FY2014 Final Hospital Inpatient Rule Summary

Transcription

1 FY2014 Final Hospital Inpatient Rule Summary Reimbursement Update Cardiac Rhythm Management (CRM) Electrophysiology (EP) Interventional Cardiology (IC) Peripheral Intervention (PI) On August 2, 2013, the Centers for Medicare & Medicaid Services (CMS) released final hospital Inpatient Prospective Payment System (IPPS) rates for FY2014. CMS final payment and policy changes are effective October 1, Overall payment rates will remain relatively flat, with a 0.7% increase for hospitals that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program. See Table 1 on page 5-6 for payment rates for procedures of interest to CRM, EP, IC and PI. IPPS FR HIGHLIGHTS Inpatient Admission and Medical Review Criteria (Two Midnight Stay) The Final Rule (FR) provides greater clarity regarding when inpatient hospital admissions are generally considered clinically appropriate as well as addresses concerns about Medicare beneficiaries having long stays as hospital outpatients. In the CMS press release, it is stated that Under the rule, if a physician expects a beneficiary s surgical procedure, diagnostic test or other treatment to require a stay in the hospital lasting at least two midnights, and admits the beneficiary to the hospital based on that expectation, it is presumed to be appropriate that the hospital receive Medicare Part A payment. While the FR requires the physician to document a formal order to begin an inpatient admission status, it permits the physician to consider all time a patient has already spent in the hospital as an outpatient receiving observation services, or in the emergency department, operating room, or other treatment area in guiding their two-midnight expectation. The medical record should include the two midnight medical necessity expectation as well as any unplanned or unexpected circumstance where the patient is discharged earlier than noted. The FR also redefines the timeframe at one year from the date of service in which to bill Medicare Part B for hospital inpatient services inappropriately billed under Part A. Refinement of the MS-DRG Relative Weights (Charge Compression) Increased payment rates for high-cost implantable devices will be implemented on October 1 st when CMS uses newly obtained hospital cost data to adjust inpatient payment rates. As a result, payment rates for ICD/CRT-D and pacemaker procedure stays, in particular, increase substantially, specifically MS-DRGs 227 and 245 go up 7.2% and 11.0% respectively. See Table 1 for other CRM payment changes. This change started in FY2009 when CMS began to require that hospitals report cost data separately for medical supplies and implantable devices. The differentiated cost data allows CMS to more accurately calculate the relative weights for DRGs (using cost-to-charge ratios) and to adjust for charge compression, which occurs when hospitals apply a higher percentage markup for lower cost supplies (e.g., bandages) and apply a lower percentage markup for higher cost devices (e.g., implantable devices such as defibrillators). CMS will begin using this improved data in their calculation for inpatient MS- DRG payment rates beginning in FY2014. (CMS used the improved data for outpatient rates starting January 2013.) CRV AA August 2013 Page 1 of 6

2 Readmission Reduction Program The Hospital Readmissions Reduction Program, which was implemented in FY2013, reduces payments for certain hospitals with excess 30-day readmissions caused by heart attack, heart failure, and pneumonia. In FY2014 the maximum payment reduction will increase from 1 to 2%. Also, hip and knee surgery, and chronic obstructive pulmonary disease will be added to the list of conditions effective in FY2015. Quality Outcomes-- FY2014 Value Based Purchasing (VBP) and Inpatient Quality Reporting (IQR) Programs The Value Based Purchasing program builds upon the current Inpatient Quality Reporting Program, using performance data to adjust payments. In FY2014, the VBP will redistribute 1.25% (up from 1.0%) of hospital payments, which CMS estimates will allow for $1.1 billion in incentive payments. IQR participating hospitals will have the option to electronically submit their data through Certified Electronic Health Record Technology (CEHRT) for up to sixteen selected measures across four measure sets (stroke, venous thromboembolism, emergency department, and perinatal care). Selected cardiovascular measures are listed below: IQR: Inpatient Quality Reporting VBP: Value Based Purchasing AMI Mortality Readmissions HF Median Time to Primary PCI Timing of Receipt of Primary PCI Inpatient Mortality AMI 30-Day Mortality Rate AMI 30-Day Readmission Rate Evaluation of LVS Function ACEI or ARB for LVSD Primary PCI Received Within 90 Minutes of Hospital Arrival* Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival *Note: Finalized deletion in FY2016 Acute Myocardial Infarction (AMI) 30-day mortality rate Discharge Instructions *Note: Finalized deletion in FY2016 Mortality HF 30-Day Mortality Rate Heart Failure (HF) 30-day mortality rate Readmission Total Program Measures HF 30-Day Readmission Rate 57 Measures 2014: 17 total measures including 13 Clinical Process, 1 Patient Experience of Care Measure and 3 Mortality Outcomes Hospital Acquired Conditions (HAC) Reduction Program The HACs payment policy prohibits hospitals from being paid at a higher MS-DRG rate for patients with major complications if the sole reason for the higher payment is the occurrence of one of the conditions on the HACs list during the beneficiary s hospital stay. The FY2014 FR provides the framework for the HAC Reduction Program scheduled for FY2015 implementation. Under this program, hospitals would be paid 99 percent of what they would otherwise be paid under the IPPS if they rank in the lowest-performing quartile. CRV AA August 2013 Page 2 of 6

