes Do the current P-code descriptors represent the current technologies in blood bank? CMS is requesting public comments on HCPCS codes assigned for brachytherapy sources Recommendations for new HCPCS Codes based on brachytherapy sources including rationale for new HCPCS codes 18

19 Updates Affecting Proposed OPPS Payments CMS has implemented 35 comprehensive APCs (C-APCs) through 2016 Comprehensive APCs are HCPCS Codes designated as the primary service (SI=J1) for which there is a single payment for all services that are considered as integral, ancillary, supportive and adjunctive to the primary service Only excludes services not covered by Medicare Part B or services not payable under OPPS such as: Self-administerable drugs not considered supplies Pass-through drugs and devices Ambulance services Diagnostic and screening mammography Recurring therapy services Brachytherapy Preventive services 19

20 Updates Affecting Proposed OPPS Payments CMS is proposed to add 25 more C-APCs in

21 Updates Affecting Proposed OPPS Payments 21

22 Updates Affecting Proposed OPPS Payments 22

23 Updates Affecting Proposed OPPS Payments Proposed Allogeneic Hematopoietic Stem Cell Transplantation APC 5244 In allogeneic stem cell transplantations, donor acquisition services are not paid separately since donor is not Medicare recipient receiving the transplant New requirement to use new Revenue Code 815 for Allogeneic Stem Cell Acquisition Services and report on a separate line of the UB-04 claim form u Should include all services required to obtain stem cells from a donor and must be reported with the same date of service as the transplant procedure Transplant procedure reported with CPT Code Stem cell transplantation per donor u Status Indicator J1 with $15,267 payment 23

24 Updates Affecting Proposed OPPS Payments All Composite APCs are proposed to continue as is: LDR prostate brachytherapy Mental Health Services Multiple Imaging procedures 24

25 Proposed OPPS Packaging Policy Changes for 2017 Proposing to eliminate the unrelated laboratory packaging exception and the use of the L1 modifier Multiple hospitals informed them (CMS) that the unrelated laboratory test exception is not useful to them because they cannot determine when a laboratory test has been ordered by a different physician and for a different diagnosis than the other services reported on the same claim. Also proposing to expand the packaging exception for molecular pathology tests to include all advanced diagnostic laboratory tests (ADLTs) ADLTs to be assigned Status Indicator A and paid under the Clinical Laboratory Fee Schedule 25

26 Proposed OPPS Packaging Policy Changes for 2017 Proposing to use consistent packaging criteria for the conditionally packaged Status Indicators In 2016, Status Indicator Q1 packages all items and services on the same date of service with services assigned S, T, or V Status Indicator. In 2016, Status Indicator Q2 packages all items and services on the same date of service with services assigned Status Indicator T. Status Indicator Q4 (Laboratory) and J1/J2 (C-APCs) package all items on the same claim regardless of date of service. CMS proposing in 2017 to change Status Indicators Q1 and Q2 to packaging based on same claim regardless of date of service. 26

27 Updates Affecting Proposed OPPS Payments Other Issues CY 2017 full market basket conversion factor of $ ($ in 2016) and a reduced market basket conversion factor of $ ($ in 2016) for hospitals not meeting the quality reporting requirements. FY 2017 IPPS post-reclassified wage indices for urban and rural areas will be used to calculate CY 2017 OPPS payment rates Continue policy of a budget neutral 7.1 percent payment adjustment for rural SCHs, including EACHs, for all services and procedures paid under the OPPS, excluding separately payable drugs and biologicals, devices paid under the pass-through payment policy, and items paid at charges reduced to costs. 27

28 Updates Affecting Proposed OPPS Payments Cancer Hospitals For the 11 designated cancer hospitals in the country, Medicare will adjust each cancer hospital s OPPS payment by the percentage difference between their individual PCR (payment to cost ratio) without TOPs (Transitional outpatient payments) and the weighted average PCR ( target PCR ) of the other hospitals paid under OPPS 2017 target PCR is 0.92 (target was 0.92 in 2016) Additional payment at cost report settlement will be the amount needed to result in a target PCR equal to 0.92 for each cancer hospital 28

