CY 2012 Medicare Outpatient Prospective Payment System (OPPS) Final Rule
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1 CY 2012 Medicare Outpatient Prospective Payment System (OPPS) Final Rule Lori Mihalich-Levin, J.D ) Jennifer Faerberg ) Jane Eilbacher ) November 30, 2011
2 Outpatient PPS Proposed Rule Released Nov. 1, Published in Federal Register on November 30 at 76 Fed. Reg , at 30/pdf/ pdf. 2
3 Topics Included in These Slides Hospital Outpatient Quality Reporting Program Electronic Reporting Pilot (for quality measures) ASC Quality Reporting Program Hospital Inpatient VBP Program Conversion Factor Update Payments to Certain Cancer Hospitals Payment Rate for Separately Payable Drugs/Biologicals New Technology APCs Transitional Pass-Through Payments Inpatient Only Procedures Physician Supervision Proposals Wage Index Proposals 3
4 4 Hospital Outpatient Quality Reporting Program (HOP QDRP)
5 Finalized Measures for CY 2014 CY 2014 Cardiac Rehabilitation Referral Safe Surgery Checklist Use Volume Data on Selected Outpatient Surgical Procedures See pages
6 Hospital Outpatient Volume Categories Cardiovascular Eye Gastrointestinal Genitourinary Musculoskeletal Nervous System Respiratory Skin Volume based on procedures between January 1, 2012 through December 31, 2012 Data submission between July 1, 2013 to August 15, 2013 through portal 6 See pages
7 Validation Changes Submit aggregate population and sample size counts for chart abstracted measures on a quarterly basis Number of hospitals selected for validation reduced from 800 to 450 Increase number of patient encounters per hospital to 12 per quarter See pages
8 8 Electronic Reporting Pilot
9 EHR Incentive Program Electronic Reporting Pilot Certified EHR standards for collecting quality data not viable for hospitals Hospitals can continue to submit quality data via attestation for OR Participate in a voluntary Electronic Reporting Pilot See pages
10 Electronic Reporting Pilot Participation in pilot would satisfy reporting requirements for quality measures Hospitals to submit one year of patient level data on Medicare patients only via EHR. Results will be calculated by CMS Hospitals still required to meet other meaningful use objectives See pages
11 11 Ambulatory Surgical Centers Quality Reporting Program
12 ASC Quality Reporting Failure to report results in 2% point reduction to annual increase Program effective for CY 2014 payment determination; data collection beginning CY 2012 Finalized three year plan for reporting measures (CY ) Quality data submitted through quality data codes on Part B Medicare claims CPT II or HCPCS G-codes See pages
13 Finalized Measures CY 2014 Patient Burn Patient Fall Wrong Site, Side, Patient Surgery Wrong Procedure, Implant Hospital Transfer/Admission Prophylactic IV Antibiotic Timing CY 2015 Safe Surgery Checklist Use Facility Volume Data CY 2016 Influenza Vaccination among Healthcare Personnel See page
14 14 Hospital Inpatient Value-Based Purchasing Program
15 VBP Domain Weighting FY 2014 Care Domains HCAHPS 30% Clinical Process 45% Outcomes 25% 15 See page 74544
16 Outcome and Efficiency Domains CMS finalized inclusion of HAC rates, AHRQ composites and Medicare Spending per Beneficiary in VBP in the FY 2012 IPPS Final Rule o However, the ACA requires measures included in VBP must be reported on Hospital Compare for at least one year o RESULT: HACs, AHRQ PSIs and Medicare Spending have been deferred and will not be included in the FY 2014 VBP 16 See pages
17 Additional Measure for FY 2014 SCIP-Infection 9 Postoperative Urinary Catheter Removal on Postoperative Day 1 or 2 Postoperative Urinary Catheter 17 See page 74530
18 VBP FY 2014 Performance Periods 18 See page 74535
19 Review and Correction Process Implement data correction process currently utilized in hospital IQR program for process measures Two-phase review and correction process for HCAHPS 19 See pages
20 20 OPPS Non-Quality Provisions
21 CY 2012 OPPS Conversion Factor Update Use IPPS market basket increase = 3.0 percent Less 2 percent if hospital doesn t submit quality data Less multi-factor productivity adjustment = 1 percent Less an additional 0.1 percent Aggregate update to OPD fee schedule = 1.9% See pages
22 Payments to Certain Cancer Hospitals ACA requires adjustment for any of the 11 cancer hospitals with outpatient costs higher than those of other hospitals Final Rule Result? Net increase to cancer hospitals = 9.5% Budget neutrality requirement = 0.2% adjustment to all other hospitals (down from 0.7%). No increase to beneficiary co-payments See pages
23 Payment Rate for Separately Payable Drugs and Biologicals CY 2012 packaging threshold = $75 (up from $70 in 2010, down from $80 in proposed rule) Payment rate = Average sales price (ASP) + 4% (down from ASP + 5% in CY 2011, same as proposed rule) CMS uses the same methodology as in CYs 2010 & 2011 to calculate the payment rate for these products See pages
24 New Technology APCs For CY 2012, CMS will continue New Technology payments for HCPCS codes G0417, G0418, G0419, but reassign them to different New Technology APCs CY 2011 HCPCS code CY 2011 Short Descriptor CY 2011 APC CY 2011 Payment Proposed CY 2012 APC Proposed CY 2012 Payment G0417 Sat biopsy prostate Level VI ($400-$500) 1505 Level V ($300-$400) G0418 Sat biopsy prostate Level XI ($900-$1,000) 1506 Level VI ($400-$500) G0419 Sat biopsy prostate > Level XIII ($1,100-1,200) 1508 Level VIII ($600-$700) 24 See pages Note: The final payment rates for these HCPCS codes can be found in Addendum B of the final rule, available on CMS website.
25 Transitional Pass-Through Payments There are now three new device categories eligible for pass-through payments (up from one at the time of the proposed rule release): HCPCS code C1749: Announced in the October 2010 update and will receive payment through December 31, 2012 HCPCS code C1830: announced September 2, 2011; effective for payment October 1, 2011 (end date for payment in future rulemaking) HCPCS code C1840: announced September 2, 2011; effective for payment October 1, 2011 (end date for payment in future rulemaking) See pages
26 Transitional Pass-Through Payments (cont.) Pass through payments will expire for 19 drugs and biologicals on December 21, 2011; listed in Table 32, p CMS will continue paying for pass through drugs and biologicals at ASP +6%, equivalent to the rate paid in the physician s office setting Table 33, p , lists the drugs and biologicals with pass-through status in CY 2012 See pages
27 Changes to the Inpatient Only List Finalizing proposal to remove CPT codes 21346, 35045, and from the inpatient list, as well as 0184T, 20930, 20931, 22551, 22554, 43281, based on comments Table 46, p , lists the procedures removed from the inpatient only list and their CY 2012 APC assignments See pages
28 28 Physician Supervision CMS appointed APC Panel as independent review entity to make recommendations to CMS about supervision of specific OPD services Direct supervision remains default level for OPD therapeutic services APC Panel will evaluate supervision level for therapeutic services general, direct, or personal CMS s decisions would be posted on OPPS Web site for public review & comment (30 day comment period) Decisions effective July or January following most recent APC Panel meeting See pages
29 Wage Index Policy CMS concerned about significant fluctuations in wage index (e.g. caused by manipulation of the rural floor ) Sought comments re: proposals that would decouple IPPS wage index from OPPS CMS decided to continue to use IPPS wage index for OPPS (for now) See pages
30
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Marilyn Tavenner Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Hubert H. Humphrey Building 200 Independence Avenue, S.W. Room 445-G Washington, D.C.