Webinar Replay: 2013 OPPS Final Rule Review

Event Date: 

Wednesday, November 21, 2012

Click here to see a replay of the 2013 OPPS Final Rule Review webinar. This webinar will prepare hospital staff for compliance with 2013 Medicare outpatient billing guidelines by reviewing the key provisions of the Medicare Outpatient Prospective Payment System (OPPS) Final Rule. The 2013 Medicare payment policy and billing guideline changes for hospitals will be summarized and discussed, including (but not limited to) such important areas as the market basket payment adjustment, outpatient quality data reporting, partial hospitalization, and payment rates for separately payable drugs.

*Note* - Replays are NOT eligible for CEU credits

Questions & Answers


Question: On slide 50 you refer to MPFS rule. Can you provide a link so that we can review the new rule?

Answer: The MPFS Final Rule was published in the Federal Register on November 16, 2012.

You can access it on the MediRegs in the Guidance for Coders Library

The information about transitional care management begins on page 68978.

  • 2013 PFS Final Rule Table of Contents
  • 2013 PFS Final Rule III. H. Primary Care and Care Coordination


Question: Do you think that the hospital will shoulder the cost, now CMS is changing or adjusting the cost in 2013. Does CMS help some way to share the expense?

Answer: CMS is transitioning to a new method of calculating APC payment amounts that is based on the geometric mean cost of services within the APC, rather than the median cost. CMS is not planning to provide any additional reimbursement to hospitals that experience a decrease in reimbursement as a result of this change. However, according to CMS projections, most providers will experience little overall impact.


Question: Can you show me how to get to a list of OPPS tables and changes that would be good to bookmark?

Answer: See Related links section of this Study Aid


Question: CMS posted a new HCPCS download files late yesterday replacing Version 2 and in discussion with CMS will be posting a corrections document in mid-December. They still have a few date issues, typos and duplicate descriptions not corrected in this latest posting.

Answer: A: Thanks. It's common for CMS to post corrections, particularly during fourth quarter, when the agency is releasing so many large data files during a short period of time, and data users should always watch for revised files.

  • Pre-release 2013 CodeBook: Download Center | Update & Changes Report


Question: Please confirm that CPT-90792 (Initial Evaluation with medical service) can only be used by physician? Can other provider types such as psychologist, clinical social workers and clinical nurse specialist may bill 90792 when medical services are provided?


Answer: The OPPS Final Rule states:

Effective January 1, 2013, CPT codes 90801 and 90802 will be deleted and the E/M services will be billed using the following CPT codes: CPT code 90791 (Psychiatric diagnostic evaluation (no medical services) when completed by a non-physician) and CPT code 90792 (Psychiatric diagnostic evaluation (with medical services) when completed by a physician).

  • OPPS Final Rule VIII. C. Coding Changes


Question: Regarding the new Therapy modifiers- is there a specific sequencing as there are already GO, GN, GP, and now the new KX modifers? Could there be the potential of having a GN, KX, CH?


Answer: The new impairment modifiers (CH-CN) are not discussed in the OPPS Final Rule. They are discussed on page 68968 of the Medicare Physician Fee Schedule Final Rule, but the MPFS Final Rule does not contain detailed reporting requirements for the modifiers.

  • 2012 PFS Final Rule II. G. Therapy Services


Question: 99495/99496 can you bill these codes when billing a discharge and then an E/M when patient comes in for visit within the 7-14 days?


Answer: It appears this question relates to the physician's billing for professional services related to transitional care. This issue is discussed in the Medicare Physician Fee Schedule Final Rule, page 68984, which states:

We accept the AMA/RUC's recommendation (as supported by a number of commenters) to allow a physician to report both the discharge management code and a CPT TCM code. We agree with those commenters who emphasized that the physician billing discharge day management could also be the physician who is regularly responsible for the beneficiary's primary care (this may be especially the case in rural communities), and who would therefore be the appropriate physician to take responsibility for the patient's transition to the community.


Question: What would you recommend as a a good resource to get updates on the "affordable care act phases".


Answer: For a comprehensive tool that allows you to naviagate health reform rules by topic and provider type, including implementation deadlines, talk to your Wolters Kluwer Representative about the Health Reform Toolkit smartchart product.

For consumer information about the health care coverage provisions of the ACA, as well as the full law, go to:

For the administrative simplification provisions of the ACA, go to:


Question: What kind of supervision will be required for physical and occupational therapists who practice in a free-standing (non-hospital based) environment? Will there need to be a physician on site?


Answer: This question is outside the scope of this presentation. However, several Medicare contractors have issued billing guides for therapy services, and you may want to check your contractor's website to see what guidance they have available.


Question: On the Inpt only list addition did you mean knee replacement or the disc surgery that the code given matches?


Related Question: CPT 22856 disc arthorplasty but you have Total Knee replacement-pls help

Answer: We apologize for the typo on the slide about inpatient-only services. CMS originally proposed to remove two procedures from the inpatient list for 2013: Total disc arthroplasty (code 22856) and total knee replacement (code 27447). Based on public comments, CMS decided not to remove total knee replacement from the inpatient list. However, CMS did proceed with removing total disc arthroplasty from the inpatient list. You can find information about these changes in Section IX of the OPPS Final Rule.


Question: Can hospitals bill 99495 and 99496 and do these services have to be performed by Medicare defined qualified health care professionals?

Answer: Transitional care management will be payable to hospitals under OPPS in 2013. Codes 99495-99496 are designated as status V services. The OPPS Final Rule does not discuss which types of professionals might be able to perform these services.


Question: Is G9141 for H1N1 vaccination being deleted? If so, what should we report in it's place? 90471?

Answer: Code G9141 represents administration of a vaccine that was only used during the 2009-2010 H1N1 influenza pandemic. This vaccine is no longer available, so there is no replacement code for G9141.


Question: Would we use HCPCS G0379 for Direct Admit to our hospital for Observation Services if the patient was transferred from an outside hospital?


Related Question: Transfer from an ED from another hospital and was directly taken to the observation at your facility, G0379 is applicable because it is not a part of your facility.

Answer: Direct referral for observation care (code G0379) is discussed in the Medicare Claims Processing Manual, Chapter 4, Section 290.5.2. The manual states:

Hospitals should report G0379 when observation services are the result of a direct referral for observation care without an associated emergency room visit, hospital outpatient clinic visit, or critical care service on the day of initiation of observation services. Hospitals should only report HCPCS code G0379 when a patient is referred directly to observation care after being seen by a physician in the community.


Question: Might you be able to comment on how OPPS will or will not process CPT codes 99487-99489 when you are addressing 99495-99496?

Answer: Complex chronic care coordination services will not be payable to the hospital under OPPS. CMS has designated codes 99487-99489 as status N (unconditionally packaged). Additionally, these codes are not recognized for payment under the Medicare Physician Fee Schedule.