[Federal Register: November 27, 2007 (Volume 72, Number 227)]
[Rules and Regulations]
[Page 66579-67225]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr27no07-23]
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Part III
Book 2 of 2 Books
Pages 66579-67226
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 410, 411, 412, et al.
Medicare and Medicaid Programs; Interim and Final Rule
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 410, 411, 412, 413, 414, 416, 419, 482, and 485
[CMS-1392-FC], [CMS-1533-F2], and [CMS-1531-IFC2]
RIN 0938-AO71, RIN 0938-AO70, and RIN 0938-AO35
Medicare Program: Changes to the Hospital Outpatient Prospective
Payment System and CY 2008 Payment Rates, the Ambulatory Surgical
Center Payment System and CY 2008 Payment Rates, the Hospital Inpatient
Prospective Payment System and FY 2008 Payment Rates; and Payments for
Graduate Medical Education for Affiliated Teaching Hospitals in Certain
Emergency Situations Medicare and Medicaid Programs: Hospital
Conditions of Participation; Necessary Provider Designations of
Critical Access Hospitals
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Interim and final rule with comment period.
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SUMMARY: This final rule with comment period revises the Medicare
hospital outpatient prospective payment system to implement applicable
statutory requirements and changes arising from our continuing
experience with this system. We describe the changes to the amounts and
factors used to determine the payment rates for Medicare hospital
outpatient services paid under the prospective payment system. These
changes are applicable to services furnished on or after January 1,
2008. In addition, the rule sets forth the applicable relative payment
weights and amounts for services furnished in ASCs, specific HCPCS
codes to which the final policies of the ASC payment system apply, and
other pertinent rate setting information for the CY 2008 ASC payment
system. Furthermore, this final rule with comment period will make
changes to the policies relating to the necessary provider designations
of critical access hospitals and changes to several of the current
conditions of participation requirements.
The attached document also incorporates the changes to the FY 2008
hospital inpatient prospective payment system (IPPS) payment rates made
as a result of the enactment of the TMA, Abstinence Education, and QI
Programs Extension Act of 2007, Public Law 110-90. In addition, we are
changing the provisions in our previously issued FY 2008 IPPS final
rule and are establishing a new policy, retroactive to October 1, 2007,
of not applying the documentation and coding adjustment to the FY 2008
hospital-specific rates for Medicare-dependent, small rural hospitals
(MDHs) and sole community hospitals (SCHs). In the interim final rule
with comment period in this document, we are modifying our regulations
relating to graduate medical education (GME) payments made to teaching
hospitals that have Medicare affiliation agreements for certain
emergency situations.
DATES: Effective Date: The provisions of this rule are effective on
January 1, 2008.
IPPS Payment Rates: The FY 2008 IPPS payment rates, provided in
section XIX of the preamble of this document, became effective October
1, 2007.
Comment Period: We will consider comments on the payment
classifications assigned to HCPCS codes identified in Addenda B, AA,
and BB to this final rule with the ``NI'' comment indicator, and other
areas specified throughout this rule, at the appropriate address, as
provided below, no later than 5 p.m. EST on January 28, 2008. We will
also consider comments relating to the Medicare GME teaching hospital
affiliated agreement provisions, as provided below, no later than 5
p.m. EST on January 28, 2008.
Application Deadline--New Class of New Technology Intraocular Lens:
Requests for review of applications for a new class of new technology
intraocular lenses must be received by 5 p.m. EST on April 1, 2008.
Deadline for Submission of Written Medicare GME Affiliation
Agreements: Written Medicare GME affiliation agreements must be
received by 5 p.m. EST on January 1, 2008.
ADDRESSES: In commenting, please refer to file codes CMS-1392-FC (for
OPPS and ASC matters) or CMS-1531-IFC (for Medicare GME matters), as
appropriate. Because of staff and resource limitations, we cannot
accept comments by facsimile (FAX) transmission.
You may submit comments in one of four ways (no duplicates,
please):
1. Electronically. You may submit electronic comments on specific
issues in this regulation to http://www.cms.hhs.gov/eRulemaking. Click
on the link ``Submit electronic comments on CMS regulations with an
open comment period.'' (Attachments should be in Microsoft Word,
WordPerfect, or Excel; however, we prefer Microsoft Word.)
2. By regular mail. You may mail written comments (one original and
two copies) to the following address ONLY: Centers for Medicare &
Medicaid Services, Department of Health and Human Services, Attention:
CMS-1392-FC (for OPPS and ASC matters), Attention: CMS-1531-IFC (for
Medicare GME matters), P.O. Box 8013, Baltimore, MD 21244-1850.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments (one
original and two copies) to the following address ONLY: Centers for
Medicare & Medicaid Services, Department of Health and Human Services,
Attention: CMS-1392-FC (for OPPS and ASC matters), Attention: CMS-1531-
IFC (for Medicare GME matters), Mail Stop C4-26-05, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments (one original and two copies) before the
close of the comment period to one of the following addresses: Room
445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW.,
Washington, DC 20201; or 7500 Security Boulevard, Baltimore, MD 21244-
1850.
If you intend to deliver your comments to the Baltimore address,
please call telephone number (410) 786-9994 in advance to schedule your
arrival with one of our staff members.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal Government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons who wish to retain proof of filing by
stamping in and retain an extra copy of the comments being filed.)
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
Applications for a new class of new technology intraocular lenses:
Requests for review of applications for a new class of new technology
intraocular lenses must be sent by regular mail to:ASC/NTIOL, Division
of Outpatient Care, Mailstop C4-05-17, Centers for Medicare and
Medicaid Services,7500 Security Boulevard,Baltimore, MD 21244-1850.
Submissions of written Medicare GME affiliation agreements: Written
[[Page 66581]]
Medicare GME affiliation agreements must be sent by regular mail
to:Centers for Medicare and Medicaid Services, Division of Acute Care,
Attention: Elizabeth Troung or Renate Rockwell,Mailstop C4-08-06,7500
Security Boulevard, Baltimore, MD 21244-1850.
FOR FURTHER INFORMATION CONTACT:
Alberta Dwivedi, (410) 786-0378, Hospital outpatient prospective
payment issues.
Dana Burley, (410) 786-0378, Ambulatory surgical center issues.
Suzanne Asplen, (410) 786-4558, Partial hospitalization and
community mental health center issues.
Sheila Blackstock, (410) 786-3502, Reporting of quality data
issues.
Mary Collins, (410) 786-3189, and Jeannie Miller, (410) 786-3164,
Necessary provider designations for CAHs issues.
Scott Cooper, (410) 786-9465, and Jeannie Miller, (410) 786-3164,
Hospital conditions of participation issues.
Miechal Lefkowitz, (410) 786-5316, Hospital inpatient prospective
payment system issues.
Tzvi Hefter, (410) 786-4487, Graduate medical education program
issues.
SUPPLEMENTARY INFORMATION:
Submitting Comments: We welcome comments from the public on the
OPPS APC assignments and/or status indicators assigned to HCPCS codes
identified in Addendum B to this final rule with comment period with
comment indicator ``NI'' and on the ASC payment indicators assigned to
HCPCS codes identified in Addenda AA and BB to this final rule with
comment period with comment indicator ``NI'' in order to assist us in
fully considering issues and developing OPPS and ASC payment policies
for those services. You can assist us by referencing file code CMS-
1392-FC.
