|
Added line is this color Deleted line is this color -<!--StartFragment --> + <p><span style="FONT-SIZE: 10pt">A hospital outpatient, for Medicare purposes, is defined in </span><a href= "http://www.cms.hhs.gov/manuals/Downloads/bp102c06.pdf"><span style= "FONT-SIZE: 10pt">Chapter 6</span></a><span style="FONT-SIZE: 10pt"> (Hospital Services Covered Under Part B) of the </span><a href= "http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS012673"><span style="FONT-SIZE: 10pt">Medicare Benefit Policy Manual</span></a><span style="FONT-SIZE: 10pt">, section <em>20.1 - Outpatient Defined</em>, as follows:</span></p> <p><span style="FONT-SIZE: 10pt">"A person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital."</span></p> <h3 style="MARGIN: auto 0in">Medicare Manuals</h3> <ul type="disc"> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.irp.com/apc/training/trn_man.html"><span style= "FONT-SIZE: 10pt">HCFA OPPS Training Manual</span></a> <span style= "FONT-SIZE: 10pt">(revised 6/13/2000). <em>Developed by BCBSA on behalf of HCFA.</em></span></li> </ul> <h3 style="MARGIN: auto 0in"><a href= "http://www.cms.hhs.gov/HospitalOutpatientPPS/04_passthrough_payment.asp">Pass-Through Payment Status and New Technology APC</a></h3> <div style="MARGIN-LEFT: 2em"> <ul> <li> <div style="MARGIN: auto 0in" align="left"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><font size= "2">Section <a href="http://www.socialsecurity.gov/OP_Home/ssact/title18/1833.htm">1833(t)(6)(C)(i)</a> of the SSA specifies that the duration of transitional pass-through payments for drugs and biologicals must be no less than 2 years and no longer than 3 years</font></p> </div> </li> <li> <div style="MARGIN: auto 0in" align="left"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><font size="2"><a href= "http://www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/DeviceCats_OPPSUpdate.pdf"> List of Device Category Codes for Present or Previous Pass-Through Payment and Related Definitions</a> (January 2007)</font></p> </div> </li> <li> <div style="MARGIN: auto 0in" align="left"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt; TEXT-ALIGN: justify"><a href= "http://www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/newtechapc.pdf"><font size="2"> Process and Information Required for a New Technology APC Assignment Under HOPPS</font></a></p> </div> </li> <li> <div style="MARGIN: auto 0in" align="left"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/catapp.pdf"><font size= "2">Process and Information Required to Apply for Additional Device Categories for Transitional Pass-Through Payment Status Under HOPPS</font></a></p> </div> </li> <li> <div style="MARGIN: auto 0in" align="left"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/drugapplication.pdf"><font size="2"> Process and Information Required to Determine Eligibility of Drugs, Biologicals, and Radiopharmaceutical Agents for Transitional Pass-Through Status Under HOPPS</font></a></p> </div> </li> </ul> </div> +<h3 style="MARGIN: auto 0in"></h3> +<table border="1"> +<tbody> +<tr> +<td> +<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span><span><u>Pass-Through +Criteria</u> (for devices):</span></span></p> +</td> +<td> +<p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span><span><u>New Technology +APC Criteria</u> (for procedures):</span></span></p> +</td> +</tr> +<tr> +<td> +<p class="MsoNormal" style= +"MARGIN: 3pt 0in 3pt 0.5in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .5in"> +<span style="FONT-SIZE: 11pt; FONT-FAMILY: Georgia"><span style= +"FONT-SIZE: 9pt; FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"> +<span style="mso-list: Ignore">·<span style= +"FONT: 7pt 'Times New Roman'"> </span></span></span> <span dir= +"ltr"><span style="FONT-SIZE: 9pt; FONT-FAMILY: Georgia">Has FDA +approval/clearance +<?xml:namespace prefix = o ns = "urn:schemas-microsoft-com:office:office" /> +</span></span></span></p> +<p class="MsoNormal" style= +"MARGIN: 3pt 0in 3pt 0.5in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .5in"> +<span style= +"FONT-SIZE: 9pt; FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"> +<span style="mso-list: Ignore">·<span style= +"FONT: 7pt 'Times New Roman'"> </span></span></span> <span dir= +"ltr"><span style="FONT-SIZE: 9pt; FONT-FAMILY: Georgia">Determined to be +reasonable and necessary</span></span></p> +<p class="MsoNormal" style= +"MARGIN: 3pt 0in 3pt 0.5in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .5in"> +<span style= +"FONT-SIZE: 9pt; FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"> +<span style="mso-list: