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2014 Medicare Proposed Hospital Outpatient Payments

On July 8, 2013, the Centers for Medicare and Medicaid Services (CMS) released the Hospital Outpatient Prospective Payment System (OPPS) proposed rule for 2014, which is available here. The proposed rule includes relatively small changes in payments for most blood products. However, CMS is proposing significant changes in the way many products and services – including blood processing and transfusion and stem cell processing procedures – are packaged into ambulatory payment classifications (APCs).

Comments are due to CMS by September 6, 2013 and the final rule will be issued around November 1, 2013. The provisions of the rule are effective January 1, 2014 unless stated otherwise.

The following summary highlights provisions of the proposed rule of interest to the transfusion medicine and cellular therapy communities.

Inflationary Update

CMS proposes an inflationary update of 1.8 percent. CMS projects that OPPS payments will be about $4.27 billion in 2014, a 9.5 percent increase compared to 2013.

Changes in Packaging of Services

The OPPS system is a hybrid of a fee for service and a prospective payment system. When the payment system was established, it more closely resembled a fee schedule, although there was some limited packaging of items and services. For example, inexpensive drugs were not paid separately but packaged into the payment for the procedures performed. In the last few years, CMS began to expand the packaging of services so that certain supportive services (such as imaging guidance and intraoperative procedures) were included in the payment for the primary services.

In this rule, CMS is proposing some dramatic increases in the packaging of services paid under OPPS. The objective of these changes is to give hospitals greater incentives to use the most cost efficient items and services that meet the patient's needs. CMS hopes that packaging will encourage hospitals to more effectively negotiate prices with manufacturers and suppliers and establish protocols that ensure that only necessary services are provided.

The following are the major packaging changes being proposed:

Establishment of Comprehensive APC's—CMS is proposing to establish 29 comprehensive APCs. These all involve the implantation of costly devices. For these comprehensive APCs, CMS would package virtually all items and services provided in conjunction with one of these procedures. This would include costly drugs and blood and blood products which are now paid separately as well as diagnostic procedures and tests, laboratory tests and other treatments that assist in the delivery of the primary procedure; visits and evaluations performed in association with the procedure; uncoded services and supplies used during the service; outpatient department services delivered by therapists as part of the comprehensive service; durable medical equipment as well as prosthetic and orthotic items and supplies when provided as part of the outpatient service; and any other components reported by HCPCS codes that are provided during the comprehensive service.

Packaging of Ancillary Services—CMS is proposing to package most radiological imaging codes and a variety of diagnostic tests (excluding molecular tests). However, if no other significant procedure is performed on the same day as the diagnostic test, the APC for these services will be paid separately.

The services being packaged will generally be assigned a Q1 or Q2 status. Codes with aQ1 status will be packaged and not separately paid, if billed on the same day as a code with an S, T, or V status. "S" status procedures or services are separately paid under OPPS and are not discounted when performed with other services. "T" status procedures – generally assigned to surgical procedures – are also separately paid under OPPS but are subject to a multiple procedure reduction. "V" status is assigned to clinic or emergency department visits. Q2 is similar to the Q1 but is packaged only when billed with codes with a T status.

Attached to the summary (addendum D1 from the proposed rule), is a listing of the definitions of all the status indicators.

Packaging of Clinical Diagnostic Laboratory Tests—Currently, most clinical diagnostic tests are paid separately under the lab fee schedule and are excluded from OPPS. However, CMS is proposing to package clinical diagnostic lab tests – with the exception of molecular pathology tests – into the primary procedure which they support. If, however, the lab tests are the only services provided or if they are unrelated to the procedure (e.g., a surgical procedure or clinic visit) performed on the same day, they would not be packaged and would be paid separately under the lab fee schedule.

Implications of Proposed Rule for Blood and Stem Cell Providers

Attached are impact tables showing the proposed changes in the APC payment and, if applicable, the status indicator for blood, transfusion medicine and cellular therapy related codes. Chart 1 is for procedural codes, Chart 2 is for Blood APCs, and Chart 4 is for transfusion and blood processing services.

