me Agenda + PC Reimbursement impact/Changes + General 2019 OPPS Updates + Packaging -Composite APCs/Comprchensive APCS + Inpatient-only procedures + Device Intensive Procedures and Pass-thru Devices + Provider-based Departments and Clinics + EM Changes + Changes in reimbursement ‘+ ASC versus OPPS CMS compare + Telemedicine/Virtual Care ‘+ Drug Payment Changes including 3408 Update ‘+ Therapy Changes + Psych changes + Lab and Radiology changes ‘+ Price TransparencyPayment Impact = Overall net increase Of OPPS rates for CY AU ee estimates an overall impact of $5.8 billion increase in OPPS payments $73,725 increased to $ $75,001 en ates sic $78.636 Pras aeC Lag ‘$79.490, een ecu EImpact % by Hospital Type busin forrest nt A Sg er | fastest Sala sto eon ae Rue eC Lert community mental health clinics per diem A Peau for the HOPPS, Pa $143.33 to $120.58 in 2019Payment * Penalty for not meeting Quality Reporting * There is a statutory 2% reduction in payments for hospitals that do not meet their quality reporting requirements (i.e., 0.980 * APC payments and copayments) — conversion factor would be $77.9002 (2% reduction from 79.490) Patient Co-payment Beneficiary responsibility for co-insurance as a percentage of total APC payments will not change in 2019 The aggregate beneficiary liability remains at 18.5% - (19.3% - 2016, 18.5% - 2017 and 2018)Wage Index and IP Deductible itive »» Wage indexes are published in the IPPS final rule (File No. 12) > https://www.cms.gov/Medicare/Medicare-Fee-for- Service-Payment/AcutelnpatientPPS/FY2019-IPPS- Final-Rule-Home-Page-Items/FY2019-IPPS-Final- Rule-Data- Files.htm/?DLPage=1&DLEntries=10&DLSort=0&DLS ortDir=ascending » The IP deductible increased to $1,364 (2019) » $1,288 (2016) to $1,316 (2017) to $1,340 (2018) » Note that OPPS beneficiary co-payments are capped at the IP deductible on the line levelHigh Cost Outlier Calculations = Calculation methodology unchangedRural Sole Community Payment Adjustment at CMS will continue the 7.1% payment increase for SCHs and EACH (Essential Access Community Hospitals) Applied to all services paid under OPPS excluding: + Separately payable drugs and biologicals * Devices paid as pass-throughs + Items paid at charges reduced to costCancer Centers = ee lane iucck kat) pee Rs ceaey Coa eRe tec E eee Panu eters eeime ate ell Oia seuss erat lols That is, the additional payments needed to result in a PCR equal to 0.88 for each of the cancer hospitalsAPC Data Set The data set from CY 2017 was used for 2019 analysis and final changes fe SC Ue Lie) eee Neale Pe ee RUE Peer eT the historical mi Parl}Changes to Status Indicators No changes to status indicators this year See Addendum D-1 geet) Peerage current APC status at lleslcoley ‘Score s/f rte eos te or Seve ‘eter tefGs lens hmiracrags inner iogD sar auTLSoNDredee preheater trsiois Caterer Recker andELSEVIER Packaging Comprehensive APCs Composite APCs4 “ob + Move to make single payments for related services + Goal is to package services that are integral, ancillary, supportive, Packaging = F dependent or adjunctive to the primary service + Continuing to move away from the fee schedule nature of the system to a comprehensive payment system RecapComprehensive APCs C-APCs - Recap * Generally all adjunctive and secondary services provided in conjunction with the primary procedure are packaged and not reimbursed separately from the C-APCOo NOs Recap + The comprehensive payment generally includes: * Diagnostic procedures + Lab tests * Treatments that assist in the delivery of the primary procedure + Visits and evaluations associated with the procedure + Coded and un-coded service and supplies + Services provided by therapists as part of the service + DME as well as supplies to support the DME equipmentC-APC Exclusions (Addendum J) ‘CVBNG Conprabensve AP Payment Ppa tp och bre ny gaan rice a agate ay Fstop ues bape ond ees ea F can CRA secs, eats Braces wera New exclusion of services assigned to New Technology APCs (APCs 1491-15: PrayC-APCs - Recap + The procedure codes that are part of the C-APC logic are assigned status indicator of J1 or J2 + The C-APC service will be paid * Most of the remaining services will not be paid + Considered supportive, related, dependent or adjunctive * These related services will be packaged into the C-APC serviceC-APCs - Complexity adjustments * Similar to DRGs (CC’s / MCC's), Medicare recognizes more complex cases and increase payment on these cases by using a complexity adjustment + For example: + Two J1 procedures are reported on the same claim + CMS will increase the APC payment to the next higher APC in the same clinical group + See Addendum J (second tab) for the complexity adjusted paired procedure codes EPC-APCs Three new C-APCs for 2019 New C-APCs include ears, nose and throat and vascular procedures [Addendum A.