29 Updates Affecting Proposed OPPS Payments Outlier Payments For hospitals, outlier payments are made that equal 50 percent of the amount by which the cost of furnishing the services exceeds 1.75 times the APC payment when the following thresholds are met: Cost of furnishing the service by the hospital exceeds 1.75 times the APC payment amount; and Exceeds a $3,825 fixed-dollar threshold ($3,250 in 2016) For example: Total Charges =$10,000; CCR=0.50; APC payment= $1,000 Total Cost of Service=$10,000 X 0.50 = $5,000 Is $5,000 Cost of Service > 1.75 X $1,000 APC Payment= $1,750 YES Is $5,000 Cost of Service > $3,825 Fixed dollar threshold YES Outlier payment = ($5,000-$1,750) X 50% = $1,625 For CMHCs, if the cost for partial hospitalization under APC 5853 exceeds 3.4 times the APC 5853 payment, the outlier payment is calculated as 50 percent of the amount by which the cost exceeds 3.4 times the APC 5853 payment rate. 29

30 Questions 30

31 Proposed OPPS APC Group Policies 31

32 Proposed OPPS APC Group Policies 32

33 Proposed OPPS APC Group Policies 33

34 Proposed OPPS APC Group Policies 2017 CPT Codes received in time from AMA for inclusion in the proposed OPPS ( NP Comment Indicator Addendum B) Specific CPT Code numerical assignment not provided but full description included in this rule as Addendum O (Partial list below) CY 2017 OPPS/ASC PROPOSED RULE Addendum O: New Category I and III CPT Codes Effective January 1, 2017 CPT codes and descriptions only are copyright 2016 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Apply. NOTE 1: As discussed in sections III.A. (Proposed OPPS Treatment of New CPT and Level II HCPCS) and XII.B. (Proposed Treatment of New Codes) of the CY 2017 OPPS/ASC proposed rule, we are requesting comments on the new CPT codes below. Specifically, we are requesting comments on the OPPS status indicator and APC assignments, as well as the ASC payment indicator assignments. The proposed CY 2017 payment rates for these codes can be found in OPPS Addendum B, ASC Addendum AA, and ASC Addendum BB of this proposed rule, which are available via the Internet on the CMS Web site. NOTE 2: Comments will NOT be accepted for new Category I CPT laboratory codes that are not assigned to "NP" comment indicator. Comments to these codes must be submitted at the Clinical Laboratory Fee Schedule (CLFS) Public Meeting, which is scheduled for July 18, CY 2017 OPPS/ASC Proposed Rule 5- Digit Placeholder Code 22X81 Long Descriptor Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) Comment Indicator (CI) NP 34

35 2017 Proposed OPPS APC Specific Policies For new technology APCs, there are currently 48 cost bands. 3 additional cost bands proposed (Levels 49-51): 35

36 2017 Proposed OPPS APC Specific Policies For 2017, CMS will restructure and consolidate the imaging APC structure from 17 APCs to 8 APCs (payment range: $63.33-$777.31) 36

37 Proposed 2017 Payment Changes for Devices Pass-through Devices Devices with pass through status eligible for pass through payment for at least 2 years but not more than 3 years Pass-through status currently ends at the end of the calendar year when at least 2 years of pass-through payments have been made regardless of the quarter in which pass-through status initially approved CMS proposes quarterly expiration of pass-through status to afford passthrough payments as close as possible to a full 3 years Devices no longer eligible for pass through payment are packaged into the cost of the procedure CMS also proposing to use the more specific Implantable Devices Charged to Patients CCR rather than the less specific hospital-wide CCR for calculation of pass-through payment amounts. 37

38 Proposed 2017 Payment Changes for Devices Pass-through Devices As of January 1, 2017, there are three devices eligible for pass-through payment C2623 Catheter, transluminal angioplasty, drug coated, non-laser C2613 Lung biopsy plug with delivery system C1822 Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging system As of January 1, 2017, pass-through status of the following device expires: C2624 Implantable wireless pulmonary artery pressure sensor with delivery catheter including all system components 38

39 Proposed 2017 Payment Changes for Devices Pass-through Devices CMS proposes to determine device-intensive procedures(exceed 40% of cost) at the HCPCS code level rather than APC level in 2017 Device edits at HCPCS level (no specific device HCPCS code required-any device HCPCS is acceptable) No cost/ full credit and partial credit policies at HCPCS level 39

40 Proposed 2017 Payment Changes for Devices Pass-through Devices CMS is requesting comments on three potential pass-through devices relative to CMS pass-through criteria(newness, cost, clinical efficacy): BioBag (Larval Debridement Therapy in a Contained Dressing) Encore Suspension System Endophys Pressure Sensing System or Endophys Pressure Sensing Kit 40

