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 2012. The rule can be found here (please note that this link will change after the rule is published in the Federal Register at the end of November 2011). Most provisions of the rule (unless otherwise noted) are effective January 1, 2012. The following is a summary of key provisions affecting transfusion medicine and cellular therapies.
Overall Payment Rates
Overall payments for hospital outpatient services will increase by 1.9 percent in 2012. The actual impact on individual hospitals and services within a hospital will vary depending on a variety of factors such as the mix of services provided, recalibration of the APC weights, and changes in the hospital wage index. For example, rural hospitals and small urban hospitals will see less than the average 1.9 percent increase while urban hospitals in New England will see increases exceeding 5 percent.
In addition, to receive its full OPPC payment update in 2012, hospitals need to have successfully reported the hospital outpatient quality measures (OQR) in 2010. For hospitals which did not meet the OQR reporting standards, payment will be reduced by 2 percent in 2012.
Payments made under OPPS cover facility resources including equipment, supplies and hospital staff, but do not include services for physicians or non-physician practitioners paid separately under the Medicare Physician Fee Schedule. Services under OPPS which are clinically similar and require similar resources are classified into payment groups called Ambulatory Payment Classifications (APCs) and a payment rate is established for each APC.
Payments for Blood Products
As shown in Table 1, payments for the most frequently transfused blood products will not change dramatically in 2012. CMS will modestly increase payments for leukoreduced RBCs (from $194.86 in 2011 to $198.90 in 2012), leukoreduced platelets, pheresis (from $538.51 to $538.84), and leukoreduced, irradiated RBCs (from $247.84 to $261.22), but slightly decrease payments for red blood cells ($154.32 to $149.16). Payments for less frequently transfused components fluctuate more dramatically since CMS has fewer individual charges on which to base its payments and outliers have greater impact on mean payments. For example, payment for cryoprecipitate will increase 64 percent (from $50.49 to $82.78), whereas the payment for cryoprecipate reduced plasma will fall by almost 14 percent (from $86.01 to $74.37).
TABLE 1
BLOOD PRODUCTS |
CPT/ HCPCS |
Description |
2011 Final APC |
2012 Final APC |
2011 Final Payment Rate |
2012 Final Payment Rate |
$ Change |
% Change |
P9010 |
Whole blood for transfusion |
0950 |
0950 |
$202.83 |
$190.76 |
-$12.07 |
-5.95% |
P9011 |
Blood split unit |
0967 |
0967 |
$211.47 |
$117.35 |
-$94.12 |
-44.51% |
P9012 |
Cryoprecipitate each unit |
0952 |
0952 |
$50.49 |
$82.78 |
$32.29 |
63.95% |
P9016 |
RBC leukocytes reduced |
0954 |
0954 |
$194.86 |
$198.90 |
$4.04 |
2.07% |
P9017 |
Plasma 1 donor frz w/in 8 hr |
9508 |
9508 |
$79.35 |
$79.87 |
$0.52 |
0.66% |
P9019 |
Platelets, each unit |
0957 |
0957 |
