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
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.
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-
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
The Inpatient/Outpatient Code Editor will identify the combination of these two CPT codes and make a single composite
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.
New Technology APCs
CMS determined that HCPCS codes G0417, G0418, and G0419
would remain in new technology APCs. There has been minimal