Emergency Department Update 2011 Outpatient Payment System

2011 OPPS Final Rule The Facility Conversion Factor ED Facility E/M Guidelines Triage Observation Critical Care Inpatient Procedure List Hydration/Injection Infusion Update Hospital Outpatient Quality Data Reporting

2011 OPPS Final Rule

On November 2, 2010 The Centers for Medicare and Medicaid Services released the 2011 Outpatient Payment System (OPPS) Final Rule. The rule finalizes payment rates and policies for outpatient services furnished by hospitals that are paid under the OPPS. The rule was published in the Federal Register on November 24, 2010 and governs services effective January 1, 2011.

The Facility Conversion Factor

For 2011 the conversion factor under OPPS will increase 2.35% from the 2010 value of $67.241 to yield a 2011 OPPS conversion factor of $68.876. A 2% penalty will apply for hospitals not reporting outpatient quality measures in 2010 leading to a reduced conversion factor of $67.530. To calculate the CY 2011 reduced market basket conversion factor for those hospitals that fail to meet the requirements of the HOP QDRP for the full CY 2011 payment update, we used a reduced market basket increase updateand further reduced by 2.0 percentage points as required by section 1833(t)(17)(A)(i) of the Act for failure to comply with the OPD quality reporting requirements. This resulted in a reduced conversion factor for CY 2011 of $67.530 for those hospitals that fail to meet the HOP QDRP requirements. 303/2452 OPPS Final Rule

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ED Facility E/M Guidelines

For 2011 there will not be significant changes to the rules governing ED EM facility guidelines. Per the description in the 2008 OPPS Final Rule hospitals will be allowed to utilize their own scoring systems provided that they reflect facility resource utilization and are consistent with the eleven guiding principles published in the 2008 OPPS Final Rule. CMS made clear that prior to 2012 they would not mandate national guidelines and would provide advance notice of 6-12 months prior to any implementation of national ED E/M facility guidelines. CMS claims analysis using 2009 data demonstrate the distribution of emergency department levels to be normal and stable.

Medicare Type A ED Visit Level Reimbursement ED Visit Level

99281 99282 99283 99284 99285 99291

2010 Payment
$53.26 $87.85 $140.18 $223.17 $329.73 $495.38

2011 Payment
$51.77 $87.25 $139.14 $222.58 $329.54 $464.75

Variance
-2.9% -0.7% -0.7% -0.3% -0.1% -6.6%

CMS-1504-FC and CMS1504-FC Addendum B

Because a national set of hospital-specific codes and guidelines do not currently exist, we have advised hospitals that each hospitals internal guidelines that determine the levels of clinic and emergency department visits to be reported should follow the intent of the CPT code descriptors, in that the guidelines should be designed to reasonably relate the intensity of hospital resources to the different levels of effort represented by the codes. 751/2452 OPPS Final Rule We observed a normal and stable distribution of clinic and emergency department visit levels in hospital claims over the past several years. The data indicated that hospitals, on average, were billing all five levels of visit codes with varying frequency, in a consistent pattern over time. 752/2452 OPPS Final Rule

CMS ED Facility E/M Coding Principles

The guidelines should follow the intent of the CPT code descriptor in that the guidelines should be designed to reasonably relate the intensity of the hospital resources to the different levels of effort represented by the code. The coding guidelines should be based on hospital facility resources not physician resources Should be clear to facilitate accurate payments and be usable for compliance purposes and audits Should meet HIPAA guidelines Should only require documentation that is clinically necessary for the patient Should not facilitate upcoding or gaming Should be written or recorded, well documented and provide the basis for the selection of a specific code Should be applied consistently across patients in the clinic or ED to which they apply Should not change with great frequency Readily available for FI review Should result in coding decisions that could be verified by other hospital staff and outside sources CMS -1392-FC, Page 872-873

National Guidelines seem unlikely:

Based on public comments, as well as our own knowledge of how clinics operate, it seemed unlikely that one set of straightforward national guidelines could apply to the reporting of visits in all hospitals and specialty clinics. 753/2452 OPPS Final Rule

