The Centers for Medicare & Medicaid Services (CMS) wants to collapse the current five-level hierarchy of hospital outpatient visit codes to just one level for each type of visit, according to a proposed rule [CMS-1601-P] filed this week. The proposal would include a single HCPCS (Healthcare Common Procedure Coding System) code for each unique clinic visit and one for each emergency department visit.
Pitched as “streamlining” to promote efficiency, the proposed payment system would “allow a large universe of claims to be utilized for rate setting” while reducing provider temptations to provide medically unnecessary procedures, CMS noted in a fact sheet.
It’s no secret that the measure also would remove opportunities for upcoding—a longstanding problem amid CMS’ efforts to reduce fraud. On May 13, the Medicare Fraud Strike Force conducted its largest multi-state sting operation to date, charging 89 people responsible for a total of $223 million in false billings, many of them involving occupational and physical therapy or home healthcare services
As the Hospital Outpatient Prospective Payment System and the Ambulatory Surgical Center Payment System continue to move away from fee-for-service models, CMS also is proposing several new “packages” of services/items to be bundled with primary services, including introducing 29 new comprehensive Ambulatory Payment Classifications.