Medicare Program; Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2006 Payment Rates; Proposed Rule (70 Federal Register 42674)

September 16, 2005

Mark McClellan, MD, PhD
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1501-P
PO Box 8016
Baltimore, Maryland 21244-8018

Re: File Code CMS-1501-P

Medicare Program; Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2006 Payment Rates; Proposed Rule (70 Federal Register 42674)

Dear Dr. McClellan:

The American Health Information Management Association (AHIMA) welcomes the opportunity to comment on the Centers for Medicare & Medicaid Services' (CMS') proposed changes to the Hospital Outpatient Prospective Payment System (OPPS) and calendar year 2006 Rates, as published in the July 25, 2005 Federal Register. Our comments focus on those areas that are of particular interest to our members.

AHIMA is a not-for-profit professional association representing more than 50,000 health information management (HIM) professionals who work throughout the healthcare industry. AHIMA's HIM professionals are educated, trained, and certified to serve the healthcare industry and the public by managing, analyzing, and utilizing data vital for patient care, while making it accessible to healthcare providers and appropriate researchers when it is needed most.

Consistency in medical coding and the use of medical coding standards in the US is a key issue for AHIMA. As part of this effort, AHIMA is one of the Cooperating Parties, along with CMS, the Department of Health and Human Services' (HHS) National Center for Health Statistics (NCHS), and the American Hospital Association (AHA). The Cooperating Parties oversee correct coding rules associated with the International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9-CM).

AHIMA also participates in a variety of coding usage and standardization activities in the US and internationally, including the American Medical Association's (AMA's) Current Procedural Terminology® (CPT®) Editorial Panel.

III-C-3: Proposed Requirements for Assigning Services to New Technology APCs (70FR42707)

AHIMA supports CMS' proposal to require that an application for a code for a new technology service be submitted to the American Medical Association's CPT Editorial Panel before CMS accepts a New Technology APC application for review. As we have previously noted in our comment letters, the proliferation of G codes that potentially overlap CPT codes results in multiple ways of reporting the same service. HCPCS level II G codes are generally not accepted by payers other than Medicare, thus requiring hospitals to report the same procedure using two different codes. The goals of the regulations for electronic transactions and code sets promulgated under the Health Insurance Portability and Accountability Act (HIPAA) include promotion of uniformity and standardization in claims reporting and administrative simplification. Creation of duplicative methods of reporting the same service does not support either of these goals. Also, development of a National Health Information Network, a key initiative of the Office of the National Coordinator for Health Information Technology and President Bush, depends on data standardization and comparability in order to achieve information exchange across healthcare organizations - for this to happen we must get all data, data definitions, and guidelines to the point where the individual patient's payer or health plan reimbursement requirements do not dictate health information coding.

Requiring that an application for a new CPT code be submitted at the time of a New Technology APC application will minimize the need for expedited issuance of temporary G codes. It makes sense to first create a standard CPT code for a new technology service and then address special reimbursement considerations.

III-D-4: Vascular Access Procedures (70FR42711)

AHIMA supports the reconfiguration of the APCs for vascular access procedures, resulting in three new APCs differentiated by level. With the use of the CPT codes for vascular access procedures, the new APC configuration seems more logical and clinically homogenous.

IV-D-2-a: Surgical Insertion and Implantation Criterion (70FR42719)

We support CMS' proposal to modify the interpretation of the criterion that a device be surgically inserted or implanted in order to qualify for pass-through payment so that items surgically inserted or implanted either through a natual orifice or surgically created orifice are considered eligible. Advances in medical technology since the implementation of the OPPS allow many devices to be inserted or implanted without an incision.

VIII-B: Proposed Coding and Payment for Drug Administration - Proposed Changes for CY 2006 (70FR42737)

We support CMS' proposal to continue to use CPT codes to bill for drug administration services provided in the hospital outpatient setting. Using CPT codes simplifies the administrative burden for the coding of drug administration since hospitals can use the same codes for Medicare and non-Medicare payers. We believe the same codes should be reported to all payers for the same services. The use of duplicative, overlapping code sets is extraordinarily costly and can result in coding confusion and errors, compromises of clinical data, and the inability to conduct analysis longitudinally and across healthcare settings.

Because of the significant changes expected with the new 2006 CPT codes for drug administration, hospitals will need instruction and clarification on the application of these new codes under the OPPS. For example, clarification will be needed regarding the following:

  • How the use of the codes may be similar or different for the hospital outpatient setting as compared to the physician setting;
  • Definitions of what constitutes an "initial" vs. "subsequent" infusion vs. "concurrent" infusion;
  • Definition of "hydration" and how it is different from a hydration that is given for therapeutic reasons;
  • How should infusions or titrations be reported? Many times they are established with a documented start time and are administered via pump. As such, many infusions are maintained by equipment function rather than manual intervention. In these cases, a nurse may be aware of the start time of an infusion and may document it, however, it is unlikely that the stop time will be documented.