Triage Only
CMS further clarified that triage only visits represent billable services and consume facility resources and as such were reportable under OPPS. Unless indicated otherwise, we do not specify the type of hospital staff (for example, nurses or pharmacists) who may provide services in hospitals... Hospitals providing services incident to physicians services may choose a variety of staffing configurations to provide those services, taking into account other relevant factors, including state and local laws, hospital policies, and other Federal requirements such as EMTALA and the Medicare conditions of participation related to hospital staffing. 747/2452 OPPS Final Rule

For 2011 APC 8003 (Level II Extended Assessment & Management Composite observation following a high level Type A or B ED visit or critical care) will reimburse $714.33.

Reimbursement Type A Emergency Department Visits

Type A ED Visit 99281 99282 99283 99284 99285 99291 Critical Care G0390 Critical Care w/ Trauma Team Activation APC 609 613 614 615 616 617 618 2010 Payment Rate $53.03 $87.64 $139.86 $222.63 $328.92 $494.17 $831.89 2011 Payment Rate $51.77 $87.25 $139.14 $222.58 $329.54 $464.75 $924.48 Variance ($1.26) ($0.39) ($0.72) ($0.05) $0.62 ($20.64) $92.59

Reimbursement Type B Emergency Department Visits

Type B ED Visit G0380 G0381 G0382 G0383 G0384 99291 Critical Care G0390 Critical Care w/ Trauma Team Activation APC 626 627 628 629 616 617 618 2010 Payment Rate $45.70 $62.06 $97.98 $141.48 $328.92 $494.17 $831.89 2011 Payment Rate $41.36 $59.23 $101.52 $165.48 $273.24 $464.75 $924.48 Variance ($4.34) ($2.83) $3.54 $24.00 ($55.68) ($20.64) $92.59

Observation
In 2008 CMS adopted the composite APC methodology, reimbursing for ED and Observation services in a single packaged construct. For 2001 the packaged/composite methodology continues combining ED Facility and Observations services into a single APC. Additionally CMS clarified certain requirements for Observation billing including the following: 1. The patient must be in the care of a physician during the period of observation, as documented in the medical record.

2. Appropriate progress notes that are timed, written, and signed by the physician. 3. Documentation that the physician performed a risk assessment to determine that the patient would benefit from observation services.

Critical Care
For 2011 CMS clarified in the final rule that, consistent with the 2011 CPT language, facilities are allowed to report typical services such as x-rays, gastric intubation, and transcutaneous pacing that are bundled under physician payment rules. However, since 2011 payment rates are based upon 2009 claims data (which included packaged payment for these bundled procedures), in 2011 hospitals will not receive separate payment for these procedures though they are encouraged to report them for future valuations.

Inpatient procedures performed in the ED will be paid under APC 0375 if the patient expires before being admitted.

Inpatient Procedure List

Addendum E of the OPPS rule lists procedures, that are designated as inpatient status, that is, they represent services, for patient safety reasons, typically provided to inpatients. Modifier Alert! When an inpatient procedure is performed to emergently resuscitate a patient prior to being admitted the procedure may be reported with the CA modifier appended if the patient expires prior to admission. CMS pushes hospitals to educate providers: We expect hospitals to use this knowledge and to educate physicians with regard to the appropriate setting for the procedures they furnish. We recognize that there are cases in which the patient expires before he or she can be admitted and has received anInpatient only service without being admitted. In these cases, we have long made payment for the ancillary services under APC 0375. 785/2452 OPPS Final Rule

Hydration/Injection Infusion Update

Each year the OPPS Rule updates reimbursement rates for essential ED services. In particular with the complex rules surrounding Hydration, Injection, and Infusion codes there is significant revenue at stake.

