On July 8, 2013, the Centers for Medicare & Medicaid Services (CMS) released the CY 2014 proposed rule that would update payment policies and rates for hospital outpatient department and ASC services.  Apart from the annual adjustment of payment rates, other provisions are focused on policies within the Affordable Care Act (ACA) that encourage high-quality care in outpatient settings.  Some of the most significant details include:

Proposed Changes and Additions:

OPPS Payments and Policies:

• Five levels of visits to be collapsed into one.  Intending to discourage upcoding and offer additional incentive for hospitals to provide care in the most efficient manner, CMS is proposing that a single Healthcare Common Procedure Coding System (HCPCS) code replace the current five levels of outpatient visit codes, eliminating the need for hospitals to develop and maintain service level criteria.  A single code would be used for clinic visits, one for Type B emergency department visits and one for Type A emergency department visits.
• Update of the OPPS market basket by 1.8%.
• New packaging of seven categories of supporting items and services.  Separate reimbursement will continue to be made for many of these services if reported alone.  The proposed categories are:
  • 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;
  • Certain clinical diagnostic laboratory tests;
  • Procedures described by add-on codes;
  • Ancillary services, such as chest x-ray, that are assigned status indicator “X”;
  • Diagnostic tests on the bypass list, and
  • Device removal procedures.
  • Creation of 29 comprehensive ambulatory payment classifications (APC) to replace 29 existing device-dependent APCs.  CMS has assigned 148 HCPCS codes to these new APCs.

ASC Payment Updates:

• The multifactor productivity (MFP) adjusted consumer price index for all urban consumers (CPI-U) update for CY 2014 is projected to be 0.9% as a result of the projected CPI-U update of 1.4% and the projected MFP adjustment of 0.5%.
• Certain ancillary or adjunctive services that would be packaged under the OPPS for CY 2014 would also be packaged under the ASC payment system.
• Payments issued to ASCs that do not meet the ASC Quality Reporting Program requirements would receive a reduction of 2%.

Quality Program Changes:

• Five new measures added to the Hospital Outpatient Quality Reporting (OQR) Program, with data collection beginning in CY 2014 to affect payment in CY 2016:
  • Influenza Vaccination Coverage among Healthcare Personnel (NQF #0431)
  • Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures (NQF #0564)
  • Endoscopy/Poly Surveillance:  Appropriate follow-up interval for normal colonoscopy in average risk patients (NQF #0658)
  • Endoscopy/Poly Surveillance:  Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use (NQF #0659)
  • Cataracts – Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (NQF #1536)
  • Removal of two measures:
  • Transition Record with Specified Elements Received by Discharged ED Patients (OP-19)
  • Cardiac Rehabilitation Measure:  Patient Referral from an Outpatient Setting (OP-24)
  • Adoption of four new measures for the ASC Quality Reporting Program for the CY 2016 and following years payment determination.  Data will be collected through a Web-based tool, however CMS is requesting public comment on alternative collection strategies.
  • Performance and baseline periods for catheter-associated urinary tract infections (CAUTI), central line-associated bloodstream infection (CLABSI), and surgical site infection (SSI) to be set for the fiscal year (FY) 2016 Hospital Value-Based Purchasing (VBP) Program.  The performance period proposed is January 1, 2014 through December 31, 2014 with the baseline period of January 1, 2012 through December 31, 2012.
  • Creation of a second level independent CMS review process for hospitals that show dissatisfaction with the outcome of administrative appeals

The proposed rule will be published in the Federal Register on July 19, 2013.  CMS is soliciting feedback and will accept comments until September 6, 2013.  On November 1, 2013, the final ruling will be released, effective for services furnished on or after January 1, 2014.  Hospitals are strongly encouraged to thoroughly review the proposed ruling and evaluate the potential implications.  To view the proposed rule in its entirety, click on the following link: http://www.ofr.gov/(X(1)S(1cj0ufof3lwwrodp1tv2rn3a))/OFRUpload/OFRData/2013-16271_PI.pdf

HC Healthcare Consulting has a team comprised of consultants Certified in Healthcare Compliance along with certified coders, certified fraud examiners, statisticians and physician consultants.  We recommend reviewing the OIG’s report in its entirety and conducting audits of the identified risk areas that are applicable to your organization.  HC Healthcare Consulting is available to assist you with all of your auditing, education and corrective action needs.

DISCLAIMER:  This post contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link.  Any advice or recommendations given is general and specific questions should be directed to professional counsel.