Letter from the Editor

CMS 2008 OPPS Final Rule Review

John Rader, Jennifer Williams, Susan Heilman Healthcare Economics, Medtronic, Inc. Minneapolis, Minnesota
John Rader, Jennifer Williams, Susan Heilman Healthcare Economics, Medtronic, Inc. Minneapolis, Minnesota
As the range of today’s cardiovascular procedures continues to expand and their sites of service shift, familiarity with coding and reimbursement changes is critically important to assure compliance with CMS’s regulations and appropriate integrity of the hospital’s revenue cycle process. On November 1st, CMS released the Outpatient Prospective Payment System (OPPS) Final Rule, which is effective for services provided on or after January 1, 2008.
This overview will provide an update regarding the pertinent changes for services delivered in the cath lab, electrophysiology (EP) lab and peripheral vascular labs. The 2008 Final Rule includes significant policy, coding and payment changes that are important for everyone to understand.

Highlights of the 2008 Final Rule include:
• CMS projects 2008 OPPS payments to hospitals will increase by about 10% to approximately $36 billion, due in part to increased utilization.
• An increase in the APC Conversion Factor to $63.694.
• Elimination of ICD generator G-Codes beginning January 1, 2008. Hospitals will need to report CPT 33240 or 33249, as the G codes will no longer be valid for reporting purposes.
• Creation of a composite (i.e. blended) Ambulatory Payment Classification (APC) to cover payment for EP studies and catheter ablations performed in the same visit.
• Creation of a new modifier, FC, for a partial device credit. This builds on the FB modifier that was created for no-cost devices in 2007.
• The Medicare Part A deductible was increased to $1,024 and represents the annual maximum patient co-payment amount for hospital outpatient services.
• Packaging of supportive ancillary services, including imaging supervision and interpretation, for non-coronary vascular procedures.

Key Coding and Reimbursement Changes Effective January 1, 2008
Arrhythmia Procedures
• When EP studies (CPT codes 93619, 93620) and catheter ablations (CPT 93650, 93651, 93652) are provided in separate encounters, Medicare will reimburse the applicable APC (APC 0085 or APC 0086).
• APC 0087 was deleted and selected EP services were reclassified from APC 0087 to APC 0084. This list includes: Bundle of His, intra-atrial, and right ventricular recordings (CPT 93600, 93602, and 93603 respectively); as well as intra-atrial, right ventricular pacing (CPT 93610, 93612), esophageal recordings of atrial electrograms (CPT 93615, 93616), and induction of arrhythmia by electrical pacing (93618).
• AV Node ablation (CPT code 93650) was reclassified from APC 0086 to APC 0085.
• SVT and VT Ablations (CPT codes 93651 and 93652) remain in APC 0086.
• The G-Codes that were assigned to ICD generator and ICD system implants have been eliminated and replaced: - G0300 and G0299 have been replaced with CPT 33249 (insert ICD system) - G0298 and G0297 have been replaced with CPT 33240 (insert ICD generator)
• CMS created a Composite APC that provides a single payment for all clinically-related services provided within an encounter or episode of care. APC 8000 includes the performance of a cardiac electrophysiologic evaluation (CPT 93619 or 93620) and a catheter ablation (CPT 93650, 93651 or 93652).
• The Fluoroscopy CPT code 71090, has changed to a status indicator N, meaning that the payment is packaged into the APC rate for other services. Therefore, a separate APC payment is no longer available for this fluoroscopy service.

Coronary Vascular Procedures
• Payments for coronary angioplasties and atherectomies are now combined with non-coronary procedures. Payment adjustments reflect the merging of coronary and non-coronary procedures into APCs 0082 and 0083.
• The intravascular IVUS CPT codes 92978 and 92979 have been changed to a status indicator N, meaning that the payment is packaged into the APC rate for other services. Therefore, a separate APC payment is no longer available for these IVUS codes.

