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2011 OPPS/ASC Final Rule Raises Rates

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  • November 12, 2010
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A final rule with comment period went on display Nov. 2 in the Federal Register, updating 2011 payment policies and rates for both hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs). The final rule with comment period also implements several health care reform provisions and provides the Centers for Medicare & Medicaid Services (CMS) the opportunity to institute several other changes to Medicare policy.

Year 2011 payment rates for HOPDs will increase 2.35 percent, based on the 2.6 percent market basket update and the 0.25 percentage reduction mandated by the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (together, the Affordable Care Act). ASC payment rates will increase by 0.2 percent, based on a 1.5 percent conversion factor less a 1.3 percent productivity adjustment, also mandated by the Affordable Care Act.

Quality Measures to Report

While ASCs still are not required to report quality measures, the final rule with comment period increases the transparency of the Hospital Outpatient Quality Data Reporting Program (HOP QDRP).
HOPDs will be required to report four additional quality measures to the current list of 11 measures to be reported for the 2012 payment determination. These new measures include one structural health information technology (HIT) measure and three claims-based imaging efficiency measures.
HOPDs will have to report on another eight new measures (for a total of 23 measures) for the 2013 and 2014 payment determinations. Of these new measures, one is a structural measure on use of electronic health records (EHRs), and six are chart-abstracted measures of timeliness and appropriate care in the emergency department.
The complete list of existing and future measures for reporting in 2012 through 2014 is attached to the final rule as an appendix.

ASC Coding Changes

ASCs will have an additional six surgical procedures for which Medicare will pay in 2011. Two procedures will be newly designated as office-based procedures (subject to payment lesser of the amount paid under the Medicare Physician Fee Schedule (MPFS) practice expenses for providing the same procedure in an office or the payment amount under the standard ASC rate-setting methodology). The list of covered ancillary services also will be updated to reflect the OPPS update.

Other Significant Changes

The 2011 OPPS/ASC final rule with comment period will make several other significant changes in addition to those required by the Affordable Care Act. These changes include:

  • Modifying a number of the supervision requirements for outpatient therapeutic services by:
    • Requiring direct physician supervision for only the initiation of certain services and allowing general supervision once the treating practitioner deems the patient medically stable. This two-tiered approach to supervision applies to a limited set of non-surgical extended duration services, including observation services.
    • Extending through 2011 the notice of non-enforcement regarding the direct supervision requirements for outpatient therapeutic services furnished in critical access hospitals (CAHs) and expanding the scope of the notice to include small rural hospitals with 100 or fewer beds.
    • Redefining direct supervision for all hospital outpatient services to require “immediate availability” without reference to the boundaries of a physical location.
  • Establishing four separate ambulatory payment classifications (APCs) for partial hospitalization programs (PHPs), two for community mental health center (CMHC) PHPs and two for hospital-based PHPs, while continuing to pay different per diem rates within each provider type depending on the number of PHP services provided each day; that is, one APC for three services and a separate one for four or more services.
  • Paying for the acquisition and pharmacy overhead costs of separately payable drugs and biologicals without pass-through status furnished in HOPDs at 105 percent of the manufacturers’ average sales prices.

The 2011 OPPS/ASC final rule with comment period will appear in the Nov. 24, 2010 Federal Register. Comments on designated provisions are due by 5 p.m. EST Jan. 3, 2011. CMS will respond to comments in the 2012 OPPS/ASC final rule.

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