CY 2016 MEDICARE OUTPATIENT HOSPITAL FINAL RULE

CRHF ECONOMICS & HEALTH POLICY DECEMBER 1, 2015

DISCLAIMER  This presentation is intended only for educational use. Any duplication is prohibited without written consent of the authors. This information does not replace seeking coding advice from the payer and/or your coding staff. The ultimate responsibility for correct coding lies with the provider of services. Please contact your local payer for their interpretation of the appropriate codes to use for specific procedures.  Medtronic makes no guarantee that the use of this information will prevent differences of opinion or disputes with Medicare or other third party payers as to the correct form of billing or the amount that will be paid to providers of service.  CPT copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for the data contained or not contained herein.  Note: CPT® code descriptions may be abbreviated and not listed in their entirety in all cases in this presentation. For full descriptions, please refer to your 2016 CPT code book.

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CRHF ECONOMICS & HEALTH POLICY

CONTINUING EDUCATION UNITS 

This program has prior approval of the American Academy of Professional Coders (AAPC) for one continuing education hour. Granting of this prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor. The AAPC requires attendees to participate in the entire Web-EX presentation in order to qualify for the CEU certificate.

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

This program has prior approval of the American Health Information Management Association (AHIMA) for one continuing education unit. Granting of this prior approval in no way constitutes endorsement by AHIMA of the program content or the program sponsor.



Registered attendees that qualify will receive an email that includes the CEU certificate within a couple of weeks.

CRHF ECONOMICS & HEALTH POLICY

ABBREVIATION GLOSSARY            

PVI: Pulmonary Vein Isolation VT: Ventricular Tachycardia SVT: Supraventricular Tachycardia AV: Atrioventricular SC: Singe Chamber DC: Dual Chamber PM: Pacemaker ICD: Implantable Cardioverter Defibrillator EP: Electrophysiologic Gen: Generator PBDs: Provider-Based Departments NPI: National Provider Identifier

Sources: 2016 CPT code book; CY 2016 Hospital OPPS final rule; CY 2016 MPFS final rule 4

CRHF ECONOMICS & HEALTH POLICY

AGENDA

5



Coding and APC/C-APC Assignment



Other CY 2016 OPPS Updates



Medicare Coverage Policies



Provider-Based Designation



Device Monitoring



Appendix



Q&A

CRHF ECONOMICS & HEALTH POLICY

Coding and APC/C-APC Assignment

CMS renumbering of APCs resulted in new APC numbers for all of the CRHF related procedure/services

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CRHF ECONOMICS & HEALTH POLICY

CPT®1 / HCPCS2 CODES FOR CY 2016 Category III Code2

Description2

0387T

Transcatheter insertion or replacement of permanent leadless pacemaker, ventricular (CMS assigned to C-APC 5193: $14,612)3

0388T

Transcatheter removal of permanent leadless pacemaker, ventricular (CMS assigned to C-APC 5182: $2,247)3

0389T

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report, leadless pacemaker system (CMS assigned to APC 5141: $33.62)3

0390T

Peri-procedural device evaluation (in person) and programming of device system parameters before or after a surgery, procedure or test with analysis, review and report, leadless pacemaker system

0391T

Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, leadless pacemaker system (CMS assigned to APC 5141: $33.62)3

1 AMA 2016 CPT code book; 2 HCPCS: Healthcare Common Procedure Coding System; 3 Medicare CY 2016 OPPS final rule, Addendum B

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CRHF ECONOMICS & HEALTH POLICY

APC / C-APC ASSIGNMENT FOR CRHF RELATED PROCEDURE/SERVICES FOR CY 2016 CPT Code

Brief CPT Code Description

CY 2016 APC/ C-APC Assignment/ National Payment1

CY 2015 APC/ C-APC Assignment/ National Payment1

Electrophysiologic Procedures 93603, 93615, 93616, 93618, 93642

Right ventricular recording Esophageal recording Esophageal recording w/pacing Induction of arrhythmia EP evaluation, not at implant

5211 $845

0084 $873

93600, 93602, 93610, 93612, 93619-20, 93624, 93650

Bundle of His recording Intra-atrial recording Intra-atrial pacing Intraventricular pacing Comprehensive EP evaluations EP follow up study AV node ablation

5212 $4,698

0085 $4,635

93653, 93654, 93656

Catheter ablation of SVT Catheter ablation of VT Catheter ablation by PVI

5213 $15,561

0086 $14,362

1 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html

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CRHF ECONOMICS & HEALTH POLICY

APC / C-APC ASSIGNMENT FOR CRHF RELATED PROCEDURE/SERVICES FOR CY 2016 CPT Code

Brief CPT Code Description

CY 2016 APC/ C-APC Assignment National Payment1

CY 2015 APC/ C-APC Assignment National Payment1

Pacemaker and Similar Procedures 33218, 33220, 33233, 33234, 33235, 33241, 33244

Repair single transvenous lead Repair 2 transvenous leads Remove pacemaker generator Remove PM lead from SC system Remove PM lead from DC system Remove ICD generator Remove ICD lead(s) transvenously

