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DEPARTMENT OF HEALTH AND HUMAN SERVICES
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CFR Citation: 42 CFR Parts 410 and 419
RIN ID: RIN 0938-AP17
CMS ID: [CMS-1404-P]
NOTICE: Part II
DOCUMENT ACTION: Proposed rule.
SUBJECT CATEGORY: Medicare Program: Proposed Changes to the Hospital Outpatient Prospective Payment System and CY 2009 Payment Rates; Proposed Changes to the Ambulatory Surgical Center Payment System and CY 2009 Payment Rates
DATES: To be assured consideration, comments on all sections of the preamble of this proposed rule must be received at one of the addresses provided in the ADDRESSES section no later than 5 p.m. EST on September 2, 2008.
DOCUMENT SUMMARY: This proposed rule would revise the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this proposed rule, we describe the proposed changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes would be applicable to services furnished on or after January 1, 2009.
In addition, this proposed rule would update the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this proposed rule, we propose the applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these proposed changes would apply, and other pertinent ratesetting information for the CY 2009 ASC payment system. These changes would be applicable to services furnished on or after January 1, 2009.
SUMMARY: Health and Human Services Department, Centers for Medicare & Medicaid Services,
SUPPLEMENTAL INFORMATION
Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http:// www.regulations.gov. Follow the search instructions on that Web site to view public comments.
Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, on Monday through Friday of each week from 8:30 a.m. to 4 p.m. EST. To schedule an appointment to view public comments, phone 18007433951.
Electronic Access
This Federal Register document is also available from the Federal
Register online database through GPO Access, a service of the U.S.
Government Printing Office. Free public access is available on a Wide
Area Information Server (WAIS) through the Internet and via
asynchronous dialin. Internet users can access the database by using
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password required). Dialin users should use communications software
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Alphabetical List of Acronyms Appearing in This Proposed Rule
ACEP American College of Emergency Physicians
AHA American Hospital Association
AHIMA American Health Information Management Association
AMA American Medical Association
APC Ambulatory payment classification
AMP Average manufacturer price
ASC Ambulatory Surgical Center
ASP Average sales price
AWP Average wholesale price
[[Page 41417]]
BBA Balanced Budget Act of 1997, Pub. L. 10533
BBRA Medicare, Medicaid, and SCHIP [State Children's Health
Insurance Program] Balanced Budget Refinement Act of 1999, Pub. L. 106113
BCA Blue Cross Association
BCBSA Blue Cross and Blue Shield Association
BIPA Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, Pub. L. 106554
CAH Critical access hospital
CAP Competitive Acquisition Program
CBSA CoreBased Statistical Area
CCR Costtocharge ratio
CERT Comprehensive Error Rate Testing
CMHC Community mental health center
CMS Centers for Medicare & Medicaid Services
CoP Condition of participation
CORF Comprehensive outpatient rehabilitation facility
CPT [Physicians'] Current Procedural Terminology, Fourth Edition, 2007, copyrighted by the American Medical Association
CRNA Certified registered nurse anesthetist
CY Calendar year
DMEPOS Durable medical equipment, prosthetics, orthotics, and supplies
DMERC Durable medical equipment regional carrier
DRA Deficit Reduction Act of 2005, Pub. L. 109171 DSH Disproportionate share hospital
EACH Essential Access Community Hospital
E/M Evaluation and management
EPO Erythropoietin
ESRD Endstage renal disease
FACA Federal Advisory Committee Act, Pub. L. 92463
FAR Federal Acquisition Regulations
FDA Food and Drug Administration
FFS Feeforservice
FSS Federal Supply Schedule
FTE Fulltime equivalent
FY Federal fiscal year
GAO Government Accountability Office
GME Graduate medical education
HCPCS Healthcare Common Procedure Coding System
HCRIS Hospital Cost Report Information System
HHA Home health agency
HIPAA Health Insurance Portability and Accountability Act of 1996, Pub. L. 104191
HOPD Hospital outpatient department
HOP QDRP Hospital Outpatient Quality Data Reporting Program
ICD9CM International Classification of Diseases, Ninth Edition, Clinical Modification
IDE Investigational device exemption
IME Indirect medical education
I/OCE Integrated Outpatient Code Editor
IOL Intraocular lens
IPPS [Hospital] Inpatient prospective payment system
IVIG Intravenous immune globulin
MAC Medicare Administrative Contractors
MedPAC Medicare Payment Advisory Commission
MDH Medicaredependent, small rural hospital
MIEATRHCA Medicare Improvements and Extension Act under Division B,
Title I of the Tax Relief Health Care Act of 2006, Pub. L. 109432
MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108173
MMSEA Medicare, Medicaid, and SCHIP Extension Act of 2007, Pub. L. 110173
MPFS Medicare Physician Fee Schedule
MSA Metropolitan Statistical Area
NCCI National Correct Coding Initiative
NCD National Coverage Determination
NTIOL New technology intraocular lens
OMB Office of Management and Budget
OPD [Hospital] Outpatient department
OPPS [Hospital] Outpatient prospective payment system
PHP Partial hospitalization program
PM Program memorandum
PPI Producer Price Index
PPS Prospective payment system
PPV Pneumococcal pneumonia vaccine
PRA Paperwork Reduction Act
QIO Quality Improvement Organization
RFA Regulatory Flexibility Act
RHQDAPU Reporting Hospital Quality Data for Annual Payment Update [Program]
RHHI Regional home health intermediary
SBA Small Business Administration
SCH Sole community hospital
SDP Single Drug Pricer
SI Status indicator
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97 248
TOPS Transitional outpatient payments
USPDI United States Pharmacopoeia Drug Information
WAC Wholesale acquisition cost
In this document, we address two payment systems under the Medicare
program: The hospital outpatient prospective payment system (OPPS) and
the revised ambulatory surgical center (ASC) payment system. The
provisions relating to the OPPS are included in sections I. through
XIV., and XVI. through XXI. of this proposed rule and in Addenda A, B,
C (Addendum C is available on the Internet only; see section XVIII. of
this proposed rule), D1, D2, E, L, and M to this proposed rule. The
provisions related to the revised ASC payment system are included in
sections XV. and XVII. through XXI. of this proposed rule and in
Addenda AA, BB, DD1, DD2, and EE (Addendum EE is available on the
Internet only; see section XVIII. of this proposed rule) to this proposed rule.
