Journal of AHIMA - February 2012

Coding Notes
CY 2012 OPPS Update

By Theresa Rihanek, RHIA, CCS

THE FINAL RULE for calendar year 2012 Hospital Outpatient Prospective Payment System (OPPS) was released on Novem- ber 30, 2011. The rule went into effect for outpatient hospital- based services January 1, 2012. This article outlines the updates in the final rule. Financial Impact The updated conversion factor for OPPS in 2012 is $70.016 for hospitals that meet the reporting requirements of the Hospital Outpatient Quality Reporting program. This is a 1. 9 percent in- crease of the outpatient department fee schedule. The increase was calculated by using the 3 percent hospital market basket increase less 1 percentage point for the multifactor productivity adjustment and less the 0.1 percentage point adjustment required by the Affordable Care Act, which established a reduction to the fee schedule increase factor for each year through 2019.

For hospitals that are unable to meet the data-reporting requirements for the Hospital Outpatient Quality Reporting program, the adjusted conversion factor is $68.616.

Outlier Calculation

An outlier payment will continue to be provided when the cost of furnishing the service exceeds 1. 75 times the APC payment amount and exceeds the APC payment rate plus a $1,900 fixed-dollar threshold. This is a decrease from the CY 2011 fixed-dol-lar threshold of $2,025.

The additional outlier payment will be equal to 50 percent of the costs exceeding these two thresholds.

Composite APC—Cardiac Resynchronization Thera-
py Defibrillator

The Centers for Medicare and Medicaid Services (CMS) will recognize CPT codes 33225, Insertion of cardiac venous lead with defibrillator or pacemaker generator (add on code), and 33249, Insertion/replacement of defibrillator and leads, as a single, composite service when the procedures are performed on the same date of service.

These CPT codes were assigned to APC 0108 with an associated status indicator of Q3 (codes that may be paid through a composite APC) because CMS elected not to create a new composite APC for cardiac resynchronization therapy defibrillator services.

The Inpatient/Outpatient Code Editor will identify the combination of these two CPT codes and make a single composite payment.

CMS made provisions for cases where the two CPT codes are not reported on the same day. When CP T code 33249 is reported without CPT code 33225, CPT code 33249 will be assigned to APC 0108. If CPT code 33225 is reported alone, then it will be assigned to APC 0655.

A new claim-processing edit is to be developed to return claims to providers when CPT code 33225 is not billed with one of the following CPT codes: 33206–33208, 33212–33214, 33216, 33217, 33222, 33233–33235, 33240, or 33249.