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2013 Proposed Medicare Payments for Hospital Outpatient Services

On July 6, 2012, the Centers for Medicare and Medicaid Services (CMS) released the Hospital Outpatient Prospective Payment System (OPPS) proposed rule for 2013, which is available here (please note that this link will change after the rule is published in the Federal Register on July 30). The proposed rule includes relatively small reductions in payments for several frequently transfused blood products and increased payments for some cellular therapy related procedures. CMS will accept comments on the rule by September 4, 2012. The provisions of the rule are effective January 1, 2013 unless stated otherwise.

General Changes to Payment Rates

Overall, CMS is proposing to increase OPPS payment rates by 2.1 percent. The rate increase is based on a statutory formula that equals the projected hospital market basket – an inflation rate for goods and services used by hospitals – of 3.0 percent less statutory reductions totaling 0.9 percent, including an adjustment for economy-wide productivity. In addition, CMS proposes to continue the statutory 2.0 percentage point reduction in payments for hospitals failing to meet the hospital outpatient quality reporting (OQR) requirements.

CMS is proposing to use the geometric mean costs of services within an APC to determine the relative payment weights of services, rather than the median costs that have been used since the inception of the OPPS. 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). Overall, the change to geometric means from median costs would be budget neutral across all hospitals and CMS' analysis shows that the proposed change would have a limited payment impact on most providers, with a small number experiencing payment gains or losses based on their service mix. Some individual procedures will, however, see higher or lower payment.

Payments for Blood Products

As shown in Table 1, payments for several of the most frequently transfused blood products would decrease under CMS' proposal. For example, the payment for leukoreduced RBCs would fall from $198.90 in 2012 to $193.19 in 2013 and the rate for leukoreduced platelets, pheresis would drop from $538.84 to $510.12.

 

TABLE 1

BLOOD PRODUCTS

CPT/ HCPCS

Description

APC

2012 Final Payment Rate

2013 Proposed Payment Rate

$

Change

%

Change

P9010

Whole blood for transfusion

0950

$190.76

$170.00

-$20.76

-10.88%

P9011

Blood split unit

0967

$117.35

$141.73

$24.38

20.78%

P9012

Cryoprecipitate each unit

0952

$82.78

$81.05

-$1.73

-2.09%

P9016

RBC leukocytes reduced

0954

$198.90

$193.19

-$5.71

-2.87%

P9017

Plasma 1 donor frz w/in 8 hr

9508

$79.87

$77.30

-$2.57

-3.22%

P9019

Platelets, each unit

0957

$89.77

$89.62

-$0.15

-0.17%

P9020

Platelet rich plasma unit

0958

$141.83

$174.29

$32.46

22.89%

P9021

Red blood cells unit

0959

$149.16

$151.02

$1.86

1.25%

P9022

Washed red blood cells unit

0960

$287.38

$312.38

$25.00

8.70%

P9023

Frozen plasma, pooled, sd

0949

$66.84

$72.55

$5.71

8.54%

P9031

Platelets leukocytes reduced

1013

$131.07

$118.49

-$12.58

-9.60%

P9032

Platelets, irradiated

9500

$128.42

$133.86

$5.44

4.24%

P9033

Platelets leukoreduced irrad

0968

$140.00

$152.74

$12.74

9.10%

P9034

Platelets, pheresis

9507

$442.14

$431.74

-$10.40

-2.35%

P9035

Platelet pheres leukoreduced

9501

$538.84

$510.12

-$28.72

-5.33%

P9036

Platelet pheresis irradiated

9502

$554.93

$662.98

$108.05

19.47%

P9037

Plate pheres leukoredu irrad

1019

$691.79

$675.04

-$16.75

-2.42%

P9038

RBC irradiated

9505

$198.98

$204.01

$5.03

2.53%

P9039

RBC deglycerolized

9504

$238.64

$492.58

$253.94

106.41%

P9040

RBC leukoreduced irradiated

0969

$261.22

$272.13

$10.91

4.18%

P9043

Plasma protein fract,5%,50ml

0956

$18.02

$24.93

$6.91

38.35%

P9044

Cryoprecipitatereducedplasma

1009

$74.37

$67.04

-$7.33

-9.86%

P9048

Plasmaprotein fract,5%,250ml

0966

$72.55

$47.88

-$24.67

-34.00%

P9050

Granulocytes, pheresis unit

9506

$1,340.65

$1,623.25

$282.60

21.08%

P9051

Blood, l/r, cmv-neg

1010

$188.55

$182.91

-$5.64

-2.99%

P9052

Platelets, hla-m, l/r, unit

1011

$803.05

$779.45

-$23.60

-2.94%

P9053

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

1020

$615.69

$650.21

$34.52

5.61%

P9054

Blood, l/r, froz/degly/wash

1016

$104.95

$125.74

$20.79

19.81%

P9055

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

1017

$383.70

$341.51

-$42.19

-11.00%

P9056

Blood, l/r, irradiated

1018

$146.80

$177.10

$30.30

20.64%

P9057

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

1021

$448.82

$375.08

-$73.74

-16.43%

P9058

RBC, l/r, cmv-neg, irrad

1022

$305.97

$287.89

-$18.08

-5.91%

P9059

Plasma, frz between 8-24hour

0955

$72.82

$75.21

$2.39

3.28%

P9060

Fr frz plasma donor retested

9503

$80.95

$59.27

-$21.68

-26.78%

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 would increase under the proposed rule. The payment for APC 0111 (apheresis, RBC, platelets, etc. and harvest autologous stem cells) would increase from $816.59 in 2012 to $954.15 in 2013 and payment for APC 0112 (bone marrow collection, apheresis, adsorp/reinfuse, photopheresis, etc.) would rise from $2494.33 to $2877.50. 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 Final APC

