CMS Finalizes 2011 Payment Rates for Hospital Outpatient Departments and Ambulatory Surgical Centers

The Centers for Medicare and Medicaid Services (CMS) recently released a final rule that would update the policies and payment rates for services furnished in hospital outpatient departments and ambulatory surgery centers (ASC) in calendar year (CY) 2011. This final rule would also implement applicable statutory requirements of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010, also known as the Affordable Care Act, or ACA. Read the CMS press release and fact sheet.

The final rule will be published in the Federal Register on November 24, 2010 and is currently available on the CMS website. Comments on the final rule will be accepted until January 3, 2011 and CMS will respond to comments in the CY 2012 outpatient prospective payment system (OPPS) and ASC rule.

The Heart Rhythm Society's Health Policy staff will continue to review the final rule to determine any further impact upon cardiac rhythm services.

Highlights of the Final Rule Affecting Heart Rhythm Services

• For CY 2011, CMS finalizes a market basket update of 2.35 percent (that is, the CY 2011 estimate increase of 2.6 percent minus 0.25 percentage points as required by the ACA), which will result in a conversion factor of $68.876. For hospitals that fail to report quality data requirements, the proposed update is 0.35 percent (minus 2.0 percentage points), resulting in a reduced conversion factor of $67.530.
         Download a full list of heart rhythm-related APC payment changes (PDF, 38K)
• CMS finalizes continuation of payment for cardiac electrophysiologic evaluation (93619, 93620) and ablation services (93650-93652) using the composite APC (8000) methodology established in CY 2008. The calculated final payment CY 2011 is $10,787, an increase compared to the CY 2010 payment of $10,093.
• CMS will continue to calculate the median costs for device-dependent APCs for CY 2011 using only the subset of single procedure claims from CY 2009 claims data that:
• • pass the procedure-to-device and device-to-procedure edits
  • do not contain token charges (less than $1.01) for devices
  • do not contain the "FB" modifier signifying that the device was furnished without cost to the provider, supplier, or practitioner, or where a full credit was received
  • do not contain the "FC" modifier signifying that the hospital received partial credit for the device. This would apply to heart rhythm device-dependent APCs 0084, 0085, 0086, 0089, 0090, 0106, 0107, 0108, 0418, 0654, 0655 and 0680.
• The final CY 2011 payment for APC 0418 (Insertion of Left Ventricular (LV) Pacing Electrode, CPT codes 33224 and 33225), which increased approximately 53 percent from CY 2009 to CY 2010, is projected to decrease approximately 23 percent in CY 2011 to $10,630. The payment fluctuations in LV lead APC payments are due to the methodology for rate-setting under OPPS based primarily on single procedure claims. The procedures involved in CRT system implants are never captured in the claims data as these services are always represented by two CPT codes. Despite many recommendations to create a new composite rate APC for cardiac resynchronization (CRT) to stabilize payments, CMS did not finalize a policy change and will continue to evaluate the need in future rule making.
• The final rule provides a national payment of $2,727 for the new 2011 CPT code 93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture which is an add-on code to be used in conjunction with transcatheter ablation codes 93651, 93652.
• The final rule also provides national payments for new Category III CPT codes for acoustic cardiography 0223T – 0225T. Code 0223T is assigned a payment of $27.26 and 0224T/0225T will be reimbursed at $35.08. These codes describe the evaluation and optimization of physiologic data including systolic and diastolic heart sounds and their temporal relationships to electrocardiogram (ECG). Codes 0223T – 0225T include interrogation and limited reprogramming of a cardiac pacing device to ensure hemodynamic optimization (heart rate parameter and/or automated timing modes, including explicit changes of AV/VV intervals) and facilitate device parameter optimization.
• After consideration of the public comments, CMS finalized the CY 2011 proposal, without modification, to assign CPT code 93229 (Wearable mobile cardiovascular telemetry technical support) to APC 0209, with a final CY 2011 APC national payment of $781.
• After reviewing comments regarding the 2010 assignment of CPT code 93299 (implantable loop recorder technical monitoring) to APC 0689 for a national payment of $38, for FY 2011 CMS reassigned the procedure to APC 0691 for a national rate of $167. The reassignment supports the cost data analysis performed by CMS and appropriately aligns payment with cost methodology.
• CMS will continue the policy of reducing 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 would apply to APCs 0089, 0090, 0106, 0107, 0108, 0418, 0654, 0655 and 0680.
• For CY 2011, CMS will continue use of the 2010 bypass list, which includes codes 93225, 93226, 93231, 93232, 93226, 93270, 93271 and 93278. In addition, CMS is adding to the bypass list codes 93279-93296. Through bypassing specified codes, CMS is able to create "pseudo-single" claims from multiple procedure claims for possible rate setting.
• The final rule modifies a number of the supervision requirements for outpatient therapeutic services by:
• • Requiring direct physician supervision for only the initiation of certain services and allowing general supervision once the treating practitioner deems the patient medically stable. This two-tiered approach to supervision applies to a limited set of non-surgical extended duration services, including observation services.
  • Extending through 2011 the notice of non-enforcement regarding the direct supervision requirements for outpatient therapeutic services furnished in critical access hospitals (CAHs) and expanding the scope of the notice to include small rural hospitals with 100 or fewer beds.
  • Redefining direct supervision for all hospital outpatient services to require "immediate availability" without reference to the boundaries of a physical location.
• While ASCs still are not required to report quality measures, the final rule with increases the transparency of the Hospital Outpatient Quality Data Reporting Program (HOP QDRP).
• • HOPDs will be required to report four additional quality measures to the current list of 11 measures to be reported for the 2012 payment determination. These new measures include one structural health information technology (HIT) measure and three claims-based imaging efficiency measures.
  • HOPDs will have to report on another eight new measures (for a total of 23 measures) for the 2013 and 2014 payment determinations. Of these new measures, one is a structural measure on use of electronic health records (EHRs), and six are chart-abstracted measures of timeliness and appropriate care in the emergency department.

Highlights of the Final Rule Affecting Ambulatory Surgical Centers

In addition, the final rule would also update policies and payment rates for services in approximately 5,000 ASCs.

• The ACA requires the annual update factor for the ASC payment system be reduced by a productivity adjustment, which is estimated to be 1.3 percent for CY 2011. As a result, CMS is projecting a 0.2 percent annual update and a conversion factor of $41.939 for CY 2011.
• CY 2011 marks the end of the transition to the revised ASC payment system. ASC payments will now align with hospital outpatient department payments for corresponding services. As a result, services provided in an ASC would be reimbursed at a rate of approximately 61 percent of the amount paid for services provided in an outpatient department.

Additional information can be found on the CMS website at:

• OPPS: www.cms.gov/HospitalOutpatientPPS/
• ASC payment system: www.cms.gov/ASCPayment/

As noted, the Heart Rhythm Society's Health Policy staff will continue to review the final rule to determine any further impact upon cardiac rhythm services.