We also welcome comments from the public on all issues set forth
regarding the revised regulations regarding the Medicare GME
affiliation agreements to assist us in fully considering issues and
developing policies. You can assist us by referencing the file code
CMS-1531-IFC2 and the specific ``issue identifier'' that precedes the
section on which you choose to comment.
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: http://www.cms.hhs.gov/eRulemaking.
Click on the link ``Electronic Comments on
CMS Regulations'' on that Web site to view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately 3
weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, MD 21244, on Monday through Friday of each week from 8:30
a.m. to 4 p.m. To schedule an appointment to view public comments,
phone 1-800-743-3951.
Electronic Access
This Federal Register document is also available from the Federal
Register online database through GPO Access, a service of the U.S.
Government Printing Office. Free public access is available on a Wide
Area Information Server (WAIS) through the Internet and via
asynchronous dial-in. Internet users can access the database by using
the World Wide Web; the Superintendent of Documents' home page address
is http://www.gpoaccess.gov/index.html, by using local WAIS client
software, or by telnet to swais.access.gpo.gov, then login as guest (no
password required). Dial-in users should use communications software
and modem to call (202) 512-1661; type swais, then login as guest (no
password required).
Alphabetical List of Acronyms Appearing in This Final Rule With Comment
Period
ACEP American College of Emergency Physicians
AHA American Hospital Association
AHIMA American Health Information Management Association
AMA American Medical Association
APC Ambulatory payment classification
AMP Average manufacturer price
ASC Ambulatory Surgical Center
ASP Average sales price
AWP Average wholesale price
BBA Balanced Budget Act of 1997, Pub. L. 105-33
BBRA Medicare, Medicaid, and SCHIP [State Children's Health
Insurance Program] Balanced Budget Refinement Act of 1999, Pub. L.
106-113
BCA Blue Cross Association
BCBSA Blue Cross and Blue Shield Association
BIPA Medicare, Medicaid, and SCHIP Benefits Improvement and
Protection Act of 2000, Pub. L. 106-554
CAH Critical access hospital
CAP Competitive Acquisition Program
CBSA Core-Based Statistical Area
CCR Cost-to-charge ratio
CERT Comprehensive Error Rate Testing
CMHC Community mental health center
CMS Centers for Medicare & Medicaid Services
CoP [Hospital] Condition of participation
CORF Comprehensive outpatient rehabilitation facility
CPT [Physicians'] Current Procedural Terminology, Fourth Edition,
2007, copyrighted by the American Medical Association
CRNA Certified registered nurse anesthetist
CY Calendar year
DMEPOS Durable medical equipment, prosthetics, orthotics, and
supplies
DMERC Durable medical equipment regional carrier
DRA Deficit Reduction Act of 2005, Pub. L. 109-171
DSH Disproportionate share hospital
EACH Essential Access Community Hospital
E/M Evaluation and management
EPO Erythropoietin
ESRD End-stage renal disease
FACA Federal Advisory Committee Act, Pub. L. 92-463
FAR Federal Acquisition Regulations
FDA Food and Drug Administration
FFS Fee-for-service
FSS Federal Supply Schedule
FTE Full-time equivalent
FY Federal fiscal year
GAO Government Accountability Office
GME Graduate medical education
HCPCS Healthcare Common Procedure Coding System
HCRIS Hospital Cost Report Information System
HHA Home health agency
HIPAA Health Insurance Portability and Accountability Act of 1996,
Pub. L. 104-191
HOPD Hospital outpatient department
HOP QDRP Hospital Outpatient Quality Data Reporting Program
ICD-9-CM International Classification of Diseases, Ninth Edition,
Clinical Modification
IDE Investigational device exemption
IME Indirect medical education
IOL Intraocular lens
IPPS [Hospital] Inpatient prospective payment system
IVIG Intravenous immune globulin
MAC Medicare Administrative Contractors
MedPAC Medicare Payment Advisory Commission
MDH Medicare-dependent, small rural hospital
MIEA-TRHCA Medicare Improvements and Extension Act under Division B,
Title I of the Tax Relief Health Care Act of 2006, Pub. L. 109-432
MMA Medicare Prescription Drug, Improvement, and Modernization Act
of 2003, Pub. L. 108-173
MPFS Medicare Physician Fee Schedule
MSA Metropolitan Statistical Area
NCCI National Correct Coding Initiative
NCD National Coverage Determination
NTIOL New technology intraocular lens
OCE Outpatient Code Editor
OMB Office of Management and Budget
OPD [Hospital] Outpatient department
OPPS [Hospital] Outpatient prospective payment system
PHP Partial hospitalization program
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PM Program memorandum
PPI Producer Price Index
PPS Prospective payment system
PPV Pneumococcal pneumonia vaccine
PRA Paperwork Reduction Act
QIO Quality Improvement Organization
RFA Regulatory Flexibility Act
RHQDAPU Reporting Hospital Quality Data for Annual Payment Update
[Program]
RHHI Regional home health intermediary
SBA Small Business Administration
SCH Sole community hospital
SDP Single Drug Pricer
SI Status indicator
TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-
248
TOPS Transitional outpatient payments
USPDI United States Pharmacopoeia Drug Information
WAC Wholesale acquisition cost
In this document, we address several payment systems under the
Medicare program: The hospital outpatient prospective payment system
(OPPS); the revised ambulatory surgical center (ASC) payment system;
the hospital inpatient prospective payment system (IPPS); and payments
for direct and indirect graduate medical education (GME). The
provisions relating to the OPPS are included in sections I. through
XV., XVII., XXI. through XXIV. of this final rule with comment period
and in Addenda A, B, C (Addendum C is available on the Internet only;
see section XXI. of this final rule with comment period), D1, D2, E, L,
and M to this final rule with comment period. The provisions related to
the revised ASC payment system are included in sections XVI., XVII.,
and XXI. through XXIV. of this final rule with comment period and in
Addenda AA, BB, DD1, DD2, and EE (Addendum EE is available on the
Internet only; see section XXI. of this final rule with comment period)
to this final rule with comment period.
The provisions relating to the IPPS payment rates are included in
section XIX., XXIV., and XXV. of this document. The provisions relating
to policy changes to the Medicare GME affiliation provisions for
teaching hospitals in certain emergency situations are included in
sections XX., XXIV., and XXV. of this document.
