Misprint in Beneficiary Copayment Amount for Hospital Clinic Visits


CMS has reportedly erred in publishing a 40 percent beneficiary copayment amount for hospital outpatient clinic visits beginning in CY 2014.  According to information provided by CMS to one of our clients, the beneficiary copayment will be 20 percent of the clinic visit payment rate.

Under a new rule adopted in the Hospital Outpatient Prospective Payment System (OPPS) Final Rule for CY 2014 (Final Rule), which was published in the December 10, 2013 Federal Register, CMS collapsed the existing 5 levels of visit codes for hospital outpatient clinic visits into a single new HCPCS G‑code (G0463).  Beginning January 1, 2014, evaluation and management services for all hospital outpatient clinic visits for all patients, whether new or established, will be billed under this new code.  The new code is assigned to newly created APC 0634, “Hospital Clinic Visits,” which establishes a single payment level for all clinic visits. 

Under the Social Security Act, the national unadjusted (i.e., non-wage-adjusted) beneficiary copayment amount for a covered outpatient service paid under the OPPS must be between 20 percent and 40 percent of the APC payment rate.  For the most part, CMS generally sets Part B copayment percentages at 20 percent.  Addendum A to the Final Rule, which can be downloaded from the CMS website, reveals that roughly 11 percent of all APCs have national unadjusted copayment amounts that are higher than the 20 percent statutory minimum; just over 3 percent of APCs have copayments that are higher than 30 percent.

Addendum A sets the national unadjusted copayment amount for APC 0634 at 40 percent of the payment rate, or $37.01.  A client has informed us that CMS has confirmed to them that this copayment amount was an error and will be corrected.  CMS informed our client that the beneficiary copayment for the new APC for hospital clinic visits will be set at 20 percent of the APC payment rate, or $18.51.

Reporter, Susan Banks, Washington, D.C., +1 202 626 2953, sbanks@kslaw.com.

Topics:  Beneficiaries, CMS, Hospitals

Published In: Health Updates, Insurance Updates

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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