Ignore">·<span style= +"FONT: 7pt 'Times New Roman'"> </span></span></span> <span dir= +"ltr"><span style="FONT-SIZE: 9pt; FONT-FAMILY: Georgia">Is an integral and +subordinate part of the service furnished</span></span></p> +<p class="MsoNormal" style= +"MARGIN: 3pt 0in 3pt 0.5in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .5in"> +<span style= +"FONT-SIZE: 9pt; FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"> +<span style="mso-list: Ignore">·<span style= +"FONT: 7pt 'Times New Roman'"> </span></span></span> <span dir= +"ltr"><span style="FONT-SIZE: 9pt; FONT-FAMILY: Georgia">Is surgically +implanted or inserted</span></span></p> +<p class="MsoNormal" style= +"MARGIN: 3pt 0in 3pt 0.5in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .5in"> +<span style= +"FONT-SIZE: 9pt; FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"> +<span style="mso-list: Ignore">·<span style= +"FONT: 7pt 'Times New Roman'"> </span></span></span> <span dir= +"ltr"><span style="FONT-SIZE: 9pt; FONT-FAMILY: Georgia">Cannot be a material +or supply furnished incident to a service</span></span></p> +<p class="MsoNormal" style= +"MARGIN: 3pt 0in 3pt 0.5in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .5in"> +<span style= +"FONT-SIZE: 9pt; FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"> +<span style="mso-list: Ignore">·<span style= +"FONT: 7pt 'Times New Roman'"> </span></span></span> <span dir= +"ltr"><span style="FONT-SIZE: 9pt; FONT-FAMILY: Georgia">Cannot be a material +that may be used to replace human skin</span></span></p> +</td> +<td> +<p class="MsoNormal" style= +"MARGIN: 3pt 0in 3pt 0.5in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .5in"> +<span style= +"FONT-SIZE: 9pt; FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"> +<span style="mso-list: Ignore">·<span style= +"FONT: 7pt 'Times New Roman'"> </span></span></span><span dir= +"ltr"><span style="FONT-SIZE: 9pt; FONT-FAMILY: Georgia">Could not have been +adequately represented in the claims data</span></span></p> +<p class="MsoNormal" style= +"MARGIN: 3pt 0in 3pt 0.5in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .5in"> +<span style= +"FONT-SIZE: 9pt; FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"> +<span style="mso-list: Ignore">·<span style= +"FONT: 7pt 'Times New Roman'"> </span></span></span> <span dir= +"ltr"><span style="FONT-SIZE: 9pt; FONT-FAMILY: Georgia">Does not qualify for +pass-through payment</span></span></p> +<p class="MsoNormal" style= +"MARGIN: 3pt 0in 3pt 0.5in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .5in"> +<span style= +"FONT-SIZE: 9pt; FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"> +<span style="mso-list: Ignore">·<span style= +"FONT: 7pt 'Times New Roman'"> </span></span></span> <span dir= +"ltr"><span style="FONT-SIZE: 9pt; FONT-FAMILY: Georgia">Cannot be reasonably +placed in an existing APC group based on clinical characteristics and resource +costs</span></span></p> +<p class="MsoNormal" style= +"MARGIN: 3pt 0in 3pt 0.5in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .5in"> +<span style= +"FONT-SIZE: 9pt; FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"> +<span style="mso-list: Ignore">·<span style= +"FONT: 7pt 'Times New Roman'"> </span></span></span> <span dir= +"ltr"><span style="FONT-SIZE: 9pt; FONT-FAMILY: Georgia">Falls within the scope +of Medicare benefits</span></span></p> +<p class="MsoNormal" style= +"MARGIN: 3pt 0in 3pt 0.5in; TEXT-INDENT: -0.25in; mso-list: l0 level1 lfo1; tab-stops: list .5in"> +<span style= +"FONT-SIZE: 9pt; FONT-FAMILY: Symbol; mso-fareast-font-family: Symbol; mso-bidi-font-family: Symbol"> +<span style="mso-list: Ignore">·<span style= +"FONT: 7pt 'Times New Roman'"> </span></span></span> <span dir= +"ltr"><span style="FONT-SIZE: 9pt; FONT-FAMILY: Georgia">Deemed to be +reasonable and necessary</span></span></p> +</td> +</tr> +</tbody> +</table> +<h3 style="MARGIN: auto 0in"> </h3> <h3 style="MARGIN: auto 0in">APC (Ambulatory Payment Classification)</h3> <ul type="disc"> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><strong>2008</strong></li> <li style="LIST-STYLE-TYPE: none"> <ul type="disc"> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.drg.irp.com/fedregs/apcas080101.htm"><font size="2">APC / HCPCS Assignment</font></a><font size="2"> (Jan 08)</font></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.drg.irp.com/fedregs/apctl080101.htm"><font size="2">APC Status Codes and Titles</font></a><font size="2"> (Jan 08)</font></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.drg.irp.com/fedregs/apcwt080101.htm"><font