-Final OPPS APCs for CY 2019 TRU Relative Payment | Unadjusted apc |Group Title si |Weight Rate Copayment 5163 | Level 3 ENT Procedures a 16.0913 _ $1,279.10] $255.82] 5163 [Level 3 Vascular Procedures | Jt 33.2300] $2,641.52 $528.31 fo164 [Level 4 Vascular Procedures | Jt 55.0575] $4,376.52 $875.31 ‘There are currently 2,975 separate procedures (CPT®/HCPCS) that are reimbursed as a C-APCstk Stereotactic iS¢-lolfoxU leo A (SRS) The collection period for SRS claims w/ modifier CP ended 12/31/2017 - discontinued at that timepa: Ma ce gece od Cs eA ae podels= ‘a tool for improving care and reducing expenditures for Radiation ae Tau) padiation oncology is a promising area of health care aa ae a mleis + Provides single payment for specified combinations of procedures rather than paying for Introduced in 2008 services individually * APC 8010 - Mental Health — Caps OP mental health services at APC 5863, partial hospitalization 3 or more services ($220.86) * APCs 8004 — 8008 - Multiple Imaging+ Four procedures were removed from the inpatient-only list + Two are anesthesia related (00670 and 01402) * Plus 0206T - Implantation or replacement of carotid sinus baroreflex activation device; total system + 31241 - Nasal surgical endoscopy, surgical; with ligation : of sphenopalatine artery In patient On ly * One procedure added to the inpatient-only list List + C9606 - Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel2018 2018 Add & Add B HcPcs HCPCS Add A APC National Status Status Status National APC == Minumum HCPCS Short Description APC Indicator|APC Indicator Indicator APC Rate Copay APC Copay [00570 Anesth spine cord surgery 0 C | 0 N $0.00 $0.00 $0.00] fo1402 Anesth knee arthroplasty «0 «= CS] 0 N $0.00 $0.00 $0.00] lo266T Impliiplertd snsdevtotal 0 Cc [5463 Jt s1 $18,707.16 $0.00 $3,741.44 [31241 Nsvsins ndse wiartery tig 0 oc _ {5153 a a $1,369.29 $0.00 $273.86] 19605 _Percd-ecorrevascwamis 5194 1_| 0 c Inpatient-Only List# ELSEVIER Device Related Changesmy a 2 Pass-through Devices-Status H = One new Pass-through device for 2019 » C1823 - Generator, neurostimulator (implantable), non-rechargeable, with transvenous sensing and stimulation leads » Remede® System Transvenous neurostimulator for central sleep apnea » Placement code is 0424T - Insertion or replacement of neurostimulator system for treatment of central sleep apnea; complete system > 04247 APC rate $27,697.85cus) Moved to device intensive procedures which must be eliminated reported with a device, but the device code is not the procedure-specific required device edits a Device number of years ago TST Created a C1889 - implantable/insertable device not otherwise Procedures new C classified code in 2017: New description in 2019 - C1889 - implantable/insertable device, not otherwise classified No longer refers to device intensive proceduresDevice-Intensive Procedures + Full list of device intensive procedures is in Addendum P + For device-intensive procedures: + Device must be implantable for one patient only, * Device no longer has to remain in the patient's body after the procedure, and + The device off-set amount must be significant, defined as, exceeding 30% (was 40%) of the procedure’s mean cost.