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CMS Publishes 2011 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 (OPPS) for CY 2011.  The rule, which can be found at  http://www.ofr.gov/OFRUpload/OFRData/2010-27926_PI.pdf, includes small changes – both increases and decreases – in payments for blood products (e.g, $194.86 for leukoreduced red blood cells in 2011, compared with $186.73 in 2010; and $458.54 for platelets, pheresis, down from $469.11 in 2010).  Payments for laboratory bone marrow and stem cell processing codes will increase modestly, but still fall notably below actual costs of these services.  In addition to updating OPPS payments and policies the final rule implements provisions of the recently passed healthcare reform legislation, the Affordable Care Act (ACA).  The provisions of the rule are effective January 1, 2011 unless stated otherwise.

AABB will continue to urge CMS to improve payments for transfusion and cellular therapy related products and services to ensure that patient have access to the best available care.

Overall Payment Rates

The overall OPPS payment update for 2011 will be 2.35 percent.  This reflects a 2.6 percent inflationary increase reduced by 0.25 percent as mandated by the ACA.  The full 2.35 percent update only applies to hospitals which successfully reported CMS designated quality measures in 2010.  If a hospital did not successfully report these quality measures, the update will be 0.15 percent.  There were no fundamental changes in the methodology used by CMS for calculating the OPPS rates and APC weights.

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 in payments for most blood products.  Payments for the most commonly transfused blood products, including leukoreduced RBCs, leukoreduced platelets, pheresis, and leukoreduced, irradiated RBCs, are increasing but are still lower than actual costs.

 


Table 1

Blood Products

CPT/ HCPCS

Description

2011 Final APC

2010 Final Payment Rate

2011 Final Payment Rate

$Change

%Change

P9010

Whole blood for transfusion

0950

$206.25

$202.83

-$3.42

-1.66%

P9011

Blood split unit

0967

$87.39

$211.47

$124.08

141.98%

P9012

Cryoprecipitate each unit

0952

$46.58

$50.49

$3.91

8.39%

P9016

RBC leukocytes reduced

0954

$186.73

$194.86

$8.13

4.35%

P9017

Plasma 1 donor frz w/in 8 hr

9508

$76.02

$79.35

$3.33

4.38%

P9019

Platelets, each unit

0957

$66.61

$74.25

$7.64

11.47%

P9020

Platelet rich plasma unit

0958

$136.79

$142.96

$6.17

4.51%

P9021

Red blood cells unit

0959

$141.73

$154.32

$12.59

8.88%

P9022

Washed red blood cells unit

0960

$246.00

$285.79

$39.79

16.17%

P9023

Frozen plasma, pooled, sd

0949

$51.15

$60.94

$9.79

19.14%

P9031

Platelets leukocytes reduced

1013

$104.76

$110.51

$5.75

5.49%

P9032

Platelets, irradiated

9500

$150.45

$144.71

-$5.74

-3.82%

P9033

Platelets leukoreduced irrad

0968

$131.95

$142.21

$10.26

7.78%

P9034

Platelets, pheresis

9507

$469.11

$458.54

-$10.57

-2.25%

P9035

Platelet pheres leukoreduced

9501

$512.11

$538.51

$26.40

5.16%

P9036

Platelet pheresis irradiated

9502

$357.96

$452.85

$94.89

26.51%

P9037

Plate pheres leukoredu irrad

1019

$676.57

$655.33

-$21.24

-3.14%

P9038

RBC irradiated

9505

$225.80

$224.19

-$1.61

-0.71%

P9039

RBC deglycerolized

9504

$363.91

$364.97

$1.06

0.29%

P9040

RBC leukoreduced irradiated

0969

$245.02

$247.84

$2.82

1.15%

P9043

Plasma protein fract,5%,50ml

0956

$65.75

$27.68

-$38.07

-57.90%

P9044

Cryoprecipitatereduced plasma

1009

$94.60

$86.01

-$8.59

-9.08%

P9048

Plasmaprotein fract,5%,250ml

0966

$107.96

$98.80

-$9.16

-8.48%

P9050

Granulocytes, pheresis unit

9506

$44.92

$1,508.22

$1,463.30

3257.57%

P9051

Blood, l/r, cmv-neg

1010

$135.32

$179.67

$44.35

32.77%

P9052

Platelets, hla-m, l/r, unit

1011

$736.68

$817.22

$80.54

10.93%

P9053

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

1020

$656.72

$624.31

-$32.41

-4.94%

P9054

Blood, l/r, froz/degly/wash

1016

$103.62

$114.94

$11.32

10.92%

P9055

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

1017

$419.23

$440.99

$21.76

5.19%

P9056

Blood, l/r, irradiated

1018

$165.16

$172.16

$7.00

4.24%

P9057

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

1021

$363.04

$297.96

-$65.08

-17.93%

P9058

RBC, l/r, cmv-neg, irrad

1022

$293.92

$285.75

-$8.17

-2.78%

P9059

Plasma, frz between 8-24 hour

0955

$77.46

$73.15

-$4.31

-5.56%

P9060

Fr frz plasma donor retested

9503

$71.88

$71.14

-$0.74

-1.03%

 

Bone Marrow/Stem Cell Transplant Procedures

At its February 2010 meeting, the APC Panel recommended that CMS consider creating a composite APC or custom APC that captures the costs of stem cell acquisition performed in conjunction with recipient transplantation and preparation of tissue. CMS did not establish a new composite APC in the rule, but has indicated it will consider the APC panel's recommendation and will report the results of their assessment to the APC Panel at a future meeting.