size="2">APC Payment Rates</font></a><font size="2"> (Jan 08)</font></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.drg.irp.com/fedregs/apcqn080101.htm"><font size="2">APC Quantity HCPCS/CPT4 Edits</font></a><font size="2"> (Jan 08)</font></li> </ul> </li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><strong>2007</strong></li> <li style="LIST-STYLE-TYPE: none"> <ul> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.irp.com/apc/apc070101a.html"><span style= "FONT-SIZE: 10pt"><font color="#800080">APC / HCPCS Assignment</font></span></a> <span style="FONT-SIZE: 10pt"> (Jan 07)</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.irp.com/apc/apc070101b.html"><span style="FONT-SIZE: 10pt">APC Payment Rates</span></a><span style="FONT-SIZE: 10pt"> (Jan 07)</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt; COLOR: black"><a href= "http://www.irp.com/apc/apc070101c.html">APC Status Codes and Titles</a> (Jan 07)</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.irp.com/apc/apc070101d.html"><span style="FONT-SIZE: 10pt">APC Quantity HCPCS / CPT Edits</span></a><span style="FONT-SIZE: 10pt"> (Jan 07)</span></li> </ul> </li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 12pt"><strong>2006</strong></span></li> <li style="LIST-STYLE-TYPE: none"> <ul> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">APC / HCPCS Assignment (Jan 06)</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">APC Payment Rates (Jan 06)</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">APC Status Codes and Titles (Jan 06)</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">APC Quantity HCPCS / CPT Edits (Jan 06)</span></li> </ul> </li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 12pt"><strong>2005</strong></span></li> <li style="LIST-STYLE-TYPE: none"> <ul> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">APC / HCPCS Assignment (<a href= "http://www.drg.irp.com/fedregs/apcas050401.htm">Apr 05</a>,<a href= "http://www.drg.irp.com/fedregs/apcas050701.htm">Jul 05</a>)</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">APC Payment Rates (<a href= "http://www.drg.irp.com/fedregs/apcwt050401.htm">Apr 05</a>)</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">APC Status Codes and Titles (Jan 05)</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">APC Quantity HCPCS / CPT Edits (Jan 05)</span></li> </ul> </li> </ul> <h4 style="MARGIN: auto 0in"><a id="Status_Indicator" name= "Status_Indicator"></a>APC Status Indicators / Codes</h4> <p><span style="FONT-SIZE: 10pt">The status indicator provides information on the type of service represented by the APC. Common indicators are below; <a href= "http://www.cms.hhs.gov/hospitaloutpatientpps/downloads/cms-1501-fc_addd1.pdf"><font color="#800080">Addendum D1</font></a> of the OPPS final rule lists them all.</span></p> <p><strong>Addendum D1. Payment Status Indicators for HOPPS</strong></p> <table class="MsoNormalTable" style="WIDTH: 461.25pt" cellspacing="1" cellpadding="0" width="615" border="1"> <tbody> <tr> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p style="TEXT-ALIGN: center" align="center"><strong><span style= "FONT-SIZE: 10pt">Indicator</span></strong></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><strong><span style= "FONT-SIZE: 10pt">Item/Code/Service</span></strong></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 12pt"> <strong><span style="FONT-SIZE: 10pt">OPPS Payment Status</span></strong></p> </td> </tr> <tr> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p style="TEXT-ALIGN: center" align="center"><strong><span style= "FONT-SIZE: 10pt">A</span></strong></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS.</span></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Not paid under OPPS.<span> </span>Paid by fiscal intermediaries under a fee schedule or payment system other than OPPS.</span></p> </td> </tr> <tr> <td style="TEXT-ALIGN: center"><small><span style= "FONT-WEIGHT: bold">C</span></small></td> <td><small>Inpatient Procedures</small></td> <td><small>Not paid under OPPS. Admit patient. Bill as<br> inpatient.</small></td> </tr> <tr> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p style="TEXT-ALIGN: center" align="center"><strong><span style= "FONT-SIZE: 10pt">G</span></strong></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Pass-Through Drugs and Biologicals</span></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Paid under OPPS; Separate APC payment includes pass-through amount.