CMS Manual System

1 CMS Manual System Department of Health & Human Services (DHHS) Pub 100-04 Medicare Claims Processing Centers for Medicare & Medicaid Services (CMS) Transmittal 3685 Date: December 22, 2016 Change Request 9930 SUBJECT: January 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS) I. SUMMARY OF CHANGES: This Recurring Update Notification describes changes to and billing instructions for various payment policies implemented in the January 2017 OPPS update. The January 2017 Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer will reflect the Healthcare Common Procedure Coding System (HCPCS), Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in this Change Request (CR).

2 This Recurring Update Notification applies to Chapter 4, section The January 2017 revisions to I/OCE data files, instructions, and specifications are provided in the forthcoming January 2017 I/OCE CR. EFFECTIVE DATE: January 1, 2017 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: January 3, 2017 Disclaimer for Manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged. However, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.

3 II. CHANGES IN Manual INSTRUCTIONS: (N/A if Manual is not updated) R=REVISED, N=NEW, D=DELETED-Only One Per Row. R/N/D CHAPTER / SECTION / SUBSECTION / TITLE R 4/Table of Contents R 4 R 4 of Packaged Services of Different Types That are Furnished on the Same Claim R 4 Adjustments R 4 Use of Modifiers for Discontinued Services N 4 of HCPCS Modifier FX R 4 for Use in Coding Devices Eligible for Transitional Pass-Through Payments Under the Hospital OPPS R 4 Eligible for Transitional Pass-Through Payments R 4 Eligible for New Technology APC Assignment and Payments R 4 for Claims on Which Specified Procedures are to be Reported With Device Codes and For Which Specific Devices are

4 To be Reported With Procedure Codes R 4 Billing Instructions for IMRT Planning and Delivery R 4 for Multi-Source Photon (Cobalt 60-Based) Stereotactic Radiosurgery (SRS) Planning and Delivery R 4 for Allogeneic Stem Cell Transplants R 4 Partial Hospitalization Billing Requirements for Hospitals, Community Mental Health Centers, and Critical Access Hospitals R 4 Review for Partial Hospitalization Services Provided in Community Mental Health Centers (CMHC) R 4 for Partial Hospitalization Services R 16 of Payment for Clinical Laboratory Tests - Place of Service Variation III.

5 FUNDING: For Medicare Administrative Contractors (MACs): The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

6 IV. ATTACHMENTS: Business Requirements Manual Instruction Attachment - Business Requirements Pub. 100-04 Transmittal: 3685 Date: December 22, 2016 Change Request: 9930 SUBJECT: January 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS) EFFECTIVE DATE: January 1, 2017 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: January 3, 2017 I. GENERAL INFORMATION A. Background: This Recurring Update Notification describes changes to and billing instructions for various payment policies implemented in the January 2017 OPPS update.

7 The January 2017 Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer will reflect the Healthcare Common Procedure Coding System (HCPCS), Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in this Change Request (CR). This Recurring Update Notification applies to Chapter 4, section The January 2017 revisions to I/OCE data files, instructions, and specifications are provided in the forthcoming January 2017 I/OCE CR. B. Policy: 1. New Device Pass-Through Policies a. New Device Pass-Through Categories Section 1833(t)(6)(B) of the Social Security Act requires that, under the OPPS, categories of devices be eligible for transitional pass-through payments for at least 2, but not more than 3 years.

8 Section 1833(t)(6)(B)(ii)(IV) of the Act requires that we create additional categories for transitional pass-through payment of new medical devices not described by existing or previously existing categories of devices. b. Policy In the CY2017 OPPS/ASC (Outpatient Prospective Payment System /Ambulatory Surgical Center) final rule with comment period that was published in the Federal Register on November 14, 2016, we adopted a policy to revise the pass-through payment time period by having the pass-through start date begin with the date of first payment and by allowing pass-through status to expire on a quarterly basis, such that the duration of device pass-through payment will be as close to three years as possible.

9 In addition, in calculating the pass-through payment, the Implantable Devices Charged to Patients Cost to Charge Ration (CCR) will replace the hospital-specific CCR, when available and device offsets will be calculated from the HCPCS payment rate, instead of the APC payment rate (81 FR 79655 through 79657. Refer to the CY 2017 OPPS/ASC final rule with comment period for complete details of these policy changes for device pass-through that will become effective on January 1, 2017. Effective January 1, 2017, there are three device categories eligible for pass-through payment: (1) HCPCS code C2623 (Catheter, transluminal angioplasty, drug-coated, non-laser); (2) HCPCS code C2613 (Lung biopsy plug with delivery System ); and (3) HCPCS code C1822 (Generator, neurostimulator (implantable), high frequency, with rechargeable battery and charging System ).)

10 Also, refer to for most current device pass-through information. c. Transitional Pass-Through Payments for Designated Devices Certain designated new devices are assigned to APCs and identified by the OCE as eligible for payment based on the reasonable cost of the new device reduced by the amount included in the APC for the procedure that reflects the packaged payment for device(s) used in the procedure. OCE will determine the proper payment amount for these APCs as well as the coinsurance and any applicable deductible. All related payment calculations will be returned on the same APC line and identified as a designated new device.