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Various authors

HCFA denies payment for outpatient vascular procedures

Nephrol Listserve (Aug) 03:thread, 2000

On Wednesday, August 2nd, a Chicago-area nephrologist queried the NEPHROL discusson group about information regarding a new policy of HCFA to deny payment for outpatient vascular access procedures on dialysis patients. Nephrologists were told that these included were "declotting by thrombolytic agent of implanted vascular access or catheter", "percutaneous...introduction of intravascular stent", and "transluminal balloon angioplasty".

The problem was quickly confirmed by other nephrologists on the thread, including one who commented that, to his knowledge, the RPA was aware of the problem and was working with HCFA toward getting it resolved.

Apparently this new HCFA policy was the result of a new prospective payment system with the acronym of "OPPS", (Outpatient Prospective Payment System or "OPPS"). It was not clear if this policy would apply to freestanding, non-hospital facilities as well, probably so. All approved procedures will be grouped by a classification system (Ambulatory Payment Classification or "APC"), akin to DRG's for inpatients that will determine the level of reimbursement (presumably much less than under current reimbursement schemes).

Only certain procedure codes are approved for use in the OPPS, many codes are explicitly restricted to use in the inpatient setting. Apparently, this system was to have been implemented earlier this year but has been delayed until 8/1/00. HCFA has held fast on implementing it now despite acknowledged problems and deficiencies. There is supposedly some revision or fix to come in October."

According to some examples raised by nephrologists on the thread, " A simple diagnostic fistulogram can be performed, but any angioplasty (venous or arterial) can only be done (i.e. paid) as inpatient. Actually there are two components to the angioplasty coding, the surgical procedure code (i.e. 35476 for venous PTA) which is approved, and the associated "Supervision & Interpretation" code (i.e. 75978) which is not allowed. The AV access thrombolysis code (G0159 still in "test" status) is approved, but not any associated angioplasty.

The entire list of codes is available in the Federal Register here. After clicking on this link, go to the HCFA section and look for code listing in Addendum E, esp. pgs 18783-18787)."

As many on the discussion thread pointed out, the new HCFA policy represented a Catch-22 situation, since (a) many vascular access procedures would only be paid for in an inpatient setting, but (b) payment for the hospitalization itself for many of these indications might not be covered.

The consensus was, that this was "horrible public policy", and that the patients would be the big losers.

However, HCFA in fact was responding to this problem by means of an Intermediary Program Memorandum, as detailed below and originally posted on NEPHADMIN (A service of NKF cyberNephrology) http;//www.cybernephrology.org by Kim.Solez@UAlberta.CA

A special email/fax edition of the monthly

The Health Care Financing Administration has released Intermediary Program Memorandum A-00-45, 8/1/2000, which corrects the list of HCPCS codes that are on the "inpatient only" list for Medicare Outpatient PPS. This memorandum has yet to be posted (as of 8/3/2000) on the HCFA web site therefore it is provided below.

Although these changes will be effective for services furnished on or after 8/1/2000, HCFA will not be able to revise the Outpatient Code Editor (OCE) to properly pay these services as outpatient services until the OCE is released for the October update.

Program Memorandum Intermediaries
Transmittal A-OO-45


Date; AUGUST 1,2000_______ CHANGE REQUEST 1296

SUBJECT: Interim Process for Certain "Inpatient Only" Code Changes

As discussed in the outpatient prospective payment system (OPPS) final rule, which was published in the Federal Register on April 7, 2000, there are certain procedures that will not be paid if performed on an outpatient basis. A hospital will receive Medicare payment for these procedures only when they are furnished to their inpatients. The HCPCS codes that are on the "inpatient only" list were published in Addendum E of the final rule.

However, certain codes from the list were erroneously included as inpatient only procedures and as a result will be removed from the list. The following is a list of HCPCS codes which will be removed from the inpatient only list. These codes will be assigned and paid under the APCs indicated.

HCPCS Description APC

74300 X-ray bile ducts/pancreas 0263
75945 Intravascular us 0267
75946 Intravascular us add on 0267
75960 Transcatheter intro, stent 0279
75961 Retrieval, broken catheter 0279
75962 Repair arterial blockage 0280
75964 Repair artery blockage, each 0279
75966 Repair arterial blockage 0280
75968 Repair artery blockage, each 0279
75970 Vascular biopsy 0279
75978 Repair venous blockage 0279
75992 Atherectomy 0279
75995 Atherectomy 0279
92977 Dissolve clot, heart vessel 0120
95920 Intraop nerve test add on 0216
95961 Electrode stimulation, brain 0216
95962 Electrode stim, brain add on 0216

HCFA-Pub. 60A

Although these changes will be effective for services furnished on or after August 1, 2000, we will not be able to revise the Outpatient Code Editor (OCE) to properly pay these services as outpatient services until the OCE is released for the October update. Therefore, hospital outpatient claims containing any of the above codes will result in rejection of the claim. The October update to the OCE will be revised to properly process these codes for hospital outpatient claims submitted to you on or after October 1, 2000, even if the date of service on the claim occurs during the period August 1, 2000 through September 30, 2000.

In order to prevent claims containing these codes from being rejected under the revised OCE for August, please advise your hospitals to implement one of the following options:

Hold claims that contain any of the above codes until October 1, 2000.

If the hospital does not wish to hold their claims, they may submit the claim for all services furnished to a beneficiary with the exception of the codes listed above. Then, on or after October 1, 2000, the hospital must submit an adjustment claim containing all the services provided (including any of the above codes previously not billed).

In the event a hospital submits a claim containing any of the above codes prior to October I, 2000, the claim will be rejected. Intermediaries are to reprocess those claims with any of the above codes that were rejected as "inpatient only" no later than November 30, 2000.

Advise your hospitals of these procedures immediately. The effective date for this Program Memorandum (PM) is August 1,2000. The implementation date for this PM is no later than November 30,2000. Funding for implementation will be made available through the regular budget process. This PM may be discarded after August 1,2001.

If you have any questions related to the above policy contact Kitty Ahem, (410) 786-4515.

End Program Memorandum
Volume 3, Number 5, August 3, 2000
A publication of THA -- An Association of Hospitals
and Health Systems
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JT Daugirdas, MD