HCFA denies payment for outpatient vascular procedures
(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
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
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)
A special email/fax edition of the monthly
THA - FINANCIALfocus
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
HEALTH CARE FINANCING ADMINISTRATION (HCFA)
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
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
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,
End Program Memorandum
THA - FINANCIALfocus
Volume 3, Number 5, August 3, 2000
A publication of THA -- An Association of Hospitals
and Health Systems
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Nashville, TN 37210 4634
If you have questions please contact:
THA - Vice President of Finance
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JT Daugirdas, MD