$74.25 |
$89.77 |
$15.52 |
20.90% |
P9020 |
Platelet rich plasma unit |
0958 |
0958 |
$142.96 |
$141.83 |
-$1.13 |
-0.79% |
P9021 |
Red blood cells unit |
0959 |
0959 |
$154.32 |
$149.16 |
-$5.16 |
-3.34% |
P9022 |
Washed red blood cells unit |
0960 |
0960 |
$285.79 |
$287.38 |
$1.59 |
0.56% |
P9023 |
Frozen plasma, pooled, sd |
0949 |
0949 |
$60.94 |
$66.84 |
$5.90 |
9.68% |
P9031 |
Platelets leukocytes reduced |
1013 |
1013 |
$110.51 |
$131.07 |
$20.56 |
18.60% |
P9032 |
Platelets, irradiated |
9500 |
9500 |
$144.71 |
$128.42 |
-$16.29 |
-11.26% |
P9033 |
Platelets leukoreduced irrad |
0968 |
0968 |
$142.21 |
$140.00 |
-$2.21 |
-1.55% |
P9034 |
Platelets, pheresis |
9507 |
9507 |
$458.54 |
$442.14 |
-$16.40 |
-3.58% |
P9035 |
Platelet pheres leukoreduced |
9501 |
9501 |
$538.51 |
$538.84 |
$0.33 |
0.06% |
P9036 |
Platelet pheresis irradiated |
9502 |
9502 |
$452.85 |
$554.93 |
$102.08 |
22.54% |
P9037 |
Plate pheres leukoredu irrad |
1019 |
1019 |
$655.33 |
$691.79 |
$36.46 |
5.56% |
P9038 |
RBC irradiated |
9505 |
9505 |
$224.19 |
$198.98 |
-$25.21 |
-11.24% |
P9039 |
RBC deglycerolized |
9504 |
9504 |
$364.97 |
$238.64 |
-$126.33 |
-34.61% |
P9040 |
RBC leukoreduced irradiated |
0969 |
0969 |
$247.84 |
$261.22 |
$13.38 |
5.40% |
P9043 |
Plasma protein fract,5%,50ml |
0956 |
0956 |
$27.68 |
$18.02 |
-$9.66 |
-34.90% |
P9044 |
Cryoprecipitatereduced plasma |
1009 |
1009 |
$86.01 |
$74.37 |
-$11.64 |
-13.53% |
P9048 |
Plasmaprotein fract,5%,250ml |
0966 |
0966 |
$98.80 |
$72.55 |
-$26.25 |
-26.57% |
P9050 |
Granulocytes, pheresis unit |
9506 |
9506 |
$1,508.22 |
$1,340.65 |
-$167.57 |
-11.11% |
P9051 |
Blood, l/r, cmv-neg |
1010 |
1010 |
$179.67 |
$188.55 |
$8.88 |
4.94% |
P9052 |
Platelets, hla-m, l/r, unit |
1011 |
1011 |
$817.22 |
$803.05 |
-$14.17 |
-1.73% |
P9053 |
Plt, pher, l/r cmv-neg, irr |
1020 |
1020 |
$624.31 |
$615.69 |
-$8.62 |
-1.38% |
P9054 |
Blood, l/r, froz/degly/wash |
1016 |
1016 |
$114.94 |
$104.95 |
-$9.99 |
-8.69% |
P9055 |
Plt, aph/pher, l/r, cmv-neg |
1017 |
1017 |
$440.99 |
$383.70 |
-$57.29 |
-12.99% |
P9056 |
Blood, l/r, irradiated |
1018 |
1018 |
$172.16 |
$146.80 |
-$25.36 |
-14.73% |
P9057 |
RBC, frz/deg/wsh, l/r, irrad |
1021 |
1021 |
$297.96 |
$448.82 |
$150.86 |
50.63% |
P9058 |
RBC, l/r, cmv-neg, irrad |
1022 |
1022 |
$285.75 |
$305.97 |
$20.22 |
7.08% |
P9059 |
Plasma, frz between 8-24hour |
0955 |
0955 |
$73.15 |
$72.82 |
-$0.33 |
-0.45% |
P9060 |
Fr frz plasma donor retested |
9503 |
9503 |
$71.14 |
$80.95 |
$9.81 |
13.79% |
Transfusion, Apheresis and Bone Marrow/Stem Cell Procedures
As outlined in Table 2, payments for most transfusion and stem cell collection and processing procedures will increase. However, the payment for APC 0111 (apheresis, RBC, platelets, etc. and harvest autologous stem cells) will decrease from $853.18 in 2011 to $816.59 in 2012. Although payments for most stem cell processing codes are increasing, they continue to lag notably behind actual costs for such procedures. Since the APC rates are based on hospital charges, it is critical that hospitals charge accurately for these procedures.