Table of Contents
I. Background for the OPPS
A. Legislative and Regulatory Authority for the Hospital
Outpatient Prospective Payment System
B. Excluded OPPS Services and Hospitals
C. Prior Rulemaking
D. APC Advisory Panel
1. Authority of the APC Panel
2. Establishment of the APC Panel
3. APC Panel Meetings and Organizational Structure
E. Provisions of the Medicare Improvements and Extension Act
under Division B, Title I of the Tax Relief and Health Care Act of
2006
F. Summary of the Major Contents of the CY 2008 OPPS/ASC
Proposed Rule
1. Updates Affecting OPPS Payments
2. OPPS Ambulatory Payment Classification (APC) Group Policies
3. OPPS Payment for Devices
4. OPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals
5. Estimate of OPPS Transitional Pass-Through Spending for
Drugs, Biologicals, and Devices
6. OPPS Payment for Brachytherapy Sources
7. OPPS Coding and Payment for Drug Administration Services
8. OPPS Hospital Coding and Payment for Visits
9. OPPS Payment for Blood and Blood Products
10. OPPS Payment for Observation Services
11. Procedures That Will Be Paid Only as Inpatient Services
12. Nonrecurring Technical and Policy Changes
13. OPPS Payment Status and Comment Indicators
14. OPPS Policy and Payment Recommendations
15. Update of the Revised ASC Payment System
16. Quality Data for Annual Payment Updates
17. Changes Affecting Necessary Provider Critical Access
Hospitals (CAHs) and Hospital Conditions of Participation (CoPs)
18. Regulatory Impact Analysis
G. Public Comments Received in Response to the CY 2008 OPPS/ASC
Proposed Rule
H. Public Comments Received on the November 24, 2006 OPPS/ASC
Final Rule with Comment Period
II. Updates Affecting OPPS Payments
A. Recalibration of APC Relative Weights
1. Database Construction
a. Database Source and Methodology
b. Use of Single and Multiple Procedure Claims
(1) Use of Date of Service Stratification and a Bypass List to
Increase the Amount of Data Used to Determine Medians
(2) Exploration of Allocation of Packaged Costs to Separately
Paid Procedure Codes
c. Calculation of CCRs
2. Calculation of Median Costs
3. Calculation of OPPS Scaled Payment Weights
4. Changes to Packaged Services
a. Background
b. Addressing Growth in OPPS Volume and Spending
c. Packaging Approach
(1) Guidance Services
(2) Image Processing Services
(3) Intraoperative Services
(4) Imaging Supervision and Interpretation Services
(5) Diagnostic Radiopharmaceuticals
(6) Contrast Agents
(7) Observation Services
d. Development of Composite APCs
(1) Background
(2) Low Dose Rate (LDR) Prostate Brachytherapy Composite APC
(a) Background
(b) Payment for LDR Prostate Brachytherapy
(3) Cardiac Electrophysiologic Evaluation and Ablation Composite
APC
(a) Background
(b) Payment for Cardiac Electrophysiologic Evaluation and
Ablation
e. Service-Specific Packaging Issues
B. Payment for Partial Hospitalization
1. Background
2. PHP APC Update
3. Separate Threshold for Outlier Payments to CMHCs
C. Conversion Factor Update
D. Wage Index Changes
E. Statewide Average Default CCRs
F. OPPS Payments to Certain Rural Hospitals
1. Hold Harmless Transitional Payment Changes Made by Pub. L.
109-171 (DRA)
2. Adjustment for Rural SCHs Implemented in CY 2006 Related to
Pub. L. 108-173 (MMA)
G. Hospital Outpatient Outlier Payments
H. Calculation of an Adjusted Medicare Payment from the National
Unadjusted Medicare Payment
I. Beneficiary Copayments
1. Background
2. Copayment
3. Calculation of an Adjusted Copayment Amount for an APC Group
III. OPPS Ambulatory Payment Classification (APC) Group Policies
A. Treatment of New HCPCS and CPT Codes
1. Treatment of New HCPCS Codes Included in the April and July
Quarterly OPPS Updates for CY 2007
a. Background
b. Implantation of Interstitial Devices (APC 0156)
c. Other New HCPCS Codes Implemented in April or July 2007
2. Treatment of New Category I and III CPT Codes and Level II
HCPCS Codes
a. Establishment and Assignment of New Codes
b. Electronic Brachytherapy (New Technology APC 1519)
c. Other Mid-Year CPT Codes
B. Variations within APCs
1. Background
2. Application of the 2 Times Rule
3. Exceptions to the 2 Times Rule
C. New Technology APCs
1. Introduction
2. Movement of Procedures from New Technology APCs to Clinical
APCs
a. Positron Emission Tomography (PET)/Computed Tomography (CT)
Scans (APC 0308)
b. IVIG Preadministration-Related Services (APC 0430)
c. Other Services in New Technology APCs
(1) Breast Brachytherapy Catheter Implantation (APC 0648)
(2) Preoperative Services for Lung Volume Reduction Surgery
(LVRS) (APCs 0209 and 0213)
D. APC Specific Policies
1. Cardiac Procedures
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a. Cardiac Computed Tomography and Computed Tomographic
Angiography (APCs 0282 and 0383)
b. Coronary and Non-Coronary Angioplasty (PTCA/PTA)(APCs 0082,
0083, and 0103)
c. Implantation of Cardioverter-Defibrillators (APCs 0107 and
0108)
d. Removal of Patient-Activated Cardiac Event Recorder (APC
0109)
e. Stress Echocardiography (APC 0697)
2. Gastrointestinal Procedures
a. Computed Tomographic Colonography (APC 0332)
b. Laparoscopic Neurostimulator Electrode Implantation (APC
0130)
c. Screening Colonoscopies and Screening Flexible
Sigmoidoscopies (APCs 0158 and 0159)
3. Genitourinary Procedures
a. Cystoscopy with Stent (APC 0163)
b. Percutaneous Renal Cryoablation (APC 0423)
c. Prostatic Thermotherapy (APC 0163)
d. Radiofrequency Ablation of Prostate (APC 0163)
e. Ultrasound Ablation of Uterine Fibroids with Magnetic
Resonance Guidance (MRgFUS) (APC 0067)
f. Uterine Fibroid Embolization (APC 0202)
4. Nervous System Procedures
a. Chemodenervation (APC 0206)
b. Implantation of Intrathecal or Epidural Catheter (APC 0224)
c. Implantation of Spinal Neurostimulators (APC 0222)
5. Nuclear Medicine and Radiation Oncology Procedures
a. Adrenal Imaging (APC 0391)
b. Injection for Sentinel Node Identification (APC 0389)
c. Myocardial Positron Emission Tomography (PET) Scans (APC
0307)
d. Nonmyocardial Positron Emission Tomography (PET) Scans (APC
0308)
e. Proton Beam Therapy (APCs 0664 and 0667)
6. Ocular and Ear, Nose and Throat Procedures
a. Amniotic Membrane for Ocular Surface Reconstruction (APC
0244)
b. Keratoprosthesis (APC 0293)
c. Palatal Implant (New Technology APC 1510)
7. Orthopedic Procedures
a. Arthroscopic Procedures (APCs 0041 and 0042)
b. Closed Fracture Treatment (APC 0043)
c. Insertion of Posterior Spinous Process Distraction Device
(APC 0050)
d. Intradiscal Annuloplasty (APC 0050)
e. Kyphoplasty Procedures (APC 0052)
8. Vascular Procedures
a. Blood Transfusion (APC 0110)
b. Endovenous Ablation (APC 0092)
c. Insertion of Central Venous Access Device (APC 0625)
d. Noninvasive Vascular Studies (APC 0267)
9. Other Procedures
a. Hyperbaric Oxygen Therapy (APC 0659)
b. Skin Repair Procedures (APCs 0133, 0134, 0135, 0136, and
0137)
c. Stereotactic Radiosurgery (SRS) Treatment Delivery Services
(APCs 0065, 0066, and 0067)
10. Medical Services
a. Single Allergy Tests (APC 0381)
b. Continuous Glucose Monitoring (APC 0097)
