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CMS Publishes 2013 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 2013. The rule, which can be found at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1589-FC.html, includes reductions in payments for several frequently transfused blood products and increases in payments for most transfusion and stem cell collection and processing procedures. The provisions of the rule are effective January 1, 2013.

Overall Payment Rates

Overall payments for hospital outpatient services will increase by 1.8 percent in 2013. Payments made under OPPS cover facility resources including equipment, supplies, and hospital staff, but do not include services of 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. The actual impact of the final rule 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.

CMS is now basing its relative payment weights on geometric mean costs, rather than median costs. CMS believes that the geometric mean costs better reflect average costs of services than the median. Geometric means are also the basis of the Inpatient Prospective Payment System (DRG system).

In addition, CMS will continue the statutory 2.0 percentage point reduction in payments for hospitals failing to meet the hospital outpatient quality reporting (OQR) requirements.

Payments for Blood Products

As shown in Table 1, payments for some of the most frequently transfused blood products will decrease in 2013. For example, the payment for leukoreduced RBCs will fall from $198.90 in 2012 to $193.24 in 2013 and the rate for leukoreduced platelets, pheresis will drop from $538.84 to $511.27.

TABLE 1
BLOOD PRODUCTS

CPT/
HCPCS
Description APC 2012
Payment
Rate
2013
Payment
Rate
$ Change % Change
P9010 Whole blood for transfusion 0950 $190.76 $169.83 -$20.93 -10.97%
P9011 Blood split unit 0967 $117.35 $136.36 $19.01 16.20%
P9012 Cryoprecipitate each unit 0952 $82.78 $78.64 -$4.14 -5.00%
P9016 RBC leukocytes reduced 0954 $198.90 $193.24 -$5.66 -2.85%
P9017 Plasma 1 donor frz w/in 8 hr 9508 $79.87 $78.71 -$1.16 -1.45%
P9019 Platelets, each unit 0957 $89.77 $91.61 $1.84 2.05%
P9020 Platelet rich plasma unit 0958 $141.83 $175.62 $33.79 23.82%
P9021 Red blood cells unit 0959 $149.16 $151.79 $2.63 1.76%
P9022 Washed red blood cells unit 0960 $287.38 $296.39 $9.01 3.14%
P9023 Frozen plasma, pooled, sd 0949 $66.84 $72.23 $5.39 8.06%
P9031 Platelets leukocytes reduced 1013 $131.07 $118.34 -$12.73 -9.71%
P9032 Platelets, irradiated 9500 $128.42 $134.23 $5.81 4.52%
P9033 Platelets leukoreduced irrad 0968 $140.00 $156.45 $16.45 11.75%
P9034 Platelets, pheresis 9507 $442.14 $431.99 -$10.15 -2.30%
P9035 Platelet pheres leukoreduced 9501 $538.84 $511.27 -$27.57 -5.12%
P9036 Platelet pheresis irradiated 9502 $554.93 $675.77 $120.84 21.78%
P9037 Plate pheres leukoredu irrad 1019 $691.79 $674.16 -$17.63 -2.55%
P9038 RBC irradiated 9505 $198.98 $201.95 $2.97 1.49%
P9039 RBC deglycerolized 9504 $238.64 $479.74 $241.10 101.03%
P9040 RBC leukoreduced irradiated 0969 $261.22 $273.19 $11.97 4.58%
P9043 Plasma protein fract,5%,50ml 0956 $18.02 $20.31 $2.29 12.71%
P9044 Cryoprecipitatereducedplasma 1009 $74.37 $67.97 -$6.40 -8.61%
P9048 Plasmaprotein fract,5%,250ml 0966 $72.55 $47.16 -$25.39 -35.00%
P9050 Granulocytes, pheresis unit 9506 $1,340.65 $1,618.09 $277.44 20.69%
P9051 Blood, l/r, cmv-neg 1010 $188.55 $185.29 -$3.26 -1.73%
P9052 Platelets, hla-m, l/r, unit 1011 $803.05 $775.45 -$27.60 -3.44%
P9053 Plt, pher, l/r cmv-neg, irr 1020 $615.69 $660.47 $44.78 7.27%
P9054 Blood, l/r, froz/degly/wash 1016 $104.95 $122.44 $17.49 16.67%
P9055 Plt, aph/pher, l/r, cmv-neg 1017 $383.70 $336.54 -$47.16 -12.29%
P9056 Blood, l/r, irradiated 1018 $146.80 $175.91 $29.11 19.83%
P9057 RBC, frz/deg/wsh, l/r, irrad 1021 $448.82 $368.69 -$80.13 -17.85%
P9058 RBC, l/r, cmv-neg, irrad 1022 $305.97 $286.56 -$19.41 -6.34%
P9059 Plasma, frz between 8-24hour 0955 $72.82 $75.53 $2.71 3.72%
P9060 Fr frz plasma donor retested 9503 $80.95 $56.82 -$24.13 -29.81%

Payments for Transfusion, Apheresis and Bone Marrow/Stem Cell Procedures

As outlined in Table 2, payments for the majority of transfusion and stem cell collection and processing procedures will increase in 2013. The payment for APC 0111 (apheresis, RBC, platelets, etc. and harvest autologous stem cells) will increase from $816.59 in 2012 to $950.65 in 2013 and payment for APC 0112 (bone marrow collection, apheresis, adsorp/reinfuse, photopheresis, etc.) will rise from $2494.33 to $2888.70. AABB, along with other cellular therapy organizations, has expressed concerns in the past that CMS payments for such procedures fall notably below actual costs. Since the APC rates are based on hospital charges, it is critical that hospitals charge accurately for these procedures.

