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Medicare 2014 Hospital Outpatient PPS Final Rule - Summary of Major Provisions Affecting Transfusion Medicine and Cellular Therapies

The Centers for Medicare and Medicaid Services (CMS) has published its final rule governing payment policies and rates for the Medicare Hospital Outpatient Prospective Payment System (OPPS) for 2014. The rule includes relatively modest reductions in payments for several frequently transfused blood products. Payments for transfusion services, apheresis and stem cell processing, as well as many blood processing codes, will increase substantially; however, these increases likely are due to new packaging of other services, in particular laboratory tests. The rule takes effect January 1, 2014.

Overall Payment Rates

Overall payments for hospital outpatient services will increase by 1.7 percent in 2014. 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 APC payment rates are adjusted for geographic cost differences, and payment rates and policies are updated annually through rulemaking.

The following summarizes key provisions of the rule of interest to the transfusion medicine and cellular therapy community.

Changes in Packaging of Services

The hospital OPPS 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. In this rule, CMS is establishing significant 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 rather than being incentivized to use more expensive items and/or provide additional adjunct services.

In the proposed rule, CMS indicated that codes with an X status, including transfusion and blood processing codes, would be packaged into a primary procedure. However, CMS decided not to finalize this proposal until they study the issue further. The following are the major packaging changes in the final rule:

Packaging of Laboratory Tests – Currently, most clinical diagnostic lab tests are paid separately under the lab fee schedule and are excluded from OPPS. In the proposed rule, CMS indicated its intention to package clinical diagnostic lab tests into the primary procedure which they support, with the exception of molecular pathology tests. While there were numerous comments in opposition to this change, CMS decided to proceed with this policy for 2014. If the lab tests are the only services provided or if they are unrelated to another procedure (e.g., a surgical procedure or clinic visit) performed on the same day, they will not be packaged. In these situations, the lab tests will continue to be paid separately under the lab fee schedule.

Packaging of Add-on Codes – CMS will no longer provide separate payment for most add on codes. Thus, Code 88185, flow cytometry TC beyond one marker will not be paid and the costs of this procedure will be bundled into the APC for Code 88184. In the proposed rule, CMS indicated that this policy would also apply to add on drug administration codes such as “each additional hour” or “each additional drug.” However, CMS decided not to apply this policy to drug administration codes in the final rule.

Establishment of Comprehensive APC’s – For 2015, CMS will establish 29 comprehensive APCs. These all involve the implantation of costly devices. For these comprehensive APCs, CMS will package virtually all items and services provided in conjunction with one of these procedures. This will 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.

Payments for Blood Products

Table 1 outlines the 2014 payments, in comparison to 2013 rates, for blood products. Payments for some of the most frequently transfused blood products will decrease in 2014. For example, the payment for leukoreduced RBCs will fall from $193.24 in 2013 to $190.71 in 2014 and the rate for leukoreduced platelets, pheresis will drop from $511.27 to $499.68.

TABLE 1
BLOOD PRODUCTS

CPT/ HCPCS

Description

APC

2013 Payment Rate

2014 Payment Rate

$
Change

%
Change

P9010

Whole blood for transfusion

0950

$169.83

$195.65

$25.82

15.20%

P9011

Blood split unit

0967

$136.36

$101.66

-$34.70

-25.45%

P9012

Cryoprecipitate each unit

0952

$78.64

$65.53

-$13.11

-16.67%

P9016

RBC leukocytes reduced

0954

$193.24

$190.71

-$2.53

-1.31%

P9017

Plasma 1 donor frz w/in 8 hr

9508

$78.71

$79.16

$0.45

0.57%

P9019

Platelets, each unit

0957

$91.61

$117.65

$26.04

28.42%

P9020

Platelet rich plasma unit

0958

$175.62

$165.94

-$9.68

-5.51%

P9021

Red blood cells unit

0959

$151.79

$151.49

-$0.30

-0.20%

P9022

Washed red blood cells unit

0960

$296.39

$289.41

-$6.98

-2.36%

P9023

Frozen plasma, pooled, sd

0949

$72.23

$71.60

-$0.63

-0.87%

P9031

Platelets leukocytes reduced

1013

$118.34

$118.27

-$0.07

-0.06%

P9032

Platelets, irradiated

9500

$134.23

$168.42

$34.19

25.47%

P9033

Platelets leukoreduced irrad

0968

$156.45

$160.83

$4.38

2.80%

P9034

Platelets, pheresis

9507

$431.99

$402.22

-$29.77

-6.89%

P9035

Platelet pheres leukoreduced

9501

$511.27

$499.68

-$11.59

-2.27%

P9036

Platelet pheresis irradiated

9502

$675.77

$584.17

-$91.60

-13.55%

P9037

Plate pheres leukoredu irrad

1019

$674.16

$669.67

-$4.49

-0.67%

P9038

RBC irradiated

9505

$201.95

$219.34

$17.39

8.61%

P9039

RBC deglycerolized

9504

$479.74

$379.85

-$99.89

-20.82%

P9040

RBC leukoreduced irradiated

0969

$273.19

$278.41

$5.22

1.91%

P9043

Plasma protein fract,5%,50ml

0956

$20.31

$16.77

-$3.54

-17.43%

P9044

Cryoprecipitatereducedplasma

1009

$67.97

$86.00

$18.03

26.53%

P9048

Plasmaprotein fract,5%,250ml

0966

$47.16

$37.03

-$10.13

-21.48%

P9050

Granulocytes, pheresis unit

9506

$1,618.09

$1,887.17

$269.08

16.63%

P9051

Blood, l/r, cmv-neg

1010

$185.29

$169.79

-$15.50

-8.37%

P9052

Platelets, hla-m, l/r, unit

1011

$775.45

$781.78

$6.33

0.82%

P9053

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

1020

$660.47

$700.42

$39.95

6.05%

P9054

Blood, l/r, froz/degly/wash

1016

$122.44

$226.81

$104.37

85.24%

P9055

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

1017

$336.54

$432.56

$96.02

28.53%

P9056

Blood, l/r, irradiated

1018

$175.91

$165.34

-$10.57

-6.01%

P9057

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

1021

$368.69

$434.58

$65.89

17.87%

P9058

RBC, l/r, cmv-neg, irrad

1022

$286.56

$290.34

$3.78

1.32%

P9059

Plasma, frz between 8-24hour

0955

$75.53

$69.61

-$5.92

-7.84%

P9060

Fr frz plasma donor retested

9503

$56.82

$61.03

$4.21

7.41%

 

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

As outlined in Table 2, payments for transfusion and stem cell collection and processing procedures will increase significantly in 2014. The payment for APC 0111 (apheresis, RBC, platelets, etc. and harvest autologous stem cells) will increase from $950.65 in 2013 to $1,085.36 in 2014 and payment for APC 0112 (bone marrow collection, apheresis, adsorp/reinfuse, photopheresis, etc.) will rise from $2888.70 to $3,065.98. It is likely that some of these increases are due to the new packaging of services, in particular the bundling of laboratory tests.

The payment for the bone marrow biopsy and aspiration codes would more than double. Code G0364, bone marrow aspirate performed through the same incision as a biopsy on the same day will also see a dramatic increase in payments. However, this code has been assigned a status indictor “T” meaning that it would generally be subject to a multiple procedure payment reduction. The APC rate for Code 88184, flow cytometry TC, one marker, will be increased by about 56 percent presumably because the add-on code 88185 would be packaged into the base code. The pattern of the APC rates for interpreting flow cytometry tests is hard to explain. Code 88189, reading 16 or more markers will be paid much less than the codes for reading fewer markers. This may have been a mistake or potentially could be due to aberrant charging practices.