c. Home International Normalized Ratio (INR) Monitoring (APC
0097)
d. Mental Health Services (APC 0322, 0323, 0324, 0325)
IV. OPPS Payment for Devices
A. Treatment of Device Dependent APCs
1. Background
2. Payment under the OPPS
3. Payment When Devices Are Replaced with Partial Credit to the
Hospital
B. Pass-Through Payments for Devices
1. Expiration of Transitional Pass Through Payments for Certain
Devices
a. Background
b. Final Policy
2. Provisions for Reducing Transitional Pass Through Payments to
Offset Costs Packaged into APC Groups
a. Background
b. Final Policy
V. OPPS Payment Changes for Drugs, Biologicals, and
Radiopharmaceuticals
A. Transitional Pass-Through Payment for Additional Costs of
Drugs and Biologicals
1. Background
2. Drugs and Biologicals with Expiring Pass-Through Status in CY
2007
3. Drugs and Biologicals with Pass-Through Status in CY 2008
B. Payment for Drugs, Biologicals, and Radiopharmaceuticals
without Pass Through Status
1. Background
2. Criteria for Packaging Payment for Drugs and Biologicals
3. Payment for Drugs and Biologicals without Pass Through Status
That Are Not Packaged
a. Payment for Specified Covered Outpatient Drugs
(1) Background
(2) Payment Policy
(3) Payment for Blood Clotting Factors
(a) Background
(b) Payment for Diagnostic Radiopharmaceuticals
(c) Payment for Therapeutic Radiopharmaceuticals
b. Payment for Nonpass-Through Drugs, Biologicals, and
Radiopharmaceuticals with HCPCS Codes, But without OPPS Hospital
Claims Data
VI. Estimate of OPPS Transitional Pass Through Spending for Drugs,
Biologicals, Radiopharmaceuticals, and Devices
A. Total Allowed Pass Through Spending
B. Estimate of Pass Through Spending
VII. OPPS Payment for Brachytherapy Sources
A. Background
B. Payment for Brachytherapy Sources
VIII. OPPS Drug Administration Coding and Payment
A. Background
B. Coding and Payment for Drug Administration Services
IX. Hospital Coding and Payments for Visits
A. Background
B. Policies for Hospital Outpatient Visits
1. Clinic Visits: New and Established Patient Visits and
Consultations
2. Emergency Department Visits
C. Visit Reporting Guidelines
1. Background
2. CY 2007 Work on Visit Guidelines
3. Visit Guidelines
X. OPPS Payment for Blood and Blood Products
A. Background
B. Payment for Blood and Blood Products
XI. OPPS Payment for Observation Services
A. Observation Services (HCPCS Code G0378)
B. Direct Admission to Observation (HCPCS Code G0379)
XII. Procedures That Will Be Paid Only as Inpatient Procedures
A. Background
B. Changes to the Inpatient List
XIII. Nonrecurring Technical and Policy Changes
A. Outpatient Hospital Services and Supplies Incident to a
Physician Service
B. Interrupted Procedures
C. Transitional Adjustments--Hold Harmless Provisions
D. Reporting of Wound Care Services
E. Reporting of Cardiac Rehabilitation Services
F. Reporting of Bone Marrow and Stem Cell Processing Services
G. Reporting of Alcohol and/or Substance Abuse Assessment and
Intervention Services
XIV. OPPS Payment Status and Comment Indicators
A. Payment Status Indicator Definitions
1. Payment Status Indicators to Designate Services That Are Paid
under the OPPS
2. Payment Status Indicators to Designate Services That Are Paid
under a Payment System Other Than the OPPS
3. Payment Status Indicators to Designate Services That Are Not
Recognized under the OPPS But That May Be Recognized by Other
Institutional Providers
4. Payment Status Indicators to Designate Services That Are Not
Payable by Medicare
B. Comment Indicator Definitions
XV. OPPS Policy and Payment Recommendations
A. MedPAC Recommendations
B. APC Panel Recommendations
XVI. Update of the Revised Ambulatory Surgical Center Payment System
A. Legislative and Regulatory Authority for the ASC Payment
System
B. Rulemaking for the Revised ASC Payment System
C. Revisions to the ASC Payment System Effective January 1, 2008
1. Covered Surgical Procedures under the Revised ASC Payment
System
a. Definition of Surgical Procedure
b. Identification of Surgical Procedures Eligible for Payment
under the Revised ASC Payment System
c. Payment for Covered Surgical Procedures under the Revised ASC
Payment System
(1) General Policies
(2) Office-Based Procedures
(3) Device-Intensive Procedures
(4) Multiple and Interrupted Procedure Discounting
(5) Transition to Revised ASC Payment Rates
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2. Covered Ancillary Services under the Revised ASC Payment
System
a. General Policies
b. Payment Policies for Specific Items and Services
(1) Radiology Services
(2) Brachytherapy Sources
3. General Payment Policies
a. Adjustment for Geographic Wage Differences
b. Beneficiary Coinsurance
D. Treatment of New HCPCS Codes
1. Treatment of New CY 2008 Category I and III CPT Codes and
Level II HCPCS Codes
2. Treatment of New Mid-Year Category III CPT Codes
3. Treatment of Level II HCPCS Codes Released on a Quarterly
Basis
E. Updates to Covered Surgical Procedures and Covered Ancillary
Services
1. Identification of Covered Surgical Procedures
a. General Policies
b. Changes in Designation of Covered Surgical Procedures as
Office-Based
c. Changes in Designation of Covered Surgical Procedures as
Device Intensive
2. Changes in Identification of Covered Ancillary Services
F. Payment for Covered Surgical Procedures and Covered Ancillary
Services
1. Payment for Covered Surgical Procedures
a. Update to Payment Rates
b. Payment Policies When Devices Are Replaced at No Cost or with
Credit
(1) Policy When Devices Are Replaced at No Cost or with Full
Credit
(2) Policy When Implantable Devices Are Replaced with Partial
Credit
2. Payment for Covered Ancillary Services
G. Physician Payment for Procedures and Services Provided in ASC
H. Changes to Definitions of ``Radiology and Certain Other
Imaging Services'' and ``Outpatient Prescription Drugs''
I. New Technology Intraocular Lenses (NTIOLs)
1. Background
2. Changes to the NTIOL Determination Process Finalized for CY
2008
3. NTIOL Application Process for CY 2008 Payment Adjustment
4. Classes of NTIOLS Approved for Payment Adjustment
5. Payment Adjustment
6. CY 2008 ASC Payment for Insertion of IOLs
J. ASC Payment and Comment Indicators
K. ASC Policy and Payment Recommendations
L. Calculation of the ASC Conversion Factor and ASC Payment
Rates
XVII. Reporting Quality Data for Annual Payment Rate Updates
A. Background
1. Reporting Hospital Outpatient Quality Data for Annual Payment
Update
2. Reporting ASC Quality Data for Annual Payment Increase
3. Reporting Hospital Inpatient Quality Data for Annual Payment
Update
B. Hospital Outpatient Measures
C. Other Hospital Outpatient Measures
D. Implementation of the HOP QDRP and Request for Additional
Suggested Measures
E. Requirements for HOP Quality Data Reporting for CY 2009 and
Subsequent Calendar Years
1. Administrative Requirements
2. Data Collection and Submission Requirements
3. HOP QDRP Validation Requirements
F. Publication of HOP QDRP Data Collected
G. Attestation Requirement for Future Payment Years
H. HOP QDRP Reconsiderations
I. Reporting of ASC Quality Data
J. FY 2009 IPPS Quality Measures under the RHQDAPU Program
XVIII. Changes Affecting Critical Access Hospitals (CAHs) and
Hospital Conditions of Participation (CoPs)
A. Changes Affecting CAHs
1. Background
2. Co-Location of Necessary Provider CAHs
3. Provider-Based Facilities of CAHs
4. Termination of Provider Agreement
5. Regulation Changes
B. Revisions to Hospital CoPs
1. Background
2. Provisions of the Final Regulation
a. Timeframes for Completion of the Medical History and Physical
Examination
b. Requirements for Preanesthesia and Postanesthesia Evaluations
c. Technical Amendment to Nursing Services CoP
XIX. Changes to the FY 2008 Hospital Inpatient Prospective Payment
System (IPPS) Payment Rates
A. Background
B. Revised IPPS Payment Rates
1. MS-DRG Documentation and Coding Adjustment
2. Application of the Documentation and Coding Adjustment to the
Hospital Specific Rates
XX. Medicare Graduate Medical Education Affiliation Provisions for
Teaching Hospitals in Certain Emergency Situations
A. Background
1. Legislative Authority
2. Existing Medicare Direct GME and Indirect GME Policies
3. Regulatory Changes Issued in 2006 to Address Certain
Emergency Situations
B. Additional Changes in This Interim Final Rule with Comment
Period
1. Summary of Regulatory Changes
2. Discussion of Training in Nonhospital Settings
C. Responses to Comments on the April 12, 2006 Interim Final
Rule with Comment Period and This Interim Final Rule with Comment
Period
XXI. Files Available to the Public Via the Internet
A. Information in Addenda Related to the Revised CY 2008
Hospital OPPS
B. Information in Addenda Related to the Revised CY 2008 ASC
Payment System
XXII. Collection of Information Requirements
XXIII. Response to Comments
XXIV. Regulatory Impact Analysis
A. Overall Impact of Changes to the OPPS and ASC Payment Systems
1. Executive Order 12866
2. Regulatory Flexibility Act (RFA)
3. Small Rural Hospitals
4. Unfunded Mandates
5. Federalism
B. Effects of OPPS Changes in This Final Rule with Comment
Period
1. Alternatives Considered
2. Limitation of Our Analysis
3. Estimated Impact of This Final Rule with Comment Period on
Hospitals and CMHCs
4. Estimated Effect of This Final Rule with Comment Period on
Beneficiaries
5. Conclusion
6. Accounting Statement
C. Effects of ASC Payment System Changes in This Final Rule with
Comment Period
1. Alternatives Considered
2. Limitations on Our Analysis
3. Estimated Effects of This Final Rule with Comment Period on
ASCs
4. Estimated Effects of This Final Rule with Comment Period on
Beneficiaries
5. Conclusion
6. Accounting Statement
D. Effects of the Requirements for Reporting of Quality Data for
Hospital Outpatient Settings
E. Effects of the Policy on CAH Off-Campus and Co-Location
Requirements
F. Effects of the Policy Revisions to the Hospital CoPs
G. Effects of the Changes to the Hospital Inpatient Prospective
Payment System (IPPS) Payment Rates
1. Overall Impact
2. Objectives
3. Limitations of Our Analysis
4. Quantitative Effects of the IPPS Policy Changes on Operating
Costs
5. Analysis of Table I
a. Effects of All Changes with CMI Adjustment Prior to Estimated
Growth (Columns 2a and 2b)
b. Effects of All Changes with CMI Adjustment and Estimated
Growth (Column 3)
6. Overall Conclusion
7. Accounting Statement
8. Executive order 12866
H. Impact of the Policy Revisions to the Emergency Medicare GME
Affiliated Groups for Hospitals in Certain Declared Emergency Areas
1. Overall Impact
2. RFA
3. Small Rural Hospitals
4. Unfunded Mandates
5. Federalism
6. Anticipated Effects
7. Alternatives Considered
8. Conclusion
9. Executive Order 12866
XXV. Waiver of Proposed Rulemaking, Waiver of Delay in Effective
Date, and Retroactive Effective Date
A. Requirements for Waivers and Retroactive Rulemaking
B. IPPS Payment Rate Policies
C. Medicare GME Affiliation Agreement Provisions
Regulation Text
Addenda
Addendum A-OPPS APCs for CY 2008
[[Page 66585]]
Addendum AA-ASC Covered Surgical Procedures for CY 2008 (Including
Surgical Procedures for Which Payment is Packaged)
Addendum B-OPPS Payment By HCPCS Code for CY 2008
Addendum BB-ASC Covered Ancillary Services Integral to Covered
Surgical Procedures for CY 2008 (Including Ancillary Services for
Which Payment Is Packaged)
Addendum D1-OPPS Payment Status Indicators
Addendum DD1-ASC Payment Indicators
Addendum D2-OPPS Comment Indicators
Addendum DD2-ASC Comment Indicators
Addendum E-HCPCS Codes That Would Be Paid Only as Inpatient
Procedures for CY 2008
Addendum L-Out-Migration Adjustment
Addendum M-HCPCS Codes for Assignment to Composite APCs for CY 2008
I. Background for the OPPS
A. Legislative and Regulatory Authority for the Hospital Outpatient
Prospective Payment System
When the Medicare statute was originally enacted, Medicare payment
for hospital outpatient services was based on hospital-specific costs.
In an effort to ensure that Medicare and its beneficiaries pay
appropriately for services and to encourage more efficient delivery of
care, the Congress mandated replacement of the reasonable cost-based
payment methodology with a prospective payment system (PPS). The
Balanced Budget Act (BBA) of 1997 (Pub. L. 105-33) added section
1833(t) to the Social Security Act (the Act) authorizing implementation
of a PPS for hospital outpatient services.
The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act
(BBRA) of 1999 (Pub. L. 106-113) made major changes in the hospital
outpatient prospective payment system (OPPS). The Medicare, Medicaid,
and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 (Pub.
L. 106-554) made further changes in the OPPS. Section 1833(t) of the
Act was also amended by the Medicare Prescription Drug, Improvement,
and Modernization Act (MMA) of 2003 (Pub. L. 108 173). The Deficit
Reduction Act (DRA) of 2005 (Pub. L. 109-171), enacted on February 8,
2006, also made additional changes in the OPPS. In addition, the
Medicare Improvements and Extension Act under Division B of Title I of
the Tax Relief and Health Care Act (MIEA-TRHCA) of 2006 (Pub. L. 109-
432), enacted on December 20, 2006, made further changes in the OPPS. A
discussion of these changes is included in sections I.E., VII., and
XVII. of this final rule with comment period.
The OPPS was first implemented for services furnished on or after
August 1, 2000. Implementing regulations for the OPPS are located at 42
CFR part 419.
Under the OPPS, we pay for hospital outpatient services on a rate-
per-service basis that varies according to the ambulatory payment
classification (APC) group to which the service is assigned. We use the
Healthcare Common Procedure Coding System (HCPCS) codes (which include
certain Current Procedural Terminology (CPT) codes) and descriptors to
identify and group the services within each APC group. The OPPS
includes payment for most hospital outpatient services, except those
identified in section I.B. of this final rule with comment period.