Table of Contents
I. Background for the OPPS
A. Legislative and Regulatory Authority for the Hospital Outpatient Prospective Payment System
B. Excluded OPPS Services and Hospitals
C. Prior Rulemaking
D. APC Advisory Panel
1. Authority of the APC Panel
2. Establishment of the APC Panel
3. APC Panel Meetings and Organizational Structure
E. Provisions of the Medicare, Medicaid, and SCHIP Extension Act of 2007
F. Summary of the Major Contents of This Proposed Rule
1. Proposed Updates Affecting OPPS Payments
2. Proposed OPPS Ambulatory Payment Classification (APC) Group Policies
3. Proposed OPPS Payment for Devices
4. Proposed OPPS Payment for Drugs, Biologicals, and
Radiopharmaceuticals
5. Proposed Estimate of OPPS Transitional PassThrough Spending for Drugs, Biologicals, Radiopharmaceuticals, and Devices
6. Proposed OPPS Payment for Brachytherapy Sources
7. Proposed OPPS Payment for Drug Administration Services
8. Proposed OPPS Payment for Hospital Outpatient Visits
9. Proposed Payment for Partial Hospitalization Services
10. Proposed Procedures That Will Be Paid Only as Inpatient Services 11. OPPS Nonrecurring and Policy Clarifications
12. Proposed OPPS Payment Status and Comment Indicators
13. OPPS Policy and Payment Recommendations
14. Proposed Update of the Revised Ambulatory Surgical Center Payment System
15. Proposed Quality Data for Annual Payment Updates
16. HealthcareAssociated Conditions
17. Regulatory Impact Analysis
II. Proposed Updates Affecting OPPS Payments
A. Proposed Recalibration of APC Relative Weights
1. Database Construction
a. Database Source and Methodology
b. Proposed Use of Single and Multiple Procedure Claims
c. Proposed Calculation of CCRs
(1) Development of the CCRs
(2) Charge Compression
2. Proposed Calculation of Median Costs
a. Claims Preparations
b. Splitting Claims and Creation of ``Pseudo'' Single Claims
c. Completion of Claim Records and Median Cost Calculations
d. Proposed Calculation of Single Procedure APC CriteriaBased Median Costs
(1) DeviceDependent APCs
(2) Blood and Blood Products
(3) Single Allergy Tests
(4) Echocardiography Services
(5) Nuclear Medicine Services
(6) Hyperbaric Oxygen Therapy
(7) Payment for Ancillary Outpatient Services When Patient Expires (CA Modifier)
e. Proposed Calculation of Composite APC CriteriaBased Median Costs
(1) Extended Assessment and Management Composite APCs (APCs 8002 and 8003)
(2) Low Dose Rate (LDR) Prostate Brachytherapy Composite APC (APC 8001)
(3) Cardiac Electrophysiologic Evaluation and Ablation Composite APC (APC 8000)
(4) Mental Health Services Composite APC (APC 0034)
[[Page 41418]]
(5) Multiple Imaging Composite APCs (APCs 8004, 8005, 8006, 8007, and 8008)
3. Proposed Calculation of OPPS Scaled Payment Weights
4. Proposed Changes to Packaged Services
a. Background
b. ServiceSpecific Packaging Issues
(1) Package Services Addressed by APC Panel Recommendations (2) IVIG PreadministrationRelated Services
B. Proposed Conversion Factor Update
C. Proposed Wage Index Changes
D. Proposed Statewide Average Default CCRs
E. Proposed OPPS Payments to Certain Rural Hospitals
1. Hold Harmless Transitional Payment Changes Made by Pub. L. 109 171 (DRA)
2. Proposed Adjustment for Rural SCHs Implemented in CY 2006 Related to Pub. L. 108173 (MMA)
F. Proposed Hospital Outpatient Outlier Payments
1. Background
2. Proposed Outlier Calculation
3. Outlier Reconciliation
G. Proposed Calculation of an Adjusted Medicare Payment from the National Unadjusted Medicare Payment
H. Proposed Beneficiary Copayments
1. Background
2. Proposed Copayments
3. Calculation of a Proposed Adjusted Copayment Amount for an APC Group
III. Proposed OPPS Ambulatory Payment Classification (APC) Group Policies
A. Proposed OPPS Treatment of New HCPCS and CPT Codes
1. Proposed Treatment of New HCPCS Codes Included in the April and July Quarterly OPPS Updates for CY 2008
2. Proposed Treatment of New Category I and III CPT Codes and Level II HCPCS Codes
B. Proposed OPPS ChangesVariations within APCs
1. Background
2. Application of the 2 Times Rule
3. Proposed Exceptions to the 2 Times Rule
C. New Technology APCs
1. Background
2. Proposed Movement of Procedures from New Technology APCs to Clinical APCs
D. Proposed OPPS APCSpecific Policies
1. Trauma Response Associated with Hospital Critical Care Services (APC 0618)
2. Suprachoroidal Delivery of Pharmacologic Agent (APC 0236)
3. Closed Treatment Fracture of Finger/Toe/Trunk (APC 0043) 4. Individual Psychotherapy (APCs 0322 and 0323)
5. Implant Injection for Vesicoureteral Reflex (APC 0162)
IV. Proposed OPPS Payment for Devices
A. PassThrough Payments for Devices
1. Expiration of Transitional PassThrough Payments for Certain Devices
a. Background
b. Proposed Policy
2. Proposed Provisions for Reducing Transitional PassThrough Payments to Offset Costs Packaged into APC Groups
a. Background
b. Proposed Policy
B. Proposed Adjustment to OPPS Payments for Partial or Full Credit Devices
1. Background
2. Proposed APCs and Devices Subject to the Adjustment Policy
V. Proposed OPPS Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals
A. Proposed OPPS Transitional PassThrough Payment for Additional Costs of Drugs, Biologicals, and Radiopharmaceuticals
1. Background
2. Proposed Drugs and Biologicals with Expiring PassThrough Status in CY 2008
3. Proposed Drugs, Biologicals, and Radiopharmaceuticals with New or Continuing PassThrough Status in CY 2009
4. Proposed Reduction of Transitional PassThrough Payments for
Diagnostic Radiopharmaceuticals to Offset Costs Packaged into APC Groups
B. Proposed OPPS Payment for Drugs, Biologicals, and
Radiopharmaceuticals without PassThrough Status
1. Background
2. Proposed Criteria for Packaging Payment for Drugs, Biologicals, and Radiopharmaceuticals
a. Drugs, Biologicals, and Therapeutic Radiopharmaceuticals
b. Proposed Payment for Diagnostic Radiopharmaceuticals and Contrast Agents
3. Proposed Payment for Drugs and Biologicals without PassThrough Status That Are Not Packaged
a. Payment for Specified Covered Outpatient Drugs (SCODs)
b. Proposed Payment Policy
c. Proposed Payment for Blood Clotting Factors
4. Proposed Payment for Therapeutic Radiopharmaceuticals
a. Background
b. Proposed Payment Policy
5. Proposed Payment for NonpassThrough Drugs, Biologicals, and
Radiopharmaceuticals with HCPCS Codes, but without OPPS Hospital Claims Data
VI. Proposed Estimate of OPPS Transitional PassThrough Spending for Drugs, Biologicals, Radiopharmaceuticals, and Devices
A. Background
B. Proposed Estimate of PassThrough Spending
VII. Proposed OPPS Payment for Brachytherapy Sources
A. Background
B. Proposed OPPS Payment Policy
