CMS released its final rule on the hospital Outpatient Prospective Payment System for the 2012 calendar year, and Medicare payment rates for hospitals under the OPPS will increase by an average of 1.9 percent.
The payment increase was based off the projected hospital inpatient market basket percentage increase of 3 percent minus 1 percent for the multifactor productivity adjustment and minus 0.1 percent as an additional adjustment. Both of these adjustment are required by the Patient Protection and Affordable Care Act.
In total, CMS projects total outpatient payments to the more than 4,000 hospitals paid under the OPPS will total approximately $41.1 billion in calendar year 2012. Other provisions of the final rule include the following:
• As required by the PPACA, a payment adjustment for designated cancer hospitals was needed. The final rule increased total payments to cancer hospitals by 11.3 percent (or roughly $71 million), a higher increase than the 9 percent in the proposed rule.
• Several parties voiced concerns that Medicare's requirement for direct physician supervision of outpatient hospital therapeutic services could limit access for beneficiaries. Consequently, the final rule established that CMS will seek recommendations from the Ambulatory Payment Classification Advisory Panel about appropriate supervision requirements. Two small rural PPS hospital members and two critical access hospital members will represent their interests to the APC so all hospitals subject to the supervision rules for payment of outpatient therapeutic services will be represented.
• Four hundred and sixty HCPCS codes will be removed from the CY 2012 bypass list because the codes were either deleted from the HCPCS before CY 2010 or were not separately payable codes under the CY 2012 OPPS. A partial list of removed HCPCS codes can be found on page 67, and a full list can be found in Addendum N.
• Pay for the acquisition and pharmacy overhead costs of separately payable drugs and biologicals, other than new drugs and biologicals that have pass-through status, will be at the average sales price plus 4 percent. Also, 19 drugs and biologicals will have their pass-through status expire on Dec. 31, 2011, while 38 drugs and biologicals will continue their pass-through status for CY 2012. The lists can be found on pages 576 and 588.
• The policy to specify that the pass-through evaluation process and pass-through payment methodology for implantable biologicals that are surgically inserted or implanted be the device pass-through process and payment methodology only will continue.
• CMS will continue paying for all multiple imaging procedures within an imaging family performed on the same date of service using the multiple imaging composite payment methodology.
• Pay for partial hospitalization services in hospital-based programs and community mental health centers will be based on the unique cost-structures of each type of program. CMS aims to update the four partial hospitalization per diem payment rates based on the median costs calculated using the most recent claims data for each provider type.
• Because Section 1886 of the PPACA requires value-based incentive payments under the Hospital Inpatient Value-Based Purchasing Program to be made to hospitals for discharges occurring on or after Oct. 1, 2012, CMS also included final rulings on the Hospital VBP Program. CMS has already adopted a final rule for fiscal year 2013 and also added final rules for FY 2014 in the OPPS register. Program requirements for the Hospital VBP Program for FY 2014 include: adding one clinical process measure to guard against infections due to urinary catheters and establishing the weighting, performance periods and performance standards for the clinical process, patient experience and outcomes measures for FY 2014. CMS did not include hospital-acquired condition measures, Agency for Healthcare Research and Quality composite measures or Medicare spending per beneficiary measures.
CMS will accept comments on the final rule by Jan. 3, 2012, and will respond to them in the 2013 calendar year rule.
CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
CMS Clarifies Correct Coding Initiative Edits for Outpatient Payments
CMS Issues CY 2012 Outpatient Prospective Payment System Proposed Rule
The payment increase was based off the projected hospital inpatient market basket percentage increase of 3 percent minus 1 percent for the multifactor productivity adjustment and minus 0.1 percent as an additional adjustment. Both of these adjustment are required by the Patient Protection and Affordable Care Act.
In total, CMS projects total outpatient payments to the more than 4,000 hospitals paid under the OPPS will total approximately $41.1 billion in calendar year 2012. Other provisions of the final rule include the following:
• As required by the PPACA, a payment adjustment for designated cancer hospitals was needed. The final rule increased total payments to cancer hospitals by 11.3 percent (or roughly $71 million), a higher increase than the 9 percent in the proposed rule.
• Several parties voiced concerns that Medicare's requirement for direct physician supervision of outpatient hospital therapeutic services could limit access for beneficiaries. Consequently, the final rule established that CMS will seek recommendations from the Ambulatory Payment Classification Advisory Panel about appropriate supervision requirements. Two small rural PPS hospital members and two critical access hospital members will represent their interests to the APC so all hospitals subject to the supervision rules for payment of outpatient therapeutic services will be represented.
• Four hundred and sixty HCPCS codes will be removed from the CY 2012 bypass list because the codes were either deleted from the HCPCS before CY 2010 or were not separately payable codes under the CY 2012 OPPS. A partial list of removed HCPCS codes can be found on page 67, and a full list can be found in Addendum N.
• Pay for the acquisition and pharmacy overhead costs of separately payable drugs and biologicals, other than new drugs and biologicals that have pass-through status, will be at the average sales price plus 4 percent. Also, 19 drugs and biologicals will have their pass-through status expire on Dec. 31, 2011, while 38 drugs and biologicals will continue their pass-through status for CY 2012. The lists can be found on pages 576 and 588.
• The policy to specify that the pass-through evaluation process and pass-through payment methodology for implantable biologicals that are surgically inserted or implanted be the device pass-through process and payment methodology only will continue.
• CMS will continue paying for all multiple imaging procedures within an imaging family performed on the same date of service using the multiple imaging composite payment methodology.
• Pay for partial hospitalization services in hospital-based programs and community mental health centers will be based on the unique cost-structures of each type of program. CMS aims to update the four partial hospitalization per diem payment rates based on the median costs calculated using the most recent claims data for each provider type.
• Because Section 1886 of the PPACA requires value-based incentive payments under the Hospital Inpatient Value-Based Purchasing Program to be made to hospitals for discharges occurring on or after Oct. 1, 2012, CMS also included final rulings on the Hospital VBP Program. CMS has already adopted a final rule for fiscal year 2013 and also added final rules for FY 2014 in the OPPS register. Program requirements for the Hospital VBP Program for FY 2014 include: adding one clinical process measure to guard against infections due to urinary catheters and establishing the weighting, performance periods and performance standards for the clinical process, patient experience and outcomes measures for FY 2014. CMS did not include hospital-acquired condition measures, Agency for Healthcare Research and Quality composite measures or Medicare spending per beneficiary measures.
CMS will accept comments on the final rule by Jan. 3, 2012, and will respond to them in the 2013 calendar year rule.
CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
Related Articles on the Medicare OPPS:
AHA Submits Comments on 2012 Physician Fee Schedule, OPPSCMS Clarifies Correct Coding Initiative Edits for Outpatient Payments
CMS Issues CY 2012 Outpatient Prospective Payment System Proposed Rule