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Coding and Reimbursement Highlights for 2020 IPPS, MPFS & OPPS

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With the CMS Final Rule published there is a flurry of activity across the industry to come up to speed on the changes. In our experience though we’ve found that for many healthcare systems it’s easier to keep track of changes to the codes, rules, and guidelines they are already using; the challenge comes in becoming aware of and implementing when new things are introduced. However, it’s critical to know these new guidelines sooner rather than later so you can educate your coders, billers, and other reimbursement staff to ensure that your team knows what’s required for proper reimbursement.

To give you the information you need, we’ve combed through the Final Rule to pull out the new services that will have an impact on your bottom line across IPPS, MPFS, and OPPS.

Here’s a quick overview and more detailed information follows.

IPPS: Increases for both new technology and new drugs and biologics add-on payments have been finalized. Coding staff will want to review these services as the additional inpatient reimbursement is tied to specific ICD-10-PCS codes that will need to be identified and reported.

MPFS: New codes have been created for the use of Nasal Esketamine for treatment resistant depression, opioid treatment program bundled payment rates are to be based on the medication used, and services have been added within telehealth.

OPPS: New codes created by the AMA have been assigned by CMS to certain clinical groups and new HCPCS codes added by CMS that will need to be reported with applicable CPT procedure codes.

AUC Program: This program is moving from voluntary reporting to an Educational and Operations Testing Period, which requires all providers to use a qualified CDSM and report AUC consultation information on the professional and facility claims for the service. Payment will not be affected until 2021, but it is important to get systems in place now to avoid any negative repercussions.

Here are the details from the Final Rule.

IPPS Final Rule

  • Add-On Payments Update CMS finalized an increase in the new technology add-on payment percentage. Specifically, for a new technology other than a medical product designated by the FDA as a QIDP, beginning with discharges on or after October 1, 2019, if the costs of a discharge involving a new technology (determined by applying CCRs as described in § 412.84(h)) exceed the full DRG payment (including payments for IME and DSH, but excluding outlier payments), Medicare will make an add-on payment equal to the lesser of: (1) 65 percent of the costs of the new medical service or technology; or (2) 65 percent of the amount by which the costs of the case exceed the standard DRG payment.
  • Several drugs and biologics (e.g., Azedra, Cablivi, Elzonris) will begin receiving add-on payment effective 10/1/2019. There is a new bacterial test T2Bacteria Panel run on the T2Dx Instrument that will also receive add-on payment. CMS is continuing inpatient add-on payment for several other drugs and devices (e.g., AndexXa, AquaBeam). Coding staff will want to review these services as the additional inpatient reimbursement is tied to specific ICD-10-PCS codes that will need to be identified and reported.

MPFS Final Rule

  • Nasal Esketamine for Treatment Resistant Depression (TRD) CMS created two new HCPCS G codes, G2082 and G2083, that are effective January 1, 2020 on an interim final basis. The RVUs established for these services reflect the relative resource costs associated with the evaluation and management (E/M), observation and provision of the self-administered esketamine product. Nasal Esketamine is self-administered by the patient in the presence of a qualified healthcare professional and observed for a minimum of 2-hours post administration for any side effects / adverse events. Patients dosing is 56 to 84 mg and begins with doses twice a week and tapers to once a week, then every 2 weeks depending on patient’s response to treatment.
  • Opioid Treatment Program (OTP) CMS finalized to base the OTP bundled payment rates, in part, on the type of medication used for treatment. These categories reflect those drugs currently approved by the FDA under section 505 of the FFDCA for use in treatment of OUD: that is, methadone (oral), buprenorphine (oral), buprenorphine (injection), buprenorphine (implant), naltrexone (injection)). They will codify this policy of establishing the categories of bundled payments based on the type of opioid agonist and antagonist treatment medication in § 410.67(d)(1). HCPCS code range G2067 – G0280 (refer to Addendum for list of codes) created specifically for treatment of Opioid Use Disorder (OUD). Table 18 in the 2020 MPFS Final Rule contains the list of codes with drug cost, non-drug cost and total cost. These HCPCS G codes describing the OTP bundled payments and add-on codes can only be billed by OTPs and cannot be billed by other providers. To Track payment for these services a new Place of Service Code (POS) was created. Place of Service code 58 (Non-residential Opioid Treatment Facility – a location that provides treatment for OUD on an ambulatory basis. Services include methadone and other forms of MAT).
  • Added Services for Telehealth As discussed in the CY 2019 PFS final rule (83 FR 59496), section 2001(a) of the SUPPORT Act (Pub. L. 115–271, October 24, 2018) amended section 1834(m) of the Act, adding a new paragraph (7) that removes the geographic limitations for telehealth services furnished on or after July 1, 2019, for individuals diagnosed with a substance use disorder (SUD) for the purpose of treating the SUD or a co-occurring mental health disorder. Section 1834(m)(7) of the Act also allows telehealth services for treatment of a diagnosed SUD or cooccurring mental health disorder to be furnished to individuals at any telehealth originating site (other than a renal dialysis facility), including in a patient’s home. Section 2001(a) of the SUPPORT Act additionally amended section 1834(m) of the Act to require that no originating site facility fee will be paid in instances when the individual’s home is the originating site. CMS believes that adding HCPCS codes G2086, G2087, and G2088 to the Medicare telehealth list will complement the existing policies related to flexibilities in treating SUDs.