3 New Technology Add-on Payment Applications CMS considered five applications (including both drugs and devices) for New Technology Add-on Payments (NTAP) and approved three (two drugs, one device). Cardiovascular applications of interest include: Approved: Zilver PTX Drug-Eluting Stent, intended for use in treating peripheral artery disease (PAD) of the abovethe-knee femoropopliteal arteries (superficial femoral arteries). The maximum add-on payment for a procedure using the Zilver PTX is $1, NTAPs are limited to the lesser of 50 percent of the average cost of the device or 50 percent of the costs in excess of the MS-DRG payment for the case. Withdrawn: MitraClip System, a transcatheter intervention based on the mitral valve leaflet repair as an alternative to open surgery. The application was withdrawn due to lack of FDA approval by July 1 st. Disproportionate Share Hospitals (DSH) Adjustments DSH payment adjustments currently qualify for a payment adjustment under a statutory formula that considers their share of low income patients. The health care reform law modified the Medicare DSH methodology beginning in FY2014. DSH hospitals will receive 25 percent of the amount they previously would have received under the current formula and the remaining 75 percent will be adjusted to reflect the percentage of individuals that are uninsured. The FR implements these statutory changes and CMS estimates that its impact on operating costs in FY2014 will be negative 0.9 percent. SPECIFIC PAYMENT CHANGES Overall average changes across key cardiovascular device-related procedures (Table 1): CRM and EP: Increase of 5.0% and 1.5% respectively IC Stents: Increase of 1.5% PI PTA, Stent, and Embolization: Increase of 3.2% Cardiac Rhythm Management Weighted average base payments: ICD and CRT-D system implant payment rates increase by 5.4% for MS-DRGs ICD and CRT-D system replacement payment rates increase by 11.0% for MS-DRGs 245 & 265 Pacemaker and CRT-P system implant payment rates increase by 2.7% for MS-DRGs Pacemaker and CRT-P system replacement payment rates increase by 4.2% for MS-DRGs Electrophysiology Weighted average base payments: Overall, payment rates for cardiac ablation cases increase by 2.0% (Note that WATCHMAN Left Atrial Appendage Closure Device also currently maps to cardiac ablation MS-DRGs) * BSC has no ablation catheter FDA-approved for treatment of Atrial Fibrillation Interventional Cardiology Drug-eluting stent inpatient procedure reimbursement Drug-eluting stent weighted average payment increase of 2.4% for the two MS-DRGs related to DES o Payment for MS-DRG 246 patients (i.e. a drug-eluting stent procedure for a patient with major complications or comorbidities) increases by 1.3% ($233) to $18,460 o For the treatment of patients without major complications or comorbidities (MS-DRG 247), the hospital reimbursement payment increases by 3% ($339) to $11,836 Bare-metal stent procedure reimbursement BMS weighted average payment increase of 0.6% across the two MS-DRGs o MS-DRG 248 down 1.3% (-$227) to $17,097 and MS-DRG 249 up 2% ($210) to $10,581 CRV AA August 2013 Page 3 of 6

4 Structural Heart Aortic Valves Aortic valve weighted average payment increase of 1.1% across the six MS-DRGs with a payment range of $26,924 to $55,961 Peripheral Interventions Weighted average base payments: Peripheral PTA, stenting and embolization increases 3.3% to $14,835 for MS-DRGs 252, 253, 254 Changes to the CC Exclusions List: CMS has removed the peripheral atherosclerosis diagnosis codes , and from the CC Exclusion List for diagnosis code Chronic total occlusion of artery of the extremity. Effective with the FR, a diagnosis of peripheral CTO is considered a CC even when one of these atherosclerosis codes is listed as the primary diagnosis. Disclaimer: Health economic and reimbursement information provided by Boston Scientific Corporation is gathered from third-party sources and is subject to change without notice as a result of complex and frequently changing laws, regulations, rules and policies. This information is presented for illustrative purposes only and does not constitute reimbursement or legal advice. Boston Scientific encourages providers to submit accurate and appropriate claims for services. It is always the provider s responsibility to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, charges, and modifiers for services that are rendered. Boston Scientific recommends that you consult with your payers, reimbursement specialists and/or legal counsel regarding coding, coverage and reimbursement matters. Boston Scientific does not promote the use of its products outside their FDA-approved label. CRV AA August 2013 Page 4 of 6

