CMS Delays OPPS Claim Edits For Off-Campus Provider-Based Depts

Outpatient Medicare ClaimsOPPS claim edits slated to take effect this month will now start in October to give providers more take to adjust to billing changes for off-campus provider-based departments.

CMS is postponing the implementation of outpatient prospective payment system (OPPS) claim edits that would require hospitals and health systems with multiple locations to list provider addresses on outpatient medicare claims for services delivered in off-campus provider-based departments.

The announcement came June 28, 2019, in an update to Medicare Learning Network (MLN) Matters article.

“Based on stake-holder comments and to allow additional time to review the round 3 testing, however, CMS has decided to postpone full production implementation for three additional months until October 2019,” CMS wrote in the updated article.

CMS anticipated implementing the OPPS claim edits this month.

The upcoming implementation of the OPPS claim edits stem from Section 603 of the Bipartisan Budget Act of 2015, which required CMS to implement site-neutral payments for outpatient services furnished at new off-campus provider-based departments.

Specifically, the law called on CMS to identify non-excepted items and services provided at off-campus provider-based departments that would be paid under the Medicare Physician Fee Schedule starting January 1, 2017 instead of the OPPS rate.

To further ensure accurate Medicare reimbursement for the site-neutral payment policy, the law also directed Medicare systems to validate the off-campus provider-based department’s service facility location on each claim. The location must exactly match the information on Form CMS-855A, which is submitted by the provider, and be entered into the Provider Enrollment, Chain and Ownership System (PECOS).

The location must be an exact match to the data in the hospital or health system’s provider enrollment information or Medicare Administrative Contractors will return the claim to providers and eventually deny reimbursement, law firm Bricker & Eckler reported in a March 2019.

“Exact means exact,” attorneys Shannon K. DeBra, David M. Johnston, Claire Turcotte emphasized.

“So, not only must every off-campus HOPD location where your hospital provides services satisfy the provider-based requirements, be listed as a practice location on the hospital’s 855A, and be included in the hospital’s PECOS enrollment file, but there also must be an exact match between how the address is listed in PECOS and the service facility location shown on the claims submitted to Medicare,” they added.

CMS originally planned to implement the OPPS claim edits in April 2019. However, the federal agency delayed implementation after completing several rounds of testing and finding providers needed more time to adjust to the upcoming changes.

“This national test brought to light that many providers are not sending the correct exact service facility location on the claim that produces an exact match with the Medicare enrolled location as based on the information entered into the PECOS for their off-campus provider departments,” CMS wrote in the updated MLN Matters article.

The majority of discrepancies came from spelling variations, the agency added. For example, providers put “Rd” or “Rd.” on outpatient Medicare claims even though PECOS has the word entered as “Road.” A similar situation occurred with the word “Suite.”

CMS eventually allowed providers to see the practice location screen and gave them an additional quarter review data. The practice location screen allowed providers to query and validate addresses of off-campus provider-based departments as they are listed in PECOS.

Since then, the agency has completed round 3 testing and determined that providers still need more time to review their practice location addresses.

In the most recent update to the MLN Matters article, CMS advised providers to make corrections to their service facility address on outpatient Medicare claims. The agency stated that providers who need to add a new or correct an existing practice location address will need to submit a new 855A enrollment application in PECOS.

Neglecting to add or correct addresses, particularly for off-campus provider-based departments, will result in outpatient Medicare claims being returned by October 1, the agency stressed.

“CMS expects that the 2½ year time frame that the edits have not been active have provided ample time for providers to validate their claims submission system and the PECOS information for their off-campus provider departments are exact matches,” the MLN Matters article stated.

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