By Melissa Koehler, RHIA, CHDA, CDIP, CCS, CCS-P, CCDS
Just as the new year brings in resolutions, procedural code updates, and an uptick in gym memberships, the same is true for updates to the Hospital Outpatient Prospective Payment System (OPPS). The calendar year (CY) 2020 final rule for the OPPS and ambulatory surgical center (ASC) payment systems became effective January 1, 2020. This article presents a synopsis of the changes.
The CY 2020 final rule included a 2.6 percent increase for OPPS payment rates based on the projected 3.0 percent hospital market basket increase minus a 0.4 percentage point adjustment for multi-factor productivity (MFP).
The CY 2020 conversion factor for ASC payment rates was also increased based on the CY 2019 proposal to apply the hospital market basket update to ASC rates over a five-year interim period from CY 2019 through CY 2023. There were no changes to this policy for CY 2020. The conversion factor increase for ASCs meeting quality reporting requirements is also 2.6 percent. The higher rate was implemented in an effort to stimulate services provided in ASC settings that are often more cost-effective with better quality of care than the same service provided in a hospital setting.
Payment Status Indicators
Whether reimbursement for some Healthcare Procedural Coding System (HCPCS) codes will be made under OPPS are determined by payment status indicators. Addendum D1 of the final rule includes a complete listing of status indicators. CY 2019 updates included seven new status indicators added, bringing the total to 26. The CY 2020 final rule did not include any changes to the payment status indictors.
Inpatient Only List
Procedures that are designated to be performed in the inpatient setting only, and therefore not paid under OPPS, are included on the Inpatient Only (IPO) list. The criteria used to evaluate the removal of procedures from the IPO list were established in a previous OPPS final rule published in 2012. The five criteria, which remain unchanged for CY 2020, are:
- Most outpatient departments are equipped to provide the services to the Medicare population.
- The simplest procedure described by the code may be performed in most outpatient departments.
- The procedure is related to codes that were already removed from the IPO list.
- A determination is made that the procedure is being performed in numerous hospitals on an outpatient basis.
- A determination is made that the procedure can be appropriately and safely performed in an ASC and is on the list of approved ASC procedures or has been proposed by CMS for addition to the ASC list.
A procedure code does not have to meet all five criteria to be removed from the IPO list. Using the established conditions, the following Current Procedural Technology (CPT) codes were removed from the list:
- 27130, Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty) with or without autograft or allograft
- 22633, Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar
- 22634, Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar; each additional interspace and segment
- 63265, Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical
- 63266, Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic
- 63267, Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar
- 63268, Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral
In addition to the codes listed above, CPT codes 00670, 00802, 00865, 00944, and 01214 for various anesthesia services were removed from the list as the related surgical procedural codes had been previously removed from the IPO list. Also, there were not any new codes added to the IPO list for CY 2020.
ASC Covered Procedures
The list of ASC covered procedures represents those services chiefly performed in physician office settings based on volume and utilization data and clinical characteristics. Once a service, as represented by a CPT code, is added to the ASC covered procedure list, it is permanently designated as an office-based service. As with other aspects of the OPPS updates, changes are proposed each year followed by a comment solicitation period. The CY 2020 proposed rule included recommendations to add nine procedures to the ASC covered procedures list, but only four of those were included in the final rule after comments were received. The table below displays the CPT codes added to this list.
|CY 2020 CPT Code||CY 2020 Long Description|
|31298||Nasal/sinus endoscopy, surgical; with dilation of frontal and sphenoid sinus ostia (e.g., balloon dilation)|
|36465||Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; single incompetent extremity truncal vein (e.g., great saphenous vein, accessory saphenous vein)|
|36466||Injection of non-compounded foam sclerosant with ultrasound compression maneuvers to guide dispersion of the injectate, inclusive of all imaging guidance and monitoring; multiple incompetent extremity truncal vein (e.g., great saphenous vein, accessory saphenous vein), same leg|
|36482||Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (e.g., cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated|
Procedures that were proposed but not finalized due to public comments included some bronchoscopy services, surgical nasal/sinus endoscopy, delivery of placenta, and revision or removal of intracranial neurostimulator electrodes.
HCPCS Codes and APC Payments
The Advanced Payment Classification (APC) assignment for HCPCS codes establishes the payment rate for each service provided. CY 2020 has 766 APCs with changes in APC assignment for 319 HCPCS codes. The list of APCs can be found in Addendum A of the final rule. Changes in APC assignment by HCPCS code are listed in column C of Addendum B and can include a modification of the APC assignment, the payment status indicator, or both. Status indicators by HCPCS code are displayed in column D of the same addendum.
Hospital Outpatient and Ambulatory Surgical Center Quality Reporting
While CY 2019 updates brought significant changes to the Hospital Outpatient Quality Reporting (OQR) program, revisions to the CY 2020 final rule were minimal. One web-based measure was removed from CY 2020 Program Year: OP-33 External Beam Radiotherapy (EBRT) for Bone Metastasis. The change was made due to the substantial administrative burden associated with capturing data associated with the measure.
The Ambulatory Surgical Center Quality Reporting (ASCQR) program, which invokes a 2.0 percent payment reduction for ASCs that fail to meet quality reporting requirements, also saw little change in the CY 2020 updates as no measures were removed, revised, or added.
Alternative Pathway for Pass-through Status
In an effort to afford Medicare subscribers propitious access to new technology, the CY 2020 final OPPS rule added an alternative pathway for quality devices for pass-through payment status, which removes the requirement to show substantial clinical improvement. Other criteria for pass-through status would still need to be met and the devices require designation as an FDA Breakthrough Device. Pass-through payment status allows additional reimbursement for the devices aside from that for the ASC’s facility fee.
In addition to the new alternative pathway, several devices received pass-through status approval and are effective as such for three years beginning January 1, 2020. Those devices include a robotic system, bone graft material, an infusion system, a cardiac pulse generator system, and an artificial iris prosthetic.
Highlights of Other Changes
The final rule, which is available to review online, also includes details on payment methodology for 340B purchased drugs for participating hospitals and adjusted rates, as well as information on changes that impact Rural Health and Critical Access Hospitals regarding outpatient therapeutic services.
As with all other updates that impact coded data, healthcare facilities and professionals are encouraged to stay abreast of the changes to OPPS by reviewing the annual updates and understand how the changes may affect their organizations.
Center for Medicare and Medicaid Services. “CY 2020 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1717-FC).” Nov 1, 2019. www.cms.gov/newsroom/fact-sheets/cy-2020-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center-0.
Centers for Medicare and Medicaid Services. “Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs.” Federal Register 42 CFR Parts 416 and 419. November 12, 2019. www.federalregister.gov/documents/2019/11/12/2019-24138/medicare-program-changes-to-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center.
Centers for Medicare and Medicaid Services. “Hospital Outpatient Prospective Payment- Notice of Final Rulemaking with Comment (NFRM).” Regulation number CMS-1717-FC. 2020. www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1717-FC.
Melissa Koehler is division manager, coding education program at Baylor, Scott, and White Health.
Continuing Education Quiz
Review quiz questions and take the quiz based on this article online at https://my.ahima.org/store/product?id=66113.
- Quiz ID: Q2049102
- Expiration Date: February 1, 2021
- HIM Domain Area: Clinical Data Management