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CMS Proposed Rule for 2011 Hospital Outpatient Payment Rates

 
Under a proposed rule for 2011 Medicare payments for hospital outpatient services, the Centers for Medicare and Medicaid Services (CMS) has proposed small increases and in some instances modest decreases in payments for most blood products. (See http://www.ofr.gov/OFRUpload/OFRData/2010-16448_PI.pdf.)   Payment for leukocyte reduced RBCs would increase from $186.73 in 2010 to $189.06 in 2011, while payment for platelets, pheresis would fall from the current rate of $469.11 to $448.96 in 2011.  Proposed payments for laboratory bone marrow/stem cell processing codes modestly increase, but still lag notably below the actual costs of these services.  Comments on the proposed rule are due to CMS by August 31, 2010 and the payments and other provisions of the final rule will become effective January 1, 2011. 


Overall, CMS is proposing an outpatient prospective payment system overall payment update of 2.15 percent for 2011.  Only those hospitals that successfully reported CMS-designated quality measures in 2010 will be entitled to the full 2.15 percent update.  If a hospital did not successfully report the quality measures, its update will be 0.15 percent.

Payments for Blood Products 

CMS has proposed to continue to establish payment rates for blood and blood products using the blood-specific cost-to-charge ratios from the most recently available hospital cost reports.  The following table compares the proposed 2011 payment rates for blood products with current Medicare payment rates: 

Payments for Blood Components

 

CPT/ HCPCS

Description

APC

2010 Final Payment Rate

2011 Proposed Payment Rate

% Change

P9010

Whole blood for transfusion

0950

$206.25

$202.32

-1.91%

P9011

Blood split unit

0967

$87.39

$201.74

130.85%

P9012

Cryoprecipitate each unit

0952

$46.58

$50.46

8.33%

P9016

RBC leukocytes reduced

0954

$186.73

$189.06

1.25%

P9017

Plasma 1 donor frz w/in 8 hr

9508

$76.02

$79.67

4.80%

P9019

Platelets, each unit

0957

$66.61

$71.72

7.67%

P9020

Platelet rich plasma unit

0958

$136.79

$140.08

2.41%

P9021

Red blood cells unit

0959

$141.73

$149.23

5.29%

P9022

Washed red blood cells unit

0960

$246.00

$294.09

19.55%

P9023

Frozen plasma, pooled, sd

0949

$51.15

$55.47

8.45%

P9031

Platelets leukocytes reduced

1013

$104.76

$108.13

3.22%

P9032

Platelets, irradiated

9500

$150.45

$155.68

3.48%

P9033

Platelets leukoreduced irrad

0968

$131.95

$137.96

4.55%

P9034

Platelets, pheresis

9507

$469.11

$448.96

-4.30%

P9035

Platelet pheres leukoreduced

9501

$512.11

$528.37

3.18%

P9036

Platelet pheresis irradiated

9502

$357.96

$469.93

31.28%

P9037

Plate pheres leukoredu irrad

1019

$676.57

$658.36

-2.69%

P9038

RBC irradiated

9505

$225.80

$215.86

-4.40%

P9039

RBC deglycerolized

9504

$363.91

$354.07

-2.70%

P9040

RBC leukoreduced irradiated

0969

$245.02

$251.20

2.52%

P9043

Plasma protein fract,5%,50ml

0956

$65.75

$25.61

-61.05%

P9044

Cryoprecipitatereducedplasma

1009

$94.60

$79.62

-15.84%

P9048

Plasmaprotein fract,5%,250ml

0966

$107.96

$115.98

7.43%

P9050

Granulocytes, pheresis unit

9506

$44.92

$1,622.47

3511.91%

P9051

Blood, l/r, cmv-neg

1010

$135.32

$188.42

39.24%

P9052

Platelets, hla-m, l/r, unit

1011

$736.68

$722.63

-1.91%

P9053

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

1020

$656.72

$584.97

-10.93%

P9054

Blood, l/r, froz/degly/wash

1016

$103.62

$100.69

-2.83%

P9055

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

1017

$419.23

$429.24

2.39%

P9056

Blood, l/r, irradiated

1018

$165.16

$167.02

1.13%

P9057

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

1021

$363.04

$280.53

-22.73%

P9058

RBC, l/r, cmv-neg, irrad

1022

$293.92

$299.49

1.90%

P9059

Plasma, frz between 8-24hour

0955

$77.46

$72.85

-5.95%

P9060

Fr frz plasma donor retested

9503

$71.88

$66.45

-7.55%


 

Payments for Bone Marrow and Stem Cell Processing Services

At its February 2010 meeting, the Ambulatory Payment Classification (APC) Advisory 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 has indicated that it will consider the advisory panel’s recommendation and will report the results of their assessment to the panel at a future meeting. 

