OPPS Proposed Rule for 2016

July 15, 2015 / By Dave Fee

I hope the publication of the 2016 OPPS proposed rule on July 1st did not dampen anyone’s July 4th celebration. The new rule continues the migration CMS began in 2014 to a more “prospective payment” type system. That means that there continues to be more packaging and fewer APCs. A few specifics: APC restructuring

With four goals in mind, CMS is restructuring nine APC clinical families. These goals are a continuation of what they have stated for the last couple of years. They are trying to achieve:

  1. Improved clinical homogeneity
  2. Improved resource homogeneity
  3. Reduced resource overlap in longstanding APCs
  4. Greater simplicity and improved understandability of the OPPS APC structure

The nine clinical families are:

  1. Endoscopy Procedures
  2. Diagnostic Tests and Related Services
  3. Excision/Biopsy and Incision and Drainage Procedures
  4. Gastrointestinal (GI) Procedures
  5. Imaging Services
  6. Orthopedic Procedures
  7. Skin Procedures
  8. Urology and Related Services Procedures
  9. Vascular Procedures (Excluding Endovascular Procedures)

Comprehensive APCs (C-APCs)

CMS is continuing with their policies around C-APCs, adding nine additional C-APCs to the current 25.

Also, they have added a new status indicator, J2, to be used with the C-APC 8011 (Comprehensive Observation Services). It is related to certain emergency room visits for which no procedure with a status indicator of T or J1 is also on the claim.

Laboratory services and the dreaded modifier L1

There have been a number of challenges with proper use of modifier L1. Some have chosen not to use it at all, as the cost in staff time and effort didn’t make it worthwhile. Others have added it to all lab services, appropriate or not. Either way, CMS is creating a new status indicator, Q4, for this use and it appears, will add logic to the OCE to determine if the claim contains only lab services. If so, then the Q4 will be assigned and they will be paid separately. This means you don’t have to be burdened with this issue in your billing practices and hopefully this will make billing a little easier. However, it may have some implications on EMRs and billing systems and require some advance preparation.

2-midnight rule

CMS continues to be committed to the 2-midnight policy, but has softened its stance a little. It will now allow stays less than 2-midnights on a case-by-case basis, as long as the documentation is appropriate and the following is considered:

  1. The severity of the signs and symptoms exhibited by the patient
  2. The medical predictability of something adverse happening to the patient
  3. The need for diagnostic studies that, appropriately, are outpatient services

CMS is also transferring review responsibility to Quality Improvement Organizations (QIOs) instead of the MACs. It is believed the QIOs are better prepared for these types of reviews and it is more consistent with their charter.

This is nothing more than a fly-over, but I hope it whets your appetite for what is contained in the 2016 proposed rule. I encourage you to read it and take time to provide comments to CMS.

Dave Fee is Outpatient Products Marketing Manager with 3M Health Information Systems.