September 04, 2012 | | Comments 0
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CMS Releases October OPPS Update

CMS released the October OPPS update this week with a smattering of unrelated, but important updates.  There were also two corrections to the claim manual in this update.

One of the manual corrections appears to be aimed at removing a barrier to payment for bariatric surgery in hospital outpatient departments.  Although CPT code 43770 (laparoscopic placement of adjustable gastric band), was removed from the inpatient only list effective January 1 of this year, there remained a notation in the claims processing manual that the procedure was only payable on a type of bill 11X, an inpatient type of bill.   CMS corrected this to indicate that the procedure is also payable on 13X, outpatient hospital, and 85X, critical access hospital outpatient, types of bills.

There is some confusion about when this change is effective.  The text of the transmittal, as well as the “Business Requirements” instructions to the MACs, indicate this change related to the type of bill is retroactively effective back to January 1, 2012 when the procedure was removed from the inpatient only list.  However, the transmittal has an effective date of October 1, 2012 and the actual manual section header also repeats this October 1, 2012 effective date.

On a related note, the IOCE indicates that code 43775 (laparoscopic sleeve gastrectomy) was added to the inpatient only list following its approval for coverage, retroactively effective April 1, 2012.

Also included in the update were codes for two new drugs approved for pass through payment, effective October 1, 2012.  The drugs are pertuzumab injection, 10mg (C9292) and glucarpidase injection, 10 units (C9293)

There was also one new HCPCS code added for October: G9157 (Short descriptor:  “Transesophageal Doppler mon”). This new code has a status indicator of “M” indicating it is not reportable by a hospital to a MAC.  Generally, codes with a status indicator “M” are codes that are not reportable because they represent professional services or there is an alternative code available for reporting the service.

Finally, CMS made updates to manual sections on Transitional Outpatient Payments (TOP) to certain rural and Sole Community Hospitals (SCH) to account for recent legislative activity extending these payments.  The additional payments were only extended to February 29, 2012 for SCHs and Essential Access Community Hospitals (EACH) with more than 100 beds.  However, for rural hospitals, as well as SCHs and EACHs with 100 or fewer beds the additional TOPs payments were extended through the end of this calendar year.

Lastly, on an unrelated note, I want to remind everyone that the comment period for comments to the CY2013 OPPS proposed rule, including CMS’ solicitation of comments on patient status issues, is open until September 4 at 5 p.m.  I encourage you all to comment.

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Kimberly Hoy About the Author:

Kimberly Anderwood Hoy is director of Medicare and compliance for HCPro, Inc.

As a hospital compliance officer, Kimberly regularly provided research and guidance on coding, billing, and reimbursement issues for a wide range of hospital services. She has a particular expertise in charge description master operation, development, and maintenance. She has experience conducting billing compliance audits and internal investigations. Kimberly also has had primary responsibility for HIPAA privacy regulation compliance, including risk assessment, program development, implementation of policies and procedures, and ongoing operations.

As In-House Legal Counsel, Kimberly had oversight of expense contracting and regulatory compliance, including federal and state laws and regulations. Kimberly regularly provided legal advice on such complex topics as consents, EMTALA, Stark, anti-kickback and anti-inducement laws, physician recruiting, and tax exemption regulations.

Kimberly has served as a speaker at compliance-related conferences in the areas of compliance program effectiveness and physician education. Kimberly is an active member of the American and California Bar Associations, the American Health Lawyers Association and the Health Care Compliance Association.

Kimberly earned her Juris Doctor degree from the University of Montana School of Law, where she received the Corpus Juris Secundum Award for Excellence in Contracts. She also holds a Bachelor of Arts degree in Philosophy from Yale University.

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