As outlined in Table 2, payments for the vast majority of relevant procedural codes, including blood transfusion, apheresis procedures, and stem cell collection and processing, will increase.  However, payments for the cell processing codes continue to lag far behind actual costs for such procedures.   Since the APC rates are based on hospital charges, it is critical that hospitals charge more accurately for these procedures.  

 

Table 2

Transfusion, Apheresis and Stem Cell Collection/Processing Procedures

 

CPT/ HCPCS

Description

2011 Final APC

2010 Final Payment Rate

2011 Final Payment Rate

$Change

%Change

 

36430

Blood transfusion service

0110

$227.89

$233.61

$5.72

2.51%

 

36440

Bl push transfuse, 2 yr or <

0110

$227.89

$233.61

$5.72

2.51%

 

36450

Bl exchange/transfuse, nb

0110

$227.89

$233.61

$5.72

2.51%

 

36455

Bl exchange/transfuse non-nb

0110

$227.89

$233.61

$5.72

2.51%

 

36511

Apheresis wbc

0111

$804.99

$853.18

$48.19

5.99%

 

36512

Apheresis rbc

0111

$804.99

$853.18

$48.19

5.99%

 

36513

Apheresis platelets

0111

$804.99

$853.18

$48.19

5.99%

 

36514

Apheresis plasma

0111

$804.99

$853.18

$48.19

5.99%

 

36515

Apheresis, adsorp/reinfuse

0112

$2,246.01

$2,166.33

-$79.68

-3.55%

 

36516

Apheresis, selective

0112

$2,246.01

$2,166.33

-$79.68

-3.55%

 

36522

Photopheresis

0112

$2,246.01

$2,166.33

-$79.68

-3.55%

 

38206

Harvest auto stem cells

0111

$804.99

$853.18

$48.19

5.99%

 

38207

Cryopreserve stem cells

0110

$227.89

$233.61

$5.72

2.51%

 

38208

Thaw preserved stem cells

0110

$227.89

$233.61

$5.72

2.51%

 

38209

Wash harvest stem cells

0110

$227.89

$233.61

$5.72

2.51%

 

38210

T-cell depletion of harvest

0393

$390.10

$418.39

$28.29

7.25%

 

38211

Tumor cell deplete of harvst

0393

$390.10

$418.39

$28.29

7.25%

 

38212

Rbc depletion of harvest

0393

$390.10

$418.39

$28.29

7.25%

 

38213

Platelet deplete of harvest

0393

$390.10

$418.39

$28.29

7.25%

 

38214

Volume deplete of harvest

0393

$390.10

$418.39

$28.29

7.25%

 

38215

Harvest stem cell concentrte

0393

$390.10

$418.39

$28.29

7.25%

 

38220

Bone marrow aspiration

0003

$208.95

$257.53

$48.58

23.25%

 

38221

Bone marrow biopsy

0003

$208.95

$257.53

$48.58

23.25%

 

38230

Bone marrow collection

0112

$2,246.01

$2,166.33

-$79.68

-3.55%

 

38240

Bone marrow/stem transplant

0112

$2,246.01

$2,166.33

-$79.68

-3.55%

 

38241

Bone marrow/stem transplant

0112

$2,246.01

$2,166.33

-$79.68

-3.55%

 

38242

Lymphocyte infuse transplant

0111

$804.99

$853.18

$48.19

5.99%

 

88184

Flowcytometry/ tc, 1 marker

0433

$16.73

$17.07

$0.34

2.03%

 

88185

Flowcytometry/tc, add-on

0433

$16.73

$17.07

$0.34

2.03%

 

88187

Flowcytometry/read, 2-8

0342

$10.42

$11.04

$0.62

5.95%

 

88188

Flowcytometry/read, 9-15

0343

$35.73

$36.48

$0.75

2.10%

 

88189

Flowcytometry/read, 16 & >

0343

$35.73

$36.48

$0.75

2.10%

 

99363

Anticoag mgmt, init

Code not recognized by OPPS

 

99364

Anticoag mgmt, subseq

Code not recognized by OPPS

 

G0364

Bone marrow aspirate &biopsy

0340

$45.11

$46.23

$1.12

2.48%

 

G0267

Bone marrow or psc harvest

--

--

 

N/A

N/A

 

 

Blood Clotting Factors

In 2011, payment for blood clotting factors will again be average sales price (ASP) +5% plus a separate furnishing fee to help ensure patient access to blood clotting factors.  CMS rejected comments requesting payment at ASP + 6%.