+ Recap: * Devices replaced at no cost must be reported with value code — FD + Must report in conjunction with one of the Device- following condition codes: + 49 — Product replacement within product lifecycle + 50- Product replacement for known recall + 2019 Change: + The associated device off-set has been lowered to 31%. Intensive ProceduresEs ELSEVIER Professional Evaluation and Management 2019 and 2021 Changes Source: https://www.cms.gov/Regulations-and- Guidance/Guidance/Transmittals/2018Downloads/R4176CP.pdfSiete id Curae ist aU Cre et er Peta rota Pte?2019 Finalized Changes + Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit * Removal of duplicative requirements for notations by residents or other members of the medical team for E/M visits by teaching physicians * Allow the presence and participation of the teaching physician during E/M office visits to be demonstrated by notes in the medical record made by a physician, resident or nurse* For both new and established visits * Do not need to re-enter patient's chief complaint and history already entered by ancillary staff or the beneficiary * Practitioner may indicate in the medical record that he/she has reviewed and verified the information* For established office and outpatient visits * For history and exam when relevant information is already contained in the medical record * Practitioners may choose to focus their documentation on what was changed since the last visit + Oron pertinent items that have not changed * Do not need to re-record the defined list of required elements when there is evidence that the practitioner reviewed the previous relevant information and updated it as needed2021 E/M Provisions + Reduce E/M payment variation + Single MPFS fee for office visit levels 2-4, one for established and one for new * Separate MPFS fee for level 5 + Add-on codes for levels 2-4 * Describe the additional resource inherent in visits for primary care and particular kinds of non-procedural specialized medical care + Extended visit codes for levels 2-4 + Account for additional resources required ‘when practitioners need to spend additional time with patients atv021 E/M Provision + For levels 2-5 * Can choose to document using medical decision making (MDM) or Time + When Time is used - Document the medical necessity of the visit and the required face-to-face time (typical CPT® time for the code plus any extended/prolonged time) + When using current framework (1995 or 1997) or MDM, levels 2-4 will only require the supporting documentation currently associated with level 2 visitsDocumenting Using Time These are proposed for the future only erro) tener ome 99212 10 $90 99213 15 $90 99214 25 $90 99215, 40 p148 Source: Mtp/wa os gu] CutreschandESxaonOwrendVNACNatna Pee Calan vet em /208 IL 38 aRwNne 4 enn at ad (Ga cus) $45 $76 $110 $167 $211 * curent Payment for CY 2018 * Estimated Payment based on the CY2019fnaiedrelative value unit and the 12018 payment rate Pee aaa esa ea oa $44 $130 (or $143 for primary care and non- procedural care) $211 sd aterrr ere ers (established patient) beginning 2021** Estimated $24 $90 ($103 for primary care and non- procedural care) $148* Off Campus PBD Clinic ReimbursementLede geo) Cree en Sn cena © originally were grandfathered from cuts as established in the Bipartisan Budget Act of 2015. Medicare will pay for clinic visits( at tae Cr) BRON cue OE se Sn ee ae SE eeu eae eae ee etre ae ees kage ere ae ce EEL Eee cre)ieee HCPCS short Orson Tear ‘APC |Weone Arc eestor Rate tow eneptd PDs | cepted PDs fox o°rs Payment Isa] —v —} sare + Non-ercented off-campus PBDS (modifier PN} are aleady reimbursed at 40% OPPS. 1+ Now the excepted of ampus PBDs wil be moving to the same reduced reimbursement fr GO463. + Professional compenentis nat reduces ‘+ Oncampus PBDs OPPS payment is not impacted [arc copay, Seqverraton|‘campus PBDs Will remain at 40% of the OPPS, the “PFS Relativity Adjuster” Non-excepted PBDs were not impacted in 2018\WKete [ii t=1amm = + New modifier effective January 2019 + Items and services furnished by a provider-based, off-campus emergency department + Does not impact reimbursement yet, collecting data on off campus emergency departments + Reported on every facility (technical) claim line for hospital services furnished in an off-campus PB ‘emergency department + CAHs are not required to report this modifierELSEVIER CMS Comparison ASC to OPPS Payment/Co- Paymentoer elas Too! Procedure Price See a etd Lookup + Allows beneficiaries to am compare Medicare ED Payments for certain Ambulatory surgical contors Hospital outpatient departments procedures performed both by hospitals and einen te alate em Ambulatory Surgical Centers (ASCs) + https://wwwmedicare gov /procedure-price-lookup/Removal of plaque in arteries in one leg, endovascular, acct Bee eocny Ambulatory surgical centers Hospit outpatient departments nt is not capped as it is with hospital Tne ol Ores eee