Summary of the Final 2013 Policy, Payment Changes For Hospital Outpatient Departments

Transcription

1 Summary of the Final 2013 Policy, Payment Changes For Hospital Outpatient Departments A. Introduction On November 1, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that will update payment policies and rates for both hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs) for calendar year (CY) CMS will increase HOPD payment rates 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 less statutory reductions totaling 0.8 percent, including a 0.7 percent adjustment for economy-wide productivity and a 0.1 percentage point adjustment required by statute. Based on the updates and other policies in the final rule, CMS projects that total payments to hospitals under the Outpatient Prospective Payment System (OPPS) in calendar year 2013 will be approximately $48.1 billion. CMS is finalizing the use of geometric mean costs of services within an APC to determine the relative payment weights of services, rather than the median costs that have been used since the inception of the OPPS. CMS is making this change because geometric mean costs better reflect average costs of services than the median. Geometric means are the basis of the Inpatient Prospective Payment System. With more than a decade of experience under the OPPS, CMS believes hospital cost reporting is now sufficiently improved to allow this change to geometric mean costs. CMS analysis shows that the proposed change to geographic mean costs would have a limited payment impact on most providers, with a small number experiencing payment gains or losses based on their service-mix. Specific Specialty Procedure Payment Impacts CMS estimates the percentage change in total payments by specialty groups under the CY 2013 payment rates compared to estimated CY 2012 payment rates ranges between -3 percent for respiratory system procedures, integumentary system procedures, and cardiovascular system procedures.

2 B. Final Conversion Factor under the OPPS in CY 2013 For CY 2013, CMS has calculated a final conversion factor of $ for the national unadjusted payment rates for those items and services paid under the Outpatient Prospective Payment System for which payment rates are calculated using geometric mean costs. CMS finalizes a reduced conversion factor of $ in the calculation of payments for hospitals that fail to comply with the Hospital Outpatient Quality Reporting requirements. C. Summary of Final Changes CRM Related APC Changes CMS standard process for dealing with new CPT codes effective on January 1 for the upcoming calendar year is to assign each code to the APC that it believe contains services that are comparable with respect to clinical characteristics and resources required to furnish the service. Cardioverter-Defibrillator (APC 0107 and 0108) CMS interim assignment of some of the new CPT codes for CY 2013 to device-dependent APCs prompted a change in the titles of two APCs to reflect more accurately the clinical configurations of those APCs for CY Specifically, CMS assigned, on an interim basis, the following codes to device-dependent APC 0107, currently titled Insertion of Cardioverter-Defibrillator : CPT code 0319T (Insertion or replacement of subcutaneous implantable defibrillator system with subcutaneous electrode), 0321T (Insertion of subcutaneous implantable defibrillator pulse generator only with existing subcutaneous electrode), and 0323T (Removal of subcutaneous implantable defibrillator pulse generator with replacement of subcutaneous implantable defibrillator pulse generator only). We note that the title of APC 0108 is currently Insertion/Replacement/Repair of AICD Leads, Generator and Pacing Electrode. In order to streamline and simplify the titles of APCs 0107 and 0108, which both contain procedures for the implantation of cardioverter-defibrillator pulse generators, leads, and electrodes, CMS is revising their titles to reflect the insertion of cardioverter-defibrillators without specifying the component pieces involved. Specifically, CMS is revising the title of APC 0107 to read Level I Implantation of Cardioverter-Defibrillator and the title of APC 0108 to read Level II Implantation of Cardioverter-Defibrillator.

