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Hospital Outpatient Prospective Payment System

CMS published their update of the Hospital Outpatient Prospective Payment System (OPPS) with a summary of changes cover 17 topics in Transmittal 4204, Change Request 11099 dated January 17, 2019.

The changes impact policies for the integrated outpatient code editor (I/OCE), updates with various Healthcare Common Procedure Coding System (HCPCS) codes, HCPCS modifiers, Ambulatory Payment Classifications (APCs), revenue codes, and cover a multitude of additions, revisions, and deletions of this data.

One example which providers were apprised of is Modifier “ER” and the details are as follows:

Modifier “ER” Effective January 1, 2019, hospitals will be required to report new HCPCS modifier “ER” (Items and services furnished by a provider-based off-campus emergency department) with every claim line for outpatient hospital services furnished in an off-campus provider-based emergency department.

Modifier ER would be reported on the UB–04 form (CMS Form 1450) for hospital outpatient services. Critical Access Hospitals (CAHs) would not be required to report this modifier. Modifier ER is required to be reported in provider-based off-campus emergency departments that meet the definition of a “dedicated emergency department” as defined in 42 Code of Federal Regulations (CFR) 489.24 under the Emergency Medical Treatment and Labor Act (EMTALA) regulations. Per 42 CFR 489.24, a “dedicated emergency department” means any department or facility of the hospital, regardless of whether it is located on or off the main hospital campus, that meets at least one of the following requirements:

(1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department;

(2) It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or

(3) During the calendar year immediately preceding the calendar year in which a determination under 42 CFR 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.

In light of this policy change we are creating a new section 20.6.18 of chapter 4 of the Medicare Claims Processing Manual.