Peripheral Vascular Procedures
• The intravascular IVUS CPT codes 37250, 37251 and 75946, have been changed to a status indicator N, meaning that the payment is packaged into the APC rate for other services. Therefore, a separate APC payment is no longer available for these IVUS codes.
• Imaging supervision and interpretation for non-coronary stenting has been changed to a status indicator N, meaning that the payment is packaged into the APC rate for the stenting itself. Therefore, a separate APC payment is no longer available for the imaging supervision and interpretation.
• Other imaging and supervision codes, including diagnostic angiograms, have been changed to a status indicator Q, meaning that they are separately payable only when specific criteria are met. Below are two short description of scenarios involving angiograms and how/if they would be payable: • Diagnostic angiograms: In this example, we are assuming that multiple angiograms were performed in the lower extremity: - 2007: Each angiogram mapped to an APC and every line item was paid at 100% of its APC value. - 2008: The highest-value procedure is paid at 100% of its APC value and all other eligible codes are packaged into that one payment. • Angiograms occurring during an intervention: In this example, we are assuming that multiple angiograms were performed in the lower extremity while an angioplasty also occurred: - 2007: Each angiogram mapped to an APC and every line item was paid at 100% of its APC value. The radiological supervision and interpretation for the angioplasty was mapped to an APC and was paid at 100% of its APC value. - 2008: The angioplasty’s APC code has a status indicator of “T”, thereby resulting in all codes with status Q being packaged into the angioplasty’s payment. There is no separate payment for any radiological supervision and interpretation.

Partial Credit Devices

One other key change that is applicable to all device-related services is the addition of a new modifier for partial credit devices. In 2007, Medicare implemented the “FB” modifier for use when an “Item is Provided Without Cost to Provider, Supplier or Practitioner” (Examples, but not Limited to: Covered Under Warranty, Replaced Due to Defect, Free Samples). This year, a new “FC” modifier was created for use when a “Qualifying Partial credit is received for a replaced device.” Hospitals are instructed to append the modifier to the procedure code [not the device code] that reports the services provided to replace the device. Services that require a modifier [FB or FC] are shown in Table 1 (Source: Medicare Table 26).

Reimbursement Rates for 2008

The financial impacts of the changes to the device-related APCs are summarized in Tables 2 and 3.

Quality Monitoring
In addition to the reimbursement changes previously described as being effective January 1, 2008, reporting of quality measures begins April 1, 2008. In order to receive a full payment update in CY 2009, participating hospitals must collect data on seven required measures if they have cases meeting the data collection specifications. The Joint Commission requires accredited hospitals to collect and submit data on at least 4 quality measure sets for discharges in 2008. The seven measures include:

1. Aspirin at Arrival
2. Median Time to Fibrinolysis
3. Fibrinolytic Therapy Received Within 30 Minutes of Arrival
4. Median Time to Electrocardiogram (ECG)
5. Perioperative Care: Timing of Antibiotic Prophylaxis
6. Perioperative Care: Selection of Prophylactic Antibiotic
7. Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus

In summary, while payments for outpatient cardiovascular procedures have moderate fluctuations for 2008, administrative vigilance is necessary to ensure that all coverage, coding and charging practices are compliant with federal regulations.

If you need additional assistance in understanding these changes to EP-related procedures, please contact Medtronic’s CRDM Healthcare Economics personnel through our coding hotline (1.866.877.4102, option 1) or website (www.Medtronic.com/ CRDMreimbursement ).

If you have any questions related to coronary or peripheral vascular procedures, please contact Medtronic CardioVascular at: http://www.medtronic.com/cvreimbursement

 

References

Data Sources

• CMS November 1, 2007. Press Release “New Steps to Encourage Efficiency and Quality for Medicare Hospital Outpatient Services in 2008.” Available at http://www.cms. hhs.gov/apps/media/press_releases.asp
• CMS Display Copy. Available at: http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage
• November 27, 2007 Federal Register Copy. Available at: http://www.access. gpo.gov/su_docs/fedreg/a071127c.html
• Quality monitoring information. Available at: http://www.jointcommission.org/NewsRoom/NewsReleases/nr_111507.htm