OPPS Update: Get the Scoop on the 2019 APC Final Changes

Prepare yourself for a major overhaul of the coding, billing, and payment rules for Ambulatory Surgical Centers (ASCs) under the Ambulatory Payment Classification (APC). These changes will have a significant impact on your reimbursement for medical services in each APC group.

APC rules have not stabilized—and their complex nature, compliance issues, and recent evolutions have all served to make compliance a real challenge, notes hospital regs and reimbursement expert Duane Abbey in his audio conference, “OPPS/APCs Final Changes for 2019.”

Check Out New ENT & Vascular APCs

On November 2, the Centers for Medicare & Medicaid Services (CMS) released the 2019 Hospital Outpatient Prospective Payment System (OPPS) final rule, which applies to hospital outpatient departments and ASCs. The final rule contains many changes to APCs as well.

Under the OPPS, CMS assigns each medical service to an APC group, for which CMS reimburses the grouped services at the same rate, according to the Society for Cardiovascular Magnetic Resonance (SCMR). Theoretically, all services contained in a given APC group should be similar clinically and in resource use.

Here are a few of the most important APC-related changes in the 2019 OPPS final rule:

  1. New C-APCs: CMS finalized the expansion of the Comprehensive APC (C-APC) methodology by adding new C-APCs for ear, nose, and throat (ENT) services and vascular procedures, according to the American Society for Radiation Oncology (ASTRO). Under the new policy, CMS will provide a single payment for all services on a claim, regardless of the span of the service date(s).

For the C-APC billing concept, you would report a single primary service on the claim using the status indicator “JI,” and then include all the adjunctive services provided to support the primary service’s delivery.

Don’t Miss PHP Code Updates

  1. New Technology: CMS will also pay for services assigned to new technology APCs with fewer than 100 annual claims under one of several alternative payment methodologies, according to a CMS factsheet. CMS plans to use up to four years of data to calculate the geometric mean, the median, and the arithmetic mean. CMS will create a rule to adopt the method it will use to establish payment for the new technology service, both for assigning the service to a new technology APC and to a clinical APC.

The aim of this policy is to promote transparency and predictability in the payment rates for such low-volume new technology procedures and to mitigate wide fluctuations from year to year for these services.

  1. PHP Providers: CMS is proposing to delete six existing codes from the Partial Hospitalization Program (PHP) allowable code set for Community Mental Health Center (CMHC) APC 5853 and hospital-based PHP APC 5863—and to replace them with nine new codes starting January 1, 2019.

CMS failed to include the new, revised, and deleted 2019 Category I and III CPT codes in the PHP section of the proposed rule. But you can find the code changes in Addendum B of the 2019 OPPS/ASC proposed rule.

Brace for CMR Pay Changes

  1. CMR Codes: The fact that CMS has grouped dissimilar services together in APCs is no secret—and this has resulted in a significant decrease in technical component reimbursement for many imaging services, SCMR lamented. But the good news is, CMS has moved CPT code 75559 (cardiac magnetic resonance imaging (CMR) with stress/without contrast) to a higher-level APC.

This means that the technical component reimbursement for this service will increase by 103 percent. Most other CMR codes will remain unchanged, except for 75561 (resting CMR with contrast) which will experience a 15-percent decrease in reimbursement.

Bottom line: Make sure you understand all the 2019 OPPS and APC final changes, stresses Duane Abbey in his compliance audio conference. Get to know the general trends for APCs with particular attention to increased bundling as well.

To join the conference or see a replay, order a DVD or transcript, or read more

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