VIII. Proposed OPPS Payment for Drug Administration Services A. Background
B. Proposed Coding and Payment for Drug Administration Services IX. Proposed OPPS Payment for Hospital Outpatient Visits
A. Background
B. Proposed Policies for Hospital Outpatient Visits
1. Clinic Visits: New and Established Patient Visits
2. Emergency Department Visits
3. Visit Reporting Guidelines
X. Proposed Payment for Partial Hospitalization Services
A. Background
B. Proposed PHP APC Update
C. Proposed Policy Changes
1. Proposal to Deny Payments for Low Intensity Days
2. Proposal to Strengthen PHP Patient Eligibility Criteria
3. Proposed Partial Hospitalization Coding Update
C. Proposed Separate Threshold for Outlier Payments to CMHCs
XI. Proposed Procedures That Will Be Paid Only as Inpatient Procedures
A. Background
B. Proposed Changes to the Inpatient List
XII. OPPS Nonrecurring Technical and Policy Clarifications
A. Physician Supervision of HOPD Services
1. Background
2. Summary
B. Reporting of Pathology Services for Prostrate Saturation Biopsy XIII. Proposed OPPS Payment Status and Comment Indicators
A. Proposed OPPS Payment Status Indicator Definitions
1. Proposed Payment Status Indicators to Designate Services That Are Paid under the OPPS
2. Proposed Payment Status Indicators to Designate Services That Are Paid under a Payment System Other Than the OPPS
3. Proposed Payment Status Indicators to Designate Services That Are
Not Recognized under the OPPS But That May Be Recognized by Other Institutional Providers
4. Proposed Payment Status Indicators to Designate Services That Are Not Payable by Medicare
B. Proposed Comment Indicator Definitions
XIV. OPPS Policy and Payment Recommendations
A. Medicare Payment Advisory Commission (MedPAC) Recommendations 1. March 2008 Report
2. June 2007 Report
B. APC Panel Recommendations
C. OIG Recommendations
XV. Proposed Update of the Revised Ambulatory Surgical Center Payment System
A. Background
1. Legislative Authority for the ASC Payment System
2. Prior Rulemaking
3. Policies Governing Changes to the Lists of HCPCS Codes and
Payment Rates for ASC Covered Surgical Procedures and Covered Ancillary Services
B. Proposed Treatment of New Codes
1. Proposed Treatment of New Category I and III CPT Codes and Level II HCPCS Codes
2. Proposed Treatment of New Level II HCPCS Codes Implemented in April and July 2008
C. Proposed Update to the Lists of ASC Covered Surgical Procedures and Covered Ancillary Services
1. Covered Surgical Procedures
a. Proposed Additions to the List of ASC Covered Surgical Procedures b. Covered Surgical Procedures Designated as Office Based
(1) Background
(2) Proposed Changes to Covered Surgical Procedures Designated as OfficeBased for CY 2009
c. Covered Surgical Procedures Designated as DeviceIntensive [[Page 41419]]
(1) Background
(2) Proposed Changes to List of Covered Surgical Procedures Designated as DeviceIntensive for CY 2009
2. Covered Ancillary Services
D. Proposed ASC Payment for Covered Surgical Procedures and Covered Ancillary Services
1. Proposed Payment for Covered Surgical Procedures
a. Background
b. Proposed Update to ASC Covered Surgical Procedure Payment Rates for CY 2009
c. Proposed Adjustment to ASC Payments for Partial or Full Device Credit
2. Proposed Payment for Covered Ancillary Services
a. Background
b. Proposed Payment for Covered Ancillary Services for CY 2009 E. New Technology Intraocular Lenses
1. Background
2. NTIOL Application Process for Payment Adjustment
3. Classes of NTIOLs Approved and New Request for Payment Adjustment a. Background
b. Requests to Establish New NTIOL Class for CY 2009 and Deadline for Public Comment
4. Proposed Payment Adjustment
5. Proposed ASC Payment for Insertion of IOLs
F. Proposed ASC Payment and Comment Indicators
1. Background
2. Proposed ASC Payment and Comment Indicators
G. Calculation of the ASC Conversion Factor and ASC Payment Rates 1. Background
2. Proposed Policy Regarding Calculation of the ASC Payment Rates
a. Updating the ASC Relative Payment Weights for CY 2009 and Future Years
b. Updating the ASC Conversion Factor
3. Display of Proposed ASC Payment Rates
XVI. Reporting Quality Data for Annual Payment Rate Updates A. Background
1. Reporting Hospital Outpatient Quality Data for Annual Payment Update
2. Reporting ASC Quality Data for Annual Payment Update
B. Existing Hospital Outpatient Measures for CY 2009
C. Proposed Quality Measures for CY 2010 and Subsequent Calendar Years and Proposed Process to Update Measures
1. Proposed Quality Measures for CY 2010 Payment Determinations 2. Proposed Process for Updating Measures
3. Possible New Quality Measures for CY 2011 and Subsequent Calendar Years
D. Proposed Payment Reduction for Hospitals That Fail to Meet the HOP QDRP Requirements for the CY 2009 Payment Update
1. Background
2. Proposed Reduction of OPPS Payments for Hospitals That Fail to Meet the HOP QDRP CY 2009 Payment Update Requirements
a. Calculation of Reduced National Unadjusted Payment Rates
b. Calculation of Reduced Minimum Unadjusted and National Unadjusted Beneficiary Copayments
c. Treatment of Other Payment Adjustments
E. Requirements for HOP Quality Data Reporting for CY 2010 and Subsequent Calendar Years
1. Administrative Requirements
2. Data Collection and Submission Requirements
3. HOP QDRP Validation Requirements
a. Proposed Data Validation Requirements for CY 2010
b. Alternative Data Validation Approaches for CY 2011
F. Publication of HOP QDRP Data
G. Proposed HOP QDRP Reconsideration and Appeals Procedures H. Reporting of ASC Quality Data
XVII. HealthcareAssociated Conditions
A. Background
B. Broadening the Concept of the IPPS HospitalAcquired Conditions Payment Provision to the OPPS
1. Criteria for Possible Candidate OPPS Conditions
2. Collaboration Process
3. Potential OPPS HealthcareAssociated Conditions
4. OPPS Infrastructure and Payment for Encounters Resulting in HealthcareAssociated Conditions
XVIII. Files Available to the Public Via the Internet
A. Information in Addenda Related to the Proposed CY 2009 Hospital OPPS
B. Information in Addenda Related to the Proposed CY 2009 ASC Payment System
XIX. Collection of Information Requirements
A. Legislative Requirement for Solicitation of Comments
B. Associated Information Collections Not Specified in Regulatory Text
C. Addresses for Submittal of Comments on ICRs
XX. Response to Comments
XXI. Regulatory Impact Analysis
A. Overall Impact
1. Executive Order 12866
2. Regulatory Flexibility Act (RFA)
3. Small Rural Hospitals
4. Unfunded Mandates
5. Federalism
B. Effects of OPPS Changes in This Proposed Rule
1. Alternatives Considered
2. Limitation of Our Analysis
