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CMS Publishes 2010 Hospital Outpatient Prospective Payment System Rule

The Centers for Medicare and Medicaid Services (CMS) has published its final rule governing payment policies and rates for the Medicare hospital outpatient payment system (HOPPS) for CY 2010. The rule, which can be found at http://federalregister.gov/OFRUpload/OFRData/2009-26499_PI.pdf, includes modest changes in payments for most frequently transfused blood products and relatively small increases in payment for most transfusion, apheresis and stem cell procedural codes, still lagging significantly behind actual costs for many of these services.

Overall Payment Rates

Overall, CMS projects that 2010 payment rates to the more than 4,000 hospitals that provide hospital outpatient services to Medicare beneficiaries under the HOPPS will add up to $32.2 billion – a $1.9 billion increase over projected payments in 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 2010 equal to the annual payment update factor minus 2.0 percentage points – or 0.1 percent.

Payments for Blood Products

As shown in Table 1, payments for the most frequently transfused blood products will not change dramatically in 2010, with relatively modest increases or decreases in payments for various products. As in years past, payments for less frequently transfused blood products are very volatile with increases as high as 320 percent and decreases as low as 97 percent.

Table 1
Blood Products

CPT/ HCPCS

Description

2010 Final APC
2009 Final Payment Rate
2010 Final Payment Rate
$Change
%Change

P9010

Whole blood for transfusion

0950
$230.40
$206.25
-$24.15
-10.48%

P9011

Blood split unit

0967
$31.12
$87.39
$56.27
180.82%

P9012

Cryoprecipitate each unit

0952
$42.46
$46.58
$4.12
9.70%

P9016

RBC leukocytes reduced

0954
$188.92
$186.73
-$2.19
-1.16%

P9017

Plasma 1 donor frz w/in 8 hr

9508
$76.73
$76.02
-$0.71
-0.93%

P9019

Platelets, each unit

0957
$73.25
$66.61
-$6.64
-9.06%

P9020

Platelet rich plasma unit

0958
$394.95
$136.79
-$258.16
-65.37%

P9021

Red blood cells unit

0959
$136.82
$141.73
$4.91
3.59%

P9022

Washed red blood cells unit

0960
$261.64
$246.00
-$15.64
-5.98%

P9023

Frozen plasma, pooled, sd

0949
$58.83
$51.15
-$7.68
-13.05%

P9031

Platelets leukocytes reduced

1013
$111.67
$104.76
-$6.91
-6.19%

P9032

Platelets, irradiated

9500
$164.42
$150.45
-$13.97
-8.50%

P9033

Platelets leukoreduced irrad

0968
$128.19
$131.95
$3.76
2.93%

P9034

Platelets, pheresis

9507
$468.66
$469.11
$0.45
0.10%

P9035

Platelet pheres leukoreduced

9501
$514.82
$512.11
-$2.71
-0.53%

P9036

Platelet pheresis irradiated

9502
$469.53
$357.96
-$111.57
-23.76%

P9037

Plate pheres leukoredu irrad

1019
$653.50
$676.57
$23.07
3.53%

P9038

RBC irradiated

9505
$250.69
$225.80
-$24.89
-9.93%

P9039

RBC deglycerolized

9504
$341.43
$363.91
$22.48
6.58%

P9040

RBC leukoreduced irradiated

0969
$251.33
$245.02
-$6.31
-2.51%

P9043

Plasma protein fract,5%,50ml

0956
$15.62
$65.75
$50.13
320.93%

P9044

Cryoprecipitatereducedplasma

1009
$85.16
$94.60
$9.44
11.09%

P9048

Plasmaprotein fract,5%,250ml

0966
$196.27
$107.96
-$88.31
-44.99%

P9050

Granulocytes, pheresis unit

9506
$1,669.99
$44.92
-1,625.07
-97.31%

P9051

Blood, l/r, cmv-neg

1010
$144.13
$135.32
-$8.81
-6.11%

P9052

Platelets, hla-m, l/r, unit

1011
$711.89
$736.68
$24.79
3.48%

P9053

Plt, pher, l/r cmv-neg, irr

1020
$649.24
$656.72
$7.48
1.15%

P9054

Blood, l/r, froz/degly/wash

1016
$101.68
$103.62
$1.94
1.91%

P9055

Plt, aph/pher, l/r, cmv-neg

1017
$480.41
$419.23
-$61.18
-12.73%

P9056

Blood, l/r, irradiated

1018
$226.31
$165.16
-$61.15
-27.02%

P9057

RBC, frz/deg/wsh, l/r, irrad

1021
$424.67
$363.04
-$61.63
-14.51%

P9058

RBC, l/r, cmv-neg, irrad

1022
$301.43
$293.92
-$7.51
-2.49%

P9059

Plasma, frz between 8-24hour

0955
$75.62
$77.46
$1.84
2.43%

P9060

Fr frz plasma donor retested

9503
$64.25
$71.88
$7.63
11.88%


CMS rejected comments submitted by AABB and others requesting that payments for blood products be increased by the 3.1 percent increase in the government-recognized producer price index for blood products. Despite concerns raised by AABB and others that payments for several products were well below the costs incurred by the hospitals, CMS stated that it would not change its proposed payments, which are determined using the agency’s current payment methodology that utilizes hospital charges adjusted by the hospital's cost-to-charge ratio.