Transfusion, Apheresis and Stem Cell Procedural Codes (Table 1)

Blood transfusion service, apheresis, and the stem cell processing codes all see substantial increases in payment under the proposed rule. Some of these changes likely are due to the packaging of services, particularly the assignment of a Q1 status to the blood processing codes as shown in Table 1. Blood processing procedures – including antibody screening, blood typing, irradiation, etc. – are being assigned a Q1 status. Therefore, they would receive a packaged APC payment if provided on the same day as a code with an S, T or V status (such as a blood transfusion or harvest of a autologous stem cells).

The APC rates for the flow cytometry codes are scheduled to increase dramatically; however, they are being assigned a Q1 status so they would only be payable if not billed on the same day as a service with an S, T or V status.

Blood Products (Table 2)

The blood product proposed payments are a mix of increases and decreases, some of which are quite substantial. However, the rates for the highest volume blood codes (P9016, P9021, P9035, P9037 and P9040) are fairly stable with most seeing modest increases in payment.

Blood Processing Codes (Table 3)

Codes 86850-86999 are all being assigned a Q1 status, meaning they will be packaged and not separately paid if billed on the same day for a service with an S, T or V status. This would include the transfusion and apheresis codes which have been assigned S status. However, if the code is not billed on the same date of service as a code with S, T or V code, it will be separately payable. The APC rates for all of these codes when separately payable are being increased dramatically.

Payments for Blood Clotting Factor

CMS proposes to continue to pay for most costly drugs and for blood clotting factor at the rate of ASP +6%. The cost threshold for determining whether to package a drug into the APC rate is being increased from $80 per day to $90 per day. Drugs with estimated costs of less than this threshold are packaged into the APC rate for the procedures and are not paid for separately.

ADDENDUM D1.—PROPOSED OPPS PAYMENT STATUS INDICATORS FOR CY 2014

Proposed Status Indicator

Item/Code/Service

Proposed OPPS Payment Status

A

Services furnished to a hospital outpatient that are paid under a fee schedule or payment system other than OPPS, for example:

Not paid under OPPS.  Paid by fiscal intermediaries/MACs under a fee schedule or payment system other than OPPS.

Services are subject to deductible or coinsurance unless indicated otherwise.

 

• Ambulance Services

 

•  Clinical Diagnostic Laboratory Services

Not subject to deductible or coinsurance.

•  Non-Implantable Prosthetic and Orthotic Devices 

•  EPO for ESRD Patients

 

•  Physical, Occupational, and Speech Therapy

 

•  Diagnostic Mammography

 

•  Screening Mammography

Not subject to deductible or coinsurance.

B

Codes that are not recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x).

Not paid under OPPS.

•  May be paid by fiscal intermediaries/MACs when submitted on a different bill type, for example, 75x (CORF), but not paid under OPPS.

•  An alternate code that is recognized by OPPS when submitted on an outpatient hospital Part B bill type (12x and 13x) may be available.

C

Inpatient Procedures

Not paid under OPPS.  Admit patient.  Bill as inpatient.

D

Discontinued Codes

Not paid under OPPS or any other Medicare payment system.

E

Items, Codes, and Services:

Not paid by Medicare when submitted on outpatient claims (any outpatient bill type).

•  That are not covered by any Medicare outpatient benefit based on statutory exclusion.   

•  That are not covered by any Medicare outpatient benefit for reasons other than statutory exclusion   

•  That are not recognized by Medicare for outpatient claims but for which an alternate  code for the same item or service  may be available.     

•  For which separate payment is not provided on outpatient claims 

F

Corneal Tissue Acquisition; Certain CRNA Services and Hepatitis B Vaccines

Not paid under OPPS.  Paid at reasonable cost.

G

Pass-Through Drugs and Biologicals 

Paid under OPPS; separate APC payment.

H

Pass-Through Device Categories

Separate cost-based pass‑through payment; not subject to copayment.

J1

Outpatient department services paid through a comprehensive APC

Paid under OPPS; other services on the claim become packaged.

