Q&A: What's changed with recurring or repetitive claim payments?

Q: Our billing office has noted that we have many recurring accounts that have seen a huge drop in reimbursement over the past couple of months. We have noted that our outpatient physical/speech therapy and speech-language pathologist accounts aren’t affected, but our wound care accounts are. What changed?

A: This is the result of CMS changing the application of comprehensive APC (C-APC) packaging methodology at the claim level. CMS reminded hospitals in the 2016 OPPS final rule that only certain services designated as “repetitive services” would be exempt from these payment applications.

As noted in the 2017 OPPS final rule, packaging is now being applied at the claim level rather than for each date of service. Based on your question, you are billing wound care services on a recurring/series account. For example, if you billed a service (e.g., CPT code 11044 [debridement, bone; first 20 sq. cm. or less]) with status indicator J1 (hospital Part B services paid through a C-APC), all the services on the claim will package into the J1 service. If you bill a combination of status indicator T (paid under OPPS; separate APC payment) services, the standard status indicator T methodology will apply–the first service will be reimbursed at 100% and the remaining will be discounted 50%.  

Providers have long viewed services such as wound care and chemotherapy administration services as “series” or “recurring” services, and in some respects this is a true statement. However, CMS has reminded providers that there is a specific list of services that are considered “repetitive” for claims processing purposes. While its claims processing system will allow monthly billing of other services that are not on the list, the definition of “repetitive” does not apply for actual adjudication of the claim. It will adjudicate the claim based on standard OPPS methodology.

CMS’ list of defined repetitive services is located in the CMS Claims Processing Manual (Pub. 100-04), chapter 1, section 50.2.2.

Editor’s note: Denise Williams, RN, CPC-H, senior vice president of revenue integrity services at Revant Solutions, in Fort Lauderdale, Florida, answered this question.

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