CMS assigned CPT code 86891 (autologous blood or component collection, processing and storage; intra- or postoperative salvage) to APC 0345 (Level I Transfusion Laboratory Procedures), which has a payment of approximately $15 in 2012 (See Table 3).
TABLE 2
TRANSFUSION, APHERESIS AND STEM CELL COLLECTION/PROCESSING PROCEDURES
|
CPT/ HCPCS |
Description |
2011 Final APC |
2012 Final APC |
2011 Final Payment Rate |
2012 Final Payment Rate |
$ Change |
% Change |
36430 |
Blood transfusion service |
0110 |
0110 |
$233.61 |
$239.57 |
$5.96 |
2.55% |
36440 |
Bl push transfuse, 2 yr or < |
0110 |
0110 |
$233.61 |
$239.57 |
$5.96 |
2.55% |
36450 |
Bl exchange/transfuse, nb |
0110 |
0110 |
$233.61 |
$239.57 |
$5.96 |
2.55% |
36455 |
Bl exchange/transfuse non-nb |
0110 |
0110 |
$233.61 |
$239.57 |
$5.96 |
2.55% |
36511 |
Apheresis wbc |
0111 |
0111 |
$853.18 |
$816.59 |
-$36.59 |
-4.29% |
36512 |
Apheresis rbc |
0111 |
0111 |
$853.18 |
$816.59 |
-$36.59 |
-4.29% |
36513 |
Apheresis platelets |
0111 |
0111 |
$853.18 |
$816.59 |
-$36.59 |
-4.29% |
36514 |
Apheresis plasma |
0111 |
0111 |
$853.18 |
$816.59 |
-$36.59 |
-4.29% |
36515 |
Apheresis, adsorp/reinfuse |
0112 |
0112 |
$2,166.33 |
$2,494.33 |
$328.00 |
15.14% |
36516 |
Apheresis, selective |
0112 |
0112 |
$2,166.33 |
$2,494.33 |
$328.00 |
15.14% |
36522 |
Photopheresis |
0112 |
0112 |
$2,166.33 |
$2,494.33 |
$328.00 |
15.14% |
38206 |
Harvest auto stem cells |
0111 |
0111 |
$853.18 |
$816.59 |
-$36.59 |
-4.29% |
38207 |
Cryopreserve stem cells |
0110 |
0110 |
$233.61 |
$239.57 |
$5.96 |
2.55% |
38208 |
Thaw preserved stem cells |
0110 |
0110 |
$233.61 |
$239.57 |
$5.96 |
2.55% |
38209 |
Wash harvest stem cells |
0110 |
0110 |
$233.61 |
$239.57 |
$5.96 |
2.55% |
38210 |
T-cell depletion of harvest |
0393 |
0393 |
$418.39 |
$484.48 |
$66.09 |
15.80% |
38211 |
Tumor cell deplete of harvst |
0393 |
0393 |
$418.39 |
$484.48 |
$66.09 |
15.80% |
38212 |
Rbc depletion of harvest |
0393 |
0393 |
$418.39 |
$484.48 |
$66.09 |
15.80% |
38213 |
Platelet deplete of harvest |
0393 |
0393 |
$418.39 |
$484.48 |
$66.09 |
15.80% |
38214 |
Volume deplete of harvest |
0393 |
0393 |
$418.39 |
$484.48 |
$66.09 |
15.80% |
38215 |
Harvest stem cell concentrte |
0393 |
0393 |
$418.39 |
$484.48 |
$66.09 |
15.80% |
38220 |
Bone marrow aspiration |
0003 |
0003 |
$257.53 |
$248.89 |
-$8.64 |
-3.35% |
38221 |
Bone marrow biopsy |
0003 |
0003 |
$257.53 |
$248.89 |
-$8.64 |
-3.35% |
38230 |
Bone marrow collection |
0112 |
0112 |
$2,166.33 |
$2,494.33 |
$328.00 |
15.14% |
38232 |
Bone marrow harvest autolog |
NA |
0112 |
NA |
$2,494.33 |
NA |
NA |
38240 |
Bone marrow/stem transplant |
0112 |
0112 |
$2,166.33 |
$2,494.33 |