5221 $2,490

0105 $2,347 0105 $2,347 0090 $6,545 0105 $2,347 0105 $2,347 0105 $2,347 0105 $2,347

33210 33211 33212 33216 33217 33227

Insert temporary SC electrode Insert temporary DC electrodes Insert PM generator only, attach to lead Insert single transvenous lead Insert 2 transvenous leads Remove PM generator with replacement of PM gen. single lead system Insert cardiac event recorder

5222 $6,697

0090 $6,545

33282

1 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html

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CRHF ECONOMICS & HEALTH POLICY

APC / C-APC ASSIGNMENT FOR CRHF RELATED PROCEDURE/SERVICES FOR CY 2016 CPT Code

Brief CPT Code Description

CY 2016 APC/ C-APC Assignment National Payment1

CY 2015 APC/ C-APC Assignment National Payment1

Pacemaker and Similar Procedures continued 33206, 33207, 33208, 33213, 33214, 33224, 33228

Insert SC PM generator & lead in atria Insert SC PM generator & lead in ventricle Insert DC PM generator & 2 leads Insert PM generator only, attach to leads Upgrade SC PM to DC pacemaker Insert LV lead & attach to existing gen. Remove PM generator with replacement of PM gen. dual lead system

5223 $9,273

0089 $9,493

33221, 33229

Insert PM generator only, attach to leads Remove PM generator with replacement of PM gen, multiple lead system

5224 $16,914

0655 $16,407

1 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html

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CRHF ECONOMICS & HEALTH POLICY

APC / C-APC ASSIGNMENT FOR CRHF RELATED PROCEDURE/SERVICES FOR CY 2016 CPT Code

Brief CPT Code Description

CY 2016 APC/ C-APC Assignment National Payment1

CY 2015 APC/ C-APC Assignment National Payment1

ICD and Similar Procedures 33230, 33240, 33262, 33263 33231, 33249, 33264, 33270

Insert ICD generator only, attach to leads Insert ICD generator only, attach to lead Remove ICD generator with replacement of ICD generator, single lead system Remove ICD generator with replacement of ICD generator, dual lead system

5231 $21,930

0107 $22,107

Insert ICD generator only, attach to leads Insert ICD system with transvenous lead(s), SC or DC Remove ICD generator with replacement of ICD generator, multiple lead system Insert subcutaneous implantable defibrillator system with subcutanous lead

5232 $30,940

0108 $30,818

1 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html

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CRHF ECONOMICS & HEALTH POLICY

APC / C-APC ASSIGNMENT FOR CRHF RELATED PROCEDURE/SERVICES FOR CY 2016 CPT Code

Brief CPT Code Description

CY 2016 APC/ C-APC Assignment National Payment1

CY 2015 APC/ C-APC Assignment National Payment1

Electronic Analysis of Devices 93291

ILR device interrogation evaluation (in person)

5732 $30.51

0450 $29.24

93260

Subcutaneous device programming evaluation (in person) Subcutaneous device interrogation (in person) PM, ICD and ILR device programming evaluation (in person) PM, ICD device interrogation (in person) Interrogation device evaluation, physiologic data elements (in person) Transtelephonic monitoring Remote monitoring PM, ICD Remote monitoring ILR, Implantable Cardiovascular Monitor (ICM)

5741 $33.62

0690 $35.15

93261, 93279-85, 93288-89, 93290 93293, 93296, 93299

1 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html

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CY 2016 OPPS MEDICARE PAYMENT COMPARISONS Single Chamber (RV) pacemaker system initial insertion $10,000 $9,500

$9,493

$9,000

$9,273 Single Chamber (RV) pacemaker system initial insertion

$8,790

$8,500 $8,000

$8,230

$7,500 2013

2014

2015

2016

Dual Chamber pacemaker system initial insertion $11,000 $10,588

$10,500 $10,000

$10,187

$9,500

$9,493

$9,273

$9,000 $8,500 2013

2014

Medicare CY 2016 OPPS final rule National Payments from Addendums 13

CRHF ECONOMICS & HEALTH POLICY

2015

2016

Dual Chamber pacemaker system initial insertion

CY 2016 OPPS MEDICARE PAYMENT COMPARISONS CRT-P initial insertion $17,500 $17,000

$16,914

$16,500

$16,407

$16,000 $15,500 $15,000

$15,882 CRT-P initial insertion $15,280

$14,500

CRT-D and ICD initial insertion

$14,000 2013

2014

2015

2016

$32,500 $32,145

$32,000 $31,500 $31,000 $30,500

$30,680

CRT-D and ICD initial insertion

$30,818 $30,490

$30,000 $29,500 2013

2014

Medicare CY 2016 OPPS final rule National Payments from Addendums 14

CRHF ECONOMICS & HEALTH POLICY

2015

2016

Other CY 2016 OPPS Updates

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TABLE 42 DEVICE INTENSIVE PROCEDURES 

