OPPSPAYMENTPACKAGING--PACEMAKERPROCEDURES

Under OPPS, only one Status J1 code will be paid, payment for all other lines will be ?packaged? to the primary (highest paying) J1 code on the same claim When CMSsets the rate of reimbursement for a ?comprehensive APC?, the rate-setting process takes into consideration costs reported from the entire body of claims submitted by facilities nationwide for the same procedure

Therefore, it?s not quite true that the hospital isn? t paid for the temporary pacemaker procedure, it?s just that its reimbursement is ?packaged?into the rate paid on the primary code, which payment has already taken into account the typical costs for accompanying procedures ? including a temporary pacemaker procedure. We found a claim that illustrates Medicare?s OPPS payment for the services described within the Medicare claims database, using the PARA Dat a Edit or CMS tab:

Here?s an excerpt from the Medicare document that explains status indicator J1 (Addendum D1 of the OPPSFinal Rule) ? it explains that ?all covered Part B services on the claim are packaged with the primary ?J1?service for the claim? ?:

Here?s an excerpt from Medicare?s Integrated OCE(IOCE) CMSSpecifications V24 0, effective 1/1/2023, which explains how Comprehensive APCpayment is processed:

5 5 Com prehensive APC Processing

Effective 1/1/2015 (v16.0), certain high cost procedure codes which have an SI=J1 are paid an all-inclusive rate to include all services submitted on the claim, except, for services excluded by statute All allowed, adjunctive services submitted on the claim are packaged into the ?comprehensive?APCpayment rate (i e , the status indicator is changed to N) Multiple comprehensive procedures, if present on the claim in specified combinations, may be assigned to a higher-paying comprehensive APCrepresenting a complexity adjustment. Services that are excluded from the all-inclusive payment retain their standard APCand SI for standard processing

5 5 1 General Com prehensive APC Assignm ent Rules and Crit eria: V16 0- Current

? C. If there are multiple comprehensive APCprocedures existing on the same claim from the different categories listed above, the comprehensive APCprocedures are packaged (SI = N) according to the hierarchy of services present; the procedure or service highest in the hierarchy is assigned the comprehensive APCfor the claim Additional processing conditions for each of the different categories is listed separately below.

Outside of the ordinary APCreimbursement rate, there are only two ways that both procedures 33210 and 33208 reported on the same claim wilI qualify for additional reimbursement under OPPS? and that additional reimbursement would be paid on only the primary J1 code on the claim:

1 Certain combinations of two or more HCPCSwith status J1 on the same claim will trigger a higher payment due to a ?complexity adjustment?? but that higher payment will be included in the amount paid on the primary code.

2.If a claim has an extraordinarily high amount of charges, the claim may become eligible for additional ?outlier?reimbursement ? but this claim did not meet outlier criteria.This case did not qualify for a complexity adjustment, nor were the total charges high enough to generate additional reimbursement under OPPSOutlier methodology Com plexit y Adjust m ent :

For certain combinations of J1 procedure reported on the same claim, OPPSprovides for additional payment on the primary code called a ?complexity adjustment.?CMSpublishes the list of code combinations that result in a complexity adjustment in Addendum Jof the OPPSFinal Rule In the 2023 Addendum J, the combination of 33208 with 33210 does not qualify for a complexity adjustment

Here?s an excerpt from Addendum Jindicating that the code pair 33208 with 33210 did not qualify for a complexity adjustment in 2023 (note there are several tabs in the workbook):

Out lier Adjust m ent ?Under OPPS, a claim paid by APCmay become eligible for additional reimbursement in the form of an outlier adjustment if two criteria are met:

1 In 2023, the cost of the procedure, as measured by total covered charges x the facility?s ?Cost to Charge?ratio, must be more than $8,625 above the regular APCrate of reimbursement, and

2 The facility?s cost must exceed 1 75 x the APCrate

Here's an example of the OPPSoutlier calculation for a claim with very high charges:

Quest ion: Has Medicare provided guidance on how t o report separat ely payable drugs w hen no docum ent at ion of w ast age exist s? How are facilit ies required t o report drugs w here t he rem aining am ount of a vial w as used for a different pat ient ? It w ould be inappropriat e t o report JW, and also inappropriat e t o report JZ if w e w ast ed a port ion of a single-use vial but had no docum ent at ion t o affirm t hat t he w ast ed port ion w as not reallocat ed t o anot her pat ient .

Answ er: At this time, Medicare has not provided guidance that permits wastage without documentation of the portion of a single-use vial that was administered and the portion that was wasted The definition of modifier JW is ?Drug amount discarded/not administered to any patient;?therefore the documentation should support that wastage was truly discarded:

Optimal documentation in support of modifier JW would attest that the wasted portion was not used for any patient That being said, this documentation could be simplified if the facility has adopted a policy that prohibits using a single-use vial to treat more than one patient The recently published FAQ regarding modifiers JZ and JW from CMS, available in the Advisor tab of the PARA Dat a Edit or, does not allow for the possibility that providers would not have documented the wastage; it states that providers must document the amount of discarded drugs: https://www cms gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/ downloads/jw-modifier-faqs pdf

Here?s the section of the FAQ document which addresses documentation:

To simplify documentation, hospitals should consider adopting a policy which prohibits administering the discarded portion of a single-use vial to any other patient. The Centers for Disease Control and Prevention (CDC) discourages providers from using a single-use vial for multiple patients as an infection control policy; guidance is offered at the following link:

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