TABLE 2
TRANSFUSION, APHERESIS AND STEM CELL PROCEDURES

CPT/ HCPCS

Description

2013 APC

2014 APC

2013 Payment Rate

2014 Payment Rate

$
Change

%
Change

36430

Blood transfusion service

0110

0110

$260.44

$285.17

$24.73

9.50%

36440

Bl push transfuse, 2 yr or <

0110

0110

$260.44

$285.17

$24.73

9.50%

36450

Bl exchange/transfuse, nb

0110

0110

$260.44

$285.17

$24.73

9.50%

36455

Bl exchange/transfuse non-nb

0110

0110

$260.44

$285.17

$24.73

9.50%

36511

Apheresis wbc

0111

0111

$950.65

$1,085.36

$134.71

14.17%

36512

Apheresis rbc

0111

0111

$950.65

$1,085.36

$134.71

14.17%

36513

Apheresis platelets

0111

0111

$950.65

$1,085.36

$134.71

14.17%

36514

Apheresis plasma

0111

0111

$950.65

$1,085.36

$134.71

14.17%

36515

Apheresis, adsorp/reinfuse

0112

0112

$2,888.70

$3,065.98

$176.98

6.13%

36516

Apheresis, selective

0112

0112

$2,888.70

$3,065.98

$176.98

6.13%

36522

Photopheresis

0112

0112

$2,888.70

$3,065.98

$176.98

6.13%

38206

Harvest auto stem cells

0111

0111

$950.65

$1,085.36

$134.71

14.17%

38207

Cryopreserve stem cells

0110

0110

$260.44

$285.17

$24.73

9.50%

38208

Thaw preserved stem cells

0110

0110

$260.44

$285.17

$24.73

9.50%

38209

Wash harvest stem cells

0110

0110

$260.44

$285.17

$24.73

9.50%

38210

T-cell depletion of harvest

0393

0393

$435.79

$565.95

$130.16

29.87%

38211

Tumor cell deplete of harvst

0393

0393

$435.79

$565.95

$130.16

29.87%

38212

Rbc depletion of harvest

0393

0393

$435.79

$565.95

$130.16

29.87%

38213

Platelet deplete of harvest

0393

0393

$435.79

$565.95

$130.16

29.87%

38214

Volume deplete of harvest

0393

0393

$435.79

$565.95

$130.16

29.87%

38215

Harvest stem cell concentrate

0393

0393

$435.79

$565.95

$130.16

29.87%

38220

Bone marrow aspiration

0003

0003

$270.40

$640.91

$370.51

137.02%

38221

Bone marrow biopsy

0003

0003

$270.40

$640.91

$370.51

137.02%

38230

Bone marrow collection

0112

0112

$2,888.70

$3,065.68

$176.98

6.13%

38232

Bone marrow harvest autolog

0112

0112

$2,888.70

$3,065.68

$176.98

6.13%

38240

Bone marrow/stem transplant

0112

0112

$2,888.70

$3,065.68

$176.98

6.13%

38241

Bone marrow/stem transplant

0112

0112

$2,888.70

$3,065.68

$176.98

6.13%

38242

Lymphocyte infuse transplant

0111

0111

$950.65

$1,085.36

$134.71

14.17%

88184

Flowcytometry/ tc, 1 marker

0433

0433

$23.43

$36.53

$13.10

55.91%

88185

Flowcytometry/tc, add-on

0342

NA*

$12.71

NA*

NA*

NA*

88187

Flowcytometry/read, 2-8

0433

0344

$23.43

$179.67

$156.24

666.84%

88188

Flowcytometry/read, 9-15

0433

0661

$23.43

$278.56

$254.80

1,087.49%

88189

Flowcytometry/read, 16 & >

0433

0433

$23.43

$36.53

$13.10

55.91%

G0364

Bone marrow aspirate &biopsy

0340

0019

$ 49.64

$318.79

$269.15

542.20%

*This add-on code is not paid separately under HOPPS

Payments for Transfusion and Blood Processing Codes

As noted in Table 3, the payment rates for blood processing Codes 86850-86999 have changed substantially. The majority will increase significantly – in some cases doubling or tripling the APC payment. However, nine of the codes would be reduced by over 30 percent. Although it is likely that most of the increases in payment are due to the packaging of clinical laboratory tests occurring on the same day, it is difficult to fully explain these changes.