41 Proposed 2017 Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals For drugs and biologicals, pass-through payment is the amount by which the drug or biological exceeds the portion of the otherwise applicable Medicare OPD fee schedule that is associated with the drug or biological (SI=G) Due to the postponement of the Part B Drug Competitive Acquisition Program, CMS pays the rate paid in the physician's office setting for all drugs and biologicals with pass-through status ASP + 6% Similar to devices, CMS is proposing quarterly expiration of pass-through status to afford pass-through payments for drugs as close as possible to a full 3 years 41

42 Proposed 2017 Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals 15 drugs and biologicals with pass-through status ending December 31,

43 Proposed 2017 Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals 38 drugs/biologicals have pass-through status (SI=G) in

44 Proposed 2017 Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals 38 drugs/biologicals have pass-through status (SI=G) in

45 Proposed 2017 Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals 38 drugs/biologicals have pass-through status (SI=G) in

46 Proposed 2017 Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals $110 per day cost threshold for separate payment (SI=K) of non-pass through drugs with payment at ASP+6% ($100 in 2016) Biosimilar products will be treated in a manner comparable to other drugs Pass through status determination and the $110 packaging threshold apply Packaging determinations will be made on a drug-specific basis rather than a HCPCS Code-specific basis for those HCPCS codes that describe the same drug or biological but different doses Non-pass-through therapeutic radiopharmaceuticals (per day cost of $110) payment is ASP + 6% Currently three diagnostic radiopharmaceuticals with pass-through payment A9586 Florbetapir f18, diagnostic, per study dose, up to 10 millicuries Q9983 Florbetaben, f18, diagnostic, per study dose, up to 8.1 millicuries Q9982 Flutemetamol, f18, diagnostic, per study dose, up to 5 millicuries 46

47 Proposed 2017 Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals Blood clotting factors under OPPS to be paid at ASP+6% Skin substitutes high cost thresholds proposed for 2017: weighted average mean unit cost (MUC) above $25 per square cm OR per day cost (PDC) greater than $729 47

48 Proposed 2017 Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals 48

49 Proposed 2017 Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals 49

50 Other Proposed 2017 OPPS Payment and Coding Changes Hospital coding and payment for visits Current single HCPCS Code G0463 for clinic visits will continue to be used in 2017 No changes to current ED level structure No changes in critical care visit payment 50

51 Other Proposed 2017 OPPS Payment and Coding Changes Partial Hospitalization In 2016 there were Level 1 Partial Hospitalization APCs (3 services) and Level 2 APCs (4 or more services) for both Hospitals and Community Mental Health Centers (CMHCs) APC 5861 Hospital Level 1 Partial Hospitalization (3 services) APC 5862 Hospital Level 2 Partial Hospitalization (4 or more services) APC 5851 CMHC Level 1 Partial Hospitalization (3 services) APC 5852 CMHC Level 2 Partial Hospitalization (4 or more services) In 2017, CMS is proposing the following: APC 5863 Hospital Partial Hospitalization (3 or more services) APC 5853 CMHC Partial Hospitalization (3 or more services) 51

52 Other Proposed 2017 OPPS Payment and Coding Changes Partial Hospitalization Some of CMS concerns include : Compliance with 20 hours of service per week under partial hospitalization u Considering multiple options for enhanced monitoring of compliance Low frequency of individual therapy under the partial hospitalization programs High outlier payments for CMHCs u In 2015, 9 of the 51 CMHCs received outlier payments with 4 receiving 99% of the outlier payments u CMS proposing an 8% cap-outlier payments could not exceed 8% of total per diem payments for the calendar year 52

53 Other Proposed 2017 OPPS Payment and Coding Changes Inpatient only list is detailed in Addendum E 6 CPT Codes proposed for removal from the inpatient only list 53

54 Other Proposed 2017 OPPS Payment and Coding Changes 6 CPT Codes proposed for removal from the inpatient only list (cont d) 54

55 Proposed 2017 Nonrecurring Policy Changes Implementation of Section 603 of the Bipartisan Budget Act of 2015 relating to payment of certain items and services furnished to certain off-campus departments of a provider Beginning January 1, 2017, these items and services will not be considered covered OPD services for purposes of payment under OPPS and will instead be paid under the applicable payment system under Medicare Part B if requirements for such payment are otherwise met. CMS estimates that this will reduce net OPPS payments by $500 million in 2017 and increase MPFS payments by $170 million resulting in a net Medicare Part B savings of $330 million This includes both the FFS and Medicare Advantage impacts 55

