with, as a result of, and in the same clinical encounter as the
Modifier “P T” must now be appended to the diagnostic procedure code that is reported instead of the screening colonoscopy
or screening flexible sigmoidoscopy HCPCS code or as a result
of the barium enema when the screening test becomes a diagnostic service.
Payment Status Indicators
There are no changes to the status indicator list for CY 2011. The
list, as approved for CY 2010, will remain in effect for CY 2011.
Supervision of Hospital Outpatient Diagnostic and
CMS required physician supervision of diagnostic and therapeutic services provided to hospital outpatient incidents in the
CY 2000 OPPS final rule. CMS adopted this as a condition of
payment to ensure that Medicare pays for high-quality hospital
outpatient services provided to beneficiaries in a safe and effective manner consistent with Medicare requirements.
CMS clarified and restated the payment requirements for physician supervision of hospital outpatient therapeutic and diagnostic services beginning with the CY 2009 rules, and it further
delineated the guidance in the CY 2010 rules. The large number
of comments it received in response has prompted CMS to address this issue once again.
In manual guidance, CMS notes that it expects outpatient ser-
vices to be performed under direct supervision. The previous
definition of direct supervision required that the physician be
“physically present on-site” and “immediately available to fur-
nish assistance and direction throughout the performance of
the procedure; however, the physician does not have to be pres-
ent in the same room when the procedure is being performed.”
The new definition states:
For services furnished in the hospital or Critical Access Hos-
pital (CAH) or in an outpatient department of the hospital
or CAH, both on- and off-campus… “direct supervision”
means that the physician or nonphysician practitioner must
be immediately available to furnish assistance and direction
throughout the performance of the procedure. It does not
mean that the physician or nonphysician practitioner must
be present in the room when the procedure is performed. For
pulmonary rehabilitation, cardiac rehabilitation, and inten-
sive cardiac rehabilitation services, direct supervision must
be furnished by a doctor of medicine or osteopathy.
Acknowledging the challenges critical access and rural hospitals face in meeting this new definition, CMS is extending its
existing notice of nonenforcement to critical access and small
rural hospitals with 100 or fewer beds through CY 2011. These
facilities will be required to comply with the physician supervision mandates effective with CY 2012.
The new rule includes minor adjustments to the list of device-dependent APCs for C Y 2011, due in some part to the creation of
new endovascular revascularization codes in CPT.
These new CPT codes (37220–37235) have been assigned to
APCs 83, 229, and new 319, Endovascular Revascularization of
the Lower Extremity.
Another new APC in the device-dependent APCs category is
318, Implantation of Cranial Neurostimulator Pulse Generator
New Technology APCs
CMS has the option to keep a procedure in the new technology
APC grouping until sufficient data have been accumulated to
allow the appropriate reassignment into a clinical APC group.
The accumulation of these data may be affected by an original
assignment that was based on inaccurate or inadequate information, although the information may have been the best information available at the time of the original assignment. Of the
four services described by G codes, only one of them is being
assigned to the clinical APC group for CY 2011.
Code G0416, Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 1–20
specimens, is now assigned to clinical APC 0661 (level V pathology).
Code G0417, Surgical pathology, gross and microscopic examination for prostate needle saturation biopsy sampling, 21–
40 specimens, which was originally assigned to APC 1507, has
been reassigned within the new technology APCs to APC 1506
as a result of median cost adjustments.
The two remaining G codes—G0148 and G0419—will continue
in their current new technology APC assignments for CY 2011.
Hospital Outpatient Quality Data Reporting
Annual payment updates are affected by hospital compliance
with the Hospital Outpatient Quality Data Reporting program
implemented for services furnished by hospitals in outpatient
settings on or after January 1, 2009. Current mandates require a
2 percent reduction to annual payment update factors for facilities that do not comply with the reporting requirements.
Currently there are 11 measures used in annual payment determination. These measures will continue for C Y 2011. Seven of
the measures are chart-abstracted measurements that are measured in three inpatient settings: AMI, cardiac care, and surgical
care. The four remaining measures address imaging efficiency
in hospital outpatient departments.
The measures for payment in C Y 2011are:
x OP–1: Median Time to Fibrinolysis
x OP–2: Fibrinolytic Therapy Received within 30 Minutes
x OP–3: Median Time to Transfer to Another Facility for
Acute Coronary Intervention
x OP–4: Aspirin at Arrival
x OP–5: Median Time to ECG
x OP–6: Timing of Antibiotic Prophylaxis