Knowledge Base Article

If your job involves keeping up with Medicare regulations, you know that sometimes there is so much information it can be overwhelming. You may also notice the same information appearing again and again. That is not a bad thing – repetition promotes learning and if you missed it one place, chances are you will see it again.

The guidelines we follow for Medicare come from laws, rules and regulations, and the sub-regulatory guidance of instructions, policies, and procedures. What is the difference in a law versus Medicare manual instructions? Laws come from Congressional actions signed into law by the President. Then a government department, such as the Centers for Medicare and Medicaid Services (CMS) issues rules in The Federal Register which become codified in the Code of Federal Regulations (CFR) to implement, interpret, or prescribe law or policy. From Medicare final rules, CMS issues sub-regulatory guidelines, such as in the form of Medicare transmittals to communicate new or changed policies or procedures that will be incorporated into Medicare manuals. And even beyond that CMS and the individual Medicare Administrative Contractors (MACs) offer instructions and numerous educational opportunities. With all of this communication, it would be hard for a provider to ever claim they were not aware of the Medicare requirements.

Like Medicare, you will see topics repeated in our Wednesday@One newsletter articles. For example, we have already written several articles based on the Outpatient Prospective Payment System (OPPS) Final Rule (FR). This article summarizes the January 2018 OPPS Update transmittal which addresses the changes from the FR to be implemented in January plus other January updates. Therefore, you will see topics again that you have seen in recent articles, but remember, repetition promotes learning.

• There are no new device categories eligible for pass-through payment for January 2018,
• Two additional New Technology APCs (1907 and 1908) are created and existing New Technology APC payment rates adjusted (see table in the transmittal).
• Effective January 1, 2017, X-rays taken using film must be reported with modifier “FX.” This results in a payment reduction of 20%.
• Effective January 1, 2018, hospitals must report modifier “FY” for X-rays taken using computed radiography technology. Use of this modifier results in a 7% payment reduction from January 1, 2018, through December 31, 2022, and a 10% reduction beginning January 1, 2023 and after.
• Modifier “CP” used to identify adjunctive services on a claim related to a procedure assigned to a Comprehensive APC (generally for Stereotactic Radio Surgery (SRS)) was deleted after December 31, 2017. Medicare will continue to make separate payments for the 10 planning and preparation services adjunctive to the delivery of the SRS treatment when furnished within 30 days of the SRS treatment. See the transmittal for more details and a list of the 10 planning and prep codes.
• CMS removed 6 procedures from the inpatient-only list (IPO) for CY 2018 – CPT 43282, laparoscopic repair of para-esophageal hernia; CPTs 43772-43774, laparoscopic gastric restrictive procedures; CPT 55866, laparoscopic prostatectomy; and creating the most discussion CPT 27447, total knee arthroplasty. CPT 92941, percutaneous transluminal revascularization during an AMI is being added to the IPO.
• CMS revised the laboratory date of service policy so that the date of service for molecular pathology tests and Advanced Diagnostic Laboratory Tests (ADLTs) that are not packaged under OPPS, that are collected from a hospital outpatient during a hospital outpatient encounter and the test is performed following the patient’s discharge from the hospital outpatient department, is the date the testing is performed. This means for tests meeting these criteria the testing lab must bill Medicare directly and the hospital laboratory should not bill Medicare. There are currently no ADLTs. Molecular pathology codes not packaged under OPPS can be identified on the OPPS Addendum B with a status indicator of “A.”
• For 2018, separately payable drugs with an OPPS status indicator of “K” purchased through the 340B program will be paid at ASP-22.5%. Hospitals to which this rule applies must report modifier “JG” on the claim to trigger the appropriate payment. Excepted hospitals (rural sole community hospitals, children’s hospitals, and OPPS-exempt cancer hospitals) will continue to be paid at ASP+6%, but should report informational modifier “TB” to identify drugs purchased through the 340B program.
• Effective January 1, 2018, newly approved biosimilar biological products with a common reference product will no longer be grouped into the same billing code with other biosimilars. CMS will be issuing new codes, but until then, continue to use existing codes and modifiers.
• See the January 2018 OPPS update (page 14) for a list of the assignment of Skin Substitute product codes as low- or high-cost.
• Medicare will be making available during CY 2018 a public searchable Internet website comparing estimated payments as required by the 21st Century Cure Acts.

This is a summary of some of the topics covered in the January 2018 OPPS Update transmittal. I encourage providers billing Medicare to read the entire transmittal for complete information.  The transmittal also includes new and revised codes.