(Medicare Claims Processing Manual)

Effective for services furnished on or after January 1, 2012, cardiac resynchronization therapy involving an implantable cardioverter defibrillator (CRT -D) will be recognized as a single, composite service combining implantable cardioverter defibrillator p rocedures (described by CPT code 33249 (Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter -defibrillator and insertion of pulse generator  )) and pacing electrode insertion procedures (described by CPT code 33225 (Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter -defibrillator or pacemaker pulse generator (including upgrade to dual chamber system))) when performed on the same date of servi ce.  When these procedures appear on the same claim but with different dates of service, or appear on the claim without the other procedure, the standard APC assignment for each service will continue to be applied.   Medicare will make a single payment for those procedures that qualify for composite service payment, as well as any packaged services furnished on the same date of service.  Because CPT codes 33225 and 33249 may be treated as a composite service for payment purposes, CMS is assigning them status indicator Q3 (Codes that may be paid through a composite APC) in Addendum B.  Hospitals will continue to use the same CPT codes to report CRT -D procedures, and the I/OCE will evaluate every claim received to determine if payment as a composite service is appropriate. Specifically, the I/OCE will determine whether payment will be mad e through a single, composite payment when the procedures are done on the same date of service, or through the standard APC payment methodology when they are done on different dates of service.   CMS is also implementing claims processing edits that will return to providers incorrectly coded claims on which a pacing electrode insertion procedure described by CPT code 33225 is billed without one of the following CPT codes for insertion of an implantable cardioverter defibrillator or pacemaker:    33206 (Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial);    33207 (Insertion or replacement of permanent pacemaker with transvenous electrode(s); ventricular);    33208 (Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular);    33212 (Insertion or replacement of pacemaker pulse generator only; single chamber, atrial or ventricular);    33213 (Insertion or replacement of pacemaker pulse generator only; dual chamber, atrial or ventricular);    33214 (Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator));    33216 (Insertion of a single transvenous electrode, permanent pacemaker or cardioverter -defibrillator);   33217 (Insertion of 2 transvenous electrodes, permanent pacemaker or cardioverter -defibrillator);   33221(Insertion of pacemaker pulse generator only; with existing multiple leads);    33222 (Revision or relocation of skin pocket for pacemaker);    33230 (Insertion of pacing cardioverter -defibrillator pulse generator only; with existing dual leads);    33231 (Insertion of pacing cardioverter -defibrillator pulse generator only; with existing multiple leads)    33233 (Removal of permanent pacemaker pulse generator);    33234 (Removal of transvenous pacemaker electrode(s); single lead system, atrial or ventricular);    33235 (Removal of transvenous pacemaker electrode(s); dual lead system, atrial or ventricular);    33240 (Insertion of single or dual chamber pacing cardioverter -defibrillator pulse generator); or    33249 (Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter -defibrillator and insertion of pulse generator).   10.2.3 - Comprehensive APCs (Rev.  12421; Issued: 12- 21-23; Effective: 01 -01-24; Implementation: 01- 02-24)   The following services are excluded from comprehensive APC packaging:   ambulance services   brachytherapy sources (status indicator U)   diagnostic and mammography screenings   physical therapy, speech- language pathology and occupational therapy services reported on a separate facility claim for recurring services   pass -through drugs, biologicals, and devices (status indicators G or H)   preventive services defined in 42 CFR 410.2   self -administered drugs (SADs) -  drugs that are usually self -administered and do not function as supplies in the provision of the comprehensive service   services assigned to OPPS status indicator F (including certain CRNA services, Hepatitis B vaccines and corneal tissue acquisition)   services assigned to OPPS status indicator L (including influenza, pneumococcal pneumonia, and COVID -19 vaccines)   certain Part B inpatient services  Ancillary Part B inpatient services payable under Part B when the primary J1 service for the claim is not a payable Medicare Part B inpatient service (for example, exhausted Medicare Part A benefits, beneficiaries with  Part B only)    services assigned to a New Technology APC   Any drug or biological described by HCPCS code C9399 (Unclassified drugs or biologicals)   10.2.4 - Reporting for Certain Outpatient Department Services (That Are Similar to Therapy Services) (Non -Therapy Outpatient Department Services) and Are Adjunctive to Comprehensive APC Procedures  (Rev. 10541; Issued: 12-31-20; Effective: 01-01-21; Implementation: 01-04 -21)  This language was originally published in the October 2016 Update of the Outpatient Perspective Payment System (OPPS) (Transmittal R3602CP). We are updating this language based on the removal of the regulations at 42 CFR 410.59(a)(4) and 42 CFR 410.60(a)(4 ) related to functional reporting for therapy services.   Non-therapy outpatient department services are services such as physical therapy, occupational therapy, and speech- language pathology provided during the perioperative period (of a Comprehensive APC (C -APC) procedure) without a certified therapy plan of care. These are not therapy services as described in section 1834(k) of the Act, regardless of whether the services are delivered by therapists or other non- therapist health care workers. Therapy services are those provided by therapists under a plan of care  in accordance with section 1835(a)(2)(C) and section 1835(a)(2)(D) of the Act and are paid for under section 1834(k) of the Act, subject to annual therapy caps as applicable (78 FR 74867 and 79 FR 66800), until they were repealed by Bipartisan Budget Act of 2018, effective January 1, 2018. Because these services are outpatient department services and not therapy services, the requirement for functional reporting under the regulations at 42 CFR 410.59(a)(4) and 42 CFR 410.60(a)(4) does not apply. The functional reporting requirements were applicable until January 1, 2019 at which time the regulations at 42 CFR 410.59(a)(4) and 42 CFR 410.60(a)(4) were removed (83 FR 41786 and 83 FR 59452).  