3 Cardiac Telemetry (APC 0213) For CY 2013, CMS proposed to reassign CPT code (External mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ecg data storage (retrievable with query) with ecg triggered and patient selected events transmitted to a remote attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis and physician prescribed transmission of daily and emergent data reports) from APC 0209 (Level II Extended EEG, Sleep, and Cardiovascular Studies), which had a proposed rule payment rate of approximately $808, to APC 0340 (Minor Ancillary Procedures), which had a proposed rule payment rate of approximately $49. Because of concerns raised by a commenter regarding reassigning CPT code to an APC that is labeled Minor Ancillary Procedures, further review of the claims data for this final rule with comment period showed that CPT code would be more appropriately assigned to APC 0213 (Level I Extended EEG, Sleep, and Cardiovascular Studies) than APC 0340 based on its clinical homogeneity and resource costs in relation to the other procedures assigned to APC CMS claims data show a geometric mean cost of approximately $172 for CPT code 93229, which is relatively similar to the final geometric mean cost of approximately $178 for APC After consideration of the public comment received, CMS is finalizing the CY 2013 proposal, with modification. Specifically, CMS is reassigning CPT code from APC 0209 to APC 0213 (instead of the proposed APC 0340) for CY The final CY 2013 geometric mean cost for APC 0213 is approximately $178. Clarification of Existing Device Category Criterion CMS establishes device category for pass-through payment for which none of the pass-through categories in effect (or that were previously in effect) is appropriate. Commenters who responded to CMS various proposed rules, as well as applicants for new device categories, had expressed concern that some of CMS existing and previously in effect device category descriptors were overly broad, and that the device category descriptors as they are currently written may preclude some new technologies from qualifying for establishment of a new device category for pass-through payment. As a result of these comments, CMS finalized a policy, effective January 1, 2006, to create an additional category for devices that meet all of the criteria required to establish a new category for pass-through payment in instances where CMS believes that an existing or previously in effect category descriptor does not appropriately describe the new device. Accordingly, effective January 1, 2006, CMS revised the regulations to reflect this policy change. In order to determine if a new device is appropriately described by any existing or previously in effect category of devices, CMS applies two tests based upon evaluation of information provided in the device category application. First, an

4 applicant for a new device category must show that its device is not similar to devices (including related predicate devices) whose costs are reflected in the currently available OPPS claims data in the most recent OPPS update. Second, an applicant must demonstrate that utilization of its device provides a substantial clinical improvement for Medicare beneficiaries compared with currently available treatments, including procedures utilizing devices in any existing or previously in effect device categories. CMS considers a new device that meets both of these tests not to be appropriately described by any existing or previously in effect pass-through device categories. For CY 2013, CMS clarifies the test that requires an applicant for a new device category to show that its device is not similar to devices (including related predicate devices) whose costs are reflected in the currently available OPPS claims data in the most recent OPPS update. CMS is clarifying that this test includes showing that a new device is not similar to predicate devices that once belonged in any existing or previously in effect pass-through device categories. Under this test, a candidate device may not be considered to be appropriately described by any existing or previously in effect pass-through device categories if the applicant adequately demonstrates that the\ candidate device is not similar to devices (including related predicate devices) that belong or once belonged to an existing or any previously in effect device category, and that the candidate device is not similar to devices whose costs are reflected in the OPPS claims data in the most recent OPPS update. The substantial clinical improvement criterion, which also must be satisfied in every case is separate from the criterion that a candidate device not be similar to devices in any existing or previously in effect pass-through categories. APCs and Devices Subject to the Adjustment Policy (Credit Devices) CMS finalizes, for CY 2013, that OPPS payments for implantation procedures to which the FB modifier is appended are reduced by 100 percent of the device offset for no cost/full credit cases when both a device code listed in Table 3 below is present on the claim, and the procedure code maps to an APC listed in Table 2 below. CMS also proposes that OPPS payments for implantation procedures to which the FC modifier is appended are reduced by 50 percent of the device offset when both a device code listed in Table 3 is present on the claim and the procedure code maps to an APC listed in Table 2. Beneficiary copayment is based on the reduced amount when either the FB modifier or the FC modifier is billed and the procedure and device codes appear on the lists of procedures and devices to which this policy applies.

5 TABLE 2 -FINAL APCs TO WHICH THE NO COST/FULL CREDIT AND PARTIAL CREDIT DEVICE ADJUSTMENT POLICY WOULD APPLY IN CY 2013 FINAL CY 2013 APC Final CY 2013 APC Title 0089 Insertion/Replacement of Permanent Pacemaker and Electrodes 0090 Insertion/Replacement of Pacemaker Pulse Generator 0106 Insertion/Replacement of Pacemaker Leads and/or Electrodes 0107 Insertion of Cardioverter- Defibrillator 0108 Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads 0654 Insertion/Replacement of a permanent dual chamber pacemaker 0655 Insertion/Replacement/Conversion of a permanent dual chamber pacemaker 0680 Insertion of Patient Activated Event Recorders Final CY 2013 Device Offset Percentage for No Cost/ Full Credit Case Final CY 2013 Device Offset Percentage for Partial Credit Case 69% 35% 71% 36% 48% 24% 84% 42% 84% 42% 74% 37% 73% 37% 74% 37%

6 TABLE 3 - FINAL DEVICES TO WHICH THE NO COST/FULL CREDIT AND PARTIAL CREDIT DEVICE ADJUSTMENT POLICY WOULD APPLY IN CY 2013 CY 2013 Device HCPCS Code C1721 C1722 C1764 C1777 C1779 C1785 C1786 C1882 C1895 C1896 C1898 C1899 C1900 C2619 C2620 C2621 CY 2013 Short Descriptor AICD, dual chamber AICD, single chamber Event recorder, cardiac Lead, AICD, endo single coil Lead, pmkr, transvenous VDD Pmkr, dual, rate-resp Pmkr, single, rate-resp AICD, other than sing/dual Lead, AICD, endo dual coil Lead, AICD, non sing/dual Lead, pmkr, other than trans Lead, pmkr/aicd combination Lead coronary venous Pmkr, dual, non rate-resp Pmkr, single, non rate-resp Pmkr, other than sing/dual Cardiac Electrophysiologic Evaluation and Ablation Composite APC (APC 8000) In the CY 2013 OPPS/ASC proposed rule (77 FR 45089), CMS proposed for CY 2013 to continue to pay for cardiac electrophysiologic evaluation and ablation services using the composite APC methodology proposed and implemented for CY 2008 through CY CMS stated that it continued to believe that the cost for these services calculated from a high volume of correctly coded multiple procedure claims would result in an accurate and appropriate proposed payment for cardiac electrophysiologic evaluation and ablation services when at least one evaluation service is furnished during the same clinical encounter as at least one ablation service. Subsequent to the publication of the CY 2013 OPPS/ASC proposed rule, the AMA s CPT Editorial Panel created five new CPT codes describing cardiac electrophysiologic evaluation and ablation services, to be effective January 1, 2013.

7 These five new codes are: CPT code (Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, His recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry); CPT code (Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, His recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of ventricular tachycardia or focus of ventricular ectopy including intracardiac electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording, when performed); CPT code (Intracardiac catheter ablation of a discrete mechanism of arrhythmia which is distinct from the primary ablated mechanism, including repeat diagnostic maneuvers, to treat a spontaneous or induced arrhythmia (List separately in addition to code for primary procedure)); CPT code (Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with atrial recording and pacing, when possible, right ventricular pacing and recording, His bundle recording with intracardiac catheter ablation of arrhythmogenic focus, with treatment of atrial fibrillation by ablation by pulmonary vein isolation); and CPT code (Additional linear or focal intracardiac catheter ablation of the left or right atrium for treatment of atrial fibrillation remaining after completion of pulmonary vein isolation (List separately in addition to code for primary procedure)). The CPT Editorial Panel also deleted two electrophysiologic ablation codes, CPT code (Intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination) and CPT code (Intracardiac catheter ablation of arrhythmogenic focus; for treatment of ventricular tachycardia), effective January 1, 2013.