</span></p> </td> </tr> <tr> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p style="TEXT-ALIGN: center" align="center"><strong><span style= "FONT-SIZE: 10pt">K</span></strong></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Non-Pass-<span style= "LETTER-SPACING: -0.15pt">T</span><span style= "LETTER-SPACING: -0.1pt">h</span>rough Drugs and Biologicals</span></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt; LINE-HEIGHT: 12pt"> <span style="FONT-SIZE: 10pt">Paid under OPPS; Separate APC pay<span style= "LETTER-SPACING: -0.15pt">m</span>ent.</span></p> </td> </tr> <tr> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p style="TEXT-ALIGN: center" align="center"><strong><span style= "FONT-SIZE: 10pt">N</span></strong></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Ite<span style="LETTER-SPACING: -0.15pt">m</span>s and Services Pac<span style="LETTER-SPACING: -0.15pt">k</span>aged into APC Rates</span></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Paid under OPPS; Pay<span style= "LETTER-SPACING: -0.15pt">m</span>ent is packaged into pay<span style= "LETTER-SPACING: -0.15pt">m</span>ent for other services, including outliers. Therefore, there is no separate APC pay<span style= "LETTER-SPACING: -0.15pt">m</span>e<span style= "LETTER-SPACING: -0.1pt">n</span>t.</span></p> </td> </tr> <tr> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p style="TEXT-ALIGN: center" align="center"><strong><span style= "FONT-SIZE: 10pt">S</span></strong></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Significant Procedure, Not Discounted when Multiple</span></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Paid under OPPS; Separate APC payment.</span></p> </td> </tr> <tr> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p style="TEXT-ALIGN: center" align="center"><strong><span style= "FONT-SIZE: 10pt">T</span></strong></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Significant Procedure, Multiple Reduction Applies</span></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Paid under OPPS; Separate APC payment. The procedure with the highest weight will be paid at 100% while each additional surgical procedure will be paid at 50%.</span></p> </td> </tr> <tr> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p style="TEXT-ALIGN: center" align="center"><strong><span style= "FONT-SIZE: 10pt">X</span></strong></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Ancillary Services</span></p> </td> <td style= "BORDER-RIGHT: rgb(236,233,216); PADDING-RIGHT: 0.75pt; BORDER-TOP: rgb(236,233,216); PADDING-LEFT: 0.75pt; PADDING-BOTTOM: 0.75pt; BORDER-LEFT: rgb(236,233,216); PADDING-TOP: 0.75pt; BORDER-BOTTOM: rgb(236,233,216); BACKGROUND-COLOR: transparent"> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Paid under OPPS; Separate APC payment.</span></p> </td> </tr> </tbody> </table> <h3 style="MARGIN: auto 0in">Coding</h3> <ul type="disc"> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt">Changes to Coding and Payment for HOP Drug Administration [</span><a href= "http://cms.hhs.gov/transmittals/downloads/R785CP.pdf"><span style= "FONT-SIZE: 10pt">PDF</span></a><span style="FONT-SIZE: 10pt">] - <u>dated</u> 16 December 2005 /<u>effective</u> 03 January 2006</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt"><a href= "http://www.cms.hhs.gov/transmittals/downloads/R1130CP.pdf">Outpatient Prospective Payment System (OPPS) Outpatient Code Editor (OCE)</a> - January 2007</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><span style= "FONT-SIZE: 10pt"><a href= "http://www.cms.hhs.gov/transmittals/downloads/R1128CP.pdf">Non-Outpatient Prospective Payment System (Non-OPPS) Outpatient Code Editor (OCE)</a> - January 2007</span></li> <li class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.cms.hhs.gov/HospitalOutpatientPPS/"><span style= "FONT-SIZE: 10pt"><font color="#800080">Device-to-Procedure Edits</font></span></a></li> </ul> <h3 class="MsoNormal" style="MARGIN: 0in 0in 0pt">HCPCS C-Codes</h3> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"> </p> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><small>The HOPPS included "C" codes, or "pass-through" codes. Medicare created over 90 "pass-through" categories of devices, each category with its own specific "C" code. If a hospital used a device that fell into a pass-through category, they could put the appropriate C-code on the bill they submitted to Medicare for additional payment. These were commonly known as "pass-through" payments and were designed to expire after two to three years, after which this additional payment would be folded into the relevant Ambulatory Payment Classification (APC) payment rates.