CMS has released the final 2018 ICD-10-CM codes to be implemented October 1, with hundreds of changes from the version released in the 2018 IPPS proposed rule.
Ochsner Clinic Foundation began its ambulatory clinical documentation excellence journey in 2004, when Medicare implemented its Hierarchical Condition Categories (HCC). Since HCCs affect patients’ Risk Adjustment Factor scores, and ultimately reimbursement for the care required to treat sicker patients, Ochsner needed to determine the best way to ensure annual HCC capture for all patients across its vast system.
There is an extensive list of coverage requirements that must be met to furnish outpatient services to Medicare beneficiaries. Hospitals may find that certain coverage requirements for therapeutic and diagnostic service are more difficult to meet than others, especially in off-campus provider-based departments.
Traditionally, the OPPS rulemaking cycle has been the main vehicle for changes to outpatient coding and billing regulations and policy that hospitals need to pay attention to. But increasingly, CMS has been introducing or discussing changes relevant to outpatient hospitals beyond the scope of the OPPS rules.
Reimbursement for provider-based departments (PBD) can be complex, and regulations affecting it have changed frequently over the past year. Section 603 of the Bipartisan Budget Act of 2015, the 2017 outpatient prospective payment system (OPPS) final rule, and the 21st Century Cures Act changed the payment methodology and made multiple adjustments to the definition of excepted (on-campus or grandfathered off-campus) and non-excepted (off-campus) PBDs. Hospitals must know the regulations inside and out and understand how they apply to their PBDs and to avoid denials or noncompliance.
Radiation oncology services billed to CMS had a 9.6% improper payment rate in 2015, leading to Medicare improperly paying $137 million for these services, according to a study reported in the Medicare Quarterly Compliance Newsletter.
Coders prepared for 2017 with numerous changes to the Official Coding Guidelines for the ICD-10-CM and the addition of many new codes. Quietly waiting in the wings was the updated CPT® Manual for 2017 with its changes waiting to be discovered.
As OPPS packaging has increased, providers may be less likely to appeal claims for certain denied charges based on medically unlikely edits, since it would not increase payments. However, providers should consider appeals when services are medically necessary and appropriate, as CMS bases future payment rates on accepted claims.
Inpatient coding departments are likely familiar with integrating clinical documentation improvement (CDI) specialists into their processes. Crystal Stalter, CPC, CCS-P, CDIP, looks at how CDI techniques can benefit outpatient settings and what services and codes facilities should target.
With a new year underway, providers likely need to get a handle on some key new modifiers, as well as important changes to an existing modifier and the deletion of a modifier that previously raised a lot of questions and operational concerns.