3. Estimated Effects of This Proposed Rule on Hospitals
4. Estimated Effects of This Proposed Rule on CMHCs
5. Estimated Effects of This Proposed Rule on Beneficiaries 6. Conclusion
7. Accounting Statement
C. Effects of ASC Payment System Changes in This Proposed Rule 1. Alternatives Considered
2. Limitations on Our Analysis
3. Estimated Effects of This Proposed Rule on ASCs
4. Estimated Effects of This Proposed Rule on Beneficiaries 5. Conclusion
6. Accounting Statement
D. Effects of Proposed Requirements for Reporting of Quality Data for Annual Hospital Payment Update
E. Executive Order 12866
Regulation Text
Addenda
Addendum AProposed OPPS APCs for CY 2009
Addendum AAProposed ASC Covered Surgical Procedures for CY 2009
(Including Surgical Procedures for Which Payment Is Packaged) Addendum BProposed OPPS Payment by HCPCS Code for CY 2009
Addendum BBProposed ASC Covered Ancillary Services Integral to
Covered Surgical Procedures for CY 2009 (Including Ancillary Services for Which Payment Is Packaged)
Addendum D1Proposed OPPS Payment Status Indicators
Addendum DD1Proposed ASC Payment Indicators
Addendum D2Proposed OPPS Comment Indicators
Addendum DD2Proposed ASC Comment Indicators
Addendum EProposed HCPCS Codes That Would Be Paid Only as
Inpatient Procedures for CY 2009
Addendum LProposed OutMigration Adjustment
Addendum MProposed HCPCS Codes for Assignment to Composite APCs for CY 2009
I. Background for the OPPS
A. Legislative and Regulatory Authority for the Hospital Outpatient Prospective Payment System
When the Medicare statute was originally enacted, Medicare payment for hospital outpatient services was based on hospitalspecific costs. In an effort to ensure that Medicare and its beneficiaries pay appropriately for services and to encourage more efficient delivery of care, the Congress mandated replacement of the reasonable costbased payment methodology with a prospective payment system (PPS). The Balanced Budget Act (BBA) of 1997 (Pub. L. 10533) added section 1833(t) to the Social Security Act (the Act) authorizing implementation of a PPS for hospital outpatient services.
The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act
(BBRA) of 1999 (Pub. L. 106113) made major changes in the hospital
outpatient prospective payment system (OPPS). The Medicare, Medicaid,
and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 (Pub.
L. 106554) made further changes in the OPPS. Section 1833(t) of the
Act was also amended by the Medicare Prescription Drug, Improvement,
and Modernization Act (MMA) of 2003 (Pub. L. 108173). The Deficit
Reduction Act (DRA) of 2005 (Pub. L. 109171), enacted on February 8,
2006, also made additional changes in the OPPS. In addition, the
Medicare Improvements and Extension Act under Division B of Title I of the
[[Page 41420]]
Tax Relief and Health Care Act (MIEATRHCA) of 2006 (Pub. L. 109432),
enacted on December 20, 2006, made further changes in the OPPS.
Further, the Medicare, Medicaid, and SCHIP Extension Act (MMSEA) of
2007 (Pub. L. 110173), enacted on December 29, 2007, made additional
changes in the OPPS. A discussion of these changes is included in sections I.E., II.C., V., and VII. of this proposed rule.
The OPPS was first implemented for services furnished on or after August 1, 2000. Implementing regulations for the OPPS are located at 42 CFR part 419.
Under the OPPS, we pay for hospital outpatient services on a rate
perservice basis that varies according to the ambulatory payment
classification (APC) group to which the service is assigned. We use the
Healthcare Common Procedure Coding System (HCPCS) codes (which include
certain Current Procedural Terminology (CPT) codes) and descriptors to
identify and group the services within each APC group. The OPPS
includes payment for most hospital outpatient services, except those identified in section I.B. of this proposed rule. Section
1833(t)(1)(B)(ii) of the Act provides for Medicare payment under the
OPPS for hospital outpatient services designated by the Secretary
(which includes partial hospitalization services furnished by community
mental health centers (CMHCs)) and hospital outpatient services that
are furnished to inpatients who have exhausted their Part A benefits,
or who are otherwise not in a covered Part A stay. Section 611 of Pub.
L. 108173 added provisions for Medicare coverage of an initial
preventive physical examination, subject to the applicable deductible
and coinsurance, as an outpatient department service, payable under the OPPS.
The OPPS rate is an unadjusted national payment amount that includes the Medicare payment and the beneficiary copayment. This rate is divided into a laborrelated amount and a nonlaborrelated amount. The laborrelated amount is adjusted for area wage differences using the hospital inpatient wage index value for the locality in which the hospital or CMHC is located.
All services and items within an APC group are comparable clinically and with respect to resource use (section 1833(t)(2)(B) of the Act). In accordance with section 1833(t)(2) of the Act, subject to certain exceptions, services and items within an APC group cannot be considered comparable with respect to the use of resources if the highest median (or mean cost, if elected by the Secretary) for an item or service in the APC group is more than 2 times greater than the lowest median cost for an item or service within the same APC group (referred to as the ``2 times rule''). In implementing this provision, we generally use the median cost of the item or service assigned to an APC group.
For new technology items and services, special payments under the OPPS may be made in one of two ways. Section 1833(t)(6) of the Act provides for temporary additional payments, which we refer to as ``transitional passthrough payments,'' for at least 2 but not more than 3 years for certain drugs, biological agents, brachytherapy devices used for the treatment of cancer, and categories of other medical devices. For new technology services that are not eligible for transitional passthrough payments, and for which we lack sufficient data to appropriately assign them to a clinical APC group, we have established special APC groups based on costs, which we refer to as New Technology APCs. These New Technology APCs are designated by cost bands which allow us to provide appropriate and consistent payment for designated new procedures that are not yet reflected in our claims data. Similar to passthrough payments, an assignment to a New Technology APC is temporary; that is, we retain a service within a New Technology APC until we acquire sufficient data to assign it to a clinically appropriate APC group.
