2008 Final Rule for the Hospital Outpatient Prospective Payment System (HOPPS)
The Centers for Medicare and Medicaid Services (CMS)
released the 2008 final HOPPS rule on their website on
November 1, 2007. It is scheduled for publication in the
Federal Register on November 27, 2007. The final rule
provides a 3.8 percent overall average increase in Medicare
payments to hospitals. Provisions described below in this
newsletter will be implemented January 1, 2008.
Like the proposed rule, the final rule reflects significant
revision to CMS policy regarding the packaging of drugs and
services into the payment for the procedure. They have
included guidance services, intraoperative services, image
processing services, imaging supervision and interpretation
services, diagnostic radiopharmaceuticals, contrast agents,
and observation services into their packaging policy. CMS
notes that these groups of supportive ancillary services are
integral to the performance of primary diagnostic and treatment
procedures. Moreover, packaging is a fundamental
component of a prospective payment system and encourages
efficiency. For example, drugs and diagnostic radiopharmaceuticals
are “dependent” services that are packaged
into the payment of primary or “independent” services
(procedures). Their goal is to make HOPPS a truly prospective
payment system. Therefore, the agency declined to accept
the public comments on the proposed rule which requested
that CMS delay or postpone packaging indefinitely.
Key highlights in the final 2008 HOPPS rule include:
Threshold for Separately Payable Outpatient
Drugs
CMS has set the threshold for determining separately payable
outpatient drugs at $60, increased from $55 in 2007. CMS will
pay separately for drugs with a per day cost that exceeds $60.
Payment for Contrast Agents in the HOPPS
Setting
CMS has decided that all contrast agents will be packaged
into the procedures, even if the per day cost of the contrast
exceeds the proposed $60 threshold. Their goal of increased
packaging notwithstanding, CMS notes that three quarters
of all contrast agents would fall under the proposed $60
threshold anyway.
CMS reconfigured LOCM codes Q9945-Q9950. The new LOCM
codes are Q9965-Q9967:
CMS discontinued Q9952 Inj, Gadolinium-Based MR, per ML
and created a new MR contrast code A9579, Gadolinium-Based MR contrast, NOS, 1 ml. The payment for the contrast is
packaged.
Payment for Radiopharmaceuticals in the
HOPPS Setting
As noted above, CMS finalized its decision to package payment
for diagnostic radiopharmaceuticals into the payment
for the nuclear medicine procedures. All diagnostic radiopharmaceuticals
have status indicator “N”.
CMS will pay separately for therapeutic radiopharmaceuticals
that have per day costs of more than $60.
Billing for Contrast Agents and Radiopharmaceuticals
CMS expects that hospitals will bill the contrast agent on the same
claim as the other independent service(s) for which the contrast agent
was administered. This will ensure that hospitals are appropriately
packaging the cost of the contrast agent into the payment for the
significant independent procedure.
CMS has instituted a code edit for nuclear medicine procedures. The
Outpatient Code Editor has been updated to reject nuclear medicine
claims that do not contain a HCPCS code and charge for a radiopharmaceutical.
Cardiac Imaging Payment Increases, APCs combined
Payment for the cardiac imaging APCs increased. CMS decided to
reconfigure the three APCs in the proposed rule to two APCs in the
final rule. Unlike the proposed rule which included only CPT 78465 in
Level II Cardiac Imaging, this newly configured Level II Cardiac
Imaging includes a wider array of cardiac procedures (CPT codes
78460, 78461, 78464, and 78465).
New Echocardiography Codes
CMS responded to GE Healthcare and other interested
parties’ requests to create echocardiography codes
that describe whether or not contrast was used. This
is particularly important now that the ultrasound contrast
will be packaged into the payment for the procedure.
CMS created the following new Ambulatory Payment
Group 128 along with eight Level II HCPCS codes that
describe echocardiography procedures performed
with contrast. The payment rate for APC 128 is
$540.74. CMS noted in the rule that they will provide
further instruction about reporting echocardiography
procedures in its next HOPPS update.
C8921 Comp transtho echo w/contrast
C8922 Limit transtho echo w/contrast
C8923 2D com transtho echo w/contrast
C8924 2D lim transtho echo w/contrast
C8925 2D TEE w/contrast, int/report
C8926 Cong TEE w/contr, int/report
C8927 TEE w/contrast; monitor
C8928 2D transtho w/contr; stress
For more information about the proposed HOPPS
rule visit:
http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage |