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Proposed 2009 OPPS Update
The 2009 OPPS Proposed Rule was published on the CMS website on July 3, 2008 and
in the Federal Register on July 18, 2008. Comments on the Proposed Rule are due
to CMS on September 2, 2008.
It appears that most of the changes will be financial rather than operational to
facilities. The Proposed Rule anticipates an overall 3.2% increase to the
Medicare payment rates for most services that would be paid under OPPS.
This newsletter will summarize three (3) issues described in the proposed rule:
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Composite Imaging APCs
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Type B Emergency Departments
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Quality Initiatives
Multiple Imaging Composite APCs
CMS is proposing to create five (5) composite APCs for families of radiological
procedures: ultrasound, CT and CTA, and MRI and MRA. Currently (CY 2008) a full
APC payment is made for each imaging service on a claim, regardless of how many
procedures are performed during a single session using the same imaging
modality. The method of reimbursement does not reflect the types of
efficiencies hospitals can achieve when multiple imaging procedures are
performed during a single session.
To implement this proposed policy, CMS would reimburse the provider one
composite APC payment each time a hospital bills more than one procedure in an
imaging family (3) on the same date of service. See Table 7 of the Proposed
Rule for the Imaging Families (ultrasound, CT and CTA with and without
contrast, MRI and MRA with and without contrast) and HCPCS codes.
Hospitals would continue to report the appropriate HCPCS code to report the
imaging service. The I/OCE would determine when combinations of imaging
procedures would qualify for a composite APC or a standard APC.
Type B Emergency Department Visits
National guidelines for clinic and emergency department (ED) visits
were still not published in the proposed 2009 OPPS rule. While waiting the
development of the national guidelines, CMS has advised hospitals to develop
their own internal guidelines for the clinic and ED that determine the level of
care. The guidelines should be designed to reasonably relate the intensity of
the hospital resources to the different levels of care represented by the CPT
codes.
In 2007 CMS designated two (2) types of emergency departments. The
Type A Emergency Department is open 24 hours a day, 7 days a week and must meet
EMTALA requirements. There are five (5) CPT E & M emergency department
visit codes for the Type A ED. The Type B ED was defined as any ED that met
EMTALA regulations but not the Type A ED definition. A set of five (5) G-codes
were utilized for hospitals to report a Type B ED visit on the claim. The Type
B ED visit is paid at the same rate as a non-emergency visit to the OP
department.
CMS now has data that shows that most ED Type B visits are more
expensive than clinic visits, but less costly than Type A ED visits. CMS is
proposing to pay for Level 1-4 Type B ED visits by creating four (4) new APCs.
They are also proposing to pay for a Level 5 Type B ED visit the same as a Type
A ED visit. The proposed rule also includes the Level 5 Type B ED visit in the
criteria for assigning the Level II Extended Assignment and Management
Composite APC.
The chart below describes the proposed Type B ED visit APCs and
associated median cost:
Type B Emergency
Department Visit Level |
Proposed CY 2009 APC
Assignment |
Proposed CY 2009
APC Median Cost |
| Level 1 |
0626 |
$48.00 |
| Level 2 |
0627 |
$65.00 |
| Level 3 |
0628 |
$92.00 |
| Level 4 |
0629 |
$156.00 |
| Level 5 |
0616 |
$325.00 |
Quality Initiatives
Currently, in order to receive the full OPPS payment in 2009,
hospitals must report data in CY 2008 on seven (7) quality measures of ED and
perioperative surgical care. CMS has proposed to add four (4) imaging
efficiency measures for 2009. Hospitals that fail to meet the quality
initiatives in 2009 will receive a 2.0% reduction to their market basket in
2010.
The proposed additional quality measures are as follows:
| Topic |
Measure |
| Imaging Efficiency |
OP-8: MRI Lumbar Spine for Low Back Pain
OP-9: Mammography Follow-up Rates.
OP-10: Abdomen CT – Use of Contrast Material:
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OP-10: CT Abdomen – Use of Contrast Material.
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OP-10a: CT Abdomen – Use of Contrast Material excluding calculi of the kidneys,
ureter, and/or urinary tract.
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OP-10b: CT Abdomen – Use of Contrast Material for diagnosis of calculi in the
kidneys, ureter, and/or urinary tract.
OP-11: Thorax CT - Use of Contrast Material.
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These services were identified because of growing concerns
regarding the overuse of imaging services.
When the Final Rule is published in November 2008, the changes will
be effective January 1, 2009.
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