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CMS Publishes 2008 Hospital Outpatient Prospective Payment System Rule

On November 1, 2007, the Centers for Medicare and Medicaid Services (CMS) published the final Hospital Outpatient Prospective Payment System (HOPPS) rule for 2008. The rule includes modest payment increases for most blood products and more significant changes in the way CMS pays for stem cell processing.

Bone Marrow and Stem Cell Processing

After several years of effort on the part of AABB, the American Society for Hematology (ASH), and others, CMS will recognize the bone marrow/stem cell laboratory processing codes. In addition, payments for these services have increased substantially from the levels published in the proposed rule (see attached Table 1). These codes are:

38207     Cryopreserve stem cells
38208     Thaw preserved stem cells
38209     Wash harvest stem cells
38210     T-cell depletion of harvest
38211     Tumor cell deplete of harvest
38212     Rbc depletion of harvest
38213     Platelet deplete of harvest
38214     Volume deplete of harvest
38215     Harvest stem cell concentrate

CPT Codes 38207-38209, which represent freezing, storing and thawing bone marrow/stem cells prior to transplant, have been assigned to APC 0110 with a payment of $216. Although AABB believes this payment is significantly lower than actual costs, it is notably greater than the $52.00 payment CMS initially proposed for these services.

CMS will also pay more for CPT Codes 38210-38215, which represent various bone marrow/stem cell depletion codes, than originally proposed. These codes now have been assigned to APC 393, paying $362.55.

AABB had also requested that the T-cell and tumor cell depletion codes (38210 and 38211) be placed in a separate higher paying APC and provided survey data to demonstrate the costs of these services. In the discussion of this issue in the final rule CMS explained that it assigned all of the depletion codes to a single APC because there were no actual claims data for these services. CMS plans to revisit the APC placement for the individual codes once claims data become available. It is critical that providers bill using the new bone marrow and stem cell processing codes so that CMS can obtain accurate cost-data to adjust payments in future years.

Payments for Blood Products

As reflected in Table 2, the final payment rates for 19 of the 34 blood and blood product APCs will be increasing in 2008. The 19 APCs increasing in payment are generally the higher volume products, which CMS estimates represent 77 percent of the total units billed to Medicare. For 2008, CMS will continue to use a special methodology to set payment rates for blood products at the unadjusted median cost calculated using a specific simulated blood cost-to-charge ratio for each hospital that does not have a blood cost center.

Blood Transfusions

CMS will continue its current policy requiring a single unit of CPT code 36430 (Transfusion, blood or blood components) to be reported regardless of how many transfusions occur on a single date of service. (The blood product itself is paid based on the actual number of units provided.) The APC Advisory Committee had recommended to CMS at its March 2007 meeting that CMS identify when multiple units of blood or blood components are transfused and to trigger an additional discounted payment for the second and subsequent blood administration services on a single date of service. In the rule, CMS rejects the Advisory Committee recommendation, but reminds hospitals that in billing code 36430, hospitals should include charges for the totality of all transfusion services provided on a single date of service.

Payment for Part B Drugs and Blood Clotting Factors

CMS will reduce the payment for drugs paid for under HOPPS from 106 to 105 percent of Average Sales Price (ASP). In reviewing actual cost data on separately paid drugs, including blood clotting factor, CMS found that at the rate of ASP + 6 percent hospitals were being overpaid. For 2008, CMS will be reducing the payment rate to ASP + 5 percent. Further reductions are likely in future years perhaps to the level of ASP +3 percent, which CMS feels is justified based on current cost data.

Clotting Factor - CMS will be increasing the administration fee for furnishing blood clotting factor by 4 percent to $0.158 per unit.

IVIG - CMS is continuing to pay for IVIG preadmission services (G0332) at a rate of $37.71 for 2008. CMS indicates it will consider the continued need for separate payment for IVIG preadmission services for 2009, including the possibility of packaging this service in the future.

Update and Hospital Impact

For 2008, the overall inflationary update in the outpatient payment rates will be 3.3 percent. Due to other policy changes being made by the rule the average increase in outpatient payments for hospitals will be 3.8 percent, with urban hospitals seeing a slightly larger increase than rural hospitals. Teaching hospitals will see an average increase of about 3.8 percent.