K

Nonpass-Through Drugs and Nonimplantable Biologicals, Including Therapeutic Radiopharmaceuticals

Paid under OPPS; separate APC payment.

L

Influenza Vaccine; Pneumococcal Pneumonia Vaccine

Not paid under OPPS.  Paid at reasonable cost; not subject to deductible or coinsurance.

M

Items and Services Not Billable to the Fiscal Intermediary/MAC

Not paid under OPPS.

N

Items and Services Packaged into APC Rates

Paid under OPPS; payment is packaged into payment for other services.  Therefore, there is no separate APC payment.

P

Partial Hospitalization

Paid under OPPS; per diem APC payment.

Q1

STV-Packaged Codes

Paid under OPPS; Addendum B displays APC assignments when services are separately payable.

(1)  Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator “S,” “T,”or “V,” 

(2)  In other circumstances, payment is made through a separate APC payment.

Q2

T-Packaged Codes

Paid under OPPS; Addendum B displays APC assignments when services are separately payable.

(1)  Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator “T.”

(2)  In other circumstances, payment is made through a separate APC payment.

Q3

Codes That May Be Paid Through a Composite APC

Paid under OPPS; Addendum B displays APC assignments when services are separately payable.

Addendum M displays composite APC assignments when codes are paid through a composite APC.

(1)  Composite APC payment based on OPPS composite-specific payment criteria.  Payment is packaged into a single payment for specific combinations of services.

(2)  In other circumstances, payment is made through a separate APC payment or packaged into payment for other services.

R

Blood and Blood Products

Paid under OPPS; separate APC payment.

S

Procedure or Service, Not Discounted When Multiple

Paid under OPPS; separate APC payment.

T

Procedure or Service, Multiple Reduction Applies

Paid under OPPS; separate APC payment.

U

Brachytherapy Sources

Paid under OPPS; separate APC payment.

V

Clinic or Emergency Department Visit

Paid under OPPS; separate APC payment.

Y

Non-Implantable Durable Medical Equipment

Not paid under OPPS.  All institutional providers other than home health agencies bill to DMERC.

 

Table 1. Transfusion, Apheresis – Stem Cell Procedures.

   
     

CPT/ HCPCS

Description

2013 Final APC

2014 Proposed APC

2013 Final Status Indicator*

2014 Proposed Status Indicator*

2013 Final Payment Rate

2014 Proposed Payment Rate

$Change

%Change

36430

Blood transfusion service

0110

0110

S

S

$260.44

$367.89

$107.45

41.26%

36440

Bl push transfuse, 2 yr or <

0110

0110

S

S

$260.44

$367.89

$107.45

41.26%

36450

Bl exchange/transfuse, nb

0110

0110

S

S

$260.44

$367.89

$107.45

41.26%

36455

Bl exchange/transfuse non-nb

0110

0110

S

S

$260.44

$367.89

$107.45

41.26%

36511

Apheresis wbc

0111

0111

S

S

$950.65

$1,092.24

$141.59

14.89%

36512

Apheresis rbc

0111

0111

S

S

$950.65

$1,092.24

$141.59

14.89%

36513

Apheresis platelets

0111

0111

S

S

$950.65

$1,092.24

$141.59

14.89%

36514

Apheresis plasma

0111

0111

S

S

$950.65

$1,092.24

$141.59

14.89%

36515

Apheresis, adsorp/reinfuse

0112

0112

S

S

$2,888.70

$3,233.29

$344.59

11.93%

36516

Apheresis, selective

0112

0112

S

S

$2,888.70

$3,233.29

$344.59

11.93%

36522

Photopheresis

0112

0112

S

S

$2,888.70

$3,233.29

$344.59

11.93%

38206

Harvest auto stem cells

0111

0111

S

S

$950.65

$1,092.24

$141.59

14.89%

38207

Cryopreserve stem cells

0110

0110

S

S

$260.44

$367.89

$107.45

41.26%

38208

Thaw preserved stem cells

0110

0110

S

S

$260.44

$367.89

$107.45

41.26%

38209

Wash harvest stem cells

0110

0110

S

S

$260.44

$367.89

$107.45

41.26%

38210

T-cell depletion of harvest

0393

0393

S

S

$435.79

$585.65

$149.86

34.39%

38211

Tumor cell deplete of harvst

0393

0393

S

S

$435.79

$585.65

$149.86

34.39%

38212

Rbc depletion of harvest

0393

0393

S

S

$435.79

$585.65

$149.86

34.39%

38213

Platelet deplete of harvest

0393

0393

S

S

$435.79

$585.65

$149.86

34.39%

38214

Volume deplete of harvest

0393

0393

S

S

$435.79

$585.65

$149.86

34.39%

38215

Harvest stem cell concentrte

0393

0393

S

S

$435.79

$585.65

$149.86

34.39%

38220

Bone marrow aspiration

0003

0003

T

T

$270.40

$1,073.60

$803.20

297.04%

38221

Bone marrow biopsy

0003

0003

T

T

$270.40

$1,073.60

$803.20

297.04%

38230

Bone marrow collection

0112

0112

S

S

$2,888.70

$3,233.29

$344.59

11.93%

38232

Bone marrow harvest autolog

0112

0112

S

S

$2,888.70

$3,233.29

$344.59

11.93%

38240

Bone marrow/stem transplant

0112

0112

S

S

$2,888.70

$3,233.29

$344.59

11.93%

38241

Bone marrow/stem transplant

0112

0112

S

S

$2,888.70

$3,233.29

$344.59

11.93%

38242

Lymphocyte infuse transplant

0111

0111

S

S

$950.65

$1,092.24

$141.59

14.89%

88184

Flowcytometry/ tc, 1 marker

0433

0344

X

Q1

$23.43

$277.56

$254.13

1084.64%

88185

Flowcytometry/tc, add-on

0342

NA

X

N

$12.71

NA

NA

NA

88187

Flowcytometry/read, 2-8

0433

0343

X

Q1

$23.43

$144.39

$120.96

516.26%

88188

Flowcytometry/read, 9-15

0433

0433

X

Q1

$23.43

$58.44

$35.01

149.42%

88189

Flowcytometry/read, 16 & >

0433

0343

X

Q1

$23.43

$144.39

$120.96

516.26%

G0364

Bone marrow aspirate &biopsy

0340

0003

X

Q1

$49.64

$1,073.60

$1,023.96

2062.77%

 

 

 

 

 

 

 

 

 

 

* Explanation of Status Indicators

N

Items and Services Packaged into APC Rates

Paid under OPPS; payment is packaged into payment for other services.  Therefore, there is no separate APC payment.

S

Procedure or Service, Not Discounted When Multiple

Paid under OPPS; separate APC payment.

T

Procedure or Service, Multiple Reduction Applies

Paid under OPPS; separate APC payment.

Q1

STV-Packaged Codes

Paid under OPPS; Addendum B displays APC assignments when services are separately payable.

(1)  Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator “S,” “T,”or “V,” 

(2)  In other circumstances, payment is made through a separate APC payment.

 

Table 2. Blood Product Codes.

 

