2009-11-20
The Center for Medicare and Medicaid Services (CMS) posted the final
rule governing payment policies and rates for the Medicare hospital outpatient
payment system (HOPPS) for calendar year (CY) 2010 on its Web site on Friday, October 30,
2009. Overall, CMS projects that proposed CY 2010 payment rates to the more
than 4,000 hospitals that provide hospital outpatient services to Medicare
beneficiaries under the HOPPS will be $32.2 billion – a $1.9 billion increase
over projected payments in CY 2009.
CMS announced that most hospitals will receive a market basket update of 2.1
percent in their hospital outpatient payment rates. Hospitals that do not successfully
report the quality measures required under the Hospital Outpatient Quality
Data Reporting Program (HOP QDRP) will receive an update in CY 2010 equal to
the annual payment update factor minus 2 percentage points – or 0.1 percent.
This regulation is scheduled to be published in the Federal Register on November
20, 2009. Public comments on the rule are due on December 29, 2009. CMS will
respond to these comments in the CY 2011 HOPPS final rule.
The final
rule is posted on the CMS Web site.
An overview of the Ambulatory Payment Classifications (APC) Payment Rates
for CY 2010, as well as information on hematology related services, drug administration,
and blood products is available. The three charts show the
APC payment rates for codes of interest to hematologists – 1. Procedural Services,
2. Drug Administration, and 3. Blood Products.
Payment Impact on Codes of Interest to Hematology
Payment for the procedural codes, including blood transfusion codes, apheresis
procedures, bone marrow collection, and transplant will increase over and
above the market basket adjustment of 2.1 percent in 2010. Payment for the cell
processing codes and flow cytometry codes is mixed with some increasing and
some decreasing. While the volume of cell processing codes in the outpatient
department is small, the payment rates seem very low relative to data that
had been presented to CMS by ASH several years ago. Since the APC rates are
a direct byproduct of hospital charges, ASH assumes that hospitals are not
appropriately charging for the more costly services such as T-cell and tumor
cell depletion codes.
Payments for the drug administration codes are mixed, but most will increase.
The highest volume drug administration code - IV injection for chemotherapy,
first hour - will see a 17 percent increase.
As in years past, payments for blood products are very volatile with increases
as high as 320 percent and decreases as low as 97 percent. The volatility is
most pronounced in the very low volume services. For the high volume blood
codes (e.g., red blood cell (RBC) leukoreduced, units of RBC’s, RBC leukoreduced irradiated),
the year to year changes in the APC rates are much more stable with changes
from minus 2 percent to plus 3 percent.
Blood Product Payment Policies
A number of comments were offered on the proposed rule regarding the calculation
of APC rates for blood and blood products. These included concerns that payments
for some products were well below the costs incurred by the hospitals and
the wide and seemingly inexplicable fluctuations in payment from year to
year. Some commenters recommended that payment for blood and blood products
be increased by the 3.1 percent increase in the producer price index for
blood and blood products and not rely on the current payment methodology
that utilizes hospital charges adjusted by the hospital's cost to charge
ratio.
CMS is not convinced that any change is needed in the methodology for calculating
APC rates for blood products. In response to comments, CMS provides several
reasons to justify its policy:
- CMS accommodates hospitals that do not have
separate cost centers for blood by using simulated cost to charge ratios.
- The median costs for more than two-thirds of all blood and blood products changed
by less than 10 percent as compared to 2009 payment levels.
- Of the remaining
APCs that experienced changes greater than 10 percent, CMS concluded the changes
were due to the inclusion of additional claims, the addition or removal of
individual hospitals and revised cost report data.
Clearly CMS is not persuaded
that its data is erroneous. To assure that APC rates are more reflective of
costs, hospitals will need to appropriately charge for blood products.
Another comment urged CMS to recognize plasma protein fraction (PPF) products,
including P9042 and P9048, as drugs under HOPPS and be assigned a K status
(non-pass-through drugs and Nonimplanatable biological) as opposed to classifying
them as blood products with an R status. The rationale for the comment is that
PPF is similar to albumin (which is assigned a K status) in that both are blood
derivatives and should be billed with pharmacy revenue codes. CMS notes that
they addressed the issue of whether plasma-derived therapies and their recombinant
analogs should be considered blood products in the 2003 and 2004 final rules.
The decision then was not to consider any plasma derived products including
albumin and immune globulins to fall under the category of blood products since
they are highly processed, not manufactured by local blood banks and do not
have the same safety concerns.
