A Four-Step Checklist for OPPS Compliance

By Megan N. Beasley, RHIA, Rick V. Clark, CPC, and Daniel G. Gautschi
| 3/22/2016
Healthcare compliance
A polling question at a recent Crowe webinar about the calendar year 2016 Centers for Medicare & Medicaid Services (CMS) outpatient prospective payment system (OPPS) showed that 76 percent of survey respondents’ organizations have a specific process and dedicated resources for implementing the required OPPS changes that occur annually and quarterly. That is good news. Changes in the OPPS rule can have a significant impact on an organization’s Medicare reimbursements and reimbursements from payers that follow Medicare guidelines.

Organizations that do not have an established process for implementing the changes to the OPPS can use the following checklist to get started. Even those organizations that already have a process for implementing the OPPS changes can use this checklist to help streamline their activities.
  1. Analyze the current charge description master (CDM) to understand needed revisions in coding, charge structure, and pricing.

    Know your organization’s use of items and service lines within the CDM and how changes in the OPPS guidelines will affect these items and service lines.

    Focus first on analyzing how the changes will affect your highest-revenue-producing areas – the areas that will have the greatest impact on your organization’s bottom line when the OPPS changes are put into place.

    One of the biggest changes in the most recent OPPS rule was moving observation reimbursement to a comprehensive ambulatory payment classification (C-APC). Assess where and how often your organization uses observation services as well as the implications of that use for your organization in terms of reimbursements with the OPPS changes.

    Focus also on making sure that the current procedural terminology (CPT) codes that will be deleted as a result of the American Medical Association's annual changes are removed from the CDM in a timely manner. Failure to remove these codes can cause a ripple effect throughout the billing function. Billing with codes that are no longer in use will incur denials and require the need to re-bill using the new, replacement CPT codes. Re-billing is an inefficient use of staff time and resources.
  2. Inventory the specific charge capture subsystems that need to be updated.

    After you have analyzed the CDM and assessed how the annual changes will affect your organization, inventory the charge capture subsystems to determine which ones will need to be revised. Once the subsystems have been updated, test several scenarios that include the revisions to make sure that the changes made to the CDM flow correctly through the charge capture subsystems of individual departments.

    In the most recent OPPS update, many radiology tests, for example, have been bundled into surgical procedures. Providers will need to make sure they do not continue to charge separately for these radiology procedures.

    In addition, if your organization uses paper charge tickets, review these to determine which services need to be updated and which codes need to be removed.
  3. Educate the appropriate department staff on all applicable changes to the charge master and charge capture systems.

    Because clinical staff members are not involved in the behind-the-scenes information technology aspects of the CDM, they will need to be familiar with how the changes will affect their day-to-day operations and work flow, including the services that they will and will not be able to bill for as a result of the changes.

    For example, prior to 2016, CPT code 47510 would have been reported for a percutaneous placement of a biliary drainage catheter, and CPT code 75980 would have been reported for the radiological supervision and interpretation portion of the procedure. In 2016, both CPT code 47510 and CPT code 75980 have been deleted, and only CPT code 47533 should be reported for both the surgical procedure and the radiological component.1

    Staff members with a thorough understanding of the changes and their impact on the organization should provide the associated education. These staff members likely will be individuals from your organization’s revenue integrity and revenue cycle teams – the individuals who analyze the CDM and update the charge capture system.

    Some of the changes will involve only a relatively simple modification, such as the replacement of one code with another. Other more extensive changes will involve the nuanced use of several different codes.

    For example, prior to 2016, CPT code 73520 would have been reported for a bilateral X-ray of the hip with a minimum of two views of each hip (including an anteroposterior view of the pelvis). Now, in 2016, CPT code 73520 has been deleted and three new CPT codes have been created to distinguish between total views. CPT code 73521 should be reported for two views, CPT code 73522 should be reported for three or four views, and CPT code 73523 should be reported for five or more views of the hips.2

    It is also important to have a plan in place to educate new staff members as they join the organization. This frequently overlooked education for newcomers can prevent the time- and resource-draining need for a case-by-case review of inappropriate charges and denials. This education should be facilitated by the clinical departments, with oversight from the revenue integrity and revenue cycle teams.
  4. Verify accuracy and completeness once all changes to the CDM and charge capture system are implemented.

    Make sure payers are aware of and prepared for the changes, and test all of your system changes to make sure they are being seen appropriately on claims and accepted by payers. Follow accounts through to payment to ensure your organization is being accurately reimbursed according to the new OPPS guidance.

    The changes related to observation in particular will affect several departments within the hospital because observation patients are likely to receive care in various locations. Spot-check at least quarterly to verify that the new reimbursement guidelines for observation are being used correctly, regardless of the patient’s location.

Consider establishing a performance-monitoring metric to document and report on the implemented changes. Go through this checklist in January, April, July, and October. Although most of the changes to the OPPS are effective Jan. 1, typically, minor changes also go into effect each quarter.

Finally, take a proactive approach by looking for the proposed OPPS changes issued each July and submitting comments on provisions that could potentially affect your facility.

Following these basic steps will help your organization protect its reimbursement dollars.


1 “CPT® 2016 Professional Edition,” American Medical Association, 2016.
2 Ibid. 

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Megan Beasley
Rick Clark
Daniel Gautschi
Principal, Healthcare Consulting Leader