APC payment adjustment for all replacement devices furnished in conjunction with a procedure assigned to a device-intensive APC when the hospital receives a credit for the replaced device that is >50% of the replacement device cost. Only procedures that require an implantable device assigned to a “device-intensive” APC (Table 42) requires an applicable device code (HCPCS C-code). CY 2016 APC CY 2016 APC Title 1565

New Technology - Level 28 ($5,000-$5,500)

1599

New Technology – Level 48 ($90,000-$100,000)

5125

Level 5 Musculoskeletal Procedures

5166

Level 6 ENT Procedures

5192

Level 2 Endovascular Procedures

5193

Level 3 Endovascular Procedures

5222

Level 2 Pacemaker and Similar Procedures (33210-33212, 33216-33217, 33227, 33271, 33282)

5223

Level 3 Pacemaker and Similar Procedures (33206-33208, 33213-33214, 33224, 33228) CY 2016: Pages 70421-70424 of the Federal Register dated November 13, 2015.

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TABLE 42: DEVICE INTENSIVE PROCEDURES CY 2016 APC

CY 2016 APC Title

5224

Level 4 Pacemaker and Similar Procedures (33221, 33229)

5231

Level 1 ICD and Similar Procedures (33230, 33240, 33262-33263)

5232

Level 2 ICD and Similar Procedures (33231, 33249, 33264, 33270)

5377

Level 7 Urology and Related Services

5462

Level 2 Neurostimulator and Related Procedures

5463

Level 3 Neurostimulator and Related Procedures

5464

Level 4 Neurostimulator and Related Procedures

5471

Implantation of Drug Infusion Device

5493

Level 3 Intraocular Procedures

5494

Level 4 Intraocular Procedures

CY 2016: Pages 70421-70424 of the Federal Register dated November 13, 2015. 17

CRHF ECONOMICS & HEALTH POLICY

PAYMENT REDUCTIONS FOR SPECIFIC MODIFIERS 

An appropriate modifier should be reported on the hospital claim form when a procedure is discontinued, partially reduced or cancelled.



These modifiers and a brief description are: -52: Partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned -73: Procedure requiring anesthesia was terminated due to extenuating circumstances or circumstances that threatened the well being of the patient -74: Procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started



For claims that include an implantable device and Modifier -73, DOS on or after January 1, 2016 , and assigned to a Device Intensive APC (Table 42) , the reimbursement will be reduced by 100% of the device offset amount.

Page 70423-70425 of the Federal Register dated November 13, 2015.

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CY 2016 OPPS DEVICE OFFSET TABLE FOR CRHF SERVICES CY 2016 APC RATE

PERCENT

DOLLAR AMOUNT

$845.04

1.00%

$8.45

$4,697.97

32.93%

$1,547.04

$15,561.11

38.60%

$6,006.59

$2,489.69

25.28%

$629.39

$6,696.85

70.36%

$4,711.90

$9,273.40

66.44%

$6,161.25

$16,914.40

69.70%

$11,789.34

5231 Level 1 ICD and Similar Procedures

$21,930.03

77.37%

$16,967.26

5232 Level 2 ICD and Similar Procedures

$30,489.78

79.32%

$24,184.49

APC 5211 5212 5213 5221 5222 5223 5224

APC TITLE Level 1 Electrophysiologic Procedures Level 2 Electrophysiologic Procedures Level 3 Electrophysiologic Procedures Level1 Pacemaker and Similar Procedures Level 2 Pacemaker and Similar Procedures Level 3 Pacemaker and Similar Procedures Level 4 Pacemaker and Similar Procedures

https://www.cms.gov/apps/ama/license.asp?file=/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Downloads/ 2016-OPPS-APC-Offset-File.zip

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OBSERVATION SERVICES 

CY 2015 Observation Services Payment Regulations: Extended Assessment and Management (EAM) Composite APC 8009  Single payment for non-surgical encounters that include at least 8 hours of observation (HCPCS G0378) as well as a high-level visit procedure. The observation service cannot be provided on the same day of surgery or post operatively.1  CY 2015 Medicare National Payment is $1,235.2



CY 2016 Observation Service Payment Regulations: A new Comprehensive Observation C-APC 8011  The claim includes at least 8 hours of observation (HCPCS G0378) as well as a visit code (99281-99285, 99291, G0379-G0384). Eligibility for the Observation service payment is based on the claim not including a procedure assigned a Status Indicator “T” or a “J1.” See Appendix for a partial list of Status Indicators.3  Surgical procedures are excluded from C-APC 8011. The hospital can expect to receive the applicable Surgical C-APC instead of Observation C-APC 8011.  CY 2016 Medicare National Payment is $2,274 and is assigned a “J2” Status Indicator.3 See Appendix for all “J2” codes/descriptions. 1 CY 2015: Page 66812 of the Federal Register dated November 10, 2014.The link is in the Appendix. 2 Medicare National Payment rates are from Addendum A for CY 2015 and CY 2016. 3 CY 2016: Pages 70333-70336 of the Federal Register dated November 13, 2015.