OPPS Final Rule

  • APC Specific Update New codes added by the American Medical Association (AMA) have been assigned by CMS to applicable clinical groups. Some of the new codes include the following:
  • Cataract Removal with Cyclophotocoagulation – APC 5492 and Status Indicator J1. CPT code 66987 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (for example, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (for example, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with endoscopic cyclophotocoagulation). CPT code 66988 (Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (for example, irrigation and aspiration or phacoemulsification); with endoscopic cyclophotocoagulation). CPT codes 66982 and 66984 descriptions have been modified to indicate these are performed without endoscopic cyclophotocoagulation
  • Long-Term Electroencephalogram (EEG) Monitoring Services – APCs 5722, 5723, and 5724). For CY 2020, the CPT Editorial Panel deleted four existing long-term EEG monitoring services, specifically, CPT codes 95950, 95951, 95953, and 95956, and replaced them with 23 new CPT codes that consists of 10 professional component (PC) codes and 13 technical component (TC) codes. Codes 95700-95716 are assigned to Status Indicator S. Codes 95717-95726 are assigned to Status Indicator M.
  • Cardiac Positron Emission tomography (PET)/Computed Tomography (CT) Studies – APC 1522, 1523 and 5594. For CY 2020, the CPT Editorial established six new codes to describe the services associated with cardiac PET/CT studies, specifically, CPT codes 78429, 78430, 78431, 78432, 78433, and 78434. Code 78434 (Absolute quantitation of myocardial blood flow (AQMBF), positron emission tomography (PET), rest and pharmacologic stress (List separately in addition to code for primary procedure) is assigned Status Indicator N. Report this code in addition to 78431 or 78492 when AQMBG is performed.
  • Pass-Through Payments for Devices New HCPCS codes added by CMS that will need to be reported with applicable CPT procedure codes. Some of the new HCPCS codes include the following:
  • HCPCS code C1982 Surefire Spark Infusion System (flexible, ultra-thin microcatheter with a self-expanding, nonocclusive one-way microvalve at the distal end). To ensure pass-through payment is made, this device may be separately reported with CPT code 37243 (Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction).
  • HCPCS code C2596 AquaBeam System (utilizes real-time intra-operative ultrasound guidance to allow the surgeon to precisely plan the surgical resection area of the prostate and then the system delivers Aquablation therapy to accurately resect the obstructive prostate tissue without the use of heat). Consists of a disposable, single-use handpiece as well as other components that are considered capital equipment. To ensure pass-through payment is made, this device may be separately reported with CPT code 0421T (Transurethral waterjet ablation of prostate, including control of post-operative bleeding, including ultrasound guidance, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included when performed).

AUC Program 2020 Update

Under the Appropriate Use Criteria (AUC) program, at the time a practitioner orders an advanced diagnostic imaging service for a Medicare beneficiary, he/she, or clinical staff acting under his/her direction, will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (AUC) is accessed. This program impacts all physicians and practitioners (as defined in 1861(r) or described in 1842(b)(18)(C)), that order advanced diagnostic imaging services and physicians, practitioners and facilities that furnish advanced diagnostic imaging services in a physician’s office, hospital outpatient department (including the emergency department), an ambulatory surgical center or an independent diagnostic testing facility (IDTF) and whose claims are paid under the physician fee schedule, hospital outpatient prospective payment system or ambulatory surgical center payment system.

Voluntary reporting period is July 1, 2018 through January 1, 2020.

During CY 2020 CMS expects ordering professionals to begin consulting qualified CDSMs and providing information to the furnishing practitioners and providers for reporting on their claims. Situations in which furnishing practitioners and providers do not receive AUC-related information from the ordering professional can be reported by modifier MH. Even though claims will not be denied during this Educational and Operations Testing Period inclusion is encouraged as it is important for CMS to track this information.

Full program implementation is expected January 1, 2021. At that time, information regarding the ordering professional’s consultation with CDSM, or exception to such consultation, must be appended to the furnishing professional’s claim in order for that claim to be paid.

Beginning January 1, 2020, providers must use a qualified CDSM and report AUC consultation information on the professional and facility claims for the service. Specific claims processing instructions will be issued closer to 2020. Claims for advanced diagnostic imaging services will include information on:

  • The ordering professional’s NPI
  • HCPCS G code – Which CDSM was consulted (there may be multiple qualified CDSMs available / these are for informational purposes only – not paid)
  • AUC Modifier – Whether the service ordered would or would not adhere to consulted AUC or whether consulted AUC was not applicable to the service ordered

An ordering professional may delegate the AUC consultation to clinical staff acting under his/her direction if they do not personally perform the AUC consultation.

CMS identified the following 8 priority areas that may be used in the determination of outlier ordering professionals in the future:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and nontraumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (to include suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

Ordering professionals will be monitored and could become identified as an outlier ordering professional who will become subject to prior authorization based on their ordering pattern.

CMS may make AUC reporting requirements exceptions for:

  • Emergency services, when provided to patients with certain emergency medical conditions (as defined in Section 1867(e)(1) of the Act)
  • Inpatients and for which Medicare Part A payment is made
  • Ordering professionals, when experiencing a significant hardship including: Insufficient internet access
  • EHR or CDSM vendor issues
  • Extreme and uncontrollable circumstances

To meet the exception for an emergency medical condition, the clinician only needs to determine that the medical condition manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual (or a woman’s unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

CPT codes and descriptions only are copyright 2019 American Medical Association.  All Rights Reserved.  Applicable FARS/DFARS Apply. Dental codes (D codes) are copyright 2018 American Dental Association.  All Rights Reserved.