Code
96365 96366 96367 96372 96374 96375 96360 96361

Descriptor
IV infusion, initial IV infusion, add on Additional sequential IV infusion Injection, SC/IM Injection, IV push Injection, new drug add on Hydration IV infusion, initial Hydration IV infusion, add-on

2010 Payment
$128.47 $25.61 $37.35 $25.61 $37.35 $37.35 $75.50 $25.61

2011 Payment
$128.44 $26.35 $36.88 $26.35 $36.88 $36.88 $75.58 $26.35

Variance
($0.03) $0.74 ($0.47) $0.74 ($0.47) ($0.47) $0.08 $0.74

Hospital Outpatient Quality Data Reporting (HOP QDRP)

For 2011 OPPS does not add additional Outpatient quality measures, however, CMS has made clear its commitment to expanding quality tracking programs and a forecasted list of measures for years to come is included in the rule. Hospitals failing to report quality measures will suffer a 2% reduction in their conversion factor in subsequent years. Currently, for 2011 there are a total of 11 measures, with five related to treatment of Acute MI and four that are focused on imaging. Although no new measures were added for 2011, beginning in 2012 there will be an expansion of measures, including some specifically related to the ED including: Left Without Being Seen (LWBS) and length of stay for discharged outpatients.

HOP QDRP Measurement Set to be Used for the CY 2012 Payment Determination
OP-1 OP-2 OP-3 OP-4 OP-5 OP-6 OP-7 OP-8 OP-9 OP-10 OP-11 OP-12 OP-13 OP-14 OP-15 Median Time to Fibrinolysis Fibrinolytic Therapy Received Within 30 Minutes Median Time to Transfer to Another Facility for Acute Coronary Intervention Aspirin at Arrival Median Time to ECG Timing of Antibiotic Prophylaxis Prophylactic Antibiotic Selection for Surgical Patients MRSI Lumbar Spine for Low Back Pain Mammography Follow-up Rates Abdomen CT - Use of Contrast Material Thorax CT - Use of Contrast Material The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their Qualified/ Certified EHR System as Discrete Searchable Data* Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery* Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT)* Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache*
*New measure for the CY 2012 payment determination CMS has demonstrated their intent to track imaging utilization: The intent of the Simultaneous Use of Brain CT and Sinus CT measure is to assess whether potentially unnecessary sinus CTs are being performed on patients who have already undergone brain CTs. We do not intend for the rate to be reduced to zero. Despite the fact that a small proportion of claims indicate same day combined studies, we have substantial concerns regarding radiation exposure from the simultaneous use of these two imaging modalities. Our analysis of Medicare data for 2008 found that over 68,000 Medicare patients received this dual radiation exposure. 1117/2452 OPPS Final Rule

HOP QDRP Measurement Set to be Used for the CY 2013 Payment Determination
OP-1 OP-2 OP-3 OP-4 OP-5 OP-6 OP-7 OP-8 OP-9 OP-10 OP-11 OP-12 OP-13 OP-14 OP-15 OP-16 OP-17 OP-18 OP-19 OP-20 OP-21 OP-22 OP-23 Median Time to Fibrinolysis Fibrinolytic Therapy Received Within 30 Minutes Median Time to Transfer to Another Facility for Acute Coronary Intervention Aspirin at Arrival Median Time to ECG Timing of Antibiotic Prophylaxis Prophylactic Antibiotic Selection for Surgical Patients MRSI Lumbar Spine for Low Back Pain Mammography Follow-up Rates Abdomen CT - Use of Contrast Material Thorax CT - Use of Contrast Material The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their Qualified/ Certified EHR System as Discrete Searchable Data* Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery* Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT)* Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache* Troponin Results for Emergency Department acute myocardial infarction (AMT) patients or chest pain patients (with Probable Cardiac Chest Pain) Received Within 60 minutes of Arrival** Tracking Clinical Results between Visit** Median Time from ED Arrival to ED Departure for Discharged ED Patients** Transition Record with Specified Elements Received by Discharged Patients** Door to Diagnostic Evaluation by a Qualified Medical Professional** ED - Median Time to Pain Management for Long Bone Fracture** ED - Patient Left Before Being Seen** ED - Head CT Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT Scan Interpretation Within 45 minutes of Arrival**
*New measure for the CY 2012 payment determination **New measure for the CY 2013 payment determination

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