nopalatine artery has been deleted along with 01402, Anesthesia for open or surgical arthroscopic procedures on knee joint;
total knee arthroplasty. HCPCS code C9606, Percutaneous
transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or
coronary artery bypass graft, and combination of drug-elut-ing intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel
has been added to the inpatient-only coding list. This code has
been deemed to be similar to CPT 92941, which CMS added to
the inpatient-only list for CY 2018. There are 1,745 procedures
on the inpatient coding list for C Y 2019. The inpatient-only list
can be found in Addendum E of the OPPS final rule.
Changes to Hospital Outpatient Quality Reporting
In order to reduce the burden associated with information collection for the Hospital Outpatient Quality Reporting Program
requirements, the final rule has removed a total of eight measures. The removal of OP- 12, OP- 17, and OP- 30 are predicted to
reduce the burden for the CY 2021 payment determination by
approximately 530,075 hours and $19.4 million.
One of the removed measures is for CY 2020 determination:
The additional seven measures removed are for the CY 2021
OP-5: Median Time to ECG
OP-9: Mammography Follow-up Rates
OP-11: Thorax CT Use of Contrast Material
OP-12: The Ability for Providers with HI T to Receive Laboratory Data Electronically Directly into Their Qualified/
Certified EHR System as Discrete Searchable Data
OP-14: Simultaneous Use of Brain Computed Tomography (C T)
OP-17: Tracking Clinical Results Between Visits
OP-30: Endoscopy/Polyp Surveillance: Colonoscopy In-
terval for Patients with a History of Adenomatous Polyps-
Avoidance of Inappropriate Use
For CY 2019, the outlier fixed-dollar threshold is $4,600. This
is increased from the 2018 threshold of $4,150. An outlier pay-
ment is made when the cost of a service exceeds 175 percent
of the APC payment and the fixed-dollar threshold amount of
$4,600. The proposed outlier payments for C Y 2019 will remain
at one percent of the OPPS payments.
Continuation of 340B Drug Payment Plan
Under the 2019 OPPS final rule, CMS will continue to reduce
payments to 340B hospitals for drugs purchased under the
340B program. These reductions apply to disproportionate
share hospitals (DSH), rural referral hospitals (RRC), and nonrural sole community hospitals (SCH). The payment reduction
will continue to be derived by applying the average sales price
(ASP) minus 22. 5 percent just as it was for 2018. The exception is the way biosimilars will be paid for CY 2019. Non-pass
through biosimilars acquired under the 340B Program will be
reimbursed at ASP minus 22. 5 percent of the biosimilar’s ASP.
This methodology takes the place of the biosimilar’s ASP minus 22. 5 percent of the reference product’s ASP.
Additional Changes to Review
The changes to the OPPS mentioned in this article are just a
few of many. The full final rule is available for review online.
The OPPS is updated each year and it is important for all
healthcare facilities in the US to review the changes in order to
understand how their organization will be impacted. ¢
Centers for Medicare and Medicaid Services. “Medicare
Program: Changes to Hospital Outpatient Prospective
Payment and Ambulatory Surgical Center Payment Systems
and Quality Reporting Programs.” Federal Register 42 CFR
Parts 416 and 419. November 21, 2018. www.federalregister.
Abby Hansen ( email@example.com) is coding compliance
specialist at UASI and adjunct coding instructor at several community colleges in Kansas.
The OPPS is updated each year and it is important for all healthcare
facilities in the US to review the changes in order to understand how their
organization will be impacted.
Additional 2019 Coding Updates Available
Need a refresh on 2019 coding updates? Visit the AHIMA HIM Body of Knowledge
and read the following Journal of AHIMA articles providing the latest information on
fiscal year 2019 ICD-10-CM, ICD-10-PCS, and other regulatory updates:
• “2019 ICD-10-PCS Coding Updates” by Tina Bruce, MHIM, MHI, RHIA, CCS,
• “FY 2019 ICD-10-CM Updates: Getting Back to Normal” by Laurie M. Johnson,
MS, RHIA, FAHIMA: http://bok.ahima.org/doc?oid=302606
• “IPPS Final Rule Changes for Fiscal Year 2019” by Moira Hunger, RHIT: http://