Final Rule Changes for 2016 Hospital Outpatient Prospective Payment System (HOPPS)

Final Rule Changes for 2016 Hospital Outpatient Prospective Payment System (HOPPS)

November 12, 2015 Government Relations News

On October 30, 2015, the Centers for Medicare and Medicaid Services (CMS) released the Calendar Year (CY) 2016 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems and Quality Reporting Programs final rule with comment period. The final rule updates Medicare payment policies and rates for services performed in hospital outpatient departments. Hospital-based outpatient audiology services are paid under the HOPPS. Individual services are assigned to Ambulatory Payment Classifications (APC) based on clinical similarities and costs. Payments are then calculated according to the APC, with each service within a respective APC receiving the same rate of reimbursement.

APC Restructuring and Reclassification of Cochlear Implant Programming and Subsequent Reprogramming CPT Codes

In the 2015 HOPPS final rule, CMS took steps to review, revise, and reorganize APCs across the HOPPS to collectively group services that are clinically similar and have similar resource costs within the same APC. This involved reclassifying some APCs as ancillary APCS when the services in that category were considered integral, ancillary, supportive, dependent, or adjunctive to a primary service. This resulted in bundled or packaged payments, so that if other services are performed in the hospital on the same day as an ancillary service, the ancillary service would not be paid separately. This reclassification impacted a number of audiology services, including cochlear implant programming and subsequent reprograming CPT codes and audiometric CPT codes. This change meant that in 2015, these services were not paid if other services were performed in the hospital on the same date.

In our comments to CMS regarding the 2016 OPPS proposed rule, the Academy joined other stakeholders in requesting a change to the problematic classification for both the cochlear implant programming and audiometric CPT codes Though CMS did not adopt changes to the classification of audiometric services, they did make a change to the classification for cochlear implant follow-up services, allowing them to be categorized as separately payable services. CPT code 92640, Auditory brainstem implant programming, was also reclassified. These changes allows hospital audiology clinics that provide cochlear implant services to be reimbursed for those services even when they are provided on the same day as other services. This is a critical and necessary change to CMS' policy and helps to ensure the continued delivery of high quality, accessible health care for cochlear implant patients.

For CY 2016, CMS continued its reorganization efforts begun in 2015, and conducted a comprehensive review of the structure of the APCs and codes, and is finalizing its proposal, with some modifications, to consolidate and restructure nine clinical families of APCs. Restructuring was based on the following principles: (1) improved clinical homogeneity; (2) improved resource homogeneity; (3) reduced resource overlap in longstanding APCs; and (4) greater simplicity and improved understandability of the OPPS APC structure. The Academy continues to monitor these APC changes.

Tables 1-6 below discuss the APCs for 2016 for audiology codes. An "S" status indicator denotes a "Separate APC Payment" where regardless of services performed on the same date of service, the CPT code is paid at the APC rate. A "Q1" status indicator represents "STV-Packaged Codes" where APCs and CPT codes billed on the same date of service as those assigned a status indicator of "S", "T" or "V" are packaged and not paid for separately. If billed with without the "S," "T," or "V" service, payment is made at the APC rate.

Table 1: APC 5721-Level I Diagnostic Tests and Related Services ($129.75)

CPT Code Code Descriptor Status Indicator
92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stim, w/recording S
92545 Oscillating tracking test, with recording S
92546 Sinusoidal vertical axis rotational testing S
92584 Electrocochleography S
92586 Auditory evoked potentials, limited S
92601 Cochlear Implant initial programming <7 years old S
92602 Subsequent programming <7 years old S
92603 Cochlear implant initial programming > 7 years old S
92604 Subsequent programming >7 years old S
92640 Auditory brainstem implant programming S
92550 Tympanometry & reflex threshold Q1
92553 Audiometry air and bone Q1
92557 Comprehensive hearing evaluation Q1
92562 Loudness balance test Q1
92570 Acoustic immitance testing Q1
92572 Staggered spondaic word test Q1
92579 Visual audiometry (VRA) Q1
92582 Conditioning play audiometry Q1
92620 Auditory function test (60 min) Q1
92625 Tinnitus assessment Q1
92626 Evaluation of auditory rehab status Q1

Table 2: APC 5722- Level II Diagnostic Tests and Related Services ($220.35)

CPT Code Code Descriptor Status Indicator
92537 Caloric vestibular test with recording, bilateral; bithermal S
92538 Caloric vestibular test with recording, bilateral; monothermal S
92540 Basic vestibular evaluation S
92585 Auditory evoked potentials (ABR), comprehensive S
92587 OAEs, limited S
92588 OAEs, comprehensive S

Table 3: APC 5723- Level III Diagnostic Tests and Related Services ($396.52)

CPT Code Code Descriptor Status Indicator
92577 Stenger test, speech S

Table 4: APC 5731- Level I Minor Procedures ($12.70)

CPT Code Code Descriptor Status Indicator
92700 Unlisted otorhinolarngological service or procedure Q1

Table 5: APC 5732- Level II Minor Procedures ($30.51)

CPT Code Code Descriptor Status Indicator
92555 Speech threshold audiometry Q1
92556 Speech threshold and discrimination Q1
92563 Tone decay hearing test Q1
92564 SISI hearing test Q1
92565 Stenger test, pure tone Q1
92567 Tympanometry Q1
92568 Acoustic reflex threshold Q1
92571 Filtered speech test Q1
92575 Sensorineural acuity test Q1
92576 Synthetic sentence test Q1
92583 Select picture audiometry Q1
92596 Ear protection measurement Q1

Table 6: APC 5734- Level IV Minor Procedures ($91.18)

CPT Code Code Descriptor Status Indicator
92541 Spontaneous nystagmus test Q1
92542 Positional nystagmus test Q1
92548 Posturography Q1
92552 Pure tone audiometry air Q1
92561 Bekesy audiometry diagnosis Q1

OPPS Conversion Factor Update

For CY 2016, CMS is updating OPPS rates based on the projected hospital market basket increase of 2.4 percent minus both a 0.5 percentage point adjustment for multi-factor productivity and a 0.2 percentage point adjustment required by law. There is also an additional finalized 2.0 percentage point adjustment to the payment update. The final rate update will be -0.3 percent.

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