2010 OPPS, ASC Policy and Payment Changes
The Centers for Medicare & Medicaid Services (CMS) proposed, July 1, several policy and payment rate changes for hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) for fiscal year 2010. Payment rate increases for providers paid under the Outpatient Prospective Payment System (OPPS) and expanded coverage for certain Medicare services furnished in HOPDs and ASCs are projected in the 2010 proposed rule.
Proposed Payment Updates
Proposed 2010 payment rates under the OPPS include a 1.9 percent increase in Medicare payment for providers paid under the OPPS.
CMS projects a full market basket conversion factor of $67.439, or $66.118 for hospitals that fail to meet Hospital Outpatient Quality Data Reporting Program (HOP QDRP) requirements, based on a proposed market basket increase update factor of 2.1 percent and a 0.01 percent adjustment for projected OPPS spending.
Surgically implantable biologicals not currently receiving pass-through payment are being considered for pass-through payment status using the device pass-through process rather than the drug and biological pass-through process. Also under consideration is beginning the two- to three-year pass-through payment eligibility period for a new drug or nonimplantable biological on the date of the first sale in the United States, rather than on the same date payment is made.
Policy changes mandated by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) would allow HOPDs to bill Medicare for pulmonary and intensive cardiac rehabilitative services, as well as for kidney disease education services for Medicare patients with stage IV chronic kidney disease.
Providers would receive payment for separately payable therapeutic radiopharmaceuticals at the average sales price (ASP) plus 4 percent. Without ASP information, however, payment would be based on mean unit costs from hospital claims data.
Brachytherapy sources would be paid based on median unit costs, as calculated from claims data, according to the standard OPPS rate-setting methodology.
Quality Incentive Provisions
CMS is not proposing any new measures for the HOP QDRP 2011 update, but is seeking input for future measures.
As noted above, hospitals that do not participate or successfully report the existing seven chart-abstracted emergency department and preoperative measures and four existing claims-based imaging efficiency measures would receive a reduction of 0.1 percent (2.0 percentage points) to the projected payment update.
According to CMS, this reduction would not apply to payments for separately payable pass-through drugs and biologicals and devices, non-pass-through drugs and non-implantable biologicals, therapeutic radiopharmaceuticals, and services assigned to new technology ambulatory payment classifications (APCs).
New Policy Provisions
Also in the proposed rule, CMS would loosen control on one policy and tighten control on another.
Physician assistants, nurse practioners, certified nurse specialists, and certified nurse-midwives would be allowed to directly supervise all hospital outpatient therapeutic services within state and facility guidelines.
The term “direct supervision,” however, would be redefined to remove the disparity between sites, stipulating that supervising physicians must be “available to furnish assistance and direction throughout the performance of the procedure,” whether the services are provided in a hospital or an on- or off-campus provider-based department of a hospital.
ASC Payment Update
For the first time since ASC payment rates were calculated under the standard rate-setting methodology, CMS is projecting a percentage increase in the Consumer Price Index that would update the conversion factor to 0.6 percent.
ASCs can expect to see 28 additional surgical procedures, including coverage for two new CPT® codes, each with a proposed 2010 ASC payment indicator of G2.
TABLE 41. PROPOSED NEW ASC COVERED SURGICAL PROCEDURES FOR CY 2010
2009 HCPCS Code 2009 Short Descriptor
26037 Decompress fingers/hand
27475 Surgery to stop leg growth
27479 Surgery to stop leg growth
27720 Repair of tibia
35460 Repair venous blockage
35475 Repair arterial blockage
41512 Tongue suspension
42225 Reconstruct cleft palate
42227 Lengthening of palate
43130 Removal of esophagus pouch
43752 Nasal/orogastric w/stent
45541 Correct rectal prolapse
49435 Insert subq exten to ip cath
49436 Embedded ip cath exit-site
49442 Place cecostomy tube perc
50080 Removal of kidney stone
50081 Removal of kidney stone
50727 Revise ureter
51535 Repair of ureter lesion
57295 Revise vag graft via vagina
60210 Partial thyroid excision
60212 Partial thyroid excision
60220 Partial removal of thyroid
60225 Partial removal of thyroid
61770 Incise skull for treatment
0193T Rf bladder neck microremodel
0200T* Perq sacral augmt unilat inj
0201T* Perq sacral augmt bilat inj
(*Indicates new code, effective July 1)
HCPCS Level II codes G0392 AV fistula or graft arterial and G0393 AV fistula or graft venous would be deleted as of Oct. 1.
The proposed rule would also designate six procedures (Table 43, page 509) performed in the ASC as office-based (subject to payment at the lesser of the national office practice expense payment to the physician or the national standard ASC rate) and update the list of device-intensive procedures and covered ancillary services and their rates (Table 46, page 514).
ASC Quality Reporting Update
CMS is proposing to use the following HOP QDRP measures for the 2011 payment determination:
OP-1: Median Time to Fibrinolysis
OP-2: Fibrinolytic Therapy Received Within 30 Minutes
OP-3: Median Time to Transfer to Another Facility for Acute Coronary Intervention
OP-4: Aspirin at Arrival
OP-5: Median Time to ECG
OP-6: Timing of Antibiotic Prophylaxis
OP-7: Prophylactic Antibiotic Selection for Surgical Patients
OP-8: MRI Lumbar Spine for Low Back Pain
OP-9: Mammography Follow-up Rates
OP-10: Abdomen CT – Use of Contrast Material
OP-11: Thorax CT – Use of Contrast Material
Stay tuned to EdgeBlast and Coding Edge for further details on this proposed rule for 2010 OPPS/ASC payment and policy changes.