Section 1833(t)(1)(B)(ii) of the Act provides for Medicare payment
under the OPPS for hospital outpatient services designated by the
Secretary (which includes partial hospitalization services furnished by
community mental health centers (CMHCs)) and hospital outpatient
services that are furnished to inpatients who have exhausted their Part
A benefits, or who are otherwise not in a covered Part A stay. Section
611 of Pub. L. 108-173 added provisions for Medicare coverage of an
initial preventive physical examination, subject to the applicable
deductible and coinsurance, as an outpatient department service,
payable under the OPPS.
The OPPS rate is an unadjusted national payment amount that
includes the Medicare payment and the beneficiary copayment. This rate
is divided into a labor-related amount and a nonlabor-related amount.
The labor-related amount is adjusted for area wage differences using
the hospital inpatient wage index value for the locality in which the
hospital or CMHC is located.
All services and items within an APC group are comparable
clinically and with respect to resource use (section 1833(t)(2)(B) of
the Act). In accordance with section 1833(t)(2) of the Act, subject to
certain exceptions, services and items within an APC group cannot be
considered comparable with respect to the use of resources if the
highest median (or mean cost, if elected by the Secretary) for an item
or service in the APC group is more than 2 times greater than the
lowest median cost for an item or service within the same APC group
(referred to as the ``2 times rule''). In implementing this provision,
we generally use the median cost of the item or service assigned to an
APC group.
For new technology items and services, special payments under the
OPPS may be made in one of two ways. Section 1833(t)(6) of the Act
provides for temporary additional payments, which we refer to as
``transitional pass through payments,'' for at least 2 but not more
than 3 years for certain drugs, biological agents, brachytherapy
devices used for the treatment of cancer, and categories of other
medical devices. For new technology services that are not eligible for
transitional pass through payments, and for which we lack sufficient
data to appropriately assign them to a clinical APC group, we have
established special APC groups based on costs, which we refer to as New
Technology APCs. These New Technology APCs are designated by cost bands
which allow us to provide appropriate and consistent payment for
designated new procedures that are not yet reflected in our claims
data. Similar to pass through payments, an assignment to a New
Technology APC is temporary; that is, we retain a service within a New
Technology APC until we acquire sufficient data to assign it to a
clinically appropriate APC group.
B. Excluded OPPS Services and Hospitals
Section 1833(t)(1)(B)(i) of the Act authorizes the Secretary to
designate the hospital outpatient services that are paid under the
OPPS. While most hospital outpatient services are payable under the
OPPS, section 1833(t)(1)(B)(iv) of the Act excludes payment for
ambulance, physical and occupational therapy, and speech-language
pathology services, for which payment is made under a fee schedule.
Section 614 of Pub. L. 108-173 amended section 1833(t)(1)(B)(iv) of the
Act to exclude payment for screening and diagnostic mammography
services from the OPPS. The Secretary exercised the authority granted
under the statute to also exclude from the OPPS those services that are
paid under fee schedules or other payment systems. Such excluded
services include, for example, the professional services of physicians
and nonphysician practitioners paid under the Medicare Physician Fee
Schedule (MPFS); laboratory services paid under the clinical diagnostic
laboratory fee schedule (CLFS); services for beneficiaries with end
stage renal disease (ESRD) that are paid under the ESRD composite rate;
and services and procedures that require an inpatient stay that are
paid under the hospital inpatient prospective payment system (IPPS). We
set forth the services that are excluded from payment under the OPPS in
Sec. 419.22 of the regulations.
Under Sec. 419.20(b) of the regulations, we specify the types of
hospitals and entities that are excluded from payment under the OPPS.
These excluded
[[Page 66586]]
entities include Maryland hospitals, but only for services that are
paid under a cost containment waiver in accordance with section
1814(b)(3) of the Act; critical access hospitals (CAHs); hospitals
located outside of the 50 States, the District of Columbia, and Puerto
Rico; and Indian Health Service hospitals.
C. Prior Rulemaking
On April 7, 2000, we published in the Federal Register a final rule
with comment period (65 FR 18434) to implement a prospective payment
system for hospital outpatient services. The hospital OPPS was first
implemented for services furnished on or after August 1, 2000. Section
1833(t)(9) of the Act requires the Secretary to review certain
components of the OPPS, not less often than annually, and to revise the
groups, relative payment weights, and other adjustments that take into
account changes in medical practices, changes in technologies, and the
addition of new services, new cost data, and other relevant information
and factors.
Since initially implementing the OPPS, we have published final
rules in the Federal Register annually to implement statutory
requirements and changes arising from our continuing experience with
this system. We published in the Federal Register on November 24, 2006
the CY 2007 OPPS/ASC final rule with comment period (71 FR 67960). In
that final rule with comment period, we revised the OPPS to update the
payment weights and conversion factor for services payable under the CY
2007 OPPS on the basis of claims data from January 1, 2005, through
December 31, 2005, and to implement certain provisions of Pub. L. 108-
173 and Pub. L. 109-171. In addition, we responded to public comments
received on the provisions of the November 10, 2005 final rule with
comment period (70 FR 86516) pertaining to the APC assignment of HCPCS
codes identified in Addendum B of that rule with the new interim (NI)
comment indicator; and public comments received on the August 23, 2006
OPPS/ASC proposed rule for CY 2007 (71 FR 49506).
On August 2, 2007, we issued in the Federal Register (72 FR 42628)
a proposed rule for the CY 2008 OPPS/ASC to implement statutory
requirements and changes arising from our continuing experience with
both systems. We received approximately 2,180 pieces of timely
correspondence in response to the proposed rule. A summary of the
public comments we received and our responses to those comments are
included in the specific sections of this final rule with comment
period.
D. APC Advisory Panel
1. Authority of the APC Panel
Section 1833(t)(9)(A) of the Act, as amended by section 201(h) of
the BBRA, and redesignated by section 202(a)(2) of the BBRA, requires
that we consult with an outside panel of experts to review the clinical
integrity of the payment groups and their weights under the OPPS. The
Act further specifies that the panel will act in an advisory capacity.
The Advisory Panel on Ambulatory Payment Classification (APC)
Groups (the APC Panel), discussed under section I.D.2. of this final
rule with comment period, fulfills these requirements. The APC Panel is
not restricted to using data compiled by CMS, and may use data
collected or developed by organizations outside the Department in
conducting its review.
2. Establishment of the APC Panel
On November 21, 2000, the Secretary signed the initial charter
establishing the APC Panel. This expert panel, which may be composed of
up to 15 representatives of providers subject to the OPPS (currently
employed full-time, not as consultants, in their respective areas of
expertise), reviews clinical data and advises CMS about the clinical
integrity of the APC groups and their payment weights. For purposes of
this Panel, consultants or independent contractors are not considered
to be full-time employees. The APC Panel is technical in nature, and is
governed by the provisions of the Federal Advisory Committee Act
(FACA). Since its initial chartering, the Secretary has renewed the APC
Panel's charter three times: On November 1, 2002; on November 1, 2004;
and effective November 21, 2006. The current charter specifies, among
other requirements, that the APC Panel continue to be technical in
nature; be governed by the provisions of the FACA; may convene up to
three meetings per year; has a Designated Federal Officer (DFO); and is
chaired by a Federal official designated by the Secretary.