56 Proposed 2017 Nonrecurring Policy Changes Implementation of Section 603 of the Bipartisan Budget Act of 2015 relating to payment of certain items and services furnished to certain off-campus departments of a provider Excepted status for off-campus outpatient departments of a hospital (off-campus PBDs) and still able to bill OPPS include the following: Off-campus PBDs billing OPPS prior to November 2, 2015 Dedicated emergency rooms whether on-campus or off-campus PBDs that are on the hospital campus or within the required distance of the hospital PBDs within 250 yards distance from a remote location of the hospital facility 56

57 Proposed 2017 Nonrecurring Policy Changes Off-campus outpatient department of a hospital requirements include: Must be located within a 35 mile radius of the main hospital Its financial operations must be fully integrated within those of the main provider Its clinical services must be fully integrated with those of the main hospital It is held out to the public as part of the main hospital 57

58 Proposed 2017 Nonrecurring Policy Changes On-campus versus off-campus and regarding remote location: On-campus is defined as areas immediately adjacent to the hospital s main buildings and structures that are not strictly contiguous to the main hospital buildings but are located within 250 yards of the main buildings Remote location of a hospital is a facility created or acquired by the main hospital that is the main provider of inpatient services under the name, ownership and financial and administrative control of the main provider 58

59 Proposed 2017 Nonrecurring Policy Changes Excepted off-campus PBDs and the items and services provided by these PBDs will lose excepted status if the excepted off-campus PBDs move or relocate from the physical address listed on the provider hospital enrollment form as of November 1, 2015 Excepted off-campus PBDs that expand services beyond the current family of clinical services after November 1, 2015 will not be able to bill the expanded services under OPPS 59

60 Proposed 2017 Nonrecurring Policy Changes 60

61 Proposed 2017 Nonrecurring Policy Changes Individual excepted off-campus PBDs cannot be transferred from one hospital to another and maintain excepted status CMS requesting comments on whether hospitals should be required to separately identify all individual excepted off-campus PBD locations, the date each excepted off-campus PBD began billing and the clinical families of services provided by each excepted offcampus PBD prior to November 2,

62 Proposed 2017 Nonrecurring Policy Changes For non-excepted off-campus PBDs, CMS intends in the future to provide a method to bill and receive payment for the non-excepted items and services under an applicable payment system other than OPPS. A straightforward method to do so will not be ready by January 1, 2017 CMS is actively exploring options for off-campus PBDs to bill for nonexcepted items and services under another payment system such as MPFS and be paid at the applicable rate beginning in CY 2018 Temporary 1 year solution is to pay for all non-excepted items and services provided in an off-campus PBD at the MPFS non-facility rate until applicable payment system developed New provider type under professional claim to be used for offcampus PBDs and the non-excepted items and services 62

63 Proposed 2017 Nonrecurring Policy Changes Changes for Payment for Film X-Rays Effective for services furnished in 2017, there will be a 20% reduction in payment under OPPS for imaging services that are x-rays taken using film (includes x-ray component of a packaged service) Hospital required to assign to be determined modifier beginning in 2017 For 2018 through 2022 there will be a 7% payment reduction for x-rays taken using computed radiography (includes x-ray component of a packaged service) For 2023 and subsequent years, this payment reduction becomes 10% 63

64 Proposed 2017 OPPS Payment Status and Comment Indicators Addendum B of the Federal Register is your "guide" Pay attention to items with the following status indicators changes: E1 and E2 replace the E status indicator u E1-Items and services not covered by Medicare u E2-Items and services with no pricing information or claims data available Complete list of 2017 status indicators are listed in Addendum D1 64

65 Proposed 2017 OPPS Payment Status and Comment Indicators Addendum B of the Federal Register is your "guide" Pay attention to items with the following comment indicators: "CH"-Active HCPCS code with change in status indicator or APC assignment or active HCPCS code that is being discontinued. "NI"-Existing code with substantial change in 2017 with code descriptor or APC assignment NP -New code for 2017 or existing 2016 code with substantial change in 2017 with code descriptor or APC assignment NC -New code for 2017 which was assigned NP in the proposed rule 65

66 Questions 66

67 Impact of Proposed 2017 ASC Changes 67

68 Overall Impact of Proposed 2017 ASC Changes 68

69 Overall Impact of Proposed 2017 ASC Changes 69

70 ASC Payment System Background CMS implemented a revised ASC payment system in 2008 Policy established to ensure that procedures performed in an ASC Not expected to pose a significant risk to beneficiary safety Not expected to require active medical monitoring Do not last past midnight following the procedure ASC payment policies for covered surgical procedures, drugs, biologicals and certain other covered ancillary procedures are based on OPPS payment policies 70