TABLE 2
TRANSFUSION, APHERESIS AND STEM CELL PROCEDURES

CPT/
HCPCS
Description 2012
APC
2013
APC
2012
Payment
Rate
2013
Payment
Rate
$ Change % Change
36430 Blood transfusion service 0110 0110 $239.57 $260.44 $20.87 8.71%
36440 Bl push transfuse, 2 yr or < 0110 0110 $239.57 $260.44 $20.87 8.71%
36450 Bl exchange/transfuse, nb 0110 0110 $239.57 $260.44 $20.87 8.71%
36455 Bl exchange/transfuse non-nb 0110 0110 $239.57 $260.44 $20.87 8.71%
36511 Apheresis wbc 0111 0111 $816.59 $950.65 $134.06 16.42%
36512 Apheresis rbc 0111 0111 $816.59 $950.65 $134.06 16.42%
36513 Apheresis platelets 0111 0111 $816.59 $950.65 $134.06 16.42%
36514 Apheresis plasma 0111 0111 $816.59 $950.65 $134.06 16.42%
36515 Apheresis, adsorp/reinfuse 0112 0112 $2,494.33 $2,888.70 $394.37 15.81%
36516 Apheresis, selective 0112 0112 $2,494.33 $2,888.70 $394.37 15.81%
36522 Photopheresis 0112 0112 $2,494.33 $2,888.70 $394.37 15.81%
38206 Harvest auto stem cells 0111 0111 $816.59 $950.65 $134.06 16.42%
38207 Cryopreserve stem cells 0110 0110 $239.57 $260.44 $20.87 8.71 %
38208 Thaw preserved stem cells 0110 0110 $239.57 $260.44 $20.87 8.71%
38209 Wash harvest stem cells 0110 0110 $239.57 $260.44 $20.87 8.71%
38210 T-cell depletion of harvest 0393 0393 $484.48 $435.79 -$48.69 -10.05%
38211 Tumor cell deplete of harvst 0393 0393 $484.48 $435.79 -$48.69 -10.05%
38212 Rbc depletion of harvest 0393 0393 $484.48 $435.79 -$48.69 -10.05%
38213 Platelet deplete of harvest 0393 0393 $484.48 $435.79 -$48.69 -10.05%
38214 Volume deplete of harvest 0393 0393 $484.48 $435.79 -$48.69 -10.05%
38215 Harvest stem cell concentrate 0393 0393 $484.48 $435.79 -$48.69 -10.05%
38220 Bone marrow aspiration 0003 0003 $248.89 $270.40 $21.51 8.64%
38221 Bone marrow biopsy 0003 0003 $248.89 $270.40 $21.51 8.64%
38230 Bone marrow collection 0112 0112 $2,494.33 $2,888.70 $394.37 15.81%
38232 Bone marrow harvest autolog 0112 0112 $2,494.33 $2,888.70 $394.37 15.81%
38240 Bone marrow/stem transplant 0112 0112 $2,494.33 $2,888.70 $394.37 15.81%
38241 Bone marrow/stem transplant 0112 0112 $2,494.33 $2,888.70 $394.37 15.81%
38242 Lymphocyte infuse transplant 0111 0111 $816.59 $950.65 $134.06 16.42%
88184 Flowcytometry/ tc, 1 marker 0433 0433 $17.04 $23.43 $6.39 37.50%
88185 Flowcytometry/tc, add-on 0433 0342 $17.04 $12.71 -$4.33 -25.41%
88187 Flowcytometry/read, 2-8 0342 0433 $11.21 $23.43 $12.22

109.01%

88188 Flowcytometry/read, 9-15 0343 0433 $36.82 $23.43 -$13.39 -36.37%
88189 Flowcytometry/read, 16 & > 0343 0433 $36.82 $23.43 -$13.39 -36.37%
G0364 Bone marrow aspirate &biopsy 0340 0340 $45.50 $ 49.64 $4.14 9.10%

 