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CRHF ECONOMICS & HEALTH POLICY

OBSERVATION SERVICES – HYPOTHETICAL EXAMPLE #1

Patient with chest pain arrives at ED





ED Physician orders tests, receives/reviews results and orders Cardiology consult.

Cardiologist orders Observation stay to determine if patient needs inpatient admission.

Patient remains in OBS for 24 hours, results are reviewed and patient is discharged to home.

Hospital submitted the claim to Medicare with the following services:  G0378 – 24 hours of Observation - Meets Criteria for OBS C-APC  99283 – ED Level 3 (SI – J2) - Meets Criteria for OBS C-APC  93005 – EKG  Various Laboratory Tests The hospital can anticipate reimbursement based on C-APC 8011 ($2,274).

Status Indicator (SI) assignment and Medicare National Payment rates are from Addendum B.

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CRHF ECONOMICS & HEALTH POLICY

OBSERVATION SERVICES – HYPOTHETICAL EXAMPLE #2

Patient with syncopal event arrives at ED





ED Physician orders Lab tests , EKG and MRI of brain, receives/reviews results and patient history, and orders Cardiology and Neurology consults.

Neuro assessment negative. Cardiologist orders Observation stay to further determine etiology and need for inpatient admission.

Patient remains in OBS for > 8 hrs.; Cardiologist confirms prerequisites of coverage are met and orders ILR implant

Patient receives implant and is discharged to home.

Hospital submitted the claim to Medicare with the following services:  G0378 – More than 8 hours of Observation - Meets Criteria for OBS C-APC  99283 – ED Level 3 (SI J2) - Meets Criteria for OBS C-APC  93005 – EKG  70551 – MRI of brain  Various Laboratory Tests  33282 – ILR (Reveal/ LINQ implant) (SI – J1) – Claim with “J1” is ineligible for APC 8011. The hospital can anticipate receiving ILR implant C-APC payment ($6,697). Status Indicator (SI) assignment and Medicare National Payment rates are from Addendum B.

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CRHF ECONOMICS & HEALTH POLICY

THE NOTICE ACT  Related to concerns regarding to the increased use of Observation and the 2 Midnight Rule, a new Federal Law HR 876, passed by Congress and signed by the President in August 2015, requires patient disclosure of Observation cases.  The NOTICE Act, or Notice of Observation Treatment and Implication for Care Eligibility Act, would require hospitals nationwide to inform Medicare patients when they are receiving care under observation status.  The notification must be in writing with a verbal explanation of the implications of outpatient status to patient eligibility for subsequent services, such as SNF coverage.  Hospitals have 12 months to comply with the Act’s requirements.

Notice Act: http://www.gpo.gov/fdsys/pkg/BILLS-114hr876enr/pdf/BILLS-114hr876enr.pdf 23

CRHF ECONOMICS & HEALTH POLICY

TWO-MIDNIGHT RULE EXCEPTIONS 



Original Implementation Date: October 1, 2013 (FY 2014)1  An inpatient admission is generally appropriate for Medicare Part A if the physician or other qualified professional admits the patient as an Inpatient based upon the expectation that the patient will need hospital care that crosses at least two midnights.  When assessing the duration of necessary care, the physician or other qualified professional may include outpatient hospital care received prior to inpatient admission.  If the patient is expected to need less than 2 midnights of care, these services should generally be billed as outpatient services. 2016 Exceptions to the Two-Midnight rule2, 3:  Case-by-Case basis by the physician responsible for the care of the Medicare beneficiary, subject to medical review.  Quality Improvement Organizations (QIOs) contractors assumed medical responsibility for the hospital stays associated with the Two-Midnight rule on October 1, 2015 and will conduct reviews for short stays, taking over that responsibility from the Medicare Administrative Contractors (MACs). 1 FY 2014: Pages 50938-50954 of the

Federal Register dated August 19, 2013.The link is in the Appendix.

2 CY 2016: Page 70305 and 70602 of the Federal Register dated November 13, 2015. 3 The link for the CMS Fact Sheet dated October 30, 2015 is in the Appendix.

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Medicare Coverage Policies

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CRHF ECONOMICS & HEALTH POLICY

MEDICARE NCD FOR PACEMAKER IMPLANTS  August13,2013: Revised NCD in effect for DOS on or after 8/13/2013  NCD 20.8.3  July 7, 2014: Implementation – Claims Processing Rules ; Rescinded and Delayed

 July 6, 2015: Implementation – Claims Processing rules  Change Request CR 9078; MLN Matters® MM9078

 Transmittal 3384 dated October 25, 2015 – Claims Processing rules and CR 9078, MLN Matters MM9078 article revised on October 26, 2015:  Due to claims processing issues brought to the attention of CMS, MACs will implement this NCD at the local level, until CMS is able to revise the claims processing instruction and edits.

