OPPS Final Rule Highlights

Under the Hospital Outpatient Prospective Payment System (OPPS) for CY 2010, hospital outpatient departments that report quality data elements will receive a market basket update of 2.1 percent. The full market basket update conversion factor for CY 2010 is $67.406. Hospitals that did not participate in quality data reporting for outpatient services or did not report the quality data successfully will receive a reduced update of 0.1 percent, resulting in a conversion factor of $66.086 for CY 2010.

• CMS finalized its proposal to calculate the median costs for device-dependent APCs for CY 2010 using only the subset of single procedure claims from CY 2008 claims data that passed the procedure-to-device/device-to-procedure edits, do not contain token charges, and do not contain the “FB” or “FC” modifier. This applies to heart rhythm device-dependent APCs 0084, 0085, 0086, 0089, 0090, 0104, 0107, 0108, 0418, 0654, 0655 and 0680. This change will also result in a 50 percent increase for APC 0418 (Insertion of Left Ventricular Pacing Electrode).
• For CY 2010, CMS will continue its established composite APC (8000) methodology for cardiac electrophysiologic evaluation (93619, 93620) and ablation (93650-93652), resulting in a 7 percent increase.
• CMS finalized its proposal without modification to reassign CPT code 93299 from APC 209 to APC 0689, decreasing the payment from approximately $754.00 to approximately $38.00. APC 0080 (Diagnostic Cardiac Catheterization) will be subject to the contrast offset policy in CY 2010.
• CMS will consider recommendations from the APC Panel to create composite APCs for CRT-D and CRT-P, and report its findings to the Panel at a future meeting.
• CMS clarified “direct supervision” requirements for outpatient services to mean that the physician or non-physician practitioner must be present anywhere on the hospital campus and immediately available to furnish assistance and direction throughout the performance of the procedure.
• For services furnished in an off-campus provider-based department, “direct supervision” would continue to mean that the physician or non-physician practitioner must be present in the off-campus provider-based department and immediately available to furnish assistance and direction throughout the performance of the procedure.
• The supervision requirements will now allow certain non-physician practitioners, specifically physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, and licensed clinical social workers to provide “direct supervision” for all hospital outpatient therapeutic services that they are authorized to personally perform according to their state scope of practice and hospital privileges.
• CMS will continue its policy of reducing OPPS payment for specified APCs by 100 percent of the device offset amount when a hospital furnishes a specified device without cost or with a full credit and by 50 percent of the device offset amount when the hospital receives partial credit in the amount of 50 percent or more of the cost for the specified device. This policy applies to APCs 0089, 0090, 0106, 0107, 0108, 0418, 0654, 0655 and 0680, and device codes C1721-22, C1764, C1777-79, C1785-86, C1882, C1895-96, C1898-99 and C2619-21.

Download the 2010 OPPS rate table (PDF, 60K)

ASC FINAL RULE HIGHLIGHTS

• CY 2010 is the third year of a four-year phase-in on the ASC payment rates calculated under the standard rate-setting methodology.
• CMS will apply a 1.2 percent update to the conversion factor for CY 2010.
• CMS did not add any new heart rhythm related surgical procedures to the list of services approved for Medicare payment in an ASC.
• CMS also updated the list of device-intensive procedures and covered ancillary services and their rates to be consistent with the OPPS update.