CMS Proposes C-APC Expansion in 2017 OPPS Proposed Rule
In the 2017 OPPS proposed rule, CMS is proposing to continue its comprehensive APC (C-APC) policy first implemented in 2015 and has proposed 25 new C-APCs for 2017 in addition to the existing 37 C-APCs.
More than 1,870 status indicator T (significant procedure, multiple reduction applies) procedures have been grouped into these 25 new C-APCs.
New clinical families have been introduced to include these services:
- Airway endoscopy (AENDO)
- Excision, biopsy, incision, and drainage (EBIDX)
- Extraocular ophthalmic surgery (EXEYE)
- Nerve procedures (NERVE)
- Stem cell transplant (SCTXX)
- Wireless pulmonary artery pressure monitor (WPMXX)
CMS notes that in recent years, stakeholders have raised concerns about the accuracy of ratesetting for allogeneic hematopoietic stem cell transplantation (HSCT) services. While CMS said in the 2016 OPPS final rule that it would not create a new C-APC for HSCT, it would continue to monitor charges and claims.
As a result of this analysis, the agency is proposing C-APC 5244 (Level 4 Blood Product Exchange and Related Services) and proposing to assign services described by CPT code 38240 (hematopoietic progenitor cell; allogeneic transplantation per donor) to it. For 2017, the payment rate for C-APC 5244 would be $15,267.
It’s great to see CMS taking past provider comments into consideration and proposing the creation of a C-APC that will allow more appropriate payment for allogeneic bone marrow transplant, says Jugna Shah, MPH, president and founder of Nimitt Consulting, Inc.
To develop future rates for CPT code 38240, CMS is proposing to introduce a new cost center and dedicated revenue code. CMS proposes adding a new standard cost center, 112.50 (allogeneic stem cell acquisition), to Worksheet A, and other applicable worksheets, of the Medicare hospital cost report (Form CMS-2552-10). It would have the cost center code of 11250.
Proposed revenue code 0815 (allogeneic stem cell acquisition services) would be used to identify hospital charges for stem cell acquisition for allogeneic bone marrow or stem cell transplants. CMS proposes requiring hospitals to report stem cell acquisition charges for these services separately in Field 42 of the CMS-1450 or UB-04 forms when an allogenic stem cell transplant occurs.
This revenue code would be tied to all services required to acquire stem cells from a donor and reported on the same date of service as the transplant to be packaged. As a result of mapping revenue code 0815 to cost center code 11250, CMS proposes that hospitals would no longer use revenue code 0819 to identify these services.
With respect to C-APCs in general, CMS is proposing a small tweak to its logic related to complexity adjustments. These adjustments are made when a C-APC service, identified with status indicator J1, is reported on the same claim as another J1 service or certain add-on codes. In these instances, payment is made for the next higher-paying C-APC within the same clinical family. For 2017, CMS proposes an expansion in the number of code combinations that qualify for a complexity adjustment from 66 to 275—a proportionately greater expansion than in the number of C-APCs.
The complexity adjustment is made when the code combination represents a costly and complex form of the primary service according to the following criteria:
- Frequency of 25 or more claims reporting the code combination (frequency threshold)
- Violation of the two-times rule in the originating C-APC (cost threshold)
CMS is proposing to discontinue the requirement that code combinations meeting the other frequency and cost criteria thresholds also do not create a two-times rule violation in the higher-level APC. The agency says the requirement is not useful as most code combinations fall below the established frequency threshold for considering two-times rule violations. It appears that this one change resulted in the significant increase in code combinations for complexity adjustments, says Valerie Rinkle, MPA, lead regulatory specialist and instructor for HCPro, a division of BLR, in Middleton, Massachusetts.
For a full list of cost statistics and code combinations for C-APCs, see Addendum J of the proposed rule. Comments are due to CMS by September 6 and a final rule is expected by November 1.
Shah and Rinkle will analyze the rule and give a comprehensive overview of the changes and what providers may want to comment on in HCPro’s annual OPPS proposed rule webcast from 1-3 p.m. (Eastern) Wednesday, August 17.