2008 HOPPS Final Rule - Summary Overview
The Centers for Medicare and Medicaid (CMS) issued a final rule on the 2008 hospital Outpatient Prospective Payment System (OPPS) on November, 1, 2007. This final rule affects outpatient services furnished by general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and long-term acute care hospitals. Following are some of the major highlights of the significant changes pertaining to the OPPS.
Packaging Approach
CMS is extending the current packaging approach to include guidance services, image processing services, intra-operative services, imaging supervision and interpretation services, diagnostic radiopharmaceuticals, contrast agents, and observation services. CMS believes that packaging and bundling for these services into a single payment create incentives for providers to furnish services in the most efficient way by enabling hospitals to manage their resources with maximum flexibility. Hospitals will continue to bill the same way, however, the bundling of payments will be made by CMS.
The ACR analysis shows that the packaging will cause a 25 percent reduction in revenues for a hospital department with respect to interventional radiology services. The ACR gave testimony before the Ambulatory Payment Classification (APC) Advisory Panel and provided in its comments on the proposed rule of the concerns for interventional radiology. The ACR requested a delay in CMS’ packaging initiatives for all of imaging and drugs until there is further study of the impact. Below are six of seven services of importance to ACR:
1) Guidance Services - CMS will package payment for 31 Healthcare
Common Procedure Coding System (HCPCS) guidance codes for CY
2008, specifically those codes that are reported for supportive
guidance services, such as ultrasound, fluoroscopic, and stereotactic
navigation services, that aid the performance of an independent
procedure. This also includes 26 radiology guidance codes. The ACR
is opposed to the diagnostic imaging guidance services being bundled
because none of the imaging guidance codes is commonly done with
any one or only a few surgical or procedural codes, significantly
raising the risk that these services will be underpaid when packaged.
2) Imaging Processing Services – CMS will package payment for “image
processing” HCPCS codes for CY 2008, specifically those codes that
are reported as supportive dependent services to process and
integrate diagnostic test data in the development of images, performed
concurrently or after the independent service is complete. The ACR is
concerned that hospitals will not place importance on the value of
these services and will not continue to support their availability to
other specialties in the hospital if they are being inadequately
reimbursed by CMS.
3) Intraoperative Services - CMS will
package payment for “intraoperative” HCPCS codes for CY 2008,
specifically those codes that are reported for supportive dependent
diagnostic testing or other minor procedures performed during
independent procedures. CMS will change the status indicator
for 34 intraoperative services from separately paid to unconditionally
packaged (status indicator “N”) for the CY 2008 OPPS. Status
indicator “N” indicates that payment is packaged into payment for
other services.
4) Imaging Supervision and Interpretation Services - CMS will change the
packaging status of many imaging supervision and interpretation
codes for CY 2008. There are 33 interventional codes where the
status indicator will be changed to an “N” for 2008 and 93 codes that
will be assigned a “Q” status indicator. Status indicator “Q” indicates
that packaged services are subject to separate payment under OPPS
criteria. The ACR feels that these changes are too far reaching to be
accomplished in a single regulatory cycle.
5) Diagnostic Radiopharmaceuticals - For CY 2008, CMS will change the
packaging status of 47 diagnostic radiopharmaceuticals as part of
their overall enhanced packaging approach for the CY 2008 OPPS.
CMS will package payment for all diagnostic radiopharmaceuticals
that are not otherwise packaged according to the CY 2008 packaging
threshold for drugs, biologicals, and radiopharmaceuticals that they
proposed. CMS will continue with this packaging approach for
diagnostic radiopharmaceuticals, while they continue to pay
separately for therapeutic radiopharmaceuticals with an average per
day cost of more than $60. The ACR is very concerned that the
reimbursement methodology (for diagnostic radiopharmaceuticals) will
create an incentive for hospitals to shift away from advanced
technologies, which in turn will have negative implications for the
quality of patient care. The ACR is concerned that if pricing of
radiopharmaceuticals is not adequate, then hospitals will put
pressure on physicians to use less expensive radiopharmaceuticals
for nuclear medicine procedures even when that might not be the most
clinically appropriate selection for the patient.
6) Contrast Agents - For CY 2008, CMS will package payment for all
contrast media into their associated independent diagnostic and
therapeutic procedures as part of their packaging approach for the CY
2008 OPPS. CMS believe that packaging the costs of supportive
items and services into the payment for the independent procedure or
service with which they are associated encourages hospital
efficiencies and also enables hospitals to manage their resources with
maximum flexibility. As stated in the proposed rule, CMS believe that
contrast agents are particularly well suited for packaging because
they are always provided in support of an independent diagnostic or
therapeutic procedure that involves imaging, and thus payment for
contrast agents can be packaged into the payment for the associated
separately payable procedures. The ACR believes there is insufficient
justification for treating contrast agents differently from other injectable
drugs administered in the hospital outpatient setting.
Conversion Factor Update
To set the OPPS conversion factor for CY 2008, CMS increased the CY 2007 conversion factor of $61.468 to $64.768. This 3.3 percent increase in the conversation factor has a positive implication on the office setting side, i.e. when the lower of the two payment rates are chosen (OPPS vs. office setting), that rate would be paid at an increase of 3.3 percent.
