The proposed rule includes a 3.2 percent annual inflation update to Medicare payment rates for most services that would be paid under both the Outpatient Prospective Payment System and the ASC Prospective Payment System. CMS projects that hospitals would receive $28.7 billion in CY 2009 for outpatient services furnished to Medicare beneficiaries. Furthermore, CMS expects to make payments of almost $3.9 billion in CY 2009 to the approximately 5,300 ASCs that participate in Medicare.
Here is a summary of the key changes to the Ambulatory Surgical Center Prospective Payment System.
1. Proposed changes to the ASC list of covered surgical procedures: CMS is proposing to add nine surgical procedures to the list of procedures for which Medicare will pay when performed in an ASC. These include three procedures for which the American Medical Association's CPT Editorial Panel has created new codes and descriptors, and six procedures that were previously excluded from payment under the ASC payment system.
CMS is also proposing to add five procedures to the list of office-based procedures (subject to payment at the lesser of the office practice expense payment to the physician or the standard ASC rate), and to update the list of device-intensive procedures and covered ancillary services and their rates, consistent with proposals in the OPPS update.
2. Proposed payment adjustments and annual updates. The revised ASC payment rates were set to reflect the same relativity of resource use among services as under the OPPS, taking into consideration the lower costs of ASC services and the requirement for budget neutrality in CY 2008, the first year of the revised payment system. Any changes CMS proposes to make to the ASC payment system for 2009 will not increase or decrease aggregate Medicare spending. The law does not allow an inflation update to the ASC payment system CY 2009.
Here is a summary of the key changes to the OPPS.
Proposals to strengthen ties between payment and quality 1. Payment reduction for failure to report quality measures. As required by law, CMS is proposing to reduce by 2 percentage points the proposed 2010 market basket inflation update for hospitals that fail to successfully report required quality measures beginning in 2009. The proposed reduction would not apply to payments for pass-through drugs and devices, separately payable drugs and biologicals, separately payable therapeutic radiopharmaceuticals, and services assigned to New Technology APCs. CMS is also proposing to reduce the beneficiary co-payment amount for services furnished in hospitals that have not met their reporting requirements so that beneficiaries share in the reduction of payments to these hospitals.
2. New quality measures to be reported. CMS is proposing to add four imaging efficiency measures that would be calculated using Medicare claims data, increasing the number of measures that must be reported to 11 in 2009 (from seven in 2008) for hospitals to receive the full market basket updates in 2010. For consideration for future OPPS updates, CMS is also seeking public comment on eighteen additional potential quality measures in areas including cancer care, emergency department throughput, screening for fall risk, and management of certain clinical conditions such as depression, stroke and rehabilitation, osteoporosis, asthma and community-acquired pneumonia.
3. Validation of quality reporting. CMS is also proposing to implement a data-validation approach for 2010 starting with Jan. 2009 encounters. This proposed validation approach would randomly select 800 reporting hospitals and validate the accuracy of reported data by selecting 50 records per selected hospital annually.
Proposed changes to Ambulatory Payment Classifications
1. New APCs for certain Type B emergency department visits. CMS now has data that show most emergency visits in Type B emergency departments are more expensive than clinic visits but less costly than emergency visits in Type A emergency departments, and is proposing to create four new APCs for Type B emergency department visits that would be paid based on claims data from these providers. As the costs for the most intensive emergency visits are approximately the same between Type A and B emergency departments, CMS would use a single APC for these visits.
2. Composite APCs for multiple imaging services. CMS is proposing to establish five imaging composite APCs based on the families of codes used in the MPFS for the multiple imaging procedure payment reduction policy under that system. These composite APCs would provide a single APC payment when two or more imaging procedures using the same imaging modality were provided in a single session. These composite APCs include
- ultrasound;
- computed tomography and computed tomographic angiography without contrast;
- CT and CTA with contrast;
- magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) without contrast; and
- MRI and MRA with contrast.
Proposals for payment of certain services
1. Device-dependent APCs. CMS is proposing to set the payment rates using the established device-dependent APC ratesetting methodology based on claims that include the full costs of required implanted devices.
2. Drugs and pharmacy overhead. CMS is proposing to pay for separately payable drugs and biologicals based on hospitals? reported costs at the average sales price plus 4 percent. CMS is also proposing to modify the Medicare cost report to establish two cost centers for reporting drugs with high and low pharmacy overhead costs.
3. Drug administration services. CMS is proposing to restructure the drug administration APCs from a six-level into a fiv-level structure to more closely align payment to hospital claims data and eliminate unnecessary APCs.
4. Nuclear medicine procedures. CMS is proposing to set the payment rates for nuclear medicine procedures based on the established rate-setting methodology using claims that include a charge for a required diagnostic radiopharmaceutical or other radioactive product.
5. Therapeutic radiopharmaceuticals. CMS is proposing to provide payment for separately payable therapeutic radiopharmaceuticals that submit ASP information through the existing ASP process at ASP plus 4 percent as the best proxy for therapeutic radiopharmaceutical average acquisition and handling costs. If ASP information is not available, CMS is proposing that payment would be based upon mean costs from hospital claims data.
6. Brachytherapy sources. CMS is proposing to pay for brachytherapy sources based on median unit costs, as calculated from claims data, according to the standard OPPS payment methodology.
7. Implantable biologicals. CMS is proposing to package payment for implantable biologicals without pass-through status to make payment for implantable biological devices consistent with payment for implantable nonbiological devices.
Proposed change for partial hospitalization services, including services provided by CMHCs: CMS is proposing two separate Partial Hospitalization Program rates: one for days with three services ($140) and one for days with four or more services ($174). CMS is also proposing to continue the CMHC multiple outlier threshold at 3.4 times the APC payment amount for 2009.
CMS has not yet issued a proposed rule for ASC quality reporting that is slated to begin in 2009; it is expected to be issued separately later this summer.
Comments on this proposed rule will be accepted until Sept. 2 and final 2009 OPPS/ASC payment rule will be issued by Nov. 1.
Read more and download supplementary information about the proposed update to the ASC payment system. Read more and download supplementary information about the proposed update to the OPPS.