2008 Hospital Outpatient Prospective Payment System (HOPPS) Regulations (CMS-1392-FC)

Table 1, Procedural Codes

CPT/
HCPCS
Description
2007
Final
APC
2008
Final
APC
2007
Final
Payment
Rate
2008
Final
Payment
Rate
$Change
%Change
36430
Blood transfusion service
0110
0110
$212.58
$216.35
$3.77
1.77%
36440
Bl push transfuse, 2 yr or <
0110
0110
$212.58
$216.35
$3.77
1.77%
36450
Bl exchange/transfuse, nb
0110
0110
$212.58
$216.35
$3.77
1.77%
36455
Bl exchange/transfuse non-nb
0110
0110
$212.58
$216.35
$3.77
1.77%
36511
Apheresis wbc
0111
0111
$720.00
$732.85
$12.85
1.78%
36512
Apheresis rbc
0111
0111
$720.00
$732.85
$12.85
1.78%
36513
Apheresis platelets
0111
0111
$720.00
$732.85
$12.85
1.78%
36514
Apheresis plasma
0111
0111
$720.00
$732.85
$12.85
1.78%
36515
Apheresis, adsorp/reinfuse
0112
0112
$1,857.75
$1,949.26
$91.51
4.93%
36516
Apheresis, selective
0112
0112
$1,857.75
$1,949.26
$91.51
4.93%
36522
Photopheresis
0112
0112
$1,857.75
$1,949.26
$91.51
4.93%
38205
Harvest allogenic stem cells
0111
0111
$720.00
$732.85
$12.85
1.78%
38206
Harvest auto stem cells
0111
0111
$720.00
$732.85
$12.85
1.78%
38207
Cryopreserve stem cells
--
0110
Code(s) Not
Recognized by
Medicare
$216.35
N/A
N/A
38208
Thaw preserved stem cells
--
0110
$216.35
N/A
N/A
38209
Wash harvest stem cells
--
0110
$216.35
N/A
N/A
38210
T-cell depletion of harvest
--
0393
$362.55
N/A
N/A
38211
Tumor cell deplete of harvst
--
0393
$362.55
N/A
N/A
38212
Rbc depletion of harvest
--
0393
$362.55
N/A
N/A
38213
Platelet deplete of harvest
--
0393
$362.55
N/A
N/A
38214
Volume deplete of harvest
--
0393
$362.55
N/A
N/A
38215
Harvest stem cell concentrte
--
0393
$362.55
N/A
N/A
38220
Bone marrow aspiration
0003
0003
$147.59
$197.50
$49.91
33.82%
38221
Bone marrow biopsy
0003
0003
$147.59
$197.50
$49.91
33.82%
38230
Bone marrow collection
0123
0112
$1,251.38
$1,949.26
$697.88
55.77%
38240
Bone marrow/stem transplant
0123
0112
$1,251.38
$1,949.26
$697.88
55.77%
38241
Bone marrow/stem transplant
0123
0112
$1,251.38
$1,949.26
$697.88
55.77%
38242
Lymphocyte infuse transplant
0111
0111
$720.00
$732.85
$12.85
1.78%
88184
Flowcytometry/ tc, 1 marker
0433
0433
$15.72
$15.27
-$0.45
-2.86%
88185
Flowcytometry/tc, add-on
0433
0433
$15.72
$15.27
-$0.45
-2.86%
88187
Flowcytometry/read, 2-8
0433
0433
$15.72
$15.27
-$0.45
-2.86%
88188
Flowcytometry/read, 9-15
0433
0433
$15.72
$15.27
-$0.45
-2.86%
88189
Flowcytometry/read, 16 & >
0343
0343
$32.03
$32.75
$0.72
2.25%
99363
Anticoag mgmt, init
Code Not Recognized By OPPS
99364
Anticoag mgmt, subseq
Code Not Recognized By OPPS
G0364
Bone marrow aspirate &biopsy
0002
0002
$67.58
$70.68
$3.10
4.59%
G0267
Bone marrow or psc harvest
0110
--
$212.58
--
N/A
N/A

