AS ALWAYS, THE new year has brought the annual round of updates to code sets and coding procedures, including the newly released Hospital Outpatient Prospective Payment Sys- tem (OPPS) update for 2019. The final rule for calendar year (CY) 2019 was released by the Centers for Medicare and Med- icaid Services (CMS) on November 21, 2018 and went into ef- fect January 1, 2019. This article provides an overview of the changes. Conversion Factor The final rule of the CY 2019 OPPS presents a conversion fac- tor increase of 1. 25 percent. The conversion factor for CY 2019
is $79.546, compared to 2018’s conversion factor of $78.636.
This number is derived from the proposed inpatient market
basket increase of 2. 8 percent minus the multi-factor productivity index of . 8 percent in addition to a .75 percent reduction
as required by the Patient Protection and Affordable Care Act
(ACA). Hospitals that comply with the outpatient quality reporting requirements are able to use a conversion factor of
$79.546 while hospitals that fail to comply will receive a two
percent reduction, resulting in a conversion factor of $77.955.
Payment Status Indicators
Payment status indicators reveal if a service represented by
certain HCPCS codes will be reimbursed under the OPPS. The
list for the 2019 status indicators can be found in Addendum
D1. There are 26 status indicators for CY 2019, of which seven
are new. Status indicator J was further divided into two status
indicators. The additional status indicators include Q1, Q2, Q3,
Q4, and R.
J1: Comprehensive part B services paid through a Comprehensive APC
J2: Comprehensive part B services that may be paid
through a Comprehensive Ambulatory Payment Classification (APC)
Q1: STV-packaged codes
Q2: T-packaged codes
Q3: Codes that may be paid through a Composite APC
Q4: Conditionally packaged laboratory tests
R: Blood and blood products
Additional information can be found on these and all status
indicators in Addendum D1.
HCPCS Codes and APC Payments
The APC assignment determines the payment rate of a provided service. There are 719 APCs for CY 2019 located in Addendum A of the final rule. There were also 391 HCPCS codes
with some sort of change for 2019. These codes are located in
column C of Addendum B of the final rule. If a code has been
changed, it will have a comment indicator of “CH.” The changes may include a revision of the APC assignment, a change in
status indicator, or both.
Two CPT procedures were removed from the inpatient-only
list for CY 2019 and one HCPCS code was added. CPT code
31241, Nasal/sinus endoscopy, surgical; with ligation of sphe-
CY 2019 Updates to the Hospital
Outpatient Prospective Payment
By Abby Hansen, MHA, RHIA, CCS, CCS-P