(Medicare Claims Processing Manual)

 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 genera tor 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. 11457, Issued: 06- 15-22, Effective: 07- 01-22, Implmentation:07- 05-22)  Comprehensive APCs provide a single payment for a primary service, and payment for all adjunctive services reported on the same claim is packaged into payment for the primary service. With few exceptions, all other services reported on a hospital outpatient claim in combination with the primary service are considered to be related to the delivery of the primary service and packaged into the single payment for the primary service.   HCPCS codes assigned to comprehensive APCs are designated with status indica tor J1, See Addendum B at https://www.cms.gov/Medicare/Medicare -Fee-for-Service- Payment/HospitalOutpatientPPS for the list of HCPCS codes designated with status indicator J1.   Claims reporting at least one J1 procedure code will package the following items  and services that are not typically packaged under the OPPS:   major OPPS procedure codes (status indicators P, S, T, V)   lower ranked comprehensive procedure codes (status indicator J1)   non-pass-through drugs and biologicals (status indicator K)   blood products (status indicator R)   DME (status indicator Y)   therapy services (HCPCS codes with status indicator A reported on therapy revenue centers)   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 indic ators G or H)   preventive services defined in 42 CFR410.2  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 ( certain CRNA services, Hepatitis B vaccines and corneal tissue acquisition)   services assigned to OPPS status indicator L (influenza and pneumococcal pneumonia vaccines)   certain Part B inpatient services  Ancillary Part B inpatient services payable under P art 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.    For the remainder of the PHE for  COVID -19,  o Over -the-counter (OTC) COVID -19 tests  o New COVID -19 treatments that meet the following criteria:  1) The treatment must be a drug or biological product (which could include a blood product) authorized to treat COVID -19, as indicated in section I. Criteria for Issuance of Authorization of the letter of authorization for the drug or biological product, or the drug or biological product must be approved by the FDA for treating COVID -19  2) The emergency use authorization (EUA) for the drug or biologica l product (which could include a blood product) must authorize the use of the product in the outpatient setting or not limit its use to the inpatient setting, or the product must be approved by the FDA to treat COVID -19 disease and not limit its use to the  inpatient setting.   The single payment for a comprehensive claim is based on the rate associated with either the J1 service or the specific combination of J2 services. When multiple J1 services are reported on the same claim, the single payment is based on the rate associated with the highest ranking J1 service. When certain pairs of J1 services (or in certain cases a J1 service and an add -on code) are reported on the same claim, the claim is eligible for a complexity adjustment, which provides a single payment for the claim based on the rate of the next higher comprehensive APC within the same clinical family. When a J1 service and a J2 service are reported on the same claim, the single payment is based on the rate associated with the J1 service, and the combination of the J1 and J2 services on the claim does not make the claim eligible for a complexity adjustment. Note that complexity adjustments will not be applied to discontinued services (reported with mod - 73 or - 74).    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 la nguage 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) relat ed 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 ar e 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 as 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 de partment 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 s ervices (that are similar to therapy services) that are adjunctive to a C -APC procedure (SI = J1) or the specific combination of services assigned to the Observation Comprehensive APC 8011 (SI = J2), in one of two ways:   1. Without using the therapy CPT c odes 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 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 surger y 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 separately paid drugs and biologicals are generally established based on a percenta ge 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 claims 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 a dd 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 f or 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 calcul ated 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 issu es a final rule with comment period to announce 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)