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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM_ Inpatient Only Procedures

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					OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures
April 4, 2003

Office of Corporate Compliance Lynn Idle

OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures
BACKGROUND: • Inpatient Only Procedures part of OPPS effective April 7, 2000. • CMS determined list of services that are appropriate to provide only in an inpatient setting and that, therefore, are only paid when provided in an inpatient setting. • CMS had input from the APC Advisory Panel as well as CMS medical and policy staff when developing Inpatient Only Procedures list. • CMS involves professional societies and hospital associations in annual update process.

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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures

BACKGROUND (cont.): • Services are on inpatient only list because of: – The invasive nature of the procedure – The need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged – The underlying physical condition of the patient In proposed regulations, there were 1,803 codes on list. Final regulation reduced number to 1,793. CY2003 OPPS Update moved 41 more codes off Inpatient Only List to APC’s.
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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures
CRITERIA FOR REMOVAL FROM INPATIENT ONLY LIST: • Criteria used in annual update process to determine if procedure is moved from Inpatient Only Procedure list to an APC group: – Most outpatient departments are equipped to provide the services to the Medicare population. – The simplest procedure described by the code may be performed in most outpatient departments. – The procedure is related to codes CMS has already moved off the inpatient list.

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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures
CRITERIA (cont.): Additional criteria effective as of 11/1/02 for CY2003 – CMS has determined that the procedure is being performed in numerous hospitals on an outpatient basis. – CMS has determined that the procedure can be appropriately and safely performed in an ASC and is on the list of approved ASC procedures or proposed by CMS for addition to the ASC list.

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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures
• OPPS CY 2003 Updates: CMS adopted 2 additional criteria for determining whether a procedure should be removed from the inpatient list. (See page 5) CMS added the following CPT codes to APC 208 for services furnished on or after January 1, 2003: 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar-with or without lateral transverse technique 22614 Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment-list separately in addition to code for primary procedure CMS moved 41 CPT codes from Inpatient Only List to APC’s.
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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures
Response from CMS on Changing Patient Type to Inpatient: Another hospital in CMS Region VII, posed the following question to CMS about how to handle case type changes: “We have a question about the procedures that Medicare will only reimburse if the patient is admitted as an inpatient. Here is a scenario: A physician schedules an outpatient surgery. During the course of the surgery, the surgeon determines that a procedure listed on the Medicare list of "Inpatient Only" procedures is necessary. The patient does not meet Interqual criteria for admission when they present for surgery, so we would not know they need to be an inpatient. Our surgery department does not know how this surgery case will be coded, so they have no way to know this should be an inpatient.
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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures
CMS Response (cont.): Our question: Since Medicare will only reimburse this procedure as an inpatient procedure, if staff (such as Medical Records) catches this should have been an inpatient procedure, is it appropriate to obtain an order to admit the patient to acute after the fact? Or since Medicare does not look at admission criteria for these "inpatient only" procedures, does the patient have to meet inpatient criteria? Can our facility submit an inpatient bill without a physician's order to admit the patient as acute? CMS Staff’s Response to the above scenario: Here is the response I received from CO (Central Office) regarding your inpatient only question. It is appropriate to admit the patient. As long as the code is on the OPPS inpatient list, the QIO will not question the admission (although they may still review the case for medical necessity - just not for place of service.)
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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures
CMS Staff’s Response (cont.): The best way to handle it would be to have the circulating nurse inform the OR desk or the admitting office (or where ever) to say that the nature of the case has changed. (I think this does happen fairly frequently with laparoscopic procedures. The patient has adhesions or whatever, and the surgeon has to open the abdomen. That would be recognized as an inpatient case, even without knowing the code. It is important that someone at night and on weekends also know that such a list exists. Even if there are no coders available, the surgeon ought to be able to identify the code for the procedure, since it is what he/she will bill.) The admit order can be written as a post-op order, but you do need one, and it should be written while the patient is still in the house.(emphasis added)
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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures
• Payment Policy When a Surgical Procedure on the Inpatient List is Performed on an Emergency Basis or When a Patient Whose Status is Outpatient Dies: In order to receive payment for a service billed with modifier –CA, Procedure payable only in the inpatient setting when performed emergently on an outpatient who dies prior to admission, all of the following conditions must be met: a. The status of the patient is outpatient; b. The patient has an emergent, life-threatening condition; c. A procedure on the inpatient list is performed on an emergency basis to resuscitate or stabilize the patient; d. The patient dies without being admitted as an inpatient.

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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures
• Payment Policy When a Surgical Procedure on the Inpatient List is Performed on an Emergency Basis or When a Patient Whose Status is Outpatient Dies (cont.): The modifier –CA should be on the UB92 line with the HCPCS code for the inpatient procedure. Payment for all services on a claim that have the same date of service as the HCPCS code billed with modifier –CA is made under APC 977. Separate payment is not allowed for other services furnished on the same date.

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OUTPATIENT PROSPECTIVE PAYMENT SYSTEM: Inpatient Only Procedures
• Payment Policy When a Surgical Procedure on the Inpatient List is Performed on an Emergency Basis or When a Patient Whose Status is Outpatient Dies (cont.):
Examples: 44960-CA APPENDECT;RUPT W ABSC/PERIT; (-CA DIED AFTER IP-ONLY PROC) APC: 00977 – New Technology – level VIII ($1000 - $1250) REV: 9999 – No Rev Code entered; partial OCE edits only Svrc: T – Significant proc subject to multi proc discounting 44960 APPENDECT; RUPT APP W ABSC/PERIT APC: 19991 – Inpatient Procedure Edit: 018 – OCE: Inpatient procedure (LID) REV: 9999 – No Rev Code entered; partial OCE edits only Srvc: C – Inpatient procedure

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