Complexity Adjustment: CMS Updates I/OCE Specifications and Software

Jan. 23, 2015 / By Dave Fee

Last week, CMS published updated I/OCE specifications and software. The changes revolved around calculations of the complexity adjustment for the comprehensive APCs (C-APCs).

Bypassing the code pair ranking

The specific language change in the specifications is in Appendix L where there is a note added: “In some instances, code pair combinations specified for complexity-adjustment may have a secondary procedure with a higher rank than the primary procedure. In these cases, the rank is ignored and the complexity-adjusted APC remains assigned to the primary procedure of the code pair.”

The flow chart is updated to reflect this rule clarification.

You might be asking, “What does this mean?” Let me try to explain. The clarification is in reference to the complexity adjustment evaluation table, published in addendum J with the final rule. This table lists all the code pairs for which a complexity adjustment is made. In the table there are eight pairs where the rank for the secondary service or device (defined by HCPCs code) is higher that the primary service rank.

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Normally, the rank is used to define the primary service, if there are multiple C-APC services on a claim. For these eight code pairs, and perhaps others in the future, the order defined in the table is used instead of the rank. Currently, this complexity adjustment only applies to these eight pairs (this is visible by comparing columns 4 and 9 in the table); otherwise the ranking is used to determine the primary C-APC.

Add-on codes

There is a second change in the software. It affects ten code pairs where the secondary code is an add-on code. In these cases, the complexity adjustment was not being applied and the new release corrects the issue.

The following table identifies the code pair involved. It also provides a comparison of payment with and without the complexity adjustment, (column 6 and 11 respectively).

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Both of these issues are corrected with the re-release of the I/OCE, version 16.0 R1.

3M expects to have this update available today.

3M clients can visit the client support page for more information.

Dave Fee is outpatient products marketing manager with 3M Health Information Systems.