Coding Notes
CY 2011 Changes to the
Hospital OPPS
By Karen M. Karban, RHIT, CCS
THE FINAL RULE for the calendar year 2011 Hospital Outpa- tient Prospective Payment System (OPPS) was released Novem- ber 24, 2010. Changes in the rule went into effect with January 1, 2011, outpatient hospital-based services. The changes to OPPS continue to reflect packaging adjust- ments and refinement of preventive services as well as other financial adjustments mandated by provisions of the Affordable Care Act. In addition, this year there are significant changes to CPT codes representing revascularization and cardiac catheter- ization procedures. Financial Impact for CY 2011
The Centers for Medicare and Medicaid Services (CMS) finalized the conversion factor for OPPS after considering the market
basket update figures of 2. 6 percent and adjusting it to be consistent with the mandated 0.25 percent reduction required by
elements of the Affordable Care Act. The finalized adjustment
factor was calculated as a 2. 35 percent increase based on the
outpatient department fee schedule.
The result for hospitals that successfully report quality data
will be a conversion factor of $68.876. For the few hospitals that
either do not report quality data or are unable to successfully do
so, the conversion factor for CY 2011 will be $67.530.
Visit Reporting Guidelines
CMS continues to review the need to establish national guidelines for the coding and reporting of clinic and emergency department hospital visits. CMS has observed a normal and stable
distribution of clinic and emergency department visit levels in
hospital claims over the last several years. Based on this data
consistency, there is currently no proposal to implement national visit guidelines prior to CY 2012.
Inpatient-Only Procedures
CMS continues to evaluate inpatient-only procedures and as a
result of public recommendations and data analysis has determined that it is appropriate to remove three procedures from
the inpatient-only procedure list for CY 2011. CPT codes 21193
and 21395 were assigned to APC 256, and CPT code 25909 was
assigned to APC 49.
All three procedures were assigned a status indicator of “T”
indicating they are subject to multiple procedure payment reductions:
x 21193, Reconstruction of mandibular rami; horizontal,
vertical, C, or L osteotomy; without bone graft
x 21395, Open treatment of orbital blowout fracture; perior-
bital approach with bone graft (includes obtaining graft)
x 25909, Amputation, forearm, through radius and ulna; re-
amputation
New HCPCS Modifier
A provision in the Affordable Care Act waives deductibles for
colorectal cancer screening tests furnished in connection with,
as a result of, and in the same clinical encounter as a screening
test regardless of the code billed. As a result, CMS is waiving the
deductible for all surgical services furnished on the same date
as a planned screening colonoscopy, planned flexible sigmoidoscopy, or barium enema as being furnished in connection