ese hoe aELSEVIER Telemedicine and Virtual CareMedicare Telehealth Services + Historically, Social Security Act (SSA) has defined these services in a limited way: + Restricted to beneficiaries located in rural ‘geographical settings + Beneficiary must be at a clinical facility originating site") such as hospital or physician office + Must be two-way, real-time interactive ‘communication + These services are considered to be a substitute for an in-person visit + CMS has not had the regulatory authority to make changesMedicare Telehealth Services * Two new codes added to approved telehealth list for 2019 to describe prolonged preventive services 60513 Prolonged preventive services) (beyond the typicol service of the primary procedure) inthe office or other ‘outpatient setting 1 direc patient contact beyond the swat service first 30 minutes (sted separately in addition to code for preventive service) 60514 Prolonged preventive services) (beyond the typical service of the primary procedure) in the office or other ‘outpatient setting requiring aret patient contact beyond the usual service: each additional 20 minutes (listed separately in ‘adiditon to code for preventive service)+ Substance Use Disorders: SUPPORT for Patients Act of 2018 removes the originating site geographic requirement and adds the beneficiary's home as a permissible site for telehealth services + For treatment of substance use disorder or co-occurring mental health disorder + For services furnished on or after July 1, 2019 + ESRD: Renal dialysis facilities and the homes of ESRD patients receiving home dialysis may now qualify as originating sitesCommunication Technology-Based Services+ G2012, Brief non-face-to-face appointment (e.g., virtual check-in) + Separate payment when healthcare professionalhasa ii with a patient using communications technology like a telephone Cannot originate from a related E/M visit furnished within previous 7 Cee ERO mnie scan ea aya ete eee Preset Mera Urs APC SIM Communication Technology-Based ServicesSRC acne niece) ire text messaging, email or patient portal Cuan CST) Toa oh eT rR UCL RET eno Gea eel) Cle aa NO} Communication Technology-Based Services+ Patients must provide verbal (or written) consent prior to each service, and this must be documented in the medical record + Patients are responsible for any co-insurance owed Communication Technology-Based Servicesirate payment for inter-professional consultations between a treating practitioner consulting practitioner rs must obtain and document prior verbal consent eo pela kM) eLeg 1 Rema d Communication Technology-Based ServicesCommunication Technology-Based Services + Inter-professional Consultations — New Codes + 99451, Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, includes written report to the patient's treating physician/NPP, 5+ minutes of medical consultative timeCommunication Technology-Based Services + Inter-professional Consultations - New Codes + 99452, Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating physician or NPP, 30 minutes * Include time spent preparing for the referral and/or communicating with the consultant + Do not report more than once in a 14 day periodELSEVIER Drug Payment ChangesPass-through Drugs * Effective 2017, quarterly updates and eligible for as close to 3 years as possible + 37 drugs with pass-through status will expire (Table 37 of the ‘OPPS FR) + 51Lnew or continuing drugs with passthrough status (Table 38 of the OPPS FR) + These will be paid at ASP + 6% (APC SI G) *+ Not impacted by the 3408 drug reduction rulesee] oD) AUT ox9 ant =i0l8 Change The PFS FR revises the reimbursement rate for new Medicare Part B drugs to reflect the wholesale acquisition cost (WAC) plus 3% instead of the current ASP + 6% Impacts the reimbursement rate during the first quarter the drug is on the market when ASP rates are not available After that period, Part B drugs are paid according to the ASP + 6%Pree 2018 - $120NS) CMS has found SBIRT utilization to be relatively low > Added new code for assessments lasting between 5 and 14 minutes. » And reduced some of the burdensome service-specific documentation requirements » "Therefore, we are finalizing our proposal to eliminate the service specific documentation requirements for HCPCS cades G0397 and G0398.” MPFS Final 201920 New Psychiatric Codes — Many Adaptive eT lar Colm lc 1e10) aiever [on ote acres ser ose sor Onecorecsie samme arse ‘egret sonny may. 14 882 am by mi ca) Prhdopea wig utin by dete sername 888m Pahoa saphena Ym Penhooged senpoged Wt ay wh ws, 3 Poyhsogea suet wt nn yh os 8 Pahoa sanpybonged wt nn a ‘ar by eh on Asad nt pcm mop 5m ym was sass wm ws wyms so.) yams $0. ms 9 was was vansELSEVIER Lab and Radiology ChangesChanges to CLFS for 2018 changes to CLES [clinical Lab Fee Schedule} The use of market data to establish CLES payment rates will strengthen Medicare by paying more ‘appropriately for laboratory services and is expected to save the Medicare program and taxpayers money while maintaining beneficiaries’ access to high quality laboratory services. The preliminary private poyor rote-based CLFS payment amounts are estimated to have an impact ‘on Medicare Part 6, including the Part B premium effects, of about -$670 million for calendar year 2018. Phase-in of payment rate reductions for the fist six years of the revised payment system. Specfical, for the first three years after implementation (C¥ 2018 through CY 2020), payment rate reductions for most CLFS tests cannot be more than 10 percent per year, ond, for the next three years (CY 2021 through CY 2023), the reduction cannot be more than 15 percent per year,+ Crosswalk available comparing rates- 2017 to 2018-2020 + hitps://www.cms gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/PAMA- Regulations,htm| Si aSes =| = 3* 2018 Rule - Laboratories, including physician office labs, are required to report private payor data if they: + Have more than $12,500 in Medicare revenues from laboratory services and they receive more than 50 percent of their Medicare revenues from laboratory and physician services during a data collection period. + 2019- Now to include non-registered patient revenue collected on 1450 14X TOB bill + Inthe future will consider low expenditure threshold ($12,500) component of the definition of an applicable laboratory Data Collection Applicable Laboratory ChangeMost labs are status Q4 (packaged with J1, J2, S,T, V, Q1, Q, Q3) Pr ‘Advanced Diagnostic Lab Tests (aun) Chapter 18 ofthe Medicare Molecular pathology tests Claims Processing Manual)ate Radiology Assistants Providing Practice Sen tat Flexibility for Radiologist Pert wera renner ey0 removed HCPCS codes (C8904 & C8907)ie —_ Se omen arse 151) sepeataly in wbdtion code for primary provers ” ” wa aafiven * Originally published as part of the 2015 Medicare Inpatient Payment Rule: + 42 U.S.C. § 300gg-18(e) states that “each hospital operating within the United States shall for each year establish (Gfidupdote) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis- related groups established under section 1886(d)(4) of the Social Security Act.” Accountable Care Act Mandate* Updated guidance was published as part of the 2019 Medicare Inpatient Payment Rule + To encourage price transparency by improving public accessibility of charge information, U pd ated effective CY 2019 CMS updated its guidelines to F specifically require: Guidance * Hospitals to make public a list of their standard charges via the Internet in a machine readable format, * To update this information at least annually, or more often as appropriate* Additionally, CMS is concerned that challenges continue to exist for patients due to insufficient price transparency including: + Patients being surprised by out-of-network bills for Price physicians, such as anesthesiologists and radiologists, who provide services at in-network Transparency hospitals * Facility fees and physician fees for emergency room visitsPrice Transparency iia CMS is seeking information from the public regarding barriers preventing providers from informing patients of their out of pocket costs + What changes are needed to support greater transparency around patient obligations for their out-of-pocket costs; + What can be done to better inform patients of these obligations; and + What role providers should play in this initiativePrice Transparency * No clear enforcement mechanism has been published + Many questions still remain regarding the best practice implementation + https://Awww.cms.gov/Medicare/Medicare- Fee-for-Service- Payment/AcuteinpatientPPS/Downloads/FA Qs-Req-Hospital-Public-List-Standard- Charges.pdf