Hospital Outpatient Prospective
Payment System (HOPPS)
On July 3, 2008, the Centers for Medicare and Medicaid Services
(CMS) issued the 2009 proposed HOPPS rule on their website.
The proposed rule provides a 3.0 % increase overall in Medicare
payments to hospitals. The final rule will be published in
November of this year. The rule will be implemented on
January 1, 2009.
Key provisions of the proposed rule include:
Payment for Drugs and Pharmacy Overhead
in the HOPPS Setting
CMS is proposing to pay for separately payable drugs and biologicals
based on hospitals’ reported costs at the average sales
price (ASP) + 4 %. CMS is also proposing to modify the Medicare
cost report to establish two cost centers for reporting drugs
with high and low pharmacy overhead costs. This would allow
CMS to estimate drug and pharmacy overhead costs more
accurately in future rate setting.
Payment for Therapeutic Radiopharmaceuticals
in the HOPPS Setting
CMS is proposing to provide payment for separately payable
therapeutic radiopharmaceuticals ($60 and above) based on
ASP data voluntarily submitted by manufacturers through the
existing ASP process. The payment rate would be ASP + 4%. If
ASP information is not available, CMS is proposing that payment
would be based upon mean costs from hospital claims data.
Please note that legislation pending at this writing may extend
the 2008 payment methodology through 2009.
Payment for Nuclear Medicine Procedures
CMS is proposing to set the payment rates for nuclear medicine
procedures based on the established rate setting methodology
using claims from 2007 that include a charge for a required
diagnostic radiopharmaceutical or other radioactive product.
(Hospitals were not required to include radiopharmaceuticals on
nuclear medicine claim forms until 2008.) Using claims with the
radiopharmaceuticals will derive more appropriate payment
rates.
Composite APCs for Multiple Imaging Services
CMS is proposing to establish five imaging composite
Ambulatory Payment Categories (APCs) based on the families of
codes used in the Medicare Physician Fee Schedule (MPFS) for
the multiple imaging procedure payment reduction policy under
that system. These composite APCs, which would provide a
single APC payment when two or more imaging procedures
using the same imaging modality were provided in a single
session, would encourage imaging efficiencies under the OPPS.
The proposed new imaging composite APCs include:
- Ultrasound
- Computed tomography (CT) and computed tomographic
angiography (CTA) without contrast;
- CT and CTA with contrast;
- Magnetic resonance imaging (MRI) and magnetic
resonance angiography (MRA) without contrast; and
- MRI and MRA with contrast.
The proposed rule continues bundling payments of all
diagnostic radiopharmaceuticals and contrast agents with
the associated nuclear medicine APC, and will continue paying
separately for drugs, biologicals and therapeutic radiopharmaceuticals
with a cost of $60 or more per day.
For more information about the proposed OPPS rule, please visit
http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage
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