CPT/ HCPCS

Description

2013 Final APC

2014 Proposed APC

2013 Final Status Indicator*

2014 Proposed Status Indicator*

2013 Final Payment Rate

2014 Proposed Payment Rate

$Change

%Change

P9010

Whole blood for transfusion

0950

0950

R

R

$169.83

$138.21

-$31.62

-18.62%

P9011

Blood split unit

0967

0967

R

R

$136.36

$103.52

-$32.84

-24.08%

P9012

Cryoprecipitate each unit

0952

0952

R

R

$78.64

$65.84

-$12.80

-16.28%

P9016

RBC leukocytes reduced

0954

0954

R

R

$193.24

$195.30

$2.06

1.07%

P9017

Plasma 1 donor frz w/in 8 hr

9508

9508

R

R

$78.71

$80.69

$1.98

2.52%

P9019

Platelets, each unit

0957

0957

R

R

$91.61

$117.33

$25.72

28.08%

P9020

Platelet rich plasma unit

0958

0958

R

R

$175.62

$176.37

$0.75

0.43%

P9021

Red blood cells unit

0959

0959

R

R

$151.79

$158.94

$7.15

4.71%

P9022

Washed red blood cells unit

0960

0960

R

R

$296.39

$280.20

-$16.19

-5.46%

P9023

Frozen plasma, pooled, sd

0949

0949

R

R

$72.23

$72.87

$0.64

0.89%

P9031

Platelets leukocytes reduced

1013

1013

R

R

$118.34

$119.91

$1.57

1.33%

P9032

Platelets, irradiated

9500

9500

R

R

$134.23

$141.94

$7.71

5.74%

P9033

Platelets leukoreduced irrad

0968

0968

R

R

$156.45

$162.15

$5.70

3.64%

P9034

Platelets, pheresis

9507

9507

R

R

$431.99

$415.51

-$16.48

-3.81%

P9035

Platelet pheres leukoreduced

9501

9501

R

R

$511.27

$519.90

$8.63

1.69%

P9036

Platelet pheresis irradiated

9502

9502

R

R

$675.77

$602.58

-$73.19

-10.83%

P9037

Plate pheres leukoredu irrad

1019

1019

R

R

$674.16

$672.38

-$1.78

-0.26%

P9038

RBC irradiated

9505

9505

R

R

$201.95

$210.51

$8.56

4.24%

P9039

RBC deglycerolized

9504

9504

R

R

$479.74

$368.22

-$111.52

-23.25%

P9040

RBC leukoreduced irradiated

0969

0969

R

R

$273.19

$277.06

$3.87

1.42%

P9043

Plasma protein fract,5%,50ml

0956

0956

R

R

$20.31

$16.52

-$3.79

-18.66%

P9044

Cryoprecipitatereducedplasma

1009

1009

R

R

$67.97

$79.70

$11.73

17.26%

P9048

Plasmaprotein fract,5%,250ml

0966

0966

R

R

$47.16

$39.82

-$7.34

-15.56%

P9050

Granulocytes, pheresis unit

9506

9506

R

R

$1,618.09

$1,781.55

$163.46

10.10%

P9051

Blood, l/r, cmv-neg

1010

1010

R

R

$185.29

$175.32

-$9.97

-5.38%

P9052

Platelets, hla-m, l/r, unit

1011

1011

R

R

$775.45

$760.07

-$15.38

-1.98%

P9053

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

1020

1020

R

R

$660.47

$674.44

$13.97

2.12%

P9054

Blood, l/r, froz/degly/wash

1016

1016

R

R

$122.44

$246.69

$124.25

101.48%

P9055

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

1017

1017

R

R

$336.54

$291.46

-$45.08

-13.40%

P9056

Blood, l/r, irradiated

1018

1018

R

R

$175.91

$161.33

-$14.58

-8.29%

P9057

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

1021

1021

R

R

$368.69

$449.82

$81.13

22.00%

P9058

RBC, l/r, cmv-neg, irrad

1022

1022

R

R

$286.56

$294.61

$8.05

2.81%

P9059

Plasma, frz between 8-24hour

0955

0955

R

R

$75.53

$71.66

-$3.87

-5.12%

P9060

Fr frz plasma donor retested

9503

9503

R

R

$56.82

$62.36

$5.54

9.75%

* Explanation of Status Indicators

R

Blood and Blood Products

Paid under OPPS; separate APC payment.

 

Table 3. Transfusion and Blood Processing Codes.