2013 Proposed APC

2012 Payment Rate

2013 Proposed Payment Rate

$

Change

%

Change

36430

Blood transfusion service

0110

0110

$239.57

$260.18

$20.61

8.60%

36440

Bl push transfuse, 2 yr or <

0110

0110

$239.57

$260.18

$20.61

8.60%

36450

Bl exchange/transfuse, nb

0110

0110

$239.57

$260.18

$20.61

8.60%

36455

Bl exchange/transfuse non-nb

0110

0110

$239.57

$260.18

$20.61

8.60%

36511

Apheresis wbc

0111

0111

$816.59

$954.15

$137.56

16.85%

36512

Apheresis rbc

0111

0111

$816.59

$954.15

$137.56

16.85%

36513

Apheresis platelets

0111

0111

$816.59

$954.15

$137.56

16.85%

36514

Apheresis plasma

0111

0111

$816.59

$954.15

$137.56

16.85%

36515

Apheresis, adsorp/reinfuse

0112

0112

$2,494.33

$2,877.50

$383.17

15.36%

36516

Apheresis, selective

0112

0112

$2,494.33

$2,877.50

$383.17

15.36%

36522

Photopheresis

0112

0112

$2,494.33

$2,877.50

$383.17

15.36%

38206

Harvest auto stem cells

0111

0111

$816.59

$954.15

$137.56

16.85%

38207

Cryopreserve stem cells

0110

0110

$239.57

$260.18

$20.61

8.60%

38208

Thaw preserved stem cells

0110

0110

$239.57

$260.18

$20.61

8.60%

38209

Wash harvest stem cells

0110

0110

$239.57

$260.18

$20.61

8.60%

38210

T-cell depletion of harvest

0393

0393

$484.48

$423.30

-$61.18

-12.63%

38211

Tumor cell deplete of harvst

0393

0393

$484.48

$423.30

-$61.18

-12.63%

38212

Rbc depletion of harvest

0393

0393

$484.48

$423.30

-$61.18

-12.63%

38213

Platelet deplete of harvest

0393

0393

$484.48

$423.30

-$61.18

-12.63%

38214

Volume deplete of harvest

0393

0393

$484.48

$423.30

-$61.18

-12.63%

38215

Harvest stem cell concentrate

0393

0393

$484.48

$423.30

-$61.18

-12.63%

38220

Bone marrow aspiration

0003

0003

$248.89

$271.69

$22.80

9.16%

38221

Bone marrow biopsy

0003

0003

$248.89

$271.69

$22.80

9.16%

38230

Bone marrow collection

0112

0112

$2,494.33

$2,877.50

$383.17

15.36%

38232

Bone marrow harvest autolog

0112

0112

$2,494.33

$2,877.50

$383.17

15.36%

38240

Bone marrow/stem transplant

0112

0112

$2,494.33

$2,877.50

$383.17

15.36%

38241

Bone marrow/stem transplant

0112

0112

$2,494.33

$2,877.50

$383.17

15.36%

38242

Lymphocyte infuse transplant

0111

0111

$816.59

$954.15

$137.56

16.85%

88184

Flowcytometry/ tc, 1 marker

0433

0433

$17.04

$23.41

$6.37

37.38%

88185

Flowcytometry/tc, add-on

0433

0342

$17.04

$12.48

-$4.56

-26.76%

88187

Flowcytometry/read, 2-8

0342

0433

$11.21

$23.41

$12.20

108.83%

88188

Flowcytometry/read, 9-15

0343

0433

$36.82

$23.41

-$13.41

-36.42%

88189

Flowcytometry/read, 16 & >

0343

0433

$36.82

$23.41

-$13.41

-36.42%

G0364

Bone marrow aspirate &biopsy

0340

0340

$45.50

$48.95

$3.45

7.58%

 

TABLE 3

TRANSFUSION LABORATORY PROCEDURES

CPT/ HCPCS

Description

2012 Final APC

2013 Proposed APC

2012 Final Payment Rate

2013 Proposed 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

$24.71

-$0.06

-0.24%

86870

RBC antibody identification

0346

0347

$24.77

$34.21

$9.44

38.11%

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

$34.21

-$12.91

-27.40%

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

$24.71

-$0.06

-0.24%

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

$34.21

-$12.91

-27.40%

86931

Frozen blood thaw

0347

0347

$47.12

$34.21

-$12.91

-27.40%

86932

Frozen blood freeze/thaw

0347

0347

$47.12

$34.21

-$12.91

-27.40%

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

$24.71

-$0.06

-0.24%

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

$34.21

$9.44

38.11%

86976

Rbc pretreatment serum

0345

0345

$14.95

$17.96

$3.01

20.13%

86977

Rbc pretreatment serum

0347

0347

$47.12

$34.21

-$12.91

-27.40%

86978

Rbc pretreatment serum

0346

0346

$24.77

$24.71

-$0.06

-0.24%

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%

Separately Payable Drugs and Blood Clotting Factor Payment

For CY 2013, CMS is proposing to 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. The 2012 rate is $0.0181 per unit and the 2013 rate will be announced later this year.