In order to assure that Medicare’s future outpatient APC rates are more reflective of costs, hospitals need to appropriately charge for blood products.

Bone Marrow/Stem Cell Transplant Procedures

CMS responded more favorably to concerns raised about its proposed payment policies for certain stem cell procedures. In its proposed rule issued this summer, CMS had 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, and Code 38242 Bone-marrow or blood-derived peripheral stem cell transplantation; allogeneic donor lymphocyte infusions.

Based on comments submitted by AABB and other interested organizations on the proposed rule, and 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.

As outlined in Table 2, payments for the procedural codes including blood transfusion, apheresis procedures, bone marrow collection and transplant will increase over and above the market basket adjustment of 2.1% in 2010. However, payments for the cell processing codes continue to lag far behind actual costs for such procedures. Since the APC rates are a direct by-product of hospital charges, it is critical that hospitals charge more accurately for these procedures, including the more costly services such as T-cell and tumor cell depletion.

Table 2
Procedural Codes

CPT/ HCPCS
Description
2010 Final APC
2009 Final Payment Rate
2010 Final Payment Rate
$Change
%Change
36430
Blood transfusion service
0110
$221.59
$227.89
$6.30
2.84%
36440
Bl push transfuse, 2 yr or <
0110
$221.59
$227.89
$6.30
2.84%
36450
Bl exchange/transfuse, nb
0110
$221.59
$227.89
$6.30
2.84%
36455
Bl exchange/transfuse non-nb
0110
$221.59
$227.89
$6.30
2.84%
36511
Apheresis wbc
0111
$759.70
$804.99
$45.29
5.96%
36512
Apheresis rbc
0111
$759.70
$804.99
$45.29
5.96%
36513
Apheresis platelets
0111
$759.70
$804.99
$45.29
5.96%
36514
Apheresis plasma
0111
$759.70
$804.99
$45.29
5.96%
36515
Apheresis, adsorp/reinfuse
0112
$2,033.73
$2,246.01
$212.28
10.44%
36516
Apheresis, selective
0112
$2,033.73
$2,246.01
$212.28
10.44%
36522
Photopheresis
0112
$2,033.73
$2,246.01
$212.28
10.44%
38206
Harvest auto stem cells
0111
$759.70
$804.99
$45.29
5.96%
38207
Cryopreserve stem cells
0110
$221.59
$227.89
$6.30
2.84%
38208
Thaw preserved stem cells
0110
$221.59
$227.89
$6.30
2.84%
38209
Wash harvest stem cells
0110
$221.59
$227.89
$6.30
2.84%
38210
T-cell depletion of harvest
0393
$400.19
$390.10
-$10.09
-2.52%
38211
Tumor cell deplete of harvst
0393
$400.19
$390.10
-$10.09
-2.52%
38212
Rbc depletion of harvest
0393
$400.19
$390.10
-$10.09
-2.52%
38213
Platelet deplete of harvest
0393
$400.19
$390.10
-$10.09
-2.52%
38214
Volume deplete of harvest
0393
$400.19
$390.10
-$10.09
-2.52%
38215
Harvest stem cell concentrte
0393
$400.19
$390.10
-$10.09
-2.52%
38220
Bone marrow aspiration
0003
$208.26
$208.95
$0.69
0.33%
38221
Bone marrow biopsy
0003
$208.26
$208.95
$0.69
0.33%
38230
Bone marrow collection
0112
$2,033.73
$2,246.01
$212.28
10.44%
38240
Bone marrow/stem transplant
0112
$2,033.73
$2,246.01
$212.28
10.44%
38241
Bone marrow/stem transplant
0112
$2,033.73
$2,246.01
$212.28
10.44%
38242
Lymphocyte infuse transplant
0111
$759.70
$804.99
$45.29
5.96%
88184
Flowcytometry/ tc, 1 marker
0433
$16.50
$16.73
$0.23
1.39%
88185
Flowcytometry/tc, add-on
0433
$16.50
$16.73
$0.23
1.39%
88187
Flowcytometry/read, 2-8
0342
$10.06
$10.42
$0.36
3.58%
88188
Flowcytometry/read, 9-15
0343
$34.55
$35.73
$1.18
3.42%
88189
Flowcytometry/read, 16 & >
0343
$32.75
$35.73
$2.98
9.10%
99363
Anticoag mgmt, init
Code Not Recognized By OPPS
99364
Anticoag mgmt, subseq
Code Not Recognized By OPPS
G0364
Bone marrow aspirate &biopsy
0340
$42.69
$45.11
$2.42
5.67%
G0267
Bone marrow or psc harvest
--
--
--
N/A
N/A

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) + 4 percent while pass though drugs will be paid at the rate of ASP + 6 percent.

Supervision Requirements for Hospital Outpatient Departments

CMS has finalized its 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, whereas 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.

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.