The current APC Panel membership and other information pertaining
to the APC Panel, including its charter, Federal Register notices,
membership, meeting dates, agenda topics, and meeting reports can be
viewed on the CMS Web site at: http://www.cms.hhs.gov/FACA/05_AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp#TopOfPage
.
3. APC Panel Meetings and Organizational Structure
The APC Panel first met on February 27, February 28, and March 1,
2001. Since the initial meeting, the APC Panel has held 12 subsequent
meetings, with the last meeting taking place on September 5 and 6,
2007. Prior to each meeting, we publish a notice in the Federal
Register to announce the meeting, and when necessary, to solicit
nominations for APC Panel membership, and to announce new members.
The APC Panel has established an operational structure that, in
part, includes the use of three subcommittees to facilitate its
required APC review process. The three current subcommittees are the
Data Subcommittee, the Observation and Visit Subcommittee, and the
Packaging Subcommittee. The Data Subcommittee is responsible for
studying the data issues confronting the APC Panel, and for
recommending options for resolving them. The Observation and Visit
Subcommittee reviews and makes recommendations to the APC Panel on all
technical issues pertaining to observation services and hospital
outpatient visits paid under the OPPS (for example, APC configurations
and APC payment weights). The Packaging Subcommittee studies and makes
recommendations on issues pertaining to services that are not
separately payable under the OPPS, but whose payments are bundled or
packaged into APC payments. Each of these subcommittees was established
by a majority vote from the full APC Panel during a scheduled APC Panel
meeting, and their continuation as subcommittees was last approved at
the September 2007 APC Panel meetings. All subcommittee recommendations
are discussed and voted upon by the full APC Panel.
Discussions of the recommendations resulting from the APC Panel's
March 2007 and September 2007 meetings are included in the sections of
this final rule with comment period that are specific to each
recommendation. For discussions of earlier APC Panel meetings and
recommendations, we refer readers to previously published hospital OPPS
final rules or the Web site mentioned earlier in this section.
E. Provisions of the Medicare Improvements and Extension Act under
Division B of Title I of the Tax Relief and Health Care Act of 2006
The Medicare Improvements and Extension Act under Division B of
Title I of the Tax Relief and Health Care Act
[[Page 66587]]
(MIEA-TRHCA) of 2006, Pub. L. 109-432, enacted on December 20, 2006,
included the following provisions affecting the OPPS:
1. Section 107(a) of the MIEA-TRHCA amended section 1833(t)(16)(C)
of the Act to extend the period for payment of brachytherapy devices
based on the hospital's charges adjusted to cost for 1 additional year,
through December 31, 2007.
2. Section 107(b)(1) of the MIEA-TRHCA amended section
1833(t)(2)(H) of the Act by adding stranded and non stranded devices
furnished on or after July 1, 2007, as additional classifications of
brachytherapy devices for which separate payment groups must be
established for payment under the OPPS. Section 107(b)(2) of the MIEA
TRCHA provides that the Secretary may implement the section 107(b)(1)
amendment to section 1833(t)(2)(H) of the Act ``by program instruction
or otherwise.''
3. Section 109(a) of the MIEA-TRHCA added new paragraph (17) to
section 1833(t) of the Act which authorizes the Secretary, beginning in
2009 and each subsequent year, to reduce the OPPS full annual update by
2.0 percentage points if a hospital paid under the OPPS fails to submit
data as required by the Secretary in the form and manner specified on
selected measures of quality of care, including medication errors. In
accordance with this provision, the selected measures are those that
are appropriate for the measurement of quality of care furnished by
hospitals in the outpatient setting, that reflect consensus among
affected parties and, to the extent feasible and practicable, that
include measures set forth by one or more of the national consensus
entities, and that may be the same as those required for reporting by
hospitals paid under the IPPS. This provision specifies that a
reduction for 1 year cannot be taken into account when computing the
OPPS update for a subsequent year. In addition, this provision requires
the Secretary to establish a process for making the submitted data
available for public review.
F. Summary of the Major Contents of the CY 2008 OPPS/ASC Proposed Rule
On August 2, 2007, we published a proposed rule in the Federal
Register (72 FR 42628) that set forth proposed changes to the Medicare
hospital OPPS for CY 2008 to implement statutory requirements and
changes arising from our continuing experience with the system and to
implement certain statutory provisions. In addition, we proposed
changes to the revised Medicare ASC payment system for CY 2008 such as
adding procedures to the list of covered surgical procedures and
adjusting the ASC rates so that the revised ASC payment system is
budget neutral. We also proposed to make changes to the policies
relating to the necessary provider designations of CAHs that are being
recertified when a CAH enters into a new co-location arrangement with
another hospital or CAH or when the CAH creates or acquires an off-
campus location. Further, we proposed changes to several of the current
conditions of participation that hospitals must meet to participate in
the Medicare and Medicaid programs to require the completion and
documentation in the medical record of medical histories and physical
examinations of patients conducted after admission and prior to surgery
or a procedure requiring anesthesia services and for postanesthesia
evaluations of patients before discharge or transfer from the
postanesthesia recovery area. Finally, we set forth proposed quality
measures for a Hospital Outpatient Quality Data Reporting (HOP QDRP)
program for reporting quality data for annual payment rate updates for
CY 2009 and subsequent calendar years. We also briefly discussed the
legislative provisions of the MIEA-TRHCA that give the Secretary
authority to develop quality measures for reporting data by ASCs. The
following is a summary of the major changes included in the CY 2008
OPPS/ASC proposed rule:
1. Updates Affecting OPPS Payments
In section II. of the proposed rule, we set forth--
The methodology used to recalibrate the proposed APC
relative payment weights.
The proposed payment for partial hospitalization services,
including the proposed separate threshold for outlier payments for
CMHCs.
The proposed update to the conversion factor used to
determine payment rates under the OPPS.
The proposed retention of our current policy to use the
IPPS wage indices to adjust, for geographic wage differences, the
portion of the OPPS payment rate and the copayment standardized amount
attributable to labor related cost.
The proposed update of statewide average default CCRs.
The proposed application of hold harmless transitional
outpatient payments (TOPs) for certain small rural hospitals.
The proposed payment adjustment for rural SCHs.
The proposed calculation of the hospital outpatient
outlier payment.
The calculation of the proposed national unadjusted
Medicare OPPS payment.
The proposed beneficiary copayments for OPPS services.
2. OPPS Ambulatory Payment Classification (APC) Group Policies
In section III. of the proposed rule, we discussed the proposed
additions of new procedure codes to the APCs; our proposal to establish
a number of new APCs; and our analyses of Medicare claims data and
certain recommendations of the APC Panel. We also discussed the
application of the 2 times rule and proposed exceptions to it; proposed
changes to specific APCs; and the proposed movement of procedures from
New Technology APCs to clinical APCs.
3. OPPS Payment for Devices
In section IV. of the proposed rule, we discussed proposed payment
for device dependent APCs and pass-through payment for specific
categories of devices.
4. OPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals
In section V. of the proposed rule, we discussed the proposed CY
2008 OPPS payment for drugs, biologicals, and radiopharmaceuticals,
including the proposed payment for drugs, biologicals, and
radiopharmaceuticals with and without pass-through status.
