Important Changes for Hospitals in the 2013 MPFS Rule

on Tuesday, 13 November 2012. All News Items | Outpatient Services | Coding

On November 1, 2012, CMS released the CY 2013 Outpatient Prospective Payment System (OPPS) / Ambulatory Surgical Center (ASC) final rule which updates Medicare policies and payment rates for services furnished by hospital outpatient departments and ambulatory surgery centers. On the same day, the CY 2013 Medicare Physician Fee Schedule (MPFS) final rule was released updating policies and payment rates for services furnished by physicians and other practitioners. However, hospitals have to pay attention to both rules because the MPFS final rule often addresses those services furnished in a hospital outpatient department that are paid under the MPFS or the Clinical Laboratory Fee Schedule (CLFS). In fact, this year, two of the most major changes for hospitals come from the MPFS final rule.


The first concerns the reporting of Laboratory Molecular Pathology codes. In 2012, the American Medical Association (AMA) created 101 new CPT codes to describe molecular pathology services that had previously been reported with “stacked” codes. Last year, Medicare did not accept the new codes for payment purposes but continued to require the previously used “stacked” codes be reported to receive payment. However, in CY 2013, hospitals will report the Molecular Pathology CPT codes to Medicare for payment purposes. These include the 101 new codes from 2012 and 14 new codes from 2013. The challenge for hospitals is to make sure their charge description masters (CDMs) and laboratory systems are updated with this large number of new CPT codes and the associated appropriate pricing. Some hospitals may already have the 2012 codes in place since Medicare requested voluntary reporting of the new codes in addition to the “stacked” codes last year. The new codes are 115 CPT codes in the range 81200-81479; they replace the “stacked” codes 83890-83914 which are deleted from CPT for 2013.


In addition to the MPFS final rule, CMS has a Laboratory Public Meeting that makes decisions and publishes information on CLFS codes and payment determinations. This document addresses that the series of new laboratory CPT codes 81500-81599 for Multianalyte Assays with Algorithmic Analyses (MAAAs) will not be covered by Medicare for 2013. MAAAs are comprised of a number of different laboratory tests and an algorithm. Providers will continue to bill the codes for the component tests for 2013.


The second issue is the new requirement for reporting functional limitation information on claims for rehabilitative therapy services (physical therapy, occupational therapy, and speech language pathology therapy services). This reporting is required by the Tax Relief Act and is intended to provide information to assist CMS in reforming the Medicare payment system for outpatient therapy services. The following is a brief summary of the key points from the MPFS final rule.

  • The therapy reporting requirements apply to all providers and suppliers of outpatient therapy services and Comprehensive Outpatient Rehabilitation Facilities (CORFs). This includes hospital outpatient department services and therapy services in critical access hospitals (CAHs).
  • The implementation date is January 1, 2013, but there is a six-month testing period, so the reporting is not required until July 1, 2013.
  • Reporting is done with G-codes that describe eleven categorical functional limitations and three general groupings for limitations that do not fit within the categories.
  • The severity of the patient’s functional impairment is reported with modifiers on a 7-point severity/complexity scale describing the percent of impairment, limitation or restriction.
  • Reporting is required at the outset of the therapy episode, at least every 10 treatment days, at the time of discharge, and additionally if a significant change in the patient’s condition requires a re-evaluation.
  • The G-codes and related modifiers must be documented in the patient’s medical record.
  • Claims for therapy services are required to contain the functional limitation reporting. Also the goals in the therapy plan of care must be consistent with those reported on the claim.


The therapy reporting is a very detailed requirement and further direction from CMS should be forthcoming. MMP, Inc. will be providing more information in upcoming articles and updates as they become available.


Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it.This email address is being protected from spambots. You need JavaScript enabled to view it. .

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