B. Excluded OPPS Services and Hospitals
Section 1833(t)(1)(B)(i) of the Act authorizes the Secretary to designate the hospital outpatient services that are paid under the OPPS. While most hospital outpatient services are payable under the OPPS, section 1833(t)(1)(B)(iv) of the Act excludes payment for ambulance, physical and occupational therapy, and speechlanguage pathology services, for which payment is made under a fee schedule. Section 614 of Pub. L. 108173 amended section 1833(t)(1)(B)(iv) of the Act to exclude payment for screening and diagnostic mammography services from the OPPS. The Secretary exercised the authority granted under the statute to also exclude from the OPPS those services that are paid under fee schedules or other payment systems. Such excluded services include, for example, the professional services of physicians and nonphysician practitioners paid under the Medicare Physician Fee Schedule (MPFS); laboratory services paid under the clinical diagnostic laboratory fee schedule (CLFS); services for beneficiaries with end stage renal disease (ESRD) that are paid under the ESRD composite rate; and services and procedures that require an inpatient stay that are paid under the hospital inpatient prospective payment system (IPPS). We set forth the services that are excluded from payment under the OPPS in Sec. 419.22 of the regulations.
Under Sec. 419.20(b) of the regulations, we specify the types of hospitals and entities that are excluded from payment under the OPPS. These excluded entities include Maryland hospitals, but only for services that are paid under a cost containment waiver in accordance with section 1814(b)(3) of the Act; critical access hospitals (CAHs); hospitals located outside of the 50 States, the District of Columbia, and Puerto Rico; and Indian Health Service hospitals.
C. Prior Rulemaking
On April 7, 2000, we published in the Federal Register a final rule with comment period (65 FR 18434) to implement a prospective payment system for hospital outpatient services. The hospital OPPS was first implemented for services furnished on or after August 1, 2000. Section 1833(t)(9) of the Act requires the Secretary to review certain components of the OPPS, not less often than annually, and to revise the groups, relative payment weights, and other adjustments that take into account changes in medical practices, changes in technologies, and the addition of new services, new cost data, and other relevant information and factors.
Since initially implementing the OPPS, we have published final rules in the Federal Register annually to implement statutory requirements and changes arising from our continuing experience with this system. We published in the Federal Register on November 27, 2007 the CY 2008 OPPS/ASC final rule with comment period (72 FR 66580). In that final rule with comment period, we revised the OPPS to update the payment weights and conversion factor for services payable under the CY 2008 OPPS on the basis of claims data from January 1, 2006, through December 31, 2006, and to implement certain provisions of Pub. L. 108 173 and Pub. L. 109171. In addition, we responded to public comments received on the provisions of the November 26, 2006 final rule with comment period (71 FR 67960) pertaining to the APC assignment of HCPCS codes identified in Addendum B to that rule with the new interim (NI) comment indicator; and public comments received on the August 2, [[Page 41421]]
2007 OPPS/ASC proposed rule for CY 2008 (72 FR 42628).
Subsequent to publication of the CY 2008 OPPS/ASC final rule with comment period, we published in the Federal Register on February 22, 2008, a correction notice (73 FR 9860) to correct certain technical errors in the CY 2008 OPPS/ASC final rule with comment period. D. APC Advisory Panel
1. Authority of the APC Panel
Section 1833(t)(9)(A) of the Act, as amended by section 201(h) of the BBRA, and redesignated by section 202(a)(2) of the BBRA, requires that we consult with an outside panel of experts to review the clinical integrity of the payment groups and their weights under the OPPS. The Act further specifies that the panel will act in an advisory capacity. The Advisory Panel on Ambulatory Payment Classification (APC) Groups (the APC Panel), discussed under section I.D.2. of this proposed rule, fulfills these requirements. The APC Panel is not restricted to using data compiled by CMS, and it may use data collected or developed by organizations outside the Department in conducting its review. 2. Establishment of the APC Panel
On November 21, 2000, the Secretary signed the initial charter establishing the APC Panel. This expert panel, which may be composed of up to 15 representatives of providers subject to the OPPS (currently employed fulltime, not as consultants, in their respective areas of expertise), reviews clinical data and advises CMS about the clinical integrity of the APC groups and their payment weights. For purposes of this APC Panel, consultants or independent contractors are not considered to be fulltime employees. The APC Panel is technical in nature, and is governed by the provisions of the Federal Advisory Committee Act (FACA). Since its initial chartering, the Secretary has renewed the APC Panel's charter three times: on November 1, 2002; on November 1, 2004; and effective November 21, 2006. The current charter specifies, among other requirements, that the APC Panel continues to be technical in nature; is governed by the provisions of the FACA; may convene up to three meetings per year; has a Designated Federal Officer (DFO); and is chaired by a Federal official designated by the Secretary.
The current APC Panel membership and other information pertaining to the APC Panel, including its charter, Federal Register notices, membership, meeting dates, agenda topics, and meeting reports can be viewed on the CMS Web site at: http://www.cms.hhs.gov/FACA/05_ AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp#TopOfPage. 3. APC Panel Meetings and Organizational Structure
The APC Panel first met on February 27, February 28, and March 1, 2001. Since the initial meeting, the APC Panel has held 13 subsequent meetings, with the last meeting taking place on March 5, and March 6, 2008. Prior to each meeting, we publish a notice in the Federal Register to announce the meeting, and when necessary, to solicit nominations for APC Panel membership, and to announce new members.
The APC Panel has established an operational structure that, in part, includes the use of three subcommittees to facilitate its required APC review process. At its March 2008 meeting, the APC Panel recommended that the Observation and Visit Subcommittee's name be changed to the ``Visits and Observation Subcommittee.'' We are accepting this recommendation and will refer to the subcommittee by its new name, as appropriate, throughout this proposed rule. Thus, the three current subcommittees are the Data Subcommittee, the Visits and Observation Subcommittee, and the Packaging Subcommittee. The Data Subcommittee is responsible for studying the data issues confronting the APC Panel, and for recommending options for resolving them. The Visits and Observation Subcommittee reviews and makes recommendations to the APC Panel on all technical issues pertaining to observation services and hospital outpatient visits paid under the OPPS (for example, APC configurations and APC payment weights). The Packaging Subcommittee studies and makes recommendations on issues pertaining to services that are not separately payable under the OPPS, but whose payments are bundled or packaged into APC payments. Each of these subcommittees was established by a majority vote from the full APC Panel during a scheduled APC Panel meeting, and their continuation as subcommittees was last approved at the March 2008 APC Panel meeting. All subcommittee recommendations are discussed and voted upon by the full APC Panel.
Discussions of the recommendations resulting from the APC Panel's
March 2008 meeting are included in the sections of this proposed rule
that are specific to each recommendation. For discussions of earlier
APC Panel meetings and recommendations, we refer readers to previously
published hospital OPPS final rules or the Web site mentioned earlier in this section.
E. Provisions of the Medicare, Medicaid, and SCHIP Extension Act of 2007
The Medicare, Medicaid and SCHIP Extension Act (MMSEA) of 2007, (Pub. L. 110173), enacted on December 29, 2007, included the following provisions that affect the OPPS and the revised APC payment system: 1. Increase in Physician Payment Update
Section 101 of the MMSEA provides a 0.5 percent increase in the
physician payment update from January 1, 2008 through June 30, 2008;
revises the Physician Assistance and Quality Initiative Fund, and
extends through 2009 the physician quality reporting system. We refer
readers to section XV. of this proposed rule for discussion of the
effect of this provision on services paid under the revised ASC payment system.
