2012 OPPS and CPT Changes: Have You Updated Your CDM?
By: Elizabeth Schaub-DeBlock
Hard to believe that 2012 is here already, but it is, and as youread this article, your CDM should have already been updated and financialmodels been run to estimate the impact that the 2012 changes will have on your2012 financials. If you haven’t done it, do it now. There is no longer a “graceperiod” for the first quarter to implement any HCPCS changes, and if you areusing deleted or outdated codes, you will not be reimbursed. Just a reminder ofwhat is NOT paid under OPPS: Ambulance, Physical Therapy, Occupational Therapy,Speech Therapy, Screening and Diagnostic Mammography, Annual Wellness Visitsand Clinical Labs. These continue to be paid under a fee schedule.
Here is an overview of the important changes and updates for 2012:
Conversion factor: There is a final market basketincrease of 1.9%. There will continue to be two national conversion factors.One for hospitals that meet the quality reporting requirements, which increasesin 2012 to $70.016 from $68.876 and one for the hospitals that do not meetquality reporting requirements, which increases to $68.616 in 2012 from$67.530. This differential emphasizes the importance of adhering to the qualityreporting requirements of CMS. The 2012 outpatient deductible is $140.00.
Medicare Rural Health Clinics (RHC)and Federally Qualified Health Center (FQHC) Payment Rate Increases: The RHC upper payment limit isincreased from $78.07 to $79.48, effective 01-01-12. The FQHC upper paymentlimit per visit for Urban FQHCs isincreased from $126.22 to $128.49 effective 01-01-12.
Therapy Cap Values for Calendar Year2012: The BBA of 1997,P.L. 105-33 set annual caps for Part B Medicare patients. Therapy caps for 2012will be $1880. Remember this is $1880 for physical therapy and speech languagepathology combined and then $1880 for occupational therapy.
Status Indicators: Look for HCPCS codes with StatusIndicator D, which represents deleted codes for 2012. Many deleted codes havereplacement codes, so check to see if this is the case. Status Indicators (SI)are assigned to CPT/HCPCS codes and define how and if the codes are paid underOPPS.
Major code group changes: There were changes that need to beaddressed with your clinical staff to the following CPT groups: Audiology,Cardiology, E&M, General Surgery, Neurology, Ophthalmology, Orthopedics,Pain Management, Pathology, Pulmonology, Radiology and Vascular Surgery.
2012 CPT Manual: Read the green text in each section,which highlights the changes that have been made within that section. There arenew and expanded Tables in the 2012 CPT manual to aid in the coding of thefollowing:
- Evaluationand Management pp.xx-xxiii
- Pacemaker/ImplantableCardioverter-defibrillator pg.171
- CentralVenous Access Procedures pg.201
- QualitativeDrug Screening pg.400
- CardiacCatheterization pp.493-495
Additionally, there is an expanded number of “Coding Tips” foundthroughout the 2012 Manual. Many codes have been re-sequenced as well.
Molecular Pathology: One of the biggest changes for 2012 isthe addition of an entire new section of the CPT Manual, Molecular Pathology. “Molecular pathology procedures are medicallab procedures involving the analyses of nucleic acid to detect variants ingenes that may be indicative of germline (e.g., constitutional disorders) orsomatic (e.g., neoplasia) conditions, or to test for histocompatibilityantigens (e.g., HLA).”There are 92 new codes that are designated Tier 1 and an additional 9 new codesdesignated Tier 2. Lab management should be included in any decisions as towhether a new CDM needs to be developed for Molecular Pathology.
Vascular Injections: There are new and expanded guidelinesfor diagnostic studies of AV shunts, which now include access and imaging. Thereare four new codes for selective catheterization of renal arteries for renalangiography, which should be brought to the attention of the clinical staff inInterventional Radiology.
Cardiology: Radiology S&I is now included inall Pacemaker and Cardioverter-defibrulator codes. There are seven new codesspecific to dual/multiple leads.
Pain Management: There are new guidelines for PainManagement that includes the use of fluoroscopy, the placement of catheters,and endoscopic assistance during open surgical procedures.
Radiology: There is a new code, 74174, for CTA ofthe Abdomen AND Pelvis; this complements the new codes added in 2011 for CT ofthe abdomen and pelvis. There is some thought that there will be new codesadded in 2013 for CT of the Chest, Abdomen and Pelvis when performed at thesame session. Three new codes for abdominal Paracentesis (49082-49084) nowinclude imaging guidance. RadiationOncology: There are three new codes for intraoperative radiation treatment,as well as new guidelines for Treatment Management.
Hydration, Injections and Infusions: There have been revisions to thedefinitions for Initial, sequential and concurrent infusions; new examples ofinfusions have been added for clarification purposes; hydration is furtherdefined, and E&M codes that can be reported in addition to infusion codesare specified.
Other changes or additions to be noted are: a new series ofcasting and strapping codes (29582-29584); 18 new codes that cover biopsiesperformed during thoracotomy and thorascopscopy codes; audiology evaluation andtherapeutic codes have been revised to include time; many pulmonary functiontesting codes have been bundled together, producing 10 deleted codes and 4 newcodes; and last but not least the definition of New and Established Patientsfor E&M coding have been revised and the definitions for Observation nowinclude “typical times”.
Remember, all hospitals are responsible for updating their billingsystems each year, specifically in regard to the quarterly changes to HCPCScodes, including the addition of new codes. Don’t forget that CMS makesquarterly changes (January 1st, April 1st, July 1stand October 1st) to the HCPCS codes. Make sure that the financialand clinical departments maintain open communication regarding the addition ofnew services and procedures so that they can be accurately reflected in yourCDM and the hospital is reimbursed both efficiently and most importantlycompliantly.
BESLER Consulting provides a variety of customized services that canprovide the appropriate mix of experience and audits to help with your CDMreview. For more information please contact Laureen A. Rimmer at 732.839.8226or email@example.com orvisit us at www.besler.com.
 MLN Matters : MM7533, 11-4-11;Medicare Rural Health clinics (RHC) & Federally Qualified Health Centers(FQHC) Payment Rate Increases.
 CMS Pub. 100-04 Medicare ClaimsProcessing; Transmittal 2351; 11-18-11.
 2012 CPT Professional Edition; pg.407.