2013 Final OPPS
Final HOPPS 2013
Summary
SIR
On November 1, 2012 The Centers for Medicare & Medicaid Services (CMS) issued a final rule that would update payment policies and payment rates for services furnished to Medicare beneficiaries in hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) beginning Jan. 1, 2013.
The final rule affects hospital outpatient departments in more than 4,000 hospitals, including general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children’s hospitals, and cancer hospitals, and approximately 5,000 Medicare-participating ASCs.
The final rule will be published on November 15, 2012. It will take effect January 1, 2013 with a comment period that closes on December 31, 2012.
A display copy of the final rule can be found at:
http://www.ofr.gov/OFRUpload/OFRData/2012-26902_PI.pdf
The Addenda to the final rule for the HOPPS are available at:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1589-FC.html
The Addenda to the final rule for the ASC payment system are available at:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/ASC-Regulations-and-Notices-Items/CMS-1589-FC.html
Under the policies in this final rule payment rates for hospital outpatient departments will increase by 1.8 percent. The increase is based on the projected hospital market basket—an inflation rate for goods and services used by hospitals—of 2.6 percent, minus 0.8 percent in statutory reductions, including a 0.7 percent adjustment for economy-wide productivity and a 0.1 percentage point adjustment required by statute.
CMS is using a final conversion factor of $71.313 for CY2013 in the calculation of the national unadjusted payment rates for those items and services for which payment rates are calculated using geometric mean costs. They also are using a reduced conversion factor of $69.887 in the calculation of payments for hospitals that fail to comply with the Hospital OQR Program requirements.
Total payments to hospitals under the OPPS in CY 2013 will be approximately $48.1 billion.
Table 57 (page 1169) of this final rule displays the distributional impact all the OPPS changes on various groups of hospitals and CMHCs for CY 2013 compared to all estimated OPPS payments in CY 2012.
Geometric Mean-Based Relative Payment Weights (p. 172)
CY 2013 CMS is using the geometric mean costs of services within an APC to determine the relative payment weights of services, rather than the median costs they have used since the inception of the OPPS. CMS says that the final policy to base the APC relative payment weights on the geometric mean costs rather than the median costs of services within an APC will not significantly impact most providers.
Number of Claims
CMS used approximately 153 million final action claims for HOPD services furnished on or after January 1, 2011, and before January 1, 2012. Of those approximately 153 million final action claims, approximately 121 million claims )re the type of bill potentially appropriate for use in setting rates for OPPS services. Of the approximately 121 million claims, approximately 5 million claims were not for services paid under the OPPS or were excluded as not appropriate for use. From the remaining approximately 116 million claims, CMS created approximately 120 million single records, of which approximately 81 million were “pseudo” single or “single session” claims (created from approximately 39 million multiple procedure claims). Approximately 1 million claims were trimmed out on cost or units in excess of +/- 3 standard deviations from the geometric mean, yielding approximately 120 million single bills for ratesetting.
Bypass List (p. 69)
For CY2013 CMS will bypass 480 HCPCS codes, as displayed in Addendum N. Table 1 contains the list of codes that they are removing from the CY 2013 bypass list because these codes were either deleted from the HCPCS before CY 2011 (and therefore were not covered OPD services in CY 2011) or were not separately payable codes under the CY 2013 OPPS because these codes are not used for ratesetting (and therefore would not need to be bypassed). None of these deleted codes are “overlap bypass” codes.
Packaged Costs
CMS will continue to update the packaged cost threshold by the market basket increase. By applying the final CY 2012 market basket increase of 1.9 percent to the prior non-rounded dollar threshold of $52.76, CMS determined that the threshold remains for CY 2013 at $55 ($53.76 rounded to $55, the nearest $5 increment). Therefore, they will set the geometric mean packaged cost threshold on the CY 2011 claims at $55 for a code to be considered for addition to the CY 2013 OPPS bypass list.
Two Times Rule (p. 357)
CMS is finalizing their two times rule proposals with some modifications. The final list of 19 APCs exempted from the 2 times rule for CY 2013 is displayed in Table 17.
Items and services within an APC group shall not be treated as comparable with respect to the use of resources if the highest median/mean cost for an item or service within the group is more than 2 times greater than the lowest median/mean cost for an item or service within the same group (the 2 times rule).