2. Extended Expiration Date for CostBased OPPS Payment for Brachytherapy Sources and Therapeutic Radiopharmaceuticals
Section 106 of the MMSEA amended section 1833(t)(16)(C) of the Act, as amended by section 107 of the MIEATRCHA to extend for an additional 6 months, through June 30, 2008, payment for brachytherapy devices at hospitals' charges adjusted to costs and to mandate that the same cost based payment methodology apply to therapeutic radiopharmaceuticals for the same extended payment period. We refer readers to sections V. and VII of this proposed rule for discussion of this provision. 3. Alternative Volume Weighting in Computation of Average Sales Price (ASP) for Medicare Part B Drugs
Section 112 of the MMSEA amended section 1847A(b) to provide for
application of alternative volume weighting in computing the average
sales price (ASP) for payment of Part B multiple source and single
source drugs furnished after April 1, 2008, and for a special rule,
beginning April 1, 2008, for payment of single source drugs or
biologicals treated as a multiple source drug. This provision is discussed in section V. of this proposed rule.
[[Page 41422]]
4. Extended Expiration Date for Certain IPPS Wage Index Geographic Reclassifications and Special Exceptions
Section 117 of the MMSEA extended through September 30, 2008, both the reclassifications that were extended by section 106 of MIEATRCHA as well as certain special exception wage indices referenced in the FY 2005 IPPS final rule (69 FR 49105 and 49107). This provision also amended section 508 of Pub. L. 108173 to specify conditions specific to the reclassification of a group of hospitals in a geographic area for discharges occurring during FY 2008. In addition, for hospital reclassifications extended by section 106(a) of the MIEATRCHA, that resulted in a lower wage index for the second half of FY 2007 than applicable to such hospitals during the first half of FY 2007, section 117 of the MMSEA directs the Secretary to apply a higher wage index to such hospitals for the entire FY 2007. We refer readers to section II.C. of this proposed rule for discussion of this provision. F. Summary of the Major Contents of This Proposed Rule
In this proposed rule, we are setting forth proposed changes to the Medicare hospital OPPS for CY 2009. These changes would be effective for services furnished on or after January 1, 2009. We are also setting forth proposed changes to the Medicare revised ASC payment system for CY 2009. These changes would be effective for services furnished on or after January 1, 2009. The following is a summary of the major changes that we are proposing to make:
1. Proposed Updates Affecting OPPS Payments
In section II. of this proposed rule, we set forth
In section III. of this proposed rule, we discuss the proposed additions of new procedure codes to the APCs; our proposal to establish a number of new APCs; and our analyses of Medicare claims data and certain recommendations of the APC Panel. We also discuss the application of the 2 times rule and proposed exceptions to it; proposed changes to specific APCs; and the proposed movement of procedures from New Technology APCs to clinical APCs.
3. Proposed OPPS Payment for Devices
In section IV. of this proposed rule, we discuss proposed pass
through payment for specific categories of devices and the proposed
adjustment for devices furnished at no cost or with partial or full credit.
4. Proposed OPPS Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals
In section V. of this proposed rule, we discuss proposed CY 2009
OPPS payment for drugs, biologicals, and radiopharmaceuticals,
including the proposed payment for drugs, biologicals, and radiopharmaceuticals with and without passthrough status.
5. Proposed Estimate of OPPS Transitional PassThrough Spending for Drugs, Biologicals, Radiopharmaceuticals, and Devices
In section VI. of this proposed rule, we discuss the estimate of CY 2009 OPPS transitional passthrough spending for drugs, biologicals, and devices.
6. Proposed OPPS Payment for Brachytherapy Sources
In section VII. of this proposed rule, we discuss our proposal concerning coding and payment for brachytherapy sources.
7. Proposed OPPS Payment for Drug Administration Services
In section VIII. of this proposed rule, we set forth our proposed policy concerning payment and coding for drug administration services. 8. Proposed OPPS Payment for Hospital Outpatient Visits
In section IX. of this proposed rule, we set forth our proposed policies for the payment of clinic and emergency department visits and critical care services based on claims paid under the OPPS. 9. Proposed Payment for Partial Hospitalization Services
In section X. of this proposed rule, we set forth our proposed
payment for partial hospitalization services, including the proposed separate threshold for outlier payments for CMHCs.
10. Proposed Procedures That Will Be Paid Only as Inpatient Procedures
In section XI. of this proposed rule, we discuss the procedures that we are proposing to remove from the inpatient list and assign to APCs.
11. OPPS Nonrecurring Technical and Policy Clarifications
In section XII. of this proposed rule, we set forth our nonrecurring technical and policy clarifications.
12. Proposed OPPS Payment Status and Comment Indicators
In section XIII. of this proposed rule, we discuss our proposed changes to the definitions of status indicators assigned to APCs and present our proposed comment indicators for the CY 2009 OPPS/ASC final rule with comment period.
13. OPPS Policy and Payment Recommendations
In section XIV. of this proposed rule, we address recommendations
made by the Medicare Payment Advisory Commission (MedPAC) in its June
2007 and March 2008 reports to Congress, by the APC Panel regarding the
OPPS for CY 2009, and by the Office of the Inspector General (OIG) in its June 2007 report.
14. Proposed Update of the Revised Ambulatory Surgical Center Payment System
In section XV. of this proposed rule, we discuss the proposed update of the revised ASC payment system payment rates for CY 2009. 15. Proposed Reporting of Hospital Outpatient Quality Data for Annual Hospital Payment Rate Updates and CY 2009 Payment Reduction
In section XVI. of this proposed rule, we discuss the proposed quality
[[Page 41423]]
measures for reporting hospital outpatient quality data for CY 2010 and
subsequent calendar years, set forth the requirements for data
collection and submission for the annual payment update, and propose a
reduction in the OPPS payment for hospitals that fail to meet the HOP QDRP requirements for CY 2009.
16. HealthcareAssociated Conditions
In section XVII. of this proposed rule, we discuss considerations related to potentially extending the principle of Medicare not paying more for the preventable healthcareassociated conditions acquired during inpatient stays paid under the IPPS to other Medicare payment systems for healthcareassociated conditions that occur or result from care in other settings.
17. Regulatory Impact Analysis
In section XXI. of this proposed rule, we set forth an analysis of
the impact the proposed changes would have on affected entities and beneficiaries.
II. Proposed Updates Affecting OPPS Payments
A. Proposed Recalibration of APC Relative Weights
1. Database Construction
a. Database Source and Methodology
Section 1833(t)(9)(A) of the Act requires that the Secretary review and revise the relative payment weights for APCs at least annually. In the April 7, 2000 OPPS final rule with comment period (65 FR 18482), we explained in detail how we calculated the relative payment weights that were implemented on August 1, 2000 for each APC group. As discussed in the November 13, 2000 interim final rule (65 FR 67824 through 67827), except for some reweighting due to a small number of APC changes, these relative payment weights continued to be in effect for CY 2001.