See Appendix for links to NCD 20.8.3, Transmittal 3382 and MM9078

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CRHF ECONOMICS & HEALTH POLICY

CARDIAC PACEMAKER EVALUATION SERVICES NCD §20.8.1 AND 20.8.1.1 OF CMS PUB. 100-03 

The decision as to how often any patient's pacemaker should be monitored is the responsibility of the patient's physician who is best able to take into account the condition and circumstances of the individual patient.



Transtelephonic monitoring (TTM) Guidelines I and II are for both single and dual chamber pacemakers. The TTM guidelines are in this NCD.



Pacemaker clinic* service frequency guidelines for routine monitoring are:  Single chamber: Twice in the first 6 months following implant, then once every 12 months  Dual chamber: Twice in the first 6 months following implant, then once every 6 months



Increased frequency of monitoring must be supported by documented medical necessity. * Please note that “Pacemaker clinic” also includes “Physician practice” and “Hospital device monitoring departments” Rev. 182, 05-22-15 is available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part1.pdf

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Provider-Based Designation

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CRHF ECONOMICS & HEALTH POLICY

PLACE OF SERVICE FOR PROVIDER-BASED PHYSICIANS A Practice designated as office-based reports POS 11 Office. Provider-Based: Off-Campus or On-Campus claim submission1:  New POS 19: Off-Campus Outpatient Hospital A portion of an off-campus hospital provider based department that provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.  POS 22 (description change only): On-Campus Outpatient Hospital A portion of a hospital’s main campus that provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.  For existing Off-Campus Provider-Based practices (as of November 2, 2015), the hospital portion of the facility claim is paid separately (under OPPS) and the physician portion (professional claim) is reimbursed based on the Medicare Physician Fee Schedule (MPFS).  

1 Pub 100-04 Medicare Claims Processing, Transmittal

3315 dated August 6, 2015 and effective on January 1, 2016 is available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3315CP.pdf Provider Based CMS Transmittal A-03-030 dated 4.18.2003: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/a03030.pdf CMS Transmittal 143 dated 4.29.2011 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R143BP.pdf 29

CRHF ECONOMICS & HEALTH POLICY

THE PO MODIFIER  

PO Modifier definition: Services, procedures and/or surgeries furnished at off-campus, provider-based outpatient departments.1 Reporting the PO modifier2:  Voluntary in CY 2015; mandatory January 1, 2016  Required to be reported with every code for OP hospital services provided at an off-campus Provider-Based Department (PBD).  Not reported for services provided in: • Remote locations of a hospital (hospital campus other than the main hospital campus; facility or an organization that is either created by, or acquired by, a hospital that is a main provider for the purpose of furnishing Inpatient hospital services under the name, ownership, and financial and administrative control of the main provider),

•

Satellite facilities of a hospital (provides inpatient services in a building also used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital),

•

Emergency department

1 CY 2015: Pages 66913-66914 of the Federal Register (Vol. 79, No. 217) dated November 10, 2014.

The link is included in the Addendix. 2 P0 modifier information: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/Downloads/MM9097.pdf 30

CRHF ECONOMICS & HEALTH POLICY

PHYSICIAN OWNED PRACTICE AND PROVIDER-BASED PHYSICIAN PRACTICE EXAMPLES CPT® code

CPT Brief Description

CY 2016 Medicare National Payment

Physician owned practice and Place of Service 11 “Office” 93283

Dual lead ICD in person programming

$82.401 Global

Provider-Based Physician practice and Place of Service 22 “On-Campus Outpatient Hospital – so Modifier PO is not applicable” 93283-26

Dual lead ICD in person programming

$58.401 PC

93283

Dual lead ICD in person programming (Technical Component)

$33.622 TC Hospital Outpatient APC*

Total

Provider-Based Payment

$92.02

PC: Professional Component TC: Technical Component Global: PC plus TC * APC: Ambulatory Payment Classification 1 Physician payment rate: http://www.cms.gov/apps/physician-fee-schedule/overview.aspx 2 Hospital payment rate: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html

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DEVICE MONITORING

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CRHF ECONOMICS & HEALTH POLICY

OUTPATIENT HOSPITAL NATIONAL PAYMENT AMOUNTS CARDIAC DEVICE MONITORING CPT® code

Assigned Outpatient APC

January-December 2016 Medicare National Payment1

5741

$33.62

5741

$33.62

Pacemakers 93279-93281, 93288, 93293, 93296 ICDs 93282-93284, 93289, 93296

Implantable Cardiovascular Monitor (ICM)

93290, 93299

5741

$33.62

93285, 93299

5741

$33.62

93291

5732

$30.51

Implantable Loop Recorder (ILR)

1 Calendar Year 2016 Hospital APC payments are available at:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html See Addendix for CPT code descriptions.