71 ASC Payment System Background Addendum DD ASC Payment Indicators A2-Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. B5-Alternative code may be available; no payment made D5-Deleted/discontinued code; no payment made. F4-"Corneal tissue acquisition, hepatitis B vaccine; paid at reasonable cost." G2-Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. H2-Brachytherapy source paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate. J7-OPPS pass-through device paid separately when provided integral to a surgical procedure on ASC list; payment contractor-priced. 71

72 ASC Payment System Background J8-Device-intensive procedure; paid at adjusted rate. K2-Drugs and biologicals paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS rate. K7-Unclassified drugs and biologicals; payment contractor-priced. L1-Influenza vaccine; pneumococcal vaccine. Packaged item/service; no separate payment made. L6-New Technology Intraocular Lens (NTIOL); special payment. N1-Packaged service/item; no separate payment made. P2-Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight. 72

73 ASC Payment System Background P3-Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on MPFS nonfacility PE RVUs. R2-Office-based surgical procedure added to ASC list in CY 2008 or later without MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight. Z2-Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS relative payment weight. Z3-Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on MPFS nonfacility PE RVUs. 73

74 2017 Proposed Update of the ASC Payment System 74

75 2017 Proposed Update of the ASC Payment System 75

76 2017 Proposed Update of the ASC Payment System 76

77 2017 Proposed Update of the ASC Payment System 77

78 2017 Proposed Update of the ASC Payment System 1 procedure newly added to permanent office-based designation(at least 50% in office setting) 78

79 2017 Proposed Update of the ASC Payment System 79

80 2017 Proposed Update of the ASC Payment System 80

81 2017 Proposed Update of the ASC Payment System Pass-through Devices CMS proposes to determine ASC device-intensive procedures(exceed 40% of cost) at the HCPCS code level rather than ASC assignment level in 2017 Device edits at HCPCS level (no specific device HCPCS code required-any device HCPCS is acceptable) No cost/ full credit and partial credit policies at HCPCS level 81

82 2017 Proposed Update of the ASC Payment System 8 procedures added to covered list for ASCs 82

83 2017 Proposed Update of the ASC Payment System Newly identified ancillary services/procedures packaged under OPPS will also be packaged in the ASC (Status Indicator N1) Comment indicator CH is used in Addendum BB to indicate covered ancillary services for which there is an ASC payment indicator change to reflect the comparable OPPS payment indicator change 83

84 2017 Proposed Update of the ASC Payment System Adjustment to the CY 2016 ASC conversion factor ($44.190) by the wage adjustment for budget neutrality of and the MFP(multi-factor productivity)-adjusted update factor of 1.2 percent, which results in a CY 2017 ASC conversion factor of $ For ASCs not meeting the quality reporting requirements, adjustment to the CY 2016 ASC conversion factor ($44.190) by the wage adjustment for budget neutrality of and the quality reporting/mfp(multi-factor productivity)-adjusted update factor of -0.8 percent, which results in a CY 2017 ASC reduced conversion factor of $

85 2017 Proposed Update of the ASC Payment System Comment indicators in Addendum AA and BB are important Pay attention, in particular, to the following comment indicators: "CH"-Active HCPCS code with change in status indicator or ASC assignment or active HCPCS code that is being discontinued. "NI"-Existing code with substantial change in 2017 with code descriptor or ASC assignment NP"- New code or existing code with substantial change in 2017 with code descriptor or ASC assignment 85

86 Hospital Outpatient Proposed Quality Reporting Program Updates 86

87 Hospital Outpatient Proposed Quality Reporting Program Updates 87

88 Hospital Outpatient Quality Reporting Program Proposed Updates 88

89 Hospital Outpatient Quality Reporting Program Proposed Updates 89

90 Hospital Outpatient Quality Reporting Program Proposed Updates 90

91 2017 ASC Quality Reporting Program Proposed Update 91

92 2017 ASC Quality Reporting Program Proposed Update 92

93 2017 ASC Quality Reporting Program Proposed Update 93

94 Ask the speakers a question or share your experiences. Just type your question or comment into the Q&A box on your computer screen. 94

95 Thank you! Mike Kovar (410) Taylor Pedone (440) BAL 95

96 To Complete the Program Evaluation The URL below will take you to HFMA on-line evaluation form. You will need to enter your member I.D. # (can be found in your confirmation when you registered) Enter this Meeting Code: 16AT41 URL: Your comments are very important and enables us to bring you the highest quality programs! 96