5 TABLE 1: SELECT CARDIOVASCULAR MS-DRG FY2014 FINAL PAYMENT CHANGES The table below shows final FY2014 MS-DRG national average payment rates for select cardiovascular procedures and the percent change as compared to FY2013 MS-DRG final national average rates. The rates and percent changes shown are base payments. Actual rates may vary for individual hospitals due to geographic wage differences. MS- DRG Description FY2014 Final Rate FY2013 Final Rate $ Change % Change (FY (FY Final) Final) Interventional Cardiology Drug-Eluting Stents 246 Percutaneous cardiovascular proc w drug-eluting stent w MCC $18,460 $18,227 $ % 247 Percutaneous cardiovascular proc w drug-eluting stent w/o MCC $11,836 $11,497 $ % Bare Metal Stents 248 Percutaneous cardiovasc proc w non-drug-eluting stent w MCC $17,097 $17,324 ($227) (1.31%) 249 Percutaneous cardiovasc proc w non-drug-eluting stent w/o MCC $10,581 $10,371 $ % Angioplasty or Atherectomy without Stent 250 Perc cardiovasc proc w/o coronary artery stent w MCC $17,330 $17,316 $ % 251 Perc cardiovasc proc w/o coronary artery stent w/o MCC $11,447 $11,108 $ % Structural Heart - Valves 216 Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with MCC $54,981 $54,965 $ % 217 Cardiac valve and other major cardiothoracic procedures with cardiac catheterization with CC $36,442 $36,664 ($222) (0.61%) 218 Cardiac valve and other major cardiothoracic procedures with cardiac catheterization without CC/MCC $31,470 $30,851 $ % 219 Cardiac valve and other major cardiothoracic procedures without cardiac catheterization with MCC $45,928 $45,264 $ % 220 Cardiac valve and other major cardiothoracic procedures without cardiac catheterization with CC $30,690 $30,279 $ % 221 Cardiac valve and other major cardiothoracic procedures without cardiac catheterization without CC\MCC $26,924 $25,541 $1, % Cardiac Rhythm Management ICD Systems 222 Cardiac defib implant w cardiac cath w AMI/HF/shock w MCC $51,133 $49,373 $1, % 223 Cardiac defib implant w cardiac cath w AMI/HF/shock w/o MCC $37,266 $35,260 $2, % 224 Cardiac defib implant w cardiac cath w/o AMI/HF/shock w MCC $44,787 $44,322 $ % 225 Cardiac defib implant w cardiac cath w/o AMI/HF/shock w/o MCC $34,337 $33,263 $1, % 226 Cardiac defibrillator implant w/o cardiac cath w MCC $40,655 $38,892 $1, % 227 Cardiac defibrillator implant w/o cardiac cath w/o MCC $32,128 $29,960 $2, % ICD Replacements 245 AICD generator procedures $27,271 $24,564 $2, % 265 AICD lead procedures $15,595 $14,086 $1, % Pacemaker Systems 242 Permanent cardiac pacemaker implant w MCC $21,743 $21,546 $ % 243 Permanent cardiac pacemaker implant w CC $15,494 $15,131 $ % 244 Permanent cardiac pacemaker implant w/o CC/MCC $12,532 $11,909 $ % Pacemaker Revisions and PG Placements 258 Cardiac pacemaker device replacement w MCC $15,792 $15,559 $ % 259 Cardiac pacemaker device replacement w/o MCC $11,287 $10,734 $ % 260 Cardiac pacemaker revision except device replacement w MCC $21,597 $21,148 $ % 261 Cardiac pacemaker revision except device replacement w CC $10,024 $9,683 $ % 262 Cardiac pacemaker revision except device replacement w/o CC/MCC $8,042 $7,127 $ % CRV AA August 2013 Page 5 of 6

6 FY2014 FY2013 $ Change % Change MS- Description Final Final (FY (FY DRG Rate Rate Final) Final) Electrophysiology Cardiac Catheter Ablation 250 Perc cardiovasc proc w/o coronary artery stent w MCC $17,330 $17,316 $ % 251 Perc cardiovasc proc w/o coronary artery stent w/o MCC $11,447 $11,108 Business $339 Unit 3.05% Name Peripheral Interventions Carotid Artery Stenting 34 Carotid artery stent procedure w MCC $19,803 $21,317 ($1,514) (7.10%) 35 Carotid artery stent procedure w CC $12,632 $12,683 ($51) -0.40% 36 Carotid artery stent procedure w/o CC/MCC $9,989 $9,591 $ % Peripheral PTA, Stent, Atherectomy and Embolization 252 Other vascular procedure with MCC $18,255 $17,452 $ % 253 Other vascular procedure with CC $14,599 $14,285 $ % 254 Other vascular procedure without MCC\CC $9,866 $9,590 $ % MS-DRG = Medicare Severity Diagnosis Related Group Weighted Average based on 2012 MedPAR (Table 7B) inpatient volume distribution in MS-DRGs MCC = Major Complications and Comorbidities CC = Complications and Comorbidities COMMENTS / QUESTIONS If you have questions or would like additional information, contact: Tom Meskan IC & PI Tom.Meskan@bsci.com Kaye Anderson CRM & EP Kaye.Anderson@bsci.com Wendy Chan S-ICD and EP Wendy.chan@bsci.com Sue Drawert - PI Susan.Drawert@bsci.com Steve Jahn CRM & EP Steve.Jahn@bsci.com Deb Lorenz IC Deb.Lorenz@bsci.com Deb Mauer CRM & EP Debra.mauer@bsci.com Additional Information Read the full FY2014 Final IPPS Rule (CMS-1599-F) at the following link: Page.html CRV AA August 2013 Page 6 of 6