CMS adds 10 new comprehensive APCs for 2016

By Steven Andrews

CMS did not change the logic for comprehensive APCs (C-APC) or complexity adjustments in the 2016 OPPS final rule, but did add 10 new C-APCs for 2016 in addition to the 25 established for the first time for 2015.

CMS finalized C-APC 8011 (comprehensive observation services) to replace the existing extended assessment and management (EAM) composite APC 8009. Payment for C-APC 8011 will be made when a claim contains a specific combination of services performed with each other (similar to the existing EAM) instead of only using a primary service CPT® code assigned to status indicator J1 like other C-APCs. CMS will use status indicator J2 to identify these combinations of services for the observation C-APC.

Providers will need to meet all of the following criteria to qualify for C-APC 8011 payment in 2016:

• Claims do not contain a procedure with status indicator T (significant procedure subject to multiple procedure discounting)
• Claims do contain eight or more units of services described by HCPCS code G0378 (observation services, per hour)
• Claims contain HCPCS code G0378 and any one of the following codes on the same date of service or one day prior:
  • HCPCS code G0379 (direct referral of patient for hospital observation care) on the same date of service as HCPCS code G0378
  • CPT codes 99281–99284 (ED visit for the E/M of a patient [Levels 1-4])
  • CPT code 99285 (ED visit for the E/M of a patient [Level 5]) or HCPCS code G0380 (type B ED visit [Level 1])
  • HCPCS code G0381–G0384 (type B ED visit [Levels 2–5])
  • CPT code 99291 (critical care, E/M of the critically ill or critically injured patient; first 30–74 minutes)
  • HCPCS code G0463 (hospital outpatient clinic visit for assessment and management of a patient)
• Claims do not contain a J1 service

CMS originally proposed to only allow high-level ED visits to help generate the observation C-APC, similar to the current EAM composite APC. But this is one of the proposals that CMS agreed with commenters on and determined the observation C-APC should be expanded to include all visit levels, says Jugna Shah, MPH, president and founder of Nimitt Consulting, based in Washington, D.C., and Spicer, Minnesota.

The 2016 national payment rate for C-APC 8011 is $2,174.14, and while this payment is significantly higher than the EAM composite APC payment received today, providers should keep in mind that no other services are paid separately under the C-APC logic, says Shah, whereas today other services can, and do, generate separate payment.

“Any analysis that is done on separately payable observation services must be done carefully,” she says.

To read more about the final rule, see HCPro.com. For in-depth coverage of the rule, see the January 2016 edition of Briefings on APCs.