OPPS Final Rule Delayed

Due to the partial Government shut down the Outpatient Perspective Payment System final rule was not released on November 1 as originally planned.  The delay will take us to the end of November.  The final rule could be released as late as November 27, and will take effect on January 1, 2014.  This does not give us much time to get these updates added to our systems.   Planning ahead for the delay with your updating team is highly recommended.

Some of the areas of highlight for this proposed rule are the Centers of Medicare and Medicaid (CMS) collapse of Evaluation and Management codes (E/M). When we wrote about this earlier this year the proposed amounts of reimbursement were not indicated.  The following table represents the proposed APC’s and payment rates for the E/M level codes that may be affected by the change.  One thing to remember is that CMS is requesting this change, so other insurance companies will still be accepting the Category I CPT codes for reporting of Evaluation and Management services, unless otherwise indicated by the particular payer.


CY 2013


 HCPCS code  APC  Payment  HCPCS code  APC  Payment
Clinic Visit  99201  0604  $56.77   GXXXC  0634  $88.31
 99202  0605  $73.68
 99203  0606  $96.96
 99204  0607  $128.48
 99205  0608  $175.79
 99211  0604  $56.77
 99212  0605  $73.68
 99213  0605  $73.68
 99214  0606  $96.96
 99215  0607  $128.48
Type A ED     Visit  99281  0609  $51.82   GXXXA  0635  $212.90
 88282  0613  $92.16
 99283  0614  $143.36
 99284  0615  $229.37
 99285  0616  $344.71
Type B ED Visit  G0380  0626  $67.78   GXXXB  0636  $84.85
 G0381  0627  $54.12
 G0382  0628  $89.89
 G0383  0629  $136.30
 G0384  0630  $207.31

The proposed rule also indicates that CMS wants to package seven categories of items and services because they would rather not pay them separately.  The following categories would be affected:

  • Clinical Diagnostic Laboratory Tests
  • Procedures described by Add-On codes
  • Ancillary Services that have a status indicator of X
  • Diagnostic Tests on the Bypass List
  • Drugs, Biologicals, and Radiopharmaceuticals that function as supplies when used during a diagnostic test or procedure.
  • Drugs and Biologicals that function as supplies or devices when used in a surgical procedure.
  • Device Removal Procedures

The above listed categories are what CMS defines as “adjunctive services” –  any service that is integral, ancillary, supportive and/or dependent to the primary service.

CMS is also proposing to create 29 comprehensive APC’s to prospectively pay for the most costly device-dependent services. CMS defines a comprehensive APC as a classification for the provision of a primary service and all adjunct services provided to support the delivery of the primary service.  They have determined that the adjunct costs are relatively small for these APC’s.  The comprehensive APC would treat all individually reported codes as representing components of the comprehensive service, and this would result in a single prospective payment based on the cost of the individually reported codes on the claim, that represents the delivery of a primary service, as well as all adjunct services provided to support that delivery.


What about Radiology multiple imaging and Composite Payments for such services?

The proposed cost calculated for many imaging APC’s including the multiple imaging composite APC’s have significantly changed from the cost calculated for the 2013 OPPS final rule.  Let’s take a look at the proposed rates for 2014 vs. the final rule of 2013.

Multiple Composite APC’s







 8004  Ultrasound         $196.61       $319.12
 8005  CT/CTA         $400.28       $301.01
 8006  CT/CTA w/c         $682.10       $516.86
 8007  MRI/MRA         $706.85       $606.38
 8008  MRI/MRA  w/c       $1038.94       $899.36

As you can see most of the payments are proposed to decrease in the composite payment calculation.


Intraoperative Radiation Therapy (IORT) Related Services APC 0028 and 0065

CPT codes 77424 and 77425 describe the placement and removal (if performed) of an applicator into the breast for radiation therapy, as well as the delivery of radiation therapy when performed intraoperative, and HCPCS code C9726 is no longer required to report the placement and removal of the applicator, in fact CMS is proposing to delete this HPCS code effective January 1, 2014.  This proposal by CMS would have hospitals report the costs of the service to place and remove (if performed) an applicator into the breast for radiation therapy and the delivery of radiation therapy when performed intraoperative with CPT codes 77424 and 77425 with an APC of 0065.

We hope that these highlighted areas are helpful in recognizing some of the proposed changes that will be talked about in the final rule.   There is much more to review, however, to much to list out in this article.   We will be waiting on the final rule release and provide additional information as it becomes available.

By Dawn Davidson
CPC, RCC, AHIMA-Approved ICD-10-CM/PCS Trainer

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