TABLE 3
TRANSFUSION LABORATORY PROCEDURES

CPT/
HCPCS
Description 2012
APC
2013
APC
2012
Payment
Rate
2013
Payment
Rate
$ Change % Change
86850 RBC antibody screen 0345 0345 $14.95 $17.96 $3.01 20.13%
86860 RBC antibody elution 0346 0346 $24.77 $24.99 $0.22 0.89%
86870 RBC antibody identification 0346 0347 $24.77 $34.30 $9.53 38.47%
86880 Coombs test direct 0409 0409 $7.71 $9.67 $1.96 25.42%
86885 Coombs test indirect qual 0409 0409 $7.71 $9.67 $1.96 25.42%
86886 Coombs test indirect titer 0409 0409 $7.71 $9.67 $1.96 25.42%
86890 Autologous blood process 0347 0347 $47.12 $34.30 -$12.82 -27.21%
86891 Autologous blood op salvage 0345 0345 $14.95 $17.96 $3.01 20.13%
86900 Blood typing abo 0409 0409 $7.71 $9.67 $1.96 25.42%
86901 Blood typing rh (d) 0409 0409 $7.71 $9.67 $1.96 25.42%
86902 Blood type antigen donor ea 0345 0345 $14.95 $17.96 $3.01 20.13%
86904 Blood typing patient serum 0345 0345 $14.95 $17.96 $3.01 20.13%
86905 Blood typing rbc antigens 0345 0345 $14.95 $17.96 $3.01 20.13%
86906 Blood typing rh phenotype 0345 0345 $14.95 $17.96 $3.01 20.13%
86920 Compatibility test spin 0345 0345 $14.95 $17.96 $3.01 20.13%
86921 Compatibility test incubate 0345 0345 $14.95 $17.96 $3.01 20.13%
86922 Compatibility test antiglob 0346 0346 $24.77 $24.99 $0.22 0.89%
86923 Compatibility test electric 0345 0345 $14.95 $17.96 $3.01 20.13%
86927 Plasma fresh frozen 0345 0345 $14.95 $17.96 $3.01 20.13%
86930 Frozen blood prep 0347 0347 $47.12 $34.30 -$12.82 -27.21%
86931 Frozen blood thaw 0347 0347 $47.12 $34.30 -$12.82 -27.21%
86932 Frozen blood freeze/thaw 0347 0347 $47.12 $34.30 -$12.82 -27.21%
86945 Blood product/irradiation 0345 0345 $14.95 $17.96 $3.01 20.13%
86950 Leukacyte transfusion 0345 0345 $14.95 $17.96 $3.01 20.13%
86960 Vol reduction of blood/prod 0345 0345 $14.95 $17.96 $3.01 20.13%
86965 Pooling blood platelets 0346 0346 $24.77 $24.99 $0.22 0.89%
86970 RBC pretreatment 0345 0345 $14.95 $17.96 $3.01 20.13%
86971 RBC pretreatment 0345 0345 $14.95 $17.96 $3.01 20.13%
86972 RBC pretreatment 0345 0345 $14.95 $17.96 $3.01 20.13%
86975 Rbc pretreatment serum 0346 0347 $24.77 $34.30 $9.53 38.47%
86976 Rbc pretreatment serum 0345 0345 $14.95 $17.96 $3.01 20.13%
86977 Rbc pretreatment serum 0347 0347 $47.12 $34.30 -$12.82 -27.21%
86978 Rbc pretreatment serum 0346 0346 $24.77 $24.99 $0.22 0.89%
86985 Split blood or products 0345 0345 $14.95 $17.96 $3.01 20.13%
86999 Transfusion procedure 0345 0345 $14.95 $17.96 $3.01 20.13%

Molecular Pathology Services

For 2013, CMS is placing the 101 new molecular pathology services CPT codes on the Clinical Laboratory Fee Schedule (CLFS). Consistent with the OPPS assignment for the 101 molecular pathology services, the 14 new CPT codes also will be assigned to status indicator "A" for CY 2013. Specifically, CPT codes 81201 through 81203, 81235, 81252 through 81254, 81321 through 81326, and 81479 will be assigned to status indicator "A" because they will be paid under the CLFS. In announcing its plan to place the codes on the CLFS, instead of the Physician Fee Schedule, CMS stated, "we believe that the molecular pathology CPT codes describe clinical laboratory diagnostic laboratory tests that should be paid under the CLFS because these services do not ordinarily require interpretation by a physician to produce a meaningful result." However, CMS also wrote that it believes that, "in some cases, a physician interpretation of a molecular pathology test may be medically necessary to provide a clinically meaningful, beneficiary-specific result." To enable physician reimbursement in such instances, CMS has created a HCPCS G-code, G0452 (molecular pathology procedure; physician interpretation and report) to describe medically necessary interpretation and written report of a molecular pathology test.

Separately Payable Drugs and Blood Clotting Factor Payment

For CY 2013, CMS will pay for the cost of separately payable drugs and biologicals without pass-through status at the rate of average sales price (ASP) plus 6.0 percent. This is an increase from the current rate of ASP plus 4.0 percent. Blood clotting factor will also be paid at the increased ASP+ 6% rate. In addition, CMS will continue the separate payment for the cost of furnishing blood clotting factor.