CMS has proposed very modest increases in payments for bone marrow/stem cell processing codes 38207-38215, which were first recognized by the agency in 2008. The proposed payment rate for Codes 38207-38209 (cryopreservation and thawing codes) is $232.84 (compared with $227.89 now), and the proposed payment for Codes 38210-38215 (cell depletion codes) is $401.21 (compared with $390.10). It should be noted that since these payments are based on 2009 claims data, any more recent adjustments that hospitals have made in their charging practices are not yet reflected in CMS’ payments.  Hospitals are encouraged to take steps to ensure that their charges accurately reflect the actual costs of providing these services since CMS will base future payments on such charge data. 

The following table compares 2010 payment rates for transfusion and cellular therapy procedures with CMS’ proposed 2011 payments for these services:  

 Payments for Procedural Codes  

CPT/ HCPCS

Description

APC

2010 Final Payment Rate

2011 Proposed Payment Rate

%Change

36430

Blood transfusion service

0110

$227.89

$232.84

2.17%

36440

Bl push transfuse, 2 yr or <

0110

$227.89

$232.84

2.17%

36450

Bl exchange/transfuse, nb

0110

$227.89

$232.84

2.17%

36455

Bl exchange/transfuse non-nb

0110

$227.89

$232.84

2.17%

36511

Apheresis wbc

0111

$804.99

$855.02

6.21%

36512

Apheresis rbc

0111

$804.99

$855.02

6.21%

36513

Apheresis platelets

0111

$804.99

$855.02

6.21%

36514

Apheresis plasma

0111

$804.99

$855.02

6.21%

36515

Apheresis, adsorp/reinfuse

0112

$2,246.01

$2,313.60

3.01%

36516

Apheresis, selective

0112

$2,246.01

$2,313.60

3.01%

36522

Photopheresis

0112

$2,246.01

$2,313.60

3.01%

38206

Harvest auto stem cells

0111

$804.99

$855.02

6.21%

38207

Cryopreserve stem cells

0110

$227.89

$232.84

2.17%

38208

Thaw preserved stem cells

0110

$227.89

$232.84

2.17%

38209

Wash harvest stem cells

0110

$227.89

$232.84

2.17%

38210

T-cell depletion of harvest

0393

$390.10

$401.21

2.85%

38211

Tumor cell deplete of harvst

0393

$390.10

$401.21

2.85%

38212

Rbc depletion of harvest

0393

$390.10

$401.21

2.85%

38213

Platelet deplete of harvest

0393

$390.10

$401.21

2.85%

38214

Volume deplete of harvest

0393

$390.10

$401.21

2.85%

38215

Harvest stem cell concentrte

0393

$390.10

$401.21

2.85%

38220

Bone marrow aspiration

0003

$208.95

$248.17

18.77%

38221

Bone marrow biopsy

0003

$208.95

$248.17

18.77%

38230

Bone marrow collection

0112

$2,246.01

$2,313.60

3.01%

38240

Bone marrow/stem transplant

0112

$2,246.01

$2,313.60

3.01%

38241

Bone marrow/stem transplant

0112

$2,246.01

$2,313.60

3.01%

38242

Lymphocyte infuse transplant

0111

$804.99

$855.02

6.21%

88184

Flowcytometry/ tc, 1 marker

0433

$16.73

$16.83

0.60%

88185

Flowcytometry/tc, add-on

0433

$16.73

$16.83

0.60%

88187

Flowcytometry/read, 2-8

0342

$10.42

$10.90

4.61%

88188

Flowcytometry/read, 9-15

0343

$35.73

$36.53

2.24%

88189

Flowcytometry/read, 16 & >

0343

$35.73

$36.53

2.24%

G0364

Bone marrow aspirate &biopsy

0340

$45.11

$47.10

4.41%

 

Supervision Requirements

Over the last several years, CMS has attempted to clarify Medicare policy regarding physician supervision of services performed in the hospital outpatient department.  In the final outpatient rule for 2010, CMS required direct supervision for all therapeutic services and defined direct supervision as requiring a physician or non-physician practitioner to be present on the same campus and immediately available to furnish assistance and direction throughout the performance of the procedure.   While CMS did not view this as a change in current policy, hospitals – particularly small rural hospitals and critical access hospitals – raised concerns that physicians were not always available when therapeutic services were provided, particularly in the case of services of long duration such as blood transfusions and very lengthy infusions.  

In response to these concerns, CMS has identified a limited set of non-surgical services requiring direct supervision for the initiation of the service only, after which general supervision will be sufficient.  (A service provided under general supervision is furnished under the overall direction and control of the physician, but his or her physical presence is not required during the performance of the procedure.)

CMS’ list of services, referred to as “non-surgical extended duration therapeutic services,” includes services with a lengthy monitoring component that typically have a low risk of complication after an assessment is made at the beginning of the service.  The list consists of a limited number of injection and infusion codes and two observation care services.  Because of quality concerns, CMS considered and rejected a proposal to offer hospitals the flexibility to broaden the list to include chemotherapy and blood transfusions, which some stakeholders also maintain do not require direct supervision.

AABB will submit comments to CMS regarding the proposed rule.