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The New Year Ushers in Sweeping Changes to OPPS

By Leigh Poland

February 20, 2024

From potentially higher payments to new Comprehensive Ambulatory Payment Classifications (C-APCs), 2024 brings with it significant changes to the Centers for Medicare and Medicaid Services (CMS) Outpatient Prospective Payment System (OPPS). Our webinar takes a deep dive into the OPPS and Medicare Physician Fee Schedule (MPFS) final rules impacting outpatient payments in 2024, and the following highlights will help health information management (HIM) professionals understand the OPPS changes.

  • Conversion Factor – For 2024, the conversion factor is $87.32, an increase of $1.74 over 2023. That means healthcare facilities that participate in the CMS quality reporting program will receive payments that are 3% higher than last year, while non-participating facilities can expect a reduction.
  • Wage Index – While there has been a slight adjustment to the wage index for some rural areas, for the most part adjustments will be managed the same as in previous years, with decreases capped at 5%.
  • New C-APCs – There are two new C-APCs for 2024; C-APC 5342 (Level 1 Abdominal/Peritoneal/Biliary and Related Procedures) and C-APC 5496 (Level 6 Intraocular APC), which allows intraocular procedures to be paid at a higher level.
  • Outlier Payments – The 2024 OPPS outlier payments – designed to help mitigate the financial risk associated with high cost and complex procedures – will be triggered when the cost of a particular service exceeds 1.75 times the APC payment amount when both the multiplier and the fixed dollar threshold of $7,750 are met. That represents a decrease of $875 from the 2023 fixed dollar amount ($8,625), marking the first time the fixed dollar amount declined in several years.
OPPS and MPFS Final Rules A 2024 Road Map

Policy Shifts

The 2024 OPPS also includes several noteworthy policy changes, the first of which is an APC-specific policy pertaining to minimally invasive glaucoma procedures. Specifically, the codes for extra capsular cataract removal with an insertion of an intraocular lens prosthesis and an anterior segment aqueous drainage device have been reassigned to APC 5493. Additionally, the status indicator has been changed from T to J1 and reimbursement increased to $4,985.

Another Category III Code, 0671T (insertion of an anterior segment aqueous drainage device with cataract removal), was reassigned from APC 5491 to APC 5493 and reimbursement was increased significantly from $2,159 to $4,986. The APC for CPT 20982 (ablation therapy for reduction or eradication of one or more bone tumors including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed) was also changed from 5114 to 5115 and reimbursement increased from just over $6,000 to $12,553.

Leadless Pacemakers

Leadless pacemakers – a one-piece device implanted into the heart through a vein – were also the subject of several noteworthy changes in 2024 thanks to recent FDA approvals of AVEIR VR and AVEIR DR that triggered a restructuring of status indicators attaching an ACP value and enabling reimbursement. CPT codes now include:

  • 33274 – insertion of a right ventricular leadless pacemaker, reimbursed at about $18,000 with an APC value of 5224
  • Category III Code 0795T – insertion of a dual chamber leadless pacemaker, also reimbursed at about $18,000 with an APC value of APC 5224

Passthrough Payments

Passthrough payments, which provide an alternate way for facilities to receive payments to cover items or services not included in standard reimbursements, typically relate to new technology devices and require use of the appropriate Healthcare Common Procedure Coding System (HCPCS) code. In 2024, four new devices were granted passthrough status as of Jan. 1, 2024:

  • FLEX Vessel Prep™ (VP) - used in the treatment of in-stent restenosis (ISR) in the peripheral vasculature. for dialysis patients during percutaneous angioplasty to stop restenosis. Use HCPCS C1600 (Catheter, transluminal intravascular lesion preparation device, bladed, sheathed (insertable)).
  • Ambu® aScope™ – a single-use, sterile, disposable, flexible intubation scope used to facilitate the placement of a flexible tube into the trachea to maintain an open airway. Use HCPCS C1601 (Endoscope, single-use (i.e. disposable), pulmonary, imaging/illumination device (insertable)).
  • CERAMENT® G – an injectable synthetic bone void filler. Use HCPCS C1602 (Orthopedic/device/drug matrix/absorbable bone void filler, antimicrobial-eluting (implantable)).

The passthrough packaging threshold for drugs remains $135 for 2024, meaning if the cost per day for that medication based on the Average Sales Price (ASP) exceeds $135 it will be paid separately. If the cost is below $135, it will be packaged into the ASP payment.

Finally, synthetic skin substitutes assigned to A2XXX Codes are now automatically assigned to the high-cost skins to group – even if cost and pricing data are not available for any individual product.

Resources

CMS offers several resources to support HIM professionals in getting up to speed on the OPPS changes for 2024, including a fact sheet and a complete list of HCPCS codes. Additionally, AGS Health’s webinar, OPPS and MPFS Final Rules: A 2024 Road Map, takes an in-depth look at the 2024 OPPS and MPFS final rule and what they mean for hospitals and health systems’ medical coding and billing teams and overall revenues.

Leigh Poland

Leigh Poland RHIA, CCS

Author

Leigh has over 20 years of coding experience and has worked in the coding and education realm over the last 20 years. Her true passion is coding education making sure coders are equipped to do their job accurately and with excellence. Academically, Leigh has graduated from Louisiana Tech University with a Bachelor of Science. Leigh has had the opportunity to present many times in the past at the AHIMA, ACDIS, and AAPC National Conventions. She has been a guest speaker on AHIMA webinars and has written several articles that were published in the AHIMA Journal. Leigh has traveled the US and internationally providing coding education.