The comprehensive APC payment policy packages payment for adjunctive items, services, and procedures into the most costly primary procedures under the OPPS at the claim level. When non -therapy outpatient department services are included on the same claim a s a C -APC procedure (status indicator (SI) = J1) (see 80 FR 70326) or the specific combination of services assigned to the Observation Comprehensive APC 8011 (SI = J2), these services are considered adjunctive to the primary procedure. Payment for non-therapy outpatient department services is included as a packaged part of the payment for the C -APC procedure.   Effective for claims received on or after October 1, 2016  with dates of service on or after January 1, 2015, providers may report non -therapy outpatient department services (that are similar to therapy services) that are adjunctive to a C -APC procedure (SI = J1) or the specific combination of services assigned t o the Observation Comprehensive APC 8011 (SI = J2), in one of two ways:   1. Without using the therapy CPT codes and instead reporting these non -therapy services with Revenue Code 0940 (Other Therapeutic Services); or  2. Reporting non- therapy outpatient department services that are adjunctive to J1 or J2 services with the appropriate occurrence codes, CPT codes, modifiers, and revenue codes.   10.3 - Calculation of APC Payment Rates  (Rev. 1445, Issued:  02- 08-08; Effective:  01 -01-08; Implementation:  03 -10-08)  The OPPS national unadjusted payment rates for APCs other than drugs and biologicals are calculated as the products of the scaled relative weight for the APC and the OPPS conversion factor.  Hospital specific payments for these APCs are derived after application of applicable adjustment factors (e.g., multiple surgery reduction, rural sole community adjustment, etc.) and the post reclassification wage index that applies to the hospital to which payment is being made.  Payment rates for se parately paid drugs and biologicals are generally established based on a percentage of the average sales price of the drug or biological.   An APCs scaled relative weight is generally calculated based on the median cost (operating and capital) of all of the services included in the APC group.  Median costs are developed from a database of the most currently available hospital outpatient claim s using the most recently filed cost report data.   The following is a simplified description of the process used to calculate the OPPS payment rates for services for which the rate is based on the median cost.    Hospital -specific, department -specific cost -to-charge ratios are used to convert billed charges to costs for each HCPCS code;    For most APCs, single procedure bills (claims that contain only one separately paid procedure code) for all of the procedures within a particular APC are used to calculate the median costs on which APC payment weights are based to ensure that the median captures the full cost of the procedure when it is the only service furnished. The costs on the bill are summed to add the costs of any packaged services into the procedure with which the packaged services are packaged.  Composite APCs are an exception to this statement since the payment for them is calculated only from multiple procedure claims that meet the criteria for composite APC payment;    60 percent of the total cost is wage neutralized and the set of claims for each APC is trimmed at +/-  3 standard deviations from the geometric mean;    A median cost is calculated for each APC, using the claims for the procedures that meet the criteria for being assigned to that APC and the array of costs determined from those claims.  In some cases, a subset of single procedure bills that meet specified criteria are used to calculate the median cost for the APC.  For example, CMS uses only claims with correct device codes, no token charges for devices, no interrupted procedures, and without no cost or full credit devices to set the median cost for device- dependent APCs.  Similarly, the median costs for composite APCs are calculated using only claims that meet the criteria for the composite APC.   Median costs are converted to relative weights by dividing each APCs median cost by the median cost for the Level 3 Hospital Clinic Visit APC.    Relative weights are scaled for budget neutrality.    Scaled weights are converted to payment rates using a conversion factor which takes into account pass -through payments to be made in the coming year, changes to the wage index (see section 10.8.1), the cost of outlier payments (see section 10.7) and the annual market basket update factor.   CMS issues a proposed rule with a 60 day comment period in the summer of the year before the year in which the proposed payment rates would be applicable.  There is a 60 day comment period, after which CMS issues a final rule with comment period to announc e the forthcoming years payment policies and rates.  The CMS OPPS Webpage at http://www.cms.hhs.gov/HospitalOutpatientPPS/  is the best source for both rules and the supporting files.  10.4 - Packaging  (Rev. 3941; Issued: 12- 22-17; Effective: 01 - 01-18; Implementation: 01 -02-18)  Under the OPPS, packaged services are items and services that are considered to be an integral part of another service that is paid under the OPPS.  No separate payment is made for packaged services, because the cost of these items and services is included  in the APC payment for the service of which they are an integral part.  For example, routine supplies, anesthesia, recovery room use, and most drugs are considered to be an integral part of a surgical procedure so payment for these items is packaged into the APC payment for the surgical procedure.