We are proposing to use the same basic methodology that we described in the April 7, 2000 OPPS final rule with comment period to recalibrate the APC relative payment weights for services furnished on or after January 1, 2009, and before January 1, 2010 (CY 2009). That is, we are proposing to recalibrate the relative payment weights for each APC based on claims and cost report data for outpatient services. We are proposing to use the most recent available data to construct the database for calculating APC group weights. For the purpose of recalibrating the proposed APC relative payment weights for CY 2009, we used approximately 130 million final action claims for hospital outpatient department (HOPD) services furnished on or after January 1, 2007, and before January 1, 2008. (For exact counts of claims used, we refer readers to the claims accounting narrative under supporting documentation for this proposed rule on the CMS Web site at: http:// www.cms.hhs.gov/HospitalOutpatientPPS/HORD/).
Of the 130 million final action claims for services provided in hospital outpatient settings used to calculate the CY 2009 OPPS payment rates for this proposed rule, approximately 100 million claims were of the type of bill potentially appropriate for use in setting rates for OPPS services (but did not necessarily contain services payable under the OPPS). Of the 100 million claims, approximately 45 million were not for services paid under the OPPS or were excluded as not appropriate for use (for example, erroneous costtocharge ratios (CCRs) or no HCPCS codes reported on the claim). We were able to use approximately 52 million whole claims of the approximately 54 million claims that remained to set the OPPS APC relative weights that we are proposing for the CY 2009 OPPS. From the 52 million whole claims, we created approximately 90 million single records, of which approximately 60 million were ``pseudo'' single claims (created from multiple procedure claims using the process we discuss in this section). Approximately 627,000 claims trimmed out on cost or units in excess of +/3 standard deviations from the geometric mean, yielding approximately 89 million single bills used for median setting. Ultimately, we were able to use for proposed CY 2009 ratesetting some portion of the data from 96 percent of the CY 2007 claims containing services payable under the OPPS.
The proposed APC relative weights and payments for CY 2009 in Addenda A and B to this proposed rule were calculated using claims from CY 2007 that were processed before January 1, 2008, and continue to be based on the median hospital costs for services in the APC groups. We selected claims for services paid under the OPPS and matched these claims to the most recent cost report filed by the individual hospitals represented in our claims data. We continue to believe that it is appropriate to use the most current full calendar year claims data and the most recently submitted cost reports to calculate the median costs which we are proposing to convert to relative payment weights for purposes of calculating the CY 2009 payment rates.
b. Proposed Use of Single and Multiple Procedure Claims
For CY 2009, in general, we are proposing to continue to use single procedure claims to set the medians on which the APC relative payment weights would be based, with some exceptions as discussed below. We generally use single procedure claims to set the median costs for APCs because we believe that it is important that the OPPS relative weights on which payment rates are based be appropriate when one and only one procedure is furnished and because we are, so far, unable to ensure that packaged costs can be appropriately allocated across multiple procedures performed on the same date of service. We agree that, optimally, it is desirable to use the data from as many claims as possible to recalibrate the APC relative payment weights, including those claims for multiple procedures. As we have for several years, we continued to use date of service stratification and a list of codes to be bypassed to convert multiple procedure claims to ``pseudo'' single procedure claims. Through bypassing specified codes that we believe do not have significant packaged costs, we are able to use more data from multiple procedure claims. In many cases, this enables us to create multiple ``pseudo'' single claims from claims that, as submitted, contained numerous separately paid procedures reported on the same date on one claim. We refer to these newly created single procedure claims as ``pseudo'' single claims because they were submitted by providers as multiple procedure claims. The history of our use of a bypass list to generate ``pseudo'' single claims is well documented, most recently in the CY 2008 OPPS/ASC final rule with comment period (72 FR 66590 through 66597). In addition, for CY 2008, we increased packaging and created composite APCs, which also increased the number of bills we were able to use for median calculation by enabling us to use claims that contained multiple major procedures that previously would not have been usable. We refer readers to section II.A.2.e. of this proposed rule for discussion of the use of claims to establish median costs for composite APCs.
We are proposing to continue to apply these processes to enable us
to use as much claims data as possible for ratesetting for the CY 2009
OPPS. Application of these processes in development of this proposed
rule data resulted in our being able to use some or all of the data
from 96 percent of the total claims that are eligible for use in [[Page 41424]]
the OPPS ratesetting and modeling for this proposed rule. This process
enabled us to create, for this proposed rule, approximately 60 million
``pseudo'' single claims, including multiple imaging composite ``single
session'' bills (we refer readers to section II.A.2.e.(5) of this
proposed rule for further discussion), and approximately 30 million
``natural'' single bills. For this proposed rule, ``pseudo'' single
procedure bills represent 67 percent of all single bills used to
calculate median costs. This compares favorably to the CY 2008 OPPS/ASC
final rule with comment period data in which ``pseudo'' single bills
represented 66 percent of all single bills used to calculate the median costs on which the CY 2008 OPPS payment rates were based.
For CY 2009, we are proposing to bypass 452 HCPCS codes that are
identified in Table 1 of this proposed rule. We are proposing to
continue the use of the codes on the CY 2008 OPPS bypass list. Since
the inception of the bypass list, we have calculated the percent of
``natural'' single bills that contained packaging for each HCPCS code
and the amount of packaging in each ``natural'' single bill for each
code. We have generally retained the codes on the previous year's
bypass list and used the update year's data (for CY 2009, data
available for the first CY 2008 APC Panel meeting for services
furnished on and after January 1, 2007 through and including September
30, 2007) to determine whether it would be appropriate to add
additional codes to the previous year's bypass list. The entire list
(including the codes that remained on the bypass list from prior years)
is open to public comment. We removed two HCPCS codes from the CY 2008
bypass list for this CY 2009 proposal because the codes were deleted on
December 31, 2005, specifically C8951 (Intravenous infusion for
therapy/diagnosis; each additional hour (List separately in addition to
C8950)) and C8955 (Chemotherapy administration, intravenous; infusion
technique, each additional hour (List separately in addition to
C8954)). We updated HCPCS codes on the CY 2008 bypass list that were
mapped to new HCPCS codes for CY 2009 ratesetting. We are proposing to
add to the bypass list all HCPCS codes not on the CY 2008 bypass list
that, using the APC Panel data, meet the same previously established
empirical criteria for the bypass list that are summarized below. We
assume that the representation of packaging in the single claims for
any given code is comparable to packaging for that code in the multiple claims. The proposed criteria for the bypass list are:
In addition, we are proposing to add to the bypass list HCPCS codes that CMS medical advisors believe have minimal associated packaging based on their clinical assessment of the complete CY 2009 OPPS proposal. To ensure clinical consistency in our treatment of related services, we are also proposing to add the other CPT addon codes for drug administration services to the CY 2009 bypass list, in addition to the CPT codes for additional hours of infusion that were previously included on the CY 2008 bypass list, because adding them enables us to use many correctly coded claims for initial drug administration services that would otherwise not be available for ratesetting. The result of this proposal is that the packaged costs associated with add on drug administration services are packaged into payment for the initial administration service, as has been our payment policy for the past 2 years for the CPT codes for additional hours of infusion. We are also proposing to add HCPCS code G0390 (Trauma response team activation associated with hospital critical care service) because we think it is appropriate to attribute all of the packaged costs that appear on a claim with HCPCS code G0390 and CPT code 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 3074 minutes) to CPT code 99291. If we did not add HCPCS code G0390 to the bypass list, we would have many fewer claims to use to set the median costs for APCs 0617 (Critical Care) and 0618 (Trauma Response with Critical Care). By definition, we could not have any properly coded ``natural'' single bills for HCPCS code G0390. Including HCPCS code G0390 on the bypass list allows us to create more ``pseudo'' single bills for CPT code 99291 and HCPCS code G0390, and, therefore, to improve the accuracy of the median costs of APCs 0617 and 0618 to which the two codes are assigned, respectively. The Integrated Outpatient Code Editor (I/OCE) logic rejects a line for HCPCS code G0390 if CPT code 99291 is not also reported on the claim. Therefore, we cannot assess whether HCPCS code G0390 would meet the empirical criteria for inclusion on the bypass list because we have no ``natural'' single claims for HCPCS code G0390.