Low Dose Rate (LDR) Prostate Brachytherapy Composite APC
For the CY 2008 OPPS, CMS will create a composite APC 8001, titled “LDR Prostate Brachytherapy Composite,” that would provide one bundled payment for LDR prostate brachytherapy when the hospital bills both CPT codes 55875 and 77778 as component services provided during the same hospital encounter. CMS is continuing to pay brachytherapy sources separately.
Positron Emission Tomography (PET)/Computed Tomography (CT) Scans
(APC 0308)
For CY 2008, CMS will reassign the concurrent PET/CT scans, specifically CPT codes 78814, 78815, and 78816, to a clinical APC because they believed they had adequate claims data from CY 2006 upon which to determine the median cost of performing these procedures. Therefore for CY 2008 CMS proposed to reassign the CPT codes for PET/CT scans to the clinical APC where nonmyocardial PET scans were also assigned, specifically APC 0308, with a median cost of approximately $1,094. The median cost in 2007 for CPT codes 78814, 78815, and 78816, was approximately $950.
Cardiac Computed Tomography and Coronary Computed Tomographic Angiography
(APCs 0282 and 0383)
For CY 2008, CMS will assign the Cardiac Computed Tomography (CCT) and Coronary Computed Tomographic Angiography (CCTA) procedures to two new clinical APCs, specifically new clinical APC 0383 (Cardiac Computed Tomographic Imaging) and APC 0282. The median cost of approximately $314 for APC 0383 was based entirely on claims data for CPT codes 0145T, 0146T, 0147T, 0148T, 0149T, and 0150T that described CCT and CCTA services, a clinically homogeneous grouping of services. In addition, the individual median costs of these services ranged from a low of approximately $277 to a high of $437, reflecting their hospital resource similarity as well. CMS proposed to reassign the two other CCT CPT codes, specifically CPT codes 0144T and 0151T, to APC 0282. The inclusion of these two codes in APC 0282 resulted in a CY 2008 APC median cost of about $105.
Computed Tomographic Colonography (APC 0332)
For CY 2008, CMS will reassign diagnostic computed tomographic colonography, specifically described by CPT Category III code 0067T (Computed tomographic (CT) colonography (i.e., virtual colonoscopy; diagnostic), from APC 0333 (Computed Tomography without Contrast followed by Contrast) to APC 0332 (Computed Tomography without Contrast), with a payment rate of approximately $201.
Ultrasound Ablation of Uterine Fibroids with Magnetic Resonance Guidance (MRgFUS) (APC 0067)
For CY 2008 CMS will reassign CPT codes 0071T and 0072T to APC 0067, with an APC median payment of approximately $3,870.
Uterine Fibroid Embolization (APC 0202)
For CY 2008, CMS will continue assignment of CPT code 37210 to APC 0202, with a payment rate of approximately $2,753.
Myocardial Positron Emission Tomography (PET) Scans (APC 0307)
At its March 2007 meeting, the APC Panel recommended that CMS reassign CPTcode 78492 to its own clinical APC, to distinguish this multiple study procedure that theAPC Panel believed would require greater hospital resources from less resource intensive single study procedures. However, as indicated in the CY 2008 proposed rule CMS did not accept the APC Panel’s recommendation. In the CY 2008 OPPS/ASC proposed rule, CMS indicated their belief that the assignment of CPT codes 78459, 78491, and 78492 to a single clinical APC for CY 2008 was still appropriate because the CY 2006 claims data did not support a resource differential among significant myocardial PET services that would necessitate the placement of single and multiple PET scan procedures into two separate clinical APCs. Therefore, CMS will continue to assign both the single and multiple myocardial PET scan procedure codes to APC 0307, with an APC median cost of approximately $2,678 for CY 2008.
Stereotactic Radiosurgery (SRS) Treatment Delivery Services (APCs 0065, 0066, and 0067)
For CY 2008, CMS will continue with the CY 2007 HCPCS coding for LINAC-based SRS treatment delivery services under the OPPS. The LINAC-based SRS codes and their CY 2008 proposed APC assignments—i.e. they will continue to use the G-codes for reporting LINAC-based SRS treatment delivery services --- assign HCPCS codes G0173 and G0339 to APC 0067, HCPCS code G0251 to APC 0065, and HCPCS code G0340 to APC 0066. The HCPCS code G0251 was paid at a median cost of $1,249 in 2007, and will be paid at a median cost of $1,056 in 2008. The HCPCS code G0340 was paid at a median cost of $2,644 in 2007, and will be paid at a median cost of $2,870 in 2008. The HCPCS codes G0173 and G0339 were paid at a median cost of $3,895 in 2007, and will be paid at a median cost of $3,929 in 2008.
The ACR will be submitting comments on the final rule for the Hospital Outpatient Prospective Payment System for 2008. Any ACR member who has comments or questions may call Sneha Soni at (800) 227-5463 x 4576.