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CRHF ECONOMICS & HEALTH POLICY

DEVICE MONITORING DIAGNOSIS CODES ICD-9 VERSUS ICD-10 

Routine Device Monitoring ICD-9-CM Diagnosis Code

ICD-10-CM Diagnosis Code

Pacemaker V45.01

Z95.0

Cardiac pacemaker in situ

Presence of cardiac pacemaker

Implantable Defibrillator V45.02

Z95.810

Automatic implantable cardiac defibrillator in situ

Presence of automatic (implantable) cardiac defibrillator

Other Cardiac Devices (ILR) V45.09

Z95.818

Other specified cardiac device in situ

Presence of other cardiac implants and grafts

2016 ICD -10-CM and GEMs: https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html

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CRHF ECONOMICS & HEALTH POLICY

DEVICE MONITORING DIAGNOSIS CODES ICD-9 VERSUS ICD-10 

Device Monitoring for Patients with a Complaint or a Symptom ICD-9-CM Diagnosis Code

ICD-10-CM Diagnosis Code Pacemaker

V53.31

Z45.010

Fitting and adjustment of cardiac pacemaker

Encounter for checking and testing of cardiac pacemaker pulse generator [battery] Z45.018 Encounter for adjustment and management of other part of cardiac pacemaker

Implantable Defibrillator V53.32

Z45.02

Fitting and adjustment of automatic implantable cardiac defibrillator

Encounter for adjustment and management of automatic implantable cardiac defibrillator

Implantable Loop Recorder (ILR) V53.39

Z45.09

Fitting and adjustment of other cardiac device

Encounter for adjustment and management of other cardiac device

2016 ICD -10-CM and GEMs: https://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html

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CRHF ECONOMICS & HEALTH POLICY

EXAMPLES OF COMPLAINT/SYMPTOM DIAGNOSIS CODES ICD-9 VERSUS ICD-10 ICD-9-CM Diagnosis Code

ICD-10-CM Diagnosis Code

427.9: Unspecified cardiac dysrhythmia

I49.9: Cardiac arrhythmia, unspecified

780.2: Syncope and Collapse

R55: Syncope and Collapse

780.4: Dizziness and Giddiness

R42: Dizziness

785.1: Palpitations

R00.2: Palpitations

Remember to review Medicare Local Coverage Determinations (LCDs), or contact your Medicare Administrative Contractor (MAC), or refer to your private payer policies

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CARDIAC RHYTHM AND HEART FAILURE (CRHF) CARDIAC RHYTHM AND HEART FAILURE (CRHF) INFORMATION INFORMATION CRHF

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Economics and Email us: Health Policy [email protected] Call our Coding Hotline: 1 (866) 877-4102

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www.medtronic.com/crdmreimbursement

DOWNLOAD OUR ICD-10 DIAGNOSIS CROSSWALK

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APPENDIX

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SELECT STATUS INDICATORS: ADDENDUM D-1 Status Indicator / Item/Code/Service

OPPS Payment Status

C: Inpatient Procedures

Not paid under OPPS. Admit patient. Bill as inpatient.

J1: Hospital Part B services paid through a comprehensive APC

Paid under OPPS; all covered Part B services on the claim are packaged with the primary "J1" service for the claim, except services with OPPS SI=F,G, H, L and U; ambulance services; diagnostic and screening mammography; all preventive services; and certain Part B inpatient services.

J2: Hospital Part B Services That May Be Paid Through a Comprehensive APC

Paid under OPPS; Addendum B displays APC assignments when services are separately payable.

(1) Comprehensive APC payment based on OPPS comprehensivespecific payment criteria. Payment for all covered Part B services on the claim is packaged into a single payment for specific combinations of services, except services with OPPS SI=F,G, H, L and U; ambulance services; diagnostic and screening mammography; all preventive services; and certain Part B inpatient services. (2) Packaged APC payment if billed on the same claim as a HCPCS code assigned status indicator “J1.” (3) In other circumstances, payment is made through a separate APC payment or packaged into payment for other services.

N: Items and Services Packaged into APC Rates 40

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Paid under OPPS; payment is packaged into payment for other services. Therefore, there is no separate APC payment.

SELECT STATUS INDICATORS: ADDENDUM D-1 Status Indicator / Item/Code/Service

OPPS Payment Status

Q1: STV-Packaged Codes

Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator “S,” “T,” or “V.” (2) In other circumstances, payment is made through a separate APC payment.

Q2: T – Packaged Codes

Paid under OPPS; Addendum B displays APC assignments when services are separately payable. (1) Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator “T.” (2) In other circumstances, payment is made through a separate APC payment.