As a result of the multiple imaging composite APCs that we are proposing to establish for CY 2009 as discussed in section II.A.2.e.(5) of this proposed rule, the ``pseudo'' single converter logic for bypassed codes that are also members of multiple imaging composite APCs would change. When creating the set of ``pseudo'' single claims, claims that contain ``overlap bypass codes,'' that is, those HCPCS codes that are both on the bypass list and are members of the multiple imaging composite APCs, are identified first. These HCPCS codes are then processed to create multiple imaging composite ``single'' bills, that is, claims containing HCPCS codes from only one imaging family, thus suppressing the initial use of these codes as bypass codes. However, these ``overlap bypass codes'' are retained on the bypass list because single unit occurrences of these codes are identified as single bills at the end of the ``pseudo'' single processing logic. The net effect of using these HCPCS codes in building multiple imaging composite ``single session'' claims rather than for bypass purposes is a slight reduction in the number of ``pseudo'' single claims available for the ``overlap bypass codes'' and a handful of services that would be frequently billed with an ``overlap bypass code.'' This process also creates multiple imaging composite ``single session'' bills that can be used for calculating composite APC median costs. ``Overlap bypass codes'' that would be members of the proposed multiple imaging composite APCs are identified by asterisks (*) in Table 1.
We note that this list contains bypass codes that were appropriate
to claims for services in CY 2007 and, therefore, includes codes that
were deleted for CY 2008. Moreover, there are codes on the proposed
bypass list that are new for CY 2008 and which are appropriate
additions to the bypass list in preparation for use of the CY 2008
claims for creation of the CY 2010 OPPS. Table 1 below includes a list of the bypass codes that we are proposing
[[Page 41425]]
for CY 2009. We specifically request public comment on this proposed list of bypass codes for CY 2009.
Table 1.Proposed CY 2009 Bypass Codes for Creating ``Pseudo'' Single Claims for Calculating Median Costs
``Overlap bypass
HCPCS code Short descriptor codes''
11056........................... Trim skin lesions, .................. 2 to 4.
11057........................... Trim skin lesions, .................. over 4.
11300........................... Shave skin lesion. ..................
11301........................... Shave skin lesion. ..................
11719........................... Trim nail(s)...... ..................
11720........................... Debride nail, 15. ..................
11721........................... Debride nail, 6 or .................. more.
11954........................... Therapy for .................. contour defects.
17000........................... Destruct premalg .................. lesion.
17003........................... Destruct premalg .................. les, 214.
29220........................... Strapping of low .................. back.
31231........................... Nasal endoscopy, .................. dx.
31579........................... Diagnostic .................. laryngoscopy.
51798........................... Us urine capacity .................. measure.
53661........................... Dilation of .................. urethra.
54240........................... Penis study....... ..................
56820........................... Exam of vulva w/ .................. scope.
57150........................... Treat vagina .................. infection.
67820........................... Revise eyelashes.. ..................
69210........................... Remove impacted .................. earwax.
69220........................... Clean out mastoid .................. cavity.
70030........................... Xray eye for .................. foreign body.
70100........................... Xray exam of jaw. ..................
70110........................... Xray exam of jaw. ..................
70120........................... Xray exam of .................. mastoids.
70130........................... Xray exam of .................. mastoids.
70140........................... Xray exam of .................. facial bones.
70150........................... Xray exam of .................. facial bones.
70160........................... Xray exam of .................. nasal bones.
70200........................... Xray exam of eye .................. sockets.
70210........................... Xray exam of .................. sinuses.
70220........................... Xray exam of .................. sinuses.
70250........................... Xray exam of .................. skull.
70260........................... Xray exam of .................. skull.
70328........................... Xray exam of jaw .................. joint.
70330........................... Xray exam of jaw .................. joints.
70336........................... Magnetic image, *
jaw joint.
70355........................... Panoramic xray of .................. jaws.
70360........................... Xray exam of neck ..................
70370........................... Throat xray & .................. fluoroscopy.
70371........................... Speech evaluation, .................. complex.
70450........................... Ct head/brain w/o *
dye.
70480........................... Ct orbit/ear/fossa *
w/o dye.
70486........................... Ct maxillofacial w/ *
o dye.
70490........................... Ct soft tissue *
neck w/o dye.
70544........................... Mr angiography *
head w/o dye.
70551........................... Mri brain w/o dye. *
71010........................... Chest xray....... ..................
71015........................... Chest xray....... ..................
71020........................... Chest xray....... ..................
71021........................... Chest xray....... ..................
71022........................... Chest xray....... ..................
71023........................... Chest xray and .................. fluoroscopy.
71030........................... Chest xray....... ..................
71034........................... Chest xray and .................. fluoroscopy.
71035........................... Chest xray....... ..................
71100........................... Xray exam of ribs ..................
71101........................... Xray exam of ribs/ .................. chest.
71110........................... Xray exam of ribs ..................
71111.....................
FOR FURTHER INFORMATION CONTACT Alberta Dwivedi, (410) 786-0378-- Hospital outpatient prospective payment issues; Dana Burley, (410) 786 0378Ambulatory surgical center issues; Suzanne Asplen, (410) 786 4558Partial hospitalization and community mental health center issues; Sheila Blackstock, (410) 7863502Reporting of quality data issues.
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