In this final rule, CMS is inviting comments as to whether PPF should be considered
a blood or blood product or a non-pass-through drug and biological. CMS is
asking for information as to how PPF is derived and manufactured, whether the
same access and safety concerns exist that apply to blood products and the
relationship between PPF and albumin from clinical, manufacturing and safety
perspectives to help decide if they should be treated similarly for payment
purposes.
Finally, a comment was offered suggesting that a product called “prepooled
cryoprecipitate” be added to the list of blood products. CMS did not address
this issue directly but noted that there is an existing code for cryoprecipitate
(P9012) and referred the commenter to the process for establishing a new HCPCS
code.
Bone Marrow/Stem Cell Transplant Procedures
In the proposed rule, CMS indicated its belief that allogeneic stem cell transplants
were not performed on an outpatient basis and proposed to assign Codes 38205,
38240 and 38242 to a non-payable status under HOPPS. These codes are defined
as:
- Code 38205, Blood-derived hematopoietic progenitor cell harvesting for
transplantation, per collection.
- Code 38240, Bone-marrow or blood-derived
peripheral stem cell transplantation, allogeneic.
- Code 38242 Bone-marrow
or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte
infusions.
Based on comments received on the proposed rule, including comments from the
APC Advisory Panel, CMS has agreed that allogeneic stem cell transplant procedures
can be safely and appropriately performed on an outpatient basis. However,
CMS does not agree with the commenters nor the APC panel that Code 38205 should
be separately payable since it is not a service furnished directly to a beneficiary.
CMS states that the cost of cell harvesting from a donor should be included
in the payment for the transplant procedure itself and not reimbursed as a
separately payable service. For this reason, CMS is assigning a “B” status
to this code signifying a “bundled” code. CMS goes on to state that hospitals
should report all allogeneic stem cell acquisition charges, including costs
associated with the harvesting procedure, on the recipient’s inpatient or outpatient
transplant bill under revenue code 0819.
Payment for Drugs
CMS is raising the threshold for packaging drugs to $65 from the current level
of $60. Separately paid non-pass-through drugs, including blood clotting
factors, will be paid at the rate of average sales price (ASP) plus 4 percent
while pass though drugs will be paid at the rate of ASP plus 6 percent.
Supervision Requirements for Hospital Outpatient Departments
CMS has finalized the proposed supervision policy requiring that all therapeutic
services performed in a hospital outpatient department must be supervised
by a physician or non-physician practitioner. While CMS argued that this
was not new policy, it generated substantial controversy. In the final rule,
CMS states that services can be supervised by certain non-physician practitioners,
including physician assistants, nurse practitioners, nurse midwives, and
clinical nurse specialists as long as they are authorized to perform such
services under state law and have been granted hospital privileges.
For therapeutic services performed on the main hospital campus, direct supervision
must be provided by a physician or non-physician practitioner. For this purpose,
direct supervision means that the supervising physician or non-physician practitioner
is present on the hospital campus and immediately available to furnish assistance
and direction throughout the performance of the procedure. For services furnished
in an off-campus provider department, the supervising physician or non-physician
practitioner must be present in the off-campus department and immediately available
to furnish assistance and direction throughout the performance of the procedure.
For diagnostic services, the level of supervision required is identical to
the standard (general, direct or personal) that has been established for that
procedure code under the Medicare physician fee schedule. However, while direct
supervision in the physician office setting means that the physician must be
present in the office suite, in the outpatient department, it means that the
supervising physician must be present on the hospital campus where the service
is provided.
Quality Data Reporting Program (QDRP)
For 2010, CMS is maintaining the current QDRP reporting measures that consist
of seven emergency departments and surgical care measures and four imaging efficiency
measures. They are as follows:
Emergency Department and Surgical Care Measures
Median time to fibrinolysis
Fibrinolysis therapy received within 30 minutes
Median time to transfer patient to another facility for coronary intervention
Aspirin at arrival
Median time to ECG
Timing of antibiotic prophylaxis
Prophylactic antibiotic selection for surgical patients
Imaging Measures
MRI for lumbar spine
Mammography follow-up rates
Abdomen CT-Use of contrast material
Thorax CT-Use of contrast material
CMS is initiating a program to validate the accuracy of hospital reporting
of the quality measures by reviewing selected medical records. This will not,
however, initially affect the update for 2011 although it likely will in subsequent
years.
CMS also identified 16 additional measures being considered for CY 2012 payment for which reporting would occur in CY 2011. CMS asked for comments on these
measures in the proposed rule and will propose any new measures in the proposed
fee schedule rule for 2011. These measures are:
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