For purposes of identifying significant HCPCS for examination in the 2 times rule, CMS considers codes that have more than 1,000 single major claims or codes that have both greater than 99 single major claims and contribute at least 2 percent of the single major claims used to establish the APC geometric mean cost to be significant.
Packaging (p. 246)
CMS is finalizing their existing packaging policies. The HCPCS codes that CMS unconditionally packaged (assigned status indicator “N”), or conditionally packaged (assigned status indicators “Q1,” “Q2,” or “Q3”) are displayed in Addendum B.
Device Dependent APCs (p. 119)
CMS is finalizing their proposed policy to use the standard methodology for calculating costs for device-dependent APCs for CY 2013 that was finalized in the CY 2012 OPPS/ASC final rule.
Hospital Outpatient Outlier Payments (p. 313)
CMS will continue to make an outlier payment that equals 50 percent of the amount by which the cost of furnishing the service exceeds 1.75 times the APC payment amount when both the 1.75 multiple threshold and the final fixed-dollar threshold of $2,025 are met.
Rural Adjustment (p. 303)
CMS is continuing the adjustment of 7.1 percent to the OPPS payments to certain rural sole community hospitals (SCHs), including essential access community hospitals (EACHs). This adjustment will apply to all services paid under the OPPS, excluding separately payable drugs and biologicals, devices paid under the pass-through payment policy, and items paid at charges reduced to cost.
Cancer Hospital Payment Adjustment (p. 306)
For CY 2013, CMS is continuing their policy to provide additional payments to cancer hospitals so that the hospital’s payment-to-cost ratio (PCR) with the payment adjustment is equal to the weighted average PCR for the other OPPS hospitals using the most recent submitted or settled cost report data. Based on those data, a target PCR of 0.91 will be used to determine the CY 2013 cancer hospital payment adjustment to be paid at cost report settlement. That is, the payment amount associated with the cancer hospital payment adjustment will be the additional payment needed to result in a PCR equal to 0.91 for each cancer hospital.
Table 9 indicates the estimated percentage increase in OPPS payments to each cancer hospital for CY 2013 due to the cancer hospital payment adjustment policy.
New Carotid Angiography Codes for CY2013
36221 / Place cath thoracic aorta / 0279 / $2,219.82 / N/A
36222 / Place cath carotid/inom art / 0279 / $2,219.82 / N/A
36223 / Place cath carotid/inom art / 0279 / $2,219.82 / N/A
36224 / Place cath carotd art / 0280 / $3,630.40 / N/A
36225 / Place cath subclavian art / 0279 / $2,219.82 / N/A
36226 / Place cath vertebral art / 0280 / $3,630.40 / N/A
36227 / Place cath xtrnl carotid
36228 / Place cath intracranial art
New Thrombolysis Codes for CY2013
HCPCS / Short Descriptor / 2013 APC / 2013 Payment Rate / 2012 Payment Rate37211 / Thrombolytic art therapy / 0621 / $786.08 / N/A
37212 / Thrombolytic venous therapy / 0621 / $786.08 / N/A
37213 / Thromblytic art/ven therapy / 0622 / $1,754.10 / N/A
37214 / Cessj therapy cath removal / 0622 / $1,754.10 / N/A
Mechanical Thrombectomy (APC 0653) (p. 409)
CMS received comments expressing concern regarding the proposed 19.7 percent reduction in the payment rate CPT code 36870. CMS continues to believe that APC 0653 is the most appropriate APC assignment for CPT code 36870 based on its clinical homogeneity and resource costs in relation to the other procedures assigned to the APC. CMS stated that their analysis of the latest hospital outpatient data for claims submitted for services provided during CY 2011 shows a geometric mean cost for CPT code 36870 of approximately $2,662, based on 539 single claims (out of 50,476 total claims), which is relatively similar to the proposed rule payment rate of approximately $2,748 for APC 0653.
Endovascular Revascularization of the Lower Extremity (APCs 0083, 0229, and 0319) (p. 416)
Despite objections, CMS is finalizing, without modification, their LE placements:
· CPT codes 37183 and 37210 to APC 0229;
· CPT code 37223 to APC 0083; and
· CPT codes 37234 and 37235 to APC 0083.
