2018 OPPS Proposed Rule: 6,211 Code-Specific Changes May Impact Your Hospital

Review of Proposed Rule narratives and high- level analysis of the potential data changes within the Medicare payment systems can provide a preview of the work that’s ahead for Charge Master, information systems, coding, and process updates. Importantly, this is an opportunity to recognize significant shifts in revenue that may occur.


The pre-publication Display Copy of the 2018 OPPS Proposed Rule Federal Register document was posted on July 13th (later than usual). During the 7/19/17 CMS Hospital Open Door Forum call, Tiffany Swygert, Acting Director, Division of Outpatient Care, shared that the rule is subject to a 60 day comment period closing on 9/11/17; and stated that CMS is planning for an 11/1/17 release of the Final Rule.

Yesterday’s 2018 OPPS and MPFS Proposed Rule presentation by Nimitt Consulting Inc. and Merlino Healthcare Consulting Corp. provided a comprehensive overview of changes that will affect hospital charge data, claims, and payments. The presenters highlighted several critical topics that are expected to result in financial and operational burdens if proposals are finalized. The presenters reiterated the importance of providers participating in the CMS comment process.

Dramatically cut (22% under ASP) drug payments for 340B providers, claims modifiers on drugs for non-340B providers, packaging of infusion and chemo admin, and more cuts in payments for certain provider-based departments are just some of the highlights that are included in the OPPS Proposed Rule. There are also proposals relative to date of service and billing of select laboratory tests (MoPath and future ADLTs) that may impact orders as well as billing processes. Imaging using older technology has further payment cuts planned, and nuclear medicine shifts in APCs will affect payments for several rarely performed procedures. The presenters also noted MPFS changes proposed such as modifiers for 1500 claims showing provider-patient relationships, changes to the acceptable E/M guidelines, and information on the Medicare Diabetes Prevention Program.

Revenue cycle and CDM Teams should note that formal release of code sets (CPT-4 and HCPCS Level II), other CMS payment system rulemaking (CLFS, MPFS, etc.) and various claims edit data (I/OCE, fee schedule payment indicators, etc.) are all essential to an accurate CDM 2018 update for January 1st. While Proposed Rule information is interesting for a preview of changes, none of the information has been finalized.

Alert: The information that follows is provided as a preview only. Do not make CDM or other changes until the formal 2018 code release.

OPPS 2018 Proposed Rule Data Updates

Source: Data analysis through ChargeAssist®

The OPPS 2018 Proposed Rule contains 237 proposed new and deleted codes under the OPPS payment system. Again, neither CPT-4 nor HCPCS Level II codes are final for 2018 and only in a proposed status at this time.

  • 142 Proposed New CPT and HCPCS Level II codes (only reflects codes recognized by OPPS)
    • 135 New CPT-4 range codes
    • 5 Anesthesia codes
    • 42 Surgical range codes
    • 7 7XXXX range codes (4 new chest x ray codes and 3 new abdomen codes)
    • 40 8XXXX range codes (many of these have not been assigned formal CPT codes at this time as we await CLFS and AMA final decisions)
    • 26 Category III codes
    • 15 9XXXX range codes
      • 1 vaccine code (remember that vaccine codes are also released mid-year)
      • 2 pulmonary /respiratory codes
      • 1 glucose monitoring code
      • 2 rehab codes
      • 1 debridement code
      • 7 99XXX codes
      • 1 other 9XXXX range code
    • 7 New HCPCS Level II range codes
      • 2 Drug codes in C range
      • 5 G range codes (including 3 presumptive drug test codes and two codes for RHC/FQHC)
  • 95 Proposed Deleted CPT and HCPCS Level II codes
    • 82 Deleted CPT-4 range codes
      • 2 Anesthesia codes
      • 19 Surgical range codes
      • 18 7XXXX range codes (12 deleted chest and abdominal x ray codes, 4 interventional codes, one radiation therapy code and 1 kinetics platelet survival code; watch for the mapping of the new codes and be attentive to the definition of views)
      • 12 8XXXX range codes (many of these have not been assigned formal CPT codes at this time)
      • 22 Category III codes (this is the standard migration of codes that move to either ‘level 1’ or are discontinued; don’t forget mid-year AMA releases as well)
      • 6 Medicine range (9XXXX) codes –
        • 1 noninvasive physiologic cardiac study code
        • 1 pulmonary /respiratory codes
        • 1 behavioral health code
        • 1 rehab code
        • 2 99XXX codes (anticoagulant management)
  • 13 Deleted HCPCS Level II range codes
    • 1 C range code
    • 12 G range codes

OPPS status indicators (SI) and payment rate changes have been posted in the ChargeAssist® change modules for review against your files or reference to all changes. (Remember that changes due to packaging require consideration of not only code by code changes, but the larger set of charges on your high volume service lines.

Based on initial analysis of current data (3Q17) compared to the proposed (1Q18) OPPS updates, there are:

  • 219 proposed code-specific Status Indicator (SI) changes
  • 5,755 proposed OPPS Rate changes
    • 4455 with increased OPPS rates (code specific)
    • 1300 with decreased OPPS rates (code specific)

As a comparison, last year’s analysis of 3Q16 compared to proposed 1Q17 OPPS changes resulted in a much larger number of codes impacted by the OPPS payment system.

  • 3,646 SI changes
  • 5,716 OPPS rate changes

Charge Management Action Plan

This year, we believe the Proposed Rule analysis may be equally important as the Final Rule for awareness of significant changes. Revenue Cycle, CDM, and Coding Teams will want to review applicable sections of the proposed rule collaboratively to fully understand potential payment system, master file population, and claims processing changes that could result from potential finalization of the rule. Many find that it’s also helpful to attend educational webinars from trusted experts. Remember, your hospital should make its voice heard and submit comments on the Rule. It’s very easy through the CMS Proposed Rule website link.

From the data perspective, it’s helpful to evaluate how certain status indicator and rate changes may impact your organization’s service lines. Using your CDM Tool makes this process very easy. By selecting charges that represent the top 20% (by volume or revenue) for each major cost center (or billing category), your team will have a high-level view of potential reimbursement challenges. Consider code pairs, commonly performed combinations of services, and typical patient care scenarios to understand claim level payment changes.

Importantly, don’t forget that CPT and HCPCS Level II updates need to be considered for code ranges beyond the OPPS payment system proposed information noted above. Changes to codes are often more strategic than simple ‘replace’ functions and may need modifications to multiple Hospital Information systems and processes prior to January 1st.
Now’s the time to gather your team to understand possible payment system changes, develop CMS comments, and ensure your charging masterfiles are in order. As the coming months proceed, proactive teams will forge ahead with tasks to ensure clean, accurate, and appropriately-priced charge data using their Charge Master tools and consulting resources.

We will be releasing AMA’s CPT-4 and HCPCS Level II finalized and complete updates during the third and fourth quarters as data is made available. Also, we’ll discuss some of the more significant proposed changes and upcoming data releases as well as their impact on Charge Management in upcoming posts.

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