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2010 OPPS, ASC Policy and Payment Changes

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  • July 2, 2009
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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.

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.

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No Responses to “2010 OPPS, ASC Policy and Payment Changes”

  1. krista howell says:

    please simply define the new proposed medicare guidelines for “physician Supervison” in Cardiac Rehab phase 2. The program I work in may be closing due to administation reads the new law stating the physician must be in the direct room while the patients exercise. I have heard the physician can be 250 yards away and assessable?? this is mind boggling that Medicare guidelines would want to illiminate a program that promotes healthy living.
    Krista Howell