   
     

CPT/ HCPCS

Description

2013 Final APC

2014 Proposed APC

2013 Final Status Indicator*

2014 Proposed Status Indicator*

2013 Final Payment Rate

2014 Proposed Payment Rate

$Change

%Change

86850

RBC antibody screen

0345

0345

X

Q1

$17.96

$84.29

$66.33

369.32%

86860

RBC antibody elution

0346

0346

X

Q1

$24.99

$142.86

$117.87

471.67%

86870

RBC antibody identification

0347

0347

X

Q1

$34.30

$168.84

$134.54

392.24%

86880

Coombs test direct

0409

0345

X

Q1

$9.67

$84.29

$74.62

771.66%

86885

Coombs test indirect qual

0409

0346

X

Q1

$9.67

$142.86

$133.19

1377.35%

86886

Coombs test indirect titer

0409

0346

X

Q1

$9.67

$142.86

$133.19

1377.35%

86890

Autologous blood process

0347

0347

X

Q1

$34.30

$168.84

$134.54

392.24%

86891

Autologous blood op salvage

0345

0347

X

Q1

$17.96

$168.84

$150.88

840.09%

86900

Blood typing abo

0409

0345

X

Q1

$9.67

$84.29

$74.62

771.66%

86901

Blood typing rh (d)

0409

0345

X

Q1

$9.67

$84.29

$74.62

771.66%

86902

Blood type antigen donor ea

0345

0346

X

Q1

$17.96

$142.86

$124.90

695.43%

86904

Blood typing patient serum

0345

0345

X

Q1

$17.96

$84.29

$66.33

369.32%

86905

Blood typing rbc antigens

0345

0345

X

Q1

$17.96

$84.29

$66.33

369.32%

86906

Blood typing rh phenotype

0345

0346

X

Q1

$17.96

$142.86

$124.90

695.43%

86920

Compatibility test spin

0345

0345

X

Q1

$17.96

$84.29

$66.33

369.32%

86921

Compatibility test incubate

0345

0346

X

Q1

$17.96

$142.86

$124.90

695.43%

86922

Compatibility test antiglob

0346

0347

X

Q1

$24.99

$168.84

$143.85

575.63%

86923

Compatibility test electric

0345

0345

X

Q1

$17.96

$84.29

$66.33

369.32%

86927

Plasma fresh frozen

0345

0346

X

Q1

$17.96

$142.86

$124.90

695.43%

86930

Frozen blood prep

0347

0347

X

Q1

$34.30

$168.84

$134.54

392.24%

86931

Frozen blood thaw

0347

0347

X

Q1

$34.30

$168.84

$134.54

392.24%

86932

Frozen blood freeze/thaw

0347

0345

X

Q1

$34.30

$84.29

$49.99

145.74%

86945

Blood product/irradiation

0345

0345

X

Q1

$17.96

$84.29

$66.33

369.32%

86950

Leukacyte transfusion

0345

0345

X

Q1

$17.96

$84.29

$66.33

369.32%

86960

Vol reduction of blood/prod

0345

0345

X

Q1

$17.96

$84.29

$66.33

369.32%

86965

Pooling blood platelets

0346

0346

X

Q1

$24.99

$142.86

$117.87

471.67%

86970

RBC pretreatment

0345

0345

X

Q1

$17.96

$84.29

$66.33

369.32%

86971

RBC pretreatment

0345

0345

X

Q1

$17.96

$84.29

$66.33

369.32%

86972

RBC pretreatment

0345

0346

X

Q1

$17.96

$142.86

$124.90

695.43%

86975

Rbc pretreatment serum

0347

0347

X

Q1

$34.30

$168.84

$134.54

392.24%

86976

Rbc pretreatment serum

0345

0346

X

Q1

$17.96

$142.86

$124.90

695.43%

86977

Rbc pretreatment serum

0347

0346

X

Q1

$34.30

$142.86

$108.56

316.50%

86978

Rbc pretreatment serum

0346

0346

X

Q1

$24.99

$142.86

$117.87

471.67%

86985

Split blood or products

0345

0346

X

Q1

$17.96

$142.86

$124.90

695.43%

86999

Transfusion procedure

0345

0345

X

Q1

$17.96

$84.29

$66.33

369.32%

* Explanation of Status Indicators

Q1

STV-Packaged Codes

Paid under OPPS; Addendum B displays APC assignments when services are separately payable.

(1)  Packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator “S,” “T,”or “V,” 

(2)  In other circumstances, payment is made through a separate APC payment.

X

Ancillary Services

Paid under OPPS; separate APC payment.