CMS Publishes 2012 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 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.