2008 Hospital Outpatient Prospective Payment System (HOPPS) Regulations (CMS-1392-FC)

Table 2, Blood APCs

HCPCS
Description
2007
Final
APC
2008
Final
APC
2007
Final
Payment
Rate
2008
Final
Payment
Rate
$ Change
% Change
P9010
Whole blood for transfusion
0950
0950
$131.98
$254.85
$122.87
93.10%
P9011
Blood split unit
0967
0967
$137.22
$149.10
$11.88
8.66%
P9012
Cryoprecipitate each unit
0952
0952
$48.59
$41.24
-$7.35
-15.13%
P9016
RBC leukocytes reduced
0954
0954
$175.74
$185.15
$9.41
5.35%
P9017
Plasma 1 donor frz w/in 8 hr
9508
9508
$70.21
$67.03
-$3.18
-4.53%
P9019
Platelets, each unit
0957
0957
$58.95
$69.50
$10.55
17.90%
P9020
Plaelet rich plasma unit
0958
0958
$209.29
$363.50
$154.21
73.68%
P9021
Red blood cells unit
0959
0959
$129.53
$129.66
$0.13
0.10%
P9022
Washed red blood cells unit
0960
0960
$211.03
$277.03
$66.00
31.28%
P9023
Frozen plasma, pooled, sd
0949
0949
$57.45
$73.87
$16.42
28.58%
P9031
Platelets leukocytes reduced
1013
1013
$95.08
$107.51
$12.43
13.07%
P9032
Platelets, irradiated
9500
9500
$129.57
$121.72
-$7.85
-6.06%
P9033
Platelets leukoreduced irrad
0968
0968
$125.33
$139.94
$14.61
11.66%
P9034
Platelets, pheresis
9507
9507
$452.93
$441.03
-$11.90
-2.63%
P9035
Platelet pheres leukoreduced
9501
9501
$488.74
$499.53
$10.79
2.21%
P9036
Platelet pheresis irradiated
9502
9502
$418.52
$417.71
-$0.81
-0.19%
P9037
Plate pheres leukoredu irrad
1019
1019
$617.40
$630.08
$12.68
2.05%
P9038
RBC irradiated
9505
9505
$197.00
$195.18
-$1.82
-0.92%
P9039
RBC deglycerolized
9504
9504
$358.31
$347.23
-$11.08
-3.09%
P9040
RBC leukoreduced irradiated
0969
0969
$217.56
$240.27
$22.71
10.44%
P9043
Plasma protein fract,5%,50ml
0956
0956
$51.26
$93.88
$42.62
83.14%
P9044
Cryoprecipitatereducedplasma
1009
1009
$82.39
$83.69
$1.30
1.58%
P9048
Plasmaprotein fract,5%,250ml
0966
0966
$238.16
$215.23
-$22.93
-9.63%
P9050
Granulocytes, pheresis unit
9506
9506
$750.36
$1,387.55
$637.19
84.92%
P9051
Blood, l/r, cmv-neg
1010
1010
$156.70
$147.90
-$8.80
-5.62%
P9052
Platelets, hla-m, l/r, unit
1011
1011
$671.62
$645.94
-$25.68
-3.82%
P9053
Plt, pher, l/r cmv-neg, irr
1020
1020
$705.38
$686.54
-$18.84
-2.67%
P9054
Blood, l/r, froz/degly/wash
1016
1016
$211.05
$218.81
$7.76
3.68%
P9055
Plt, aph/pher, l/r, cmv-neg
1017
1017
$396.81
$488.74
$91.93
23.17%
P9056
Blood, l/r, irradiated
1018
1018
$144.28
$147.13
$2.85
1.98%
P9057
RBC, frz/deg/wsh, l/r, irrad
1021
1021
$496.21
$373.99
-$122.22
-24.63%
P9058
RBC, l/r, cmv-neg, irrad
1022
1022
$262.18
$263.46
$1.28
0.49%
P9059
Plasma, frz between 8-24hour
0955
0955
$76.77
$77.93
$1.16
1.51%
P9060
Fr frz plasma donor retested
9503
9503
$74.49
$52.64
-$21.85
-29.33%