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CMS Proposes 2007 Outpatient Payment Rates

Under a proposed rule for 2007 Medicare payments for hospital outpatient services released this week by the Centers for Medicare and Medicaid Services (CMS), reimbursement for many blood products and services would continue to lag behind actual costs, despite some proposed payment increases. In general, the agency has proposed modest payment increases for most frequently transfused blood products, but notable payment cuts for other less frequently transfused products.

For calendar year (CY) 2007, CMS has proposed payments for blood and blood products based on simulated medians calculated using CY 2005 hospital claims data. For example, CMS proposes to pay $176.89 for a unit of leukocyte-reduced red blood cells (RBCs), compared with its $163.33 payment in 2006. The actual average hospital acquisition cost for a unit of leukocyte-reduced RBCs is significantly higher than CMS’ proposed 2007 payment. The following table compares the proposed 2007 payment rates for blood products with current Medicare payment rates.

Payments for Blood Components

HCPCS
Description
2006
Final
Payment
2007
Proposed
Payment
% Change
P9010
Whole blood for transfusion
$118.04
$134.33
14%
P9011
Blood split unit
$82.59
$135.95
65%
P9012
Cryoprecipitate each unit
$47.15
$52.76
12%
P9016
RBC leukocytes reduced
$163.33
$176.89
8%
P9017
Plasma 1 donor frozen w/in 8 hr
$70.47
$71.87
2%
P9019
Platelets, each unit
$51.55
$60.28
17%
P9020
Platelet rich plasma unit
$277.73
$155.95
-44%
P9021
Red blood cells unit
$121.61
$129.53
7%
P9022
Washed red blood cells unit
$189.42
$215.60
14%
P9023
Frozen plasma, pooled, sd
$76.23
$55.77
-27%
P9031
Platelets leukocytes reduced
$98.41
$94.28
-4%
P9032
Platelets, irradiated
$86.64
$128.99
49%
P9033
Platelets leukoreduced irrad
$150.74
$130.44
-13%
P9034
Platelets, pheresis
$434.48
$463.98
7%
P9035
Platelet pheres leukoreduced
$493.66
$488.80
-1%
P9036
Platelet pheresis irradiated
$326.22
$412.14
26%
P9037
Platelet pheresis leukoreduced, irrad
$581.64
$614.53
6%
P9038
RBC irradiated
$147.63
$200.66
36%
P9039
RBC deglycerolized
$343.81
$351.49
2%
P9040
RBC leukoreduced irradiated
$218.27
$227.97
4%
P9041
Albumin (human), 5%, 50ml
$29.68
$25.48
-14%
P9043
Plasma protein fract, 5%, 50ml
$68.02
$24.72
-64%
P9044
Cryoprecipitate reduced plasma
$74.60
$79.95
7%
P9045
Albumin (human), 5%, 250 ml
$76.81
$72.09
-6%
P9046
Albumin (human), 25%, 20 ml
$28.80
$26.79
-7%
P9047
Albumin (human), 25%, 50ml
$65.26
$61.77
-5%
P9048
Plasmaprotein fract,5%,250ml
$316.05
$192.71
-39%
P9050
Granulocytes, pheresis unit
$995.72
$252.54
-75%
P9051
Blood, l/r, cmv-neg
$207.95
$135.36
-35%
P9052
Platelets, hla-m, l/r, unit
$610.14
$646.80
6%
P9053
Plt, pher, l/r cmv-neg, irr
$654.84
$720.30
10%
P9054
Blood, l/r, froz/degly/wash
$262.21
$89.02
-66%
P9055
Plt, aph/pher, l/r, cmv-neg
$526.57
$378.59
-28%
P9056
Blood, l/r, irradiated
$178.56
$133.97
-25%
P9057
RBC, frz/deg/wsh, l/r, irrad
$345.91
$425.87
23%
P9058
RBC, l/r, cmv-neg, irrad
$267.18
$263.55
-1%
P9059
Plasma, frozen between 8-24hr
$74.78
$73.02
-2%
P9060
Fresh frozen plasma donor retested
$94.82
$73.34
-23%


CMS has also proposed increasing the payment for APC 0112, which covers apheresis, photopheresis and plasmapheresis, from $1569.60 in 2006 to $1887.17 in 2007. However, the agency would modestly decrease payments for bone marrow harvesting and bone marrow/stem cell transplant (APC 0123), transfusion (APC 0110), and blood product exchange (APC 0111), as indicated in the following table.

Procedure Payments

APC
Product/Service
2006
Final
Payment
2007
Proposed
Payment
% Change
0110
Transfusion
$216.73
$212.78
-1.8%
0111
Blood Product Exchange
$718.70
$720.18
0.2%
0112
Apheresis, Photopheresis, and Plasmapheresis
$1569.60
$1887.17
20.2%
0123
Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant
$1456.95
$1431.00
-1.8%


Overall, the rule includes a 3.4% inflation update in Medicare payment rates for services paid under the outpatient prospective payment system for 2007. However, for the first time the agency proposes to tie the outpatient payment rate update to the reporting of inpatient quality measures. Hospitals that are required to report quality measures for inpatient services in order to receive the full inpatient prospective payment system (PPS) update but fail to do so would receive the outpatient PPS update minus 2.0 percentage points.

AABB will submit comments to CMS regarding the proposed rule and testify later this month before the agency’s Advisory Panel on Ambulatory Payment Classification (APC) Groups. The proposed rule can be found at http://www.cms.hhs.gov/HospitalOutpatientPPS/Downloads/CMS1506P.pdf and will be posted in the August 23 Federal Register.