$328.00 |
15.14% |
38241 |
Bone marrow/stem transplant |
0112 |
0112 |
$2,166.33 |
$2,494.33 |
$328.00 |
15.14% |
38242 |
Lymphocyte infuse transplant |
0111 |
0111 |
$853.18 |
$816.59 |
-$36.59 |
-4.29% |
88184 |
Flowcytometry/ tc, 1 marker |
0433 |
0433 |
$17.07 |
$17.04 |
-$0.03 |
-0.18% |
88185 |
Flowcytometry/tc, add-on |
0433 |
0433 |
$17.07 |
$17.04 |
-$0.03 |
-0.18% |
88187 |
Flowcytometry/read, 2-8 |
0342 |
0342 |
$11.04 |
$11.21 |
$0.17 |
1.54% |
88188 |
Flowcytometry/read, 9-15 |
0343 |
0343 |
$36.48 |
$36.82 |
$0.34 |
0.93% |
88189 |
Flowcytometry/read, 16 & > |
0343 |
0343 |
$36.48 |
$36.82 |
$0.34 |
0.93% |
G0364 |
Bone marrow aspirate &biopsy |
0340 |
0340 |
$46.23 |
$45.50 |
-$0.73 |
-1.58% |
TABLE 3
TRANSFUSION LABORATORY PROCEDURES |
APC |
HCPCS |
Group Title |
Short Description |
2012 Payment |
0345 |
|
Level I Transfusion Laboratory Procedures |
|
$14.95 |
0345 |
86850 |
|
RBC antibody screen |
|
0345 |
86891 |
|
Autologous blood op salvage |
|
0345 |
86902 |
|
Blood type antigen donor ea |
|
0345 |
86904 |
|
Blood typing patient serum |
|
0345 |
86905 |
|
Blood typing rbc antigens |
|
0345 |
86906 |
|
Blood typing rh phenotype |
|
0345 |
86920 |
|
Compatibility test spin |
|
0345 |
86921 |
|
Compatibility test incubate |
|
0345 |
86923 |
|
Compatibility test electric |
|
0345 |
86927 |
|
Plasma fresh frozen |
|
0345 |
86945 |
|
Blood product/irradiation |
|
0345 |
86950 |
|
Leukacyte transfusion |
|
0345 |
86960 |
|
Vol reduction of blood/prod |
|
0345 |
86970 |
|
RBC pretreatment |
|
0345 |
86971 |
|
RBC pretreatment |
|
0345 |
86972 |
|
RBC pretreatment |
|
0345 |
86976 |
|
Rbc pretreatment serum |
|
0345 |
86985 |
|
Split blood or products |
|
0345 |
86999 |
|
Transfusion procedure |
|
0346 |
|
Level II Transfusion Laboratory Procedures |
|
$24.77 |
0346 |
86860 |
|
RBC antibody elution |
|
0346 |
86870 |
|
RBC antibody identification |
|
0346 |
86922 |
|
Compatibility test antiglob |
|
0346 |
86965 |
|
Pooling blood platelets |
|
0346 |
86975 |
|
Rbc pretreatment serum |
|
0346 |
86978 |
|
Rbc pretreatment serum |
|
0347 |
|
Level III Transfusion Laboratory Procedures |
|
$47.12 |
0347 |
86890 |
|
Autologous blood process |
|
0347 |
86930 |
|
Frozen blood prep |
|
0347 |
86931 |
|
Frozen blood thaw |
|
0347 |
86932 |
|
Frozen blood freeze/thaw |
|
0347 |
86977 |
|
Rbc pretreatment serum |
|
Clotting Factors
CMS is reducing the payment for blood clotting factors from 105 percent of ASP to 104 percent of ASP. There will continue to be a separately paid per unit furnishing fee for blood clotting factors, which currently is set at $0.176 per unit. The furnishing fee for 2012 will be announced later this year.