Q4: Conditionally packaged laboratory tests

Paid under OPPS or CLFS. (1) Packaged APC payment if billed on the same claim as a HCPCS code assigned published status indicator “J1,” “J2,” “S,” “T,” “V,” “Q1,” “Q2,” or “Q3.” (2) In other circumstances, laboratory tests should have an SI=A and payment is made under the CLFS.

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OBSERVATION C-APC 8011 - STATUS INDICATOR “J2” CPT® Code 99281

99282

99283

99284

99285

Brief Description Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Usually, the presenting problem(s) are self limited or minor Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Usually, the presenting problem(s) are of low to moderate severity. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity. Usually, the presenting problem(s) are of moderate severity. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician or other qualified health care professionals but do not pose an immediate significant threat to life or physiologic function. Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function. Codes with Status Indicator “J2” from Addendum B and Descriptions from 2016 CPT code book

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OBSERVATION C-APC 8011 - STATUS INDICATOR “J2”..CONTINUED CPT® Code

99291

G0380

G0381

Brief Description Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes Level 1 hospital emergency department visit provided in a type B emergency department; (the ED must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) Level 2 hospital emergency department visit provided in a type B emergency department; (the ED must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) Codes with Status Indicator “J2” from Addendum B and Descriptions from 2016 CPT code book

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OBSERVATION C-APC 8011 - STATUS INDICATOR “J2”..CONTINUED CPT® Code

G0382

G0383

Description Level 3 hospital emergency department visit provided in a type B emergency department; (the ED must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) Level 4 hospital emergency department visit provided in a type B emergency department; (the ED must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment)

Codes with Status Indicator “J2” from Addendum B and Descriptions from 2016 CPT code book 44

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OBSERVATION C-APC 8011 - STATUS INDICATOR “J2”..CONTINUED CPT® Code

Description

G0384

Level 5 hospital emergency department visit provided in a type B emergency department; (the ED must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment)

G0379

Direct admission of patient for hospital observation care

G0463

Hospital outpatient clinic visit for assessment and management of a patient

Codes with Status Indicator “J2” from Addendum B and Descriptions from 2016 CPT code book

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DEVICE MONITORING CPT® Code 93279

Description Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; single lead pacemaker system

93280

dual lead pacemaker system

93281

multiple lead pacemaker system

93282

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; single lead transvenous implantable defibrillator system

93283

dual lead transvenous implantable defibrillator system

93284

multiple lead transvenous implantable defibrillator system

2016 CPT code book 46

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DEVICE MONITORING..CONTINUED CPT® Code

Description

93285

Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, review and report by a physician or other qualified health care professional; implantable loop recorder system

93288

Interrogation device evaluation (in person) with analysis, review and report by a physician or other qualified health care professional, includes connection, recording and disconnection per patient encounter; single, dual, or multiple lead pacemaker system

93289

single, dual, or multiple lead transvenous implantable defibrillator system, including analysis of heart rhythm derived data elements

93290

implantable cardiovascular monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors

93291

93293

implantable loop recorder system, including heart rhythm derived data analysis Transtelephonic rhythm strip pacemaker evaluation(s) single, dual, or multiple lead pacemaker system, includes recording with and without magnet application with analysis, review and report(s) by a physician or other qualified health care professional, up to 90 days 2016 CPT code book

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DEVICE MONITORING..CONTINUED CPT® Code

Description

93296

Interrogation device evaluation(s) (remote), up to 90 days; single, dual, or multiple lead pacemaker system or implantable defibrillator system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results

93299

Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular monitor system or implantable loop recorder system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results

2016 CPT code book 48

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HOSPITAL OUTPATIENT QUALITY REPORTING (OQR) OQR Measure Set Adopted for CY 2017 Payment Determination and Subsequent Years

NFQ #

Measure Name

N/A

OP–1: Median Time to Fibrinolysis.

0288

OP–2: Fibrinolytic Therapy Received Within 30 Minutes of ED Arrival.

0290

OP–3: Median Time to Transfer to Another Facility for Acute Coronary Intervention.

0286

OP-4: Aspirin at Arrival.

0289

OP–5: Median Time to ECG.

0514

OP–8: MRI Lumbar Spine for Low Back Pain.

N/A

OP-9: Mammography Follow-up Rates.

N/A

OP–10: Abdomen CT—Use of Contrast Material.

0513

OP-11: Thorax CT—Use of Contrast Material.

N/A

OP–12: The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their ONC-Certified EHR System as Discrete Searchable Data. CY 2016: Pages 70502-70507 of the Federal Register dated November 13, 2015.

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HOSPITAL OUTPATIENT QUALITY REPORTING (OQR) OQR Measure Set Adopted for CY 2017 Payment Determination

NFQ #

Measure Name

0669

OP–13: Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery.

N/A

OP–14: Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT).

N/A

OP-17: Tracking Clinical Results between Visits.

