The Scoop on 2011 Hospital OPPS Billing

Hospital managers trying to catch up on all of the changes made in the 2011 update of the hospital outpatient prospective payment system (OPPS) will be glad to know about three new transmittals issued by the Centers for Medicare & Medicaid Services (CMS). The following transmittals include continuing policies as well as new 2011 policies.

• Transmittal R2130CP (issued December 30, 2010) describes changes to and billing instructions for various payment policies implemented on January 1, 2011.
• Transmittal R137BP (issued December 30, 2010) updates requirements for the supervision of diagnostic and therapeutic services provided to hospital outpatients.
• Transmittal R2114CP (issued December 17, 2010) details the January 2011 integrated outpatient code editor (I/OCE) specifications (version 12).

Here are a few highlights from the above.

Device, Procedure and Product Edits

The 2011 update to the following is now available: procedure-to-device edits, device-to-procedure edits, and radiolabeled product and procedure edits.

New Supervision Policy

CMS has updated several sections of the Medicare Benefit Policy Manual (MBPM), Chapter 6, to incorporate policy changes made in the 2011 OPPS and ambulatory surgery center (ASC) final rule with comment period. Three of those sections will be of interest to radiology providers because they address coverage of outpatient diagnostic services (beginning January 1, 2010 and after). There are also revisions in the section related to outpatient diagnostic services under arrangements.

Also included is the revised definition of direct supervision for hospital outpatient services, which says that, except for diagnostic services furnished in nonhospital locations, direct supervision continues to mean that the supervisory practitioner is immediately available. However, he or she is no longer required to be physically present within a specific boundary (such as the hospital campus or provider based department).

Multiple Imaging Composite APCs

Transmittal R2130CP provides a table of affected HCPCS codes and the three imaging families and five composite APCs into which they fall.

Billing for Radiopharmaceuticals

As with all of the OPPS summaries, this section (which also includes drugs and biologicals) is the most extensive. Radiology providers will particularly want to review the following sections that summarize Medicare policies:

• Payment for therapeutic radiopharmaceuticals (RPs), including a table of the nonpass-through separately payable therapeutic RPs for January 1, 2011;
• Reporting of outpatient diagnostic nuclear medicine procedures; and
• Payment offset for pass-through diagnostic RPs and for pass-through contrast agents.

 By Janis Opplet, MedLearn Editor