</small></p> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"> </p> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"><small>Though the pass-through payments for most C-codes no longer exist, Medicare does require that C-codes continue to be included on hospital claims paid under the OPPS. This is done so that Medicare can adequately capture the resources required to provide services, and use this resource information to establish adequate payment rates in the future. In fact, Medicare has defined certain procedures as being device-dependent, and claims for these procedures will be denied if they don’t also include the necessary C-codes.</small><br></p> <h3 class="MsoNormal" style="MARGIN: 0in 0in 0pt"> </h3> <h3 class="MsoNormal" style="MARGIN: 0in 0in 0pt"><a href= "http://www.irp.com/apc/training/oppchap3.html#_Toc480604737">Surgical Discounting</a></h3> <p class="MsoNormal" style="MARGIN: 0in 0in 0pt"></p> <p class="MsoNormal" style="MARGIN: 3pt 0in"><small><span style= "FONT-SIZE: 12pt"><span style="FONT-SIZE: 11pt">Outpatient Code Editor identifies the following situations so that Pricer will apply surgical discounting to the following situations:</span></span></small></p> <ul style="MARGIN-TOP: 0in" type="disc"> <li class="MsoNormal" style="MARGIN: 3pt 0in"><small><span style= "FONT-SIZE: 11pt">When more than one type<b>-</b>T procedure billed on the same date of service (Status indicator "T" is assigned to HCPCS codes in Addendum B of the OPPS Final Rule to indicate surgical procedures to which the multiple procedure payment reduction applies.),</span></small></li> </ul> <p class="MsoNormal" style="MARGIN: 3pt 0in 3pt 60pt; TEXT-INDENT: -0.25in"> <small><span style="FONT-FAMILY: 'Courier New'"><span><font size= "2"><small>o</small></font><span style= "FONT: 7pt 'Times New Roman'; font-size-adjust: none; font-stretch: normal"> </span></span></span><span dir="ltr"><span style="FONT-SIZE: 11pt">The highest paying APC will not be discounted.</span></span></small></p> <p class="MsoNormal" style="MARGIN: 3pt 0in 3pt 60pt; TEXT-INDENT: -0.25in"> <small><span style="FONT-FAMILY: 'Courier New'"><span><font size= "2"><small>o</small></font><span style= "FONT: 7pt 'Times New Roman'; font-size-adjust: none; font-stretch: normal"> </span></span></span><span dir="ltr"><span style="FONT-SIZE: 11pt">All other type T procedure will be discounted 50%.</span></span></small></p> <p class="MsoNormal" style="MARGIN: 3pt 0in 3pt 60pt; TEXT-INDENT: -0.25in"> <small><span style="FONT-FAMILY: 'Courier New'"><span><font size= "2"><small>o</small></font><span style= "FONT: 7pt 'Times New Roman'; font-size-adjust: none; font-stretch: normal"> </span></span></span><span dir="ltr"><span style="FONT-SIZE: 11pt">A HCPCS code with modifier 73 (terminated prior to anesthesia) will be discounted 50%.</span></span></small></p> <p class="MsoNormal" style="MARGIN: 3pt 0in 3pt 60pt; TEXT-INDENT: -0.25in"> <small><span style="FONT-FAMILY: 'Courier New'"><span><font size= "2"><small>o</small></font><span style= "FONT: 7pt 'Times New Roman'; font-size-adjust: none; font-stretch: normal"> </span></span></span><span dir="ltr"><span style="FONT-SIZE: 11pt">A type-T procedure HCPCS code billed with modifier 50 (bilateral), is similar to billing for two procedures, one performed on the right side, and one on the left side. Therefore, when modifier 50 is billed,</span></span></small></p> <p class="MsoNormal" style="MARGIN: 3pt 0in 3pt 84pt; TEXT-INDENT: -0.25in"> <small><span style="FONT-FAMILY: Wingdings"><span><font size= "2"><small>§</small></font></span></span><span dir="ltr"><span style= "FONT-SIZE: 11pt">If it has the highest paying APC of the type T procedures billed for the same date of service, only one of the procedures (right or left) will be discounted (100% + 50%). This will result in a payment of 150% of the APC.</span></span></small></p> <p class="MsoNormal" style="MARGIN: 3pt 0in 3pt 84pt; TEXT-INDENT: -0.25in"> <small><span style="FONT-FAMILY: Wingdings"><span><font size= "2"><small>§</small></font></span></span><span dir="ltr"><span style= "FONT-SIZE: 11pt">If another type T procedure billed on the same date of service has the highest APC, both procedures (right and left) will be discounted (50% + 50%). This will result in a payment of 100% of the APC.</span></span></small></p> <ul style="MARGIN-TOP: 0in" type="disc"> <li class="MsoNormal" style="MARGIN: 3pt 0in"><small><span style= "FONT-SIZE: 11pt">A non-type-T radiological procedure with a modifier 50 will be identified by the OCE to pay 200% of the APC since surgical discounting does not apply.</span></small></li> </ul> |