8 CMS standard process for dealing with new CPT codes effective on January 1 for the upcoming calendar year is to assign each code to the APC that it believe contains services that are comparable with respect to clinical characteristics and resources required to furnish the service. The new CPT code is given a comment indicator of NI in Addendum B to the final rule with comment period to identify it as a new interim APC assignment for the new year and the APC assignment for the new CPT codes is then open to public comment for 60 days following the publication of the final rule with comment period. New CPT codes 93653, 93654, and are primary electrophysiologic services that encompass evaluation as well as ablation, while new CPT codes and are add-on codes. Because CPT codes 93653, 93654, and already encompass both evaluation and ablation services, CMS is assigning them to composite APC 8000 with no further requirement to have another electrophysiologic service from either Group A or Group B furnished on the same date of service, and assigning them interim status indicator Q3 (Codes that may be paid through a composite APC) in Addendum B to this final rule with comment period. To facilitate implementing this policy, CMS is assigning CPT codes 93653, 93654, and to a new Group C, which will be paid at the composite APC 8000 payment rate. Because CPT codes and are dependent services that may only be performed as ancillary services to the primary CPT codes 93653, 93654, and 93656, CMS believes that packaging CPT codes and with the primary procedures is appropriate, and is assigning them interim status indicator N. Because the CPT Editorial Panel deleted CPT codes and 93652, effective January 1, 2013, CMS is deleting them from the Group B code list, leaving only CPT (Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement) in Group B at this time. For CY 2013, using a full year of CY 2011 claims data available for this final rule with comment period, CMS was able to use 12,235 claims containing a combination of Group A and Group B CPT codes to calculate a final cost of approximately $11,466 for composite APC Table 4 below lists the groups of procedures upon which we will base composite APC 8000 for CY 2013.

9 TABLE 4. GROUPS OF CARDIAC ELECTROPHYSIOLOGIC EVALUATION AND ABLATION PROCEDURES UPON WHICH COMPOSITE APC 8000 IS BASED Codes Used in Combinations: At Least One in Group A and One in Group B, or At Least One in Group C Group A Comprehensive electrophysiologic evaluation with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording, including insertion and repositioning of multiple electrode catheters, without induction or attempted induction of arrhythmia Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording Group B Intracardiac catheter ablation of atrioventricular node function, atrioventricular conduction for creation of complete heart block, with or without temporary pacemaker placement Group C Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, His recording with intracardiac catheter ablation of CY 2013 CPT Code Single Code CY 2013 APC CY 2013 SI (Composite) Q Q Q Q3

10 Codes Used in Combinations: At Least One in Group A and One in Group B, or At Least One in Group C arrhythmogenic focus; with treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathway, accessory atrioventricular connection, cavo-tricuspid isthmus or other single atrial focus or source of atrial re-entry Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with right atrial pacing and recording, right ventricular pacing and recording, His recording with intracardiac catheter ablation of arrhythmogenic focus; with treatment of ventricular tachycardia or focus of ventricular ectopy including intracardiac electrophysiologic 3D mapping, when performed, and left ventricular pacing and recording, when performed Comprehensive electrophysiologic evaluation including transseptal catheterizations, insertion and repositioning of multiple electrode catheters with induction or attempted induction of an arrhythmia with atrial recording and pacing, when possible, right ventricular pacing and recording, His bundle recording with intracardiac catheter ablation of arrhythmogenic focus, with treatment of atrial fibrillation by ablation by pulmonary vein isolation CY 2013 CPT Code Single Code CY 2013 APC CY 2013 SI (Composite) Q3 Q3

11 D. Hospital Outpatient Quality Reporting Program Updates CMS is not adding any new measures to those previously finalized for the CY 2014 and CY 2015 payment determinations. Thus, CMS requiring the reporting of 22 measures for the CY 2014 payment determination and 25 measures for the CY 2015 payment determination. CMS is deferring data collection for one quality measure, OP-24 Cardiac Rehabilitation Patient Referral from an Outpatient Setting, for one year, and is confirming suspension of data collection for another, OP-19: Transition Record with Specified Elements Received by Discharged ED Patients. The final rule also clarifies CMS s determination that public reporting of the claimsbased imaging efficiency measure OP-15 will be deferred until July 2013 at the earliest, as discussed in the CY 2012 OPPS/ASC final rule with comment period. CMS is also finalizing program procedures affecting measure retirement, measure suspension, measure retention, and administrative forms.