HCPCS / Short Descriptor / 2013 / 2013 Payment Rate / 2012 Payment Rate / % Change in Payment RateAPC
37220 / Iliac revasc / 0083 / $4,023.05 / $4,623.91 / -12.99%
37221 / Iliac revasc w/stent / 0229 / $8,656.82 / $8,095.74 / 6.93%
37222 / Iliac revasc add-on / 0083 / $4,023.05 / $4,623.91 / -12.99%
37223 / Iliac revasc w/stent add-on / 0083 / $4,023.05 / $4,623.91 / -12.99%
37224 / Fem/popl revas w/tla / 0083 / $4,023.05 / $4,623.91 / -12.99%
37225 / Fem/popl revas w/ather / 0229 / $8,656.82 / $8,095.74 / 6.93%
37226 / Fem/popl revasc w/stent / 0229 / $8,656.82 / $8,095.74 / 6.93%
37227 / Fem/popl revasc stnt & ather / 0319 / $14,596.24 / $14,210.32 / 2.72%
37228 / Tib/per revasc w/tla / 0083 / $4,023.05 / $4,623.91 / -12.99%
37229 / Tib/per revasc w/ather / 0229 / $8,656.82 / $8,095.74 / 6.93%
37230 / Tib/per revasc w/stent / 0229 / $8,656.82 / $8,095.74 / 6.93%
37231 / Tib/per revasc stent & ather / 0319 / $14,596.24 / $14,210.32 / 2.72%
37232 / Tib/per revasc add-on / 0083 / $4,023.05 / $4,623.91 / -12.99%
37233 / Tibper revasc w/ather add-on / 0229 / $8,656.82 / $8,095.74 / 6.93%
37234 / Revsc opn/prq tib/pero stent / 0083 / $4,023.05 / $4,623.91 / -12.99%
37235 / Tib/per revasc stnt & ather / 0083 / $4,023.05 / $4,623.91 / -12.99%
Non-Ophthalmic Fluorescent Vascular Angiography (APC 0397) (p. 485)
CMS is finalizing their proposal to assign HCPCS code C9733 to APC 0397 and to continue to assign the code to status indicator “Q2.” APC 0397 has a CY 2013 final geometric mean cost of approximately $340.
New/Revised Respiratory System: Lungs and Pleura Codes for CY2013
HCPCS / Short Descriptor / 2013 APC / 2013 Payment Rate / 2012 Payment Rate / % Change in Payment Rate32551 / Insertion of chest tube / 0070 / $412.39 / $385.64 / 6.94%
32554 / Aspirate pleura w/o imaging / 0070 / $412.39 / N/A
32555 / Aspirate pleura w/ imaging / 0070 / $412.39 / N/A
32556 / Insert cath pleura w/o image / 0070 / $412.39 / N/A
32557 / Insert cath pleura w/ image / 0070 / $412.39 / N/A
Packaging Recommendation of the HOP Panel (p. 227)
For CY 2013, CMS is accepting the Panel’s recommendation and finalizing their proposal to assign a status indicator of “Q1” to HCPCS code 19290, which is assigned to APC 0340 with a CY 2013 final payment rate of approximately $51.
Therapeutic Radiopharmaceuticals (p. 561)
CMS is finalizing their proposal to provide payment for drugs, biologicals, diagnostic and therapeutic radiopharmaceuticals and contrast agents that are granted pass-through status based on the ASP methodology. If a diagnostic or therapeutic radiopharmaceutical receives passthrough status during CY 2013, they will follow the standard ASP methodology to determine the pass-through payment rate that drugs receive which is ASP+6 percent. If ASP data are not available for a radiopharmaceutical, CMS will provide pass-through payment at WAC+6 percent, the equivalent payment provided to pass-through drugs and biologicals without ASP information. If WAC information is also not available, they will provide payment for the pass-through radiopharmaceutical at 95 percent of its most recent AWP.
HCPCS / Short Descriptor / 2013 APC / 2013 Payment Rate / 2012 Payment Rate / % Change in Payment RateA9543 / Y90 ibritumomab, rx / 1643 / $38,058.06 / $35,830.70 / 6.22%
A9545 / I131 tositumomab, rx / 1645 / $30,188.56 / $29,618.96 / 1.92%
Computed Tomography of Abdomen/Pelvis (APCs 0331 and 0334) (p. 491)
CMS is finalizing their proposal, without modification to continue to assign CPT code 74176 to APC 0331 and CPT codes 74177 and 74178 to APC 0334. In addition, they are continuing to assign these CPT codes to their existing composite APCs for CY 2013. Specifically, they are continuing to assign CPT code 74176 to composite APC 8005, and to assign CPT codes 74177 and 74178 to composite APC 8006.