The AHIMA would welcome the opportunity to work with CMS on coding education.

IX: Hospital Coding for Evaluation and Management (E/M) Services (70FR42740)

We are increasingly frustrated and disappointed by CMS' failure to implement a national set of E/M guidelines for hospital outpatient reporting purposes. Since the implementation of the OPPS, hospitals have coded clinic and emergency department (ED) visits using the same CPT codes as physicians. CMS and the hospital industry acknowledge that existing CPT E/M codes do not adequately describe hospital resources.

It has now been more than two years since the independent panel convened by the American Hospital Association and AHIMA submitted its recommendations for a set of national guidelines. In the 2004 and 2005 OPPS rules, CMS stated it was considering proposed national coding guidelines recommended by the panel, and planned to make any proposed guidelines available on the OPPS Web site for public comment. CMS also proposed to implement new E/M codes only when it is also able to implement guidelines for their use. In the meantime, hospitals must continue to use hospital-specific guidelines that are not comparable across hospitals and are not compliant with HIPAA.

Further delay in adoption of a national set of guidelines is unacceptable. While we understand the need for CMS to develop and test new codes, CMS has had more than two years to complete this process. Meanwhile, hospitals are still without a standard methodology for reporting E/M services. At the time the AHA/AHIMA independent panel was convened, we were under the impression that there was some urgency in moving forward with a standardized set of guidelines because of the variability and non-comparability of the current approach. The lack of uniformity in the present system not only puts hospitals at compliance risk for multiple interpretations of the level of service that should be coded and billed, but also affects CMS' ability to gather consistent, meaningful data on services provided in the emergency department and hospital clinics. This is especially important because CMS uses the mid-level clinic visit (APC 601) as the anchor for establishing the relative weights within the outpatient PPS, and, due to a lack of national coding guidelines, there is no agreement on what a mid-level clinic visit encompasses.

XI -B: Proposed Payment for Observation Services - Proposed CY 2006 Coding Changes for Observation Services (70FR42743)

AHIMA commends CMS' proposal to shift determination of whether or not observation services are separately payable under APC 0339 from the hospital to the OPPS claims processing logic. These changes will significantly ease the administrative burden on hospital personnel and allow more of the steps involved in submitting claims for observation services to be automated.

However, we believe that CMS could go one step further and eliminate the need for proposed new code GYYYY. If the hospital bills the GXXXX code and the claim does not include a 45X (emergency department) or 516 (urgent care center) revenue code, then claims processing logic should determine that this was a direct admission to observation care. If the hospital bills the GXXXX code with a 45X or 516 revenue code, then it is clear that the patient came in through the emergency department or urgent care center. Thus, the claims processing logic would determine whether or not the observation services are a result of a direct admission.

AHIMA seeks clarification regarding the reference to inpatient status in the statement on page 42743 in the proposed rule that states "That is, hospitals would bill GXXXX when observation services are provided to any patient admitted to 'observation status,' regardless of the patient's status as an inpatient [emphasis added] or outpatient." We are concerned about this statement because if a patient is admitted as an inpatient, the hospital would not report HCPCS codes, but instead would be using the ICD-9-CM codes, since ICD-9-CM is the Health Insurance Portability and Accountability Act (HIPAA) code set standard for reporting procedures for hospital inpatient reporting.

XII-B: Procedures that Will Be Paid Only as Inpatient Procedures - Proposed Changes to the Inpatient List (70FR42745)

AHIMA agrees with CMS' proposal to retain codes 59856 and 65273 on the inpatient list because the descriptors of these codes indicate hospitalization is included in these codes. We also agree with the proposal to remove code 62160 from the inpatient list because it is an add-on code to procedures that are separately payable under the OPPS.

XII-C. Ancillary Outpatient Services When Patient Expires (70FR62747)

Based on CMS' review of claims where modifier -CA was reported, it would seem that there may be some confusion regarding the correct use of this modifier. We recommend that CMS issue clarification explaining the limited circumstances in which this modifier should be used.


We appreciate the opportunity to comment on the proposed modifications to the Hospital OPPS. If AHIMA can provide any further information, or if there are any questions or concerns with regard to this letter and its recommendations, please contact either Sue Bowman, RHIA, CCS, AHIMA's director of coding policy and compliance at (312) 233-1115 or, or myself at (202) 659-9440 or


Dan Rode, MBA, FHFMA
Vice President, Policy and Government Relations

cc. Sue Bowman, RHIA, CCS