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AABB > Programs & Services > Billing and Reimbursement Initiatives

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.

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