Summary of Medicare’s proposal for CY2013 OPPS & ASC payments

On July 6, 2012, CMS released its 2013 proposed Hospital Outpatient Prospective System (HOPPS) rule at http://www.gpo.gov/fdsys/pkg/FR-2012-07-30/pdf/2012-16813.pdf. This proposed rule will be published in the Federal Register on July 30, 2012.  Comments on this proposed rule will be accepted until September 4, 2012.  Upon review of public comments, CMS will issue the final rule for Hospital Outpatient and Ambulatory Surgery Services in early November, 2012.

Key Health Policy issues raised in this proposed rule include:

  • CMS proposes a 2.1% increase in HOPD and 1.3% increase in ASC payments.
  • Total payments for services furnished to Medicare beneficiaries in HOPDs during CY2013 = approximately $48.1 billion; while total CY13 payments under the ASC payment system = approximately $4.10 billion.
  • CY2013 HOPPS conversion factor = $71.537.
  • CY2013 ASC conversion factor = $43.190.
  • Similar to the proposed CY2013 Physician rule, also released on July 6th, CMS proposes several changes to the quality reporting programs for HOPDs, ASCs and Inpatient Rehabilitation Facilities (IRFs).

Regarding Hospital Outpatient Services, device executives should note:  

  • For CY2013, CMS proposes to clarify the test that requires a new device category applicant to show that the “new” device is not similar to other devices (including related predicate devices) whose costs are already reflected in OPPS claims data. The preamble begins on page 258 of the proposed rule.  Bottomline, the applicant must demonstrate that the candidate device is not similar to devices (including related predicate devices). This might pose a Catch 22 for many 510K-devices.  The substantial clinical improvement criterion is a separate consideration and must also be satisfied in every case.  If your new product is 510-K cleared, do you know if the predicate device was previously granted a new device category? If so, you will need to prove it is not similar to this predicate device and not previously captured in OPPS claims data.
  • CMS expressed its concern about recent increases in the length of time that Medicare beneficiaries spend as outpatients receiving observation services, but offers no proposed changes.  This means “observation” cases are under review.
  • CMS proposes to continue to pay for cardiac electrophysiologic evaluation and ablation services using the composite APC methodology, APC 8000.  CMS states, “We continue to believe that the cost for these services calculated from a high volume of correctly coded multiple procedure claims results 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”.
  • Significant revisions to the regulations governing payments for new technology intraocular lens (NTIOLs) are proposed.
  • CMS proposes to remove two procedures from the CY 2013 Inpatient list:
  • CPT code 22856: Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection, single interspace, cervical.
  • CPT code 27447: Arthroplasty, knee, condyle and plateau; medical and lateral compartments with or without patella resurfacing (total knee arthroplasty).
  • CMS also proposes that these two CPT codes be excluded from the ASC list.

With regards to Ambulatory Surgery Center & Office-based Procedure:

  • CMS states that there are approximately 5,000 Medicare-participating ASCs.
  • 16 procedures are proposed additions to the ASC Covered List found on Table 39 (page 396) and include transcatheter placement of an intravascular stent; endovascular revascularization of the lower extremity and extracorporeal shock wave for wound healing.
  • In addition, CMS proposes six surgical procedures meet the criteria for designation as office-based.  The data indicate that the procedures are performed more than 50 percent of the time in physicians’ offices, and that their medical advisors believe the services are of a level of complexity consistent with other procedures performed routinely in physicians’ offices.  The six CPT codes CMS proposes to permanently designate as office-based procedures are listed in Table 40, (page 400) and include nasal/sinus endoscopy with balloon dilation and posterior tibial neurostimulation.

For more information about a specific HCPCS code, marketing personnel should search the proposed rule at cms.gov; as well as skim Addendum A (Proposed Payments by APC) and Addendum B (Proposed Payment by HCPCS code).

For questions and/or personal assistance, please contact kathryn.barry@kbreimbursement.com. We welcome your comments and questions.