TABLE 3
TRANSFUSION LABORATORY PROCEDURES

CPT/ HCPCS

Description

2013 APC

2014 APC

2013 Payment Rate

2014 Payment Rate

$ Change

% Change

86850

RBC antibody screen

0345

0345

$17.96

$12.12

-$5.84

-32.52%

86860

RBC antibody elution

0346

0347

$24.99

$60.46

$35.47

141.94%

86870

RBC antibody identification

0347

0346

$34.30

$31.57

-$2.73

-7.96%

86880

Coombs test direct

0409

0345

$9.67

$12.12

$2.45

25.34%

86885

Coombs test indirect qual

0409

0345

$9.67

$12.12

$2.45

25.34%

86886

Coombs test indirect titer

0409

0346

$9.67

$31.57

$21.90

226.47%

86890

Autologous blood process

0347

0347

$34.30

$60.46

$26.16

76.27%

86891

Autologous blood op salvage

0345

0347

$17.96

$60.46

$42.50

236.64%

86900

Blood typing abo

0409

0345

$9.67

$12.12

$2.45

25.34%

86901

Blood typing rh (d)

0409

0345

$9.67

$12.12

$2.45

25.34%

86902

Blood type antigen donor ea

0345

0346

$17.96

$31.57

$13.61

75.78%

86904

Blood typing patient serum

0345

0345

$17.96

$12.12

-$5.84

-32.52%

86905

Blood typing rbc antigens

0345

0345

$17.96

$12.12

-$5.84

-32.52%

86906

Blood typing rh phenotype

0345

0345

$17.96

$12.12

-$5.84

-32.52%

86920

Compatibility test spin

0345

0346

$17.96

$31.57

$13.61

75.78%

86921

Compatibility test incubate

0345

0345

$17.96

$12.12

-$5.84

-32.52%

86922

Compatibility test antiglob

0346

0346

$24.99

$31.57

$6.58

26.33%

86923

Compatibility test electric

0345

0346

$17.96

$31.57

$13.61

75.78%

86927

Plasma fresh frozen

0345

0438

$17.96

$105.90

$87.94

489.64%

86930

Frozen blood prep

0347

0347

$34.30

$60.46

$26.16

76.27%

86931

Frozen blood thaw

0347

0347

$34.30

$60.46

$26.16

76.27%

86932

Frozen blood freeze/thaw

0347

0345

$34.30

$12.12

-$22.18

-64.66%

86945

Blood product/irradiation

0345

0345

$17.96

$12.12

-$5.84

-32.52%

86950

Leukacyte transfusion

0345

0345

$17.96

$12.12

-$5.84

-32.52%

86960

Vol reduction of blood/prod

0345

0346

$17.96

$31.57

$13.61

75.78%

86965

Pooling blood platelets

0346

0347

$24.99

$60.46

$35.47

141.94%

86970

RBC pretreatment

0345

0346

$17.96

$31.57

$13.61

75.78%

86971

RBC pretreatment

0345

0346

$17.96

$31.57

$13.61

75.78%

86972

RBC pretreatment

0345

0346

$17.96

$31.57

$13.61

75.78%

86975

Rbc pretreatment serum

0347

0346

$34.30

$31.57

-$2.73

-7.96%

86976

Rbc pretreatment serum

0345

0347

$17.96

$60.46

$42.50

236.64%

86977

Rbc pretreatment serum

0347

0347

$34.30

$60.46

$26.16

76.27%

86978

Rbc pretreatment serum

0346

0346

$24.99

$31.57

$6.58

26.33%

86985

Split blood or products

0345

0347

$17.96

$60.46

$42.50

236.64%

86999

Transfusion procedure

0345

0345

$17.96

$12.12

-$5.84

-32.52%

Payments for Blood Clotting Factor

CMS will continue to pay for the most costly drugs and for blood clotting factors 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.

Collapsing of Clinic Visit Codes

Consistent with the proposed rule, CMS will collapse the 10 outpatient clinic visit codes (99201-99205 and 99211-99215) into a single new HCPCS code, G0463, assigned to APC 0634 with a payment rate of $92.53. In doing this, there would be no differentiation in the level of visit or whether it is for a new or established patient. Currently, the rates for the clinic visit codes range from $56 to $173. This policy will only affect the hospital’s facility fee and will not impact the physician reporting of these CPT codes for the professional work. CMS decided not to finalize the proposal to also collapse the emergency department codes.