0496

OP–18: Median Time from ED Arrival to ED Departure for Discharged ED Patients.

N/A

OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional.

0662

OP–21: Median Time to Pain Management for Long Bone Fracture.

N/A

OP-22: ED- Left Without Being Seen.

0661

OP–23: Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT or MRI Scan Interpretation Within 45 minutes of ED Arrival. CY 2016: Pages 70502-70507 of the Federal Register dated November 13, 2015. OP-15 Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache was removed.

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HOSPITAL OUTPATIENT QUALITY REPORTING (OQR) OQR Measure Set Adopted for CY 2017 Payment Determination and Subsequent Years

NFQ #

Measure Name

N/A

OP–25: Safe Surgery Checklist Use.

N/A

OP–26: Hospital Outpatient Volume on Selected Outpatient Surgical Procedures. (Additional information is available at: www.qualitynet.org)

0431

OP-27: Influenza Vaccination Coverage among Healthcare Personnel.

0658

OP–29: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients.

0659

OP–30: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps—Avoidance of Inappropriate Use.

1536

OP–31: Cataracts—Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery. (This measure is voluntary during CY 2015)

CY 2016: Pages 70502-70505 of the Federal Register dated November 13, 2015.

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CONDITIONALLY PACKAGED DIAGNOSTIC LAB SERVICES 

When Diagnostic Laboratory services are reported on an Outpatient hospital claim that includes a procedure/service assigned a Status Indicator of “J1,” “J2,” “Q1,” “Q2,” or “Q3’’ and also “S,” “T,” or “V”, the Q4 Conditionally Packaged Laboratory Test will be applicable.



Modifier L1 became effective in 2014 , the first year that Lab test were conditionally packaged, and should be reported with the Laboratory test when reporting an Unrelated Laboratory test procedure code(s).



CY 2016 Laboratory services are eligible for separate reimbursement if: (1) it is the only service(s) provided to a hospital Outpatient and there is a payment rate included in the CLFS (Clinical Laboratory Fee Schedule) or (2) ordered for a different diagnosis than another outpatient hospital service by a practitioner different than the practitioner who ordered the other outpatient hospital service.



When only Laboratory services are reported and this test is included in the CLFS, the new Conditional Packaging Status Indicator “Q4: Conditionally Packaged Laboratory Test” is converted to Status Indicator “A” (Not Paid under OPPS) and reimbursed based on the amount included in the CLFS . The L1 modifier is not applicable for these services. CY 2016: Pages 70304, 70348-70350, 70366 of the Federal Register dated November 13, 2015.

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CHANGES IN OPPS DEVICE PASS-THROUGH PROCESS 

OPPS Device Pass-Through Payments: Enable initial access to new technology



Currently: CMS accepts and reviews applications on a quarterly basis through a subregulatory process.



In CY 2016:  The Quarterly subregulatory review process will include a description of application(s) received and rational for approving the application(s) in the next applicable Proposed OPPS rule. Applications that are not approved will also be included in the applicable Proposed OPPS rule unless the application is withdrawn.  Evaluate device pass-through applications through annual rule making.



Application must be submitted:  Within 3 years of FDA approval/clearance or the date of market availability if there is a documented, verifiable delay of product availability after receiving FDA approval/clearance. CY 2016: Pages 70305, 70416-70420 of the Federal Register dated November 13, 2015. The link for the CMS Fact Sheet dated October 30, 2015 is in the Appendix.

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APPENDIX: REFERENCES OPPS CY 2016 Federal Register dated November 13, 2015 is available at: http://www.gpo.gov/fdsys/pkg/FR-2015-11-13/pdf/2015-27943.pdf Data files released with the CY 2016 final rule are available at: https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/ Hospital-Outpatient-Regulations-and-Notices.html Click on Regulation No. CMS-1633-FC and Regulation No. CMS-1607-FC The “2016 Final Rule Addenda” zip file includes: Addendum A (APC payment), Addendum B (HCPCS listing and APC assignment), Addendum C (APC assignment and then every HCPCS assigned to that APC), Addendum D-1 (Status Indicators), Addendum J (Complexity Adjusted APC details) and other files. CMS Fact Sheets dated October 30, 2015: Fact Sheet Two-Midnight Rule: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-4.html Fact Sheet CMS Finalizes Hospital Outpatient and Ambulatory Surgical Center Policy and Payment Changes, Including Changes to the Two-Midnight Rule and Quality Reporting for 2016: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-3.html

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APPENDIX: REFERENCES Pacemaker CMS regulation links NCD: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R186NCD.pdf Claims Processing Transmittal No. 3384: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3384CP.pdf MM9078: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9078.pdf FY 2014 final rule publication in the Federal Register dated August 19, 2013: http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf CY 2015 final rule publication in the Federal Register dated November 10, 2014: http://www.gpo.gov/fdsys/pkg/FR-2014-11-10/pdf/2014-26146.pdf

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