5. Estimate of OPPS Transitional Pass-Through Spending for Drugs,
Biologicals, and Devices
In section VI. of the proposed rule, we discussed the estimate of
CY 2008 OPPS transitional pass-through spending for drugs, biologicals,
and devices.
6. OPPS Payment for Brachytherapy Sources
In section VII. of the proposed rule, we discussed our proposal
concerning coding and payment for brachytherapy sources.
7. OPPS Coding and Payment for Drug Administration Services
In section VIII. of the proposed rule, we set forth our proposed
policy concerning coding and payment for drug administration services.
8. OPPS Hospital Coding and Payments for Visits
In section IX. of the proposed rule, we set forth our proposed
policies for the coding and reporting of clinic and emergency
department visits and
[[Page 66588]]
critical care services on claims paid under the OPPS.
9. OPPS Payment for Blood and Blood Products
In section X. of the proposed rule, we discussed our proposed
payment for blood and blood products.
10. Proposed OPPS Payment for Observation Services
In section XI. of the proposed rule, we discussed the proposed
payment policies for observation services furnished to patients on an
outpatient basis.
11. Procedures That Will Be Paid Only as Inpatient Services
In section XII. of the proposed rule, we discussed the procedures
that we proposed to remove from the inpatient list and assign to APCs.
12. Nonrecurring Technical and Policy Changes
In section XIII. of the proposed rule, we set forth our proposals
for nonrecurring technical and policy changes and clarifications
relating to outpatient services and supplies incident to physicians'
services; payment for interrupted procedures prior to and after the
administration of anesthesia; transitional adjustments to payments for
covered outpatient services furnished by small rural hospitals and SCHs
located in rural areas; and reporting requirements for wound care
services, cardiac rehabilitation services, and bone marrow and stem
cell processing services.
13. OPPS Payment Status and Comment Indicators
In section XIV. of the proposed rule, we discussed proposed changes
to the definitions of status indicators assigned to APCs and presented
our proposed comment indicators for the OPPS/ASC final rule with
comment period.
14. OPPS Policy and Payment Recommendations
In section XV. of the proposed rule, we addressed recommendations
made by the Medicare Payment Advisory Commission (MedPAC) in its March
and June 2007 Reports to Congress and by the APC Panel regarding the
OPPS for CY 2008.
15. Update of the Revised ASC Payment System
In section XVI. of the proposed rule, we discussed the proposed
update of the revised ASC payment system payment rates for CY 2008. We
also discussed our proposed changes to our regulations at Sec. Sec.
414.22(b)(5)(i)(A) and (B) regarding physician payment for performing
excluded surgical procedures in ASCs. In addition, we set forth our
proposal to revise the definitions of ``radiology and certain other
imaging services'' and ``outpatient prescription drugs'' when provided
integral to an ASC covered surgical procedure.
16. Reporting Quality Data for Annual Payment Rate Updates
In section XVII. of the proposed rule, we discussed the proposed
quality measures for reporting hospital outpatient quality data for CY
2009 and subsequent years and set forth the requirements for data
collection and submission for the annual payment update. We also
briefly discussed the legislative provisions of the MIEA-TRHCA that
give the Secretary authority to develop quality measures for reporting
by ASCs. (We note that, as discussed in section XVII.J. of this final
rule with comment period, we are also finalizing a proposal from the FY
2008 IPPS proposed rule relating to the FY 2009 RHQDAPU quality
measures. Specifically, we are finalizing the inclusion of SCIP
Infection 4: Cardiac Surgery Patients with Controlled 6AM Postoperative
Serum Glucose and SCIP Infection 6: Surgery Patients with Appropriate
Hair Removal in the FY 2009 RHQDAPU measure set, bringing the total
number of measures in that measure set to 30.)
17. Changes Affecting Necessary Provider Critical Access Hospitals
(CAHs) and Hospital Conditions of Participation (CoPs)
In section XVIII. of the proposed rule, we discussed our proposed
changes affecting CAHs both when the CAH enters into a new co-location
arrangement with another hospital or CAH and when the CAH creates or
acquires a provider-based off campus location. We also discussed our
proposed changes relating to several hospital CoPs to require the
completion of physical examinations and medical histories and
documentation in the medical records for patients after admission and
prior to surgery or a procedure requiring anesthesia services, and for
postanesthesia evaluations of patients after surgery or a procedure
requiring anesthesia services but before discharge or transfer from the
postanesthesia recovery area.
18. Regulatory Impact Analysis
In section XXII. of the proposed rule, we set forth an analysis of
the impact the proposed changes would have on affected entities and
beneficiaries. (We note that this regulatory impact analysis section is
redesignated as section XXIV. of this final rule with comment period.)
G. Public Comments Received in Response to the CY 2008 OPPS/ASC
Proposed Rule
We received approximately 2,180 timely pieces of correspondence
containing multiple comments on the CY 2008 OPPS/ASC proposed rule. We
note that we received some comments that were outside the scope of the
CY 2008 OPS/ASC proposed rule. These comments are not addressed in this
CY 2008 OPPS/ASC final rule with comment period. Summaries of the
public comments that are within the scope of the proposals and our
responses to those comments are set forth in the various sections of
this final rule with comment period under the appropriate headings.
H. Public Comments Received on the November 24, 2006 OPPS/ASC Final
Rule with Comment Period
We received approximately 21 timely items of correspondence on the
CY 2007 OPPS/ASC final rule with comment period, some of which
contained multiple comments on the interim final APC assignments and/or
status indicators of HCPCS codes identified with comment indicator
``NI'' in Addendum B to that final rule with comment period. Summaries
of those public comments and our responses to them are set forth in the
various sections of this final rule with comment period under the
appropriate headings.
II. Updates Affecting OPPS Payments
A. Recalibration of APC Relative Weights
1. Database Construction
a. Database Source and Methodology
Section 1833(t)(9)(A) of the Act requires that the Secretary review
and revise the relative payment weights for APCs at least annually. In
the April 7, 2000 OPPS final rule with comment period (65 FR 18482), we
explained in detail how we calculated the relative payment weights that
were implemented on August 1, 2000 for each APC group. Except for some
reweighting due to a small number of APC changes, these relative
payment weights continued to be in effect for CY 2001. This policy is
discussed in the November 13, 2000 interim final rule (65 FR 67824
through 67827).
In the CY 2008 OPPS/ASC proposed rule, we proposed to use the same
basic methodology that we described in the
[[Page 66589]]
April 7, 2000 OPPS final rule with comment period to recalibrate the
APC relative payment weights for services furnished on or after January
1, 2008 and before January 1, 2009. That is, we proposed to recalibrate
the relative payment weights for each APC based on claims and cost
report data for outpatient services. We proposed to use the most recent
available data to construct the database for calculating APC group
weights. For the purpose of recalibrating the proposed APC relative
payment weights for CY 2008, we used approximately 131 million final
action claims for hospital outpatient department (HOPD) services
furnished on or after January 1, 2006 and before January 1, 2007. (For
exact counts of claims used, we refer readers to the claims accounting
narrative under supporting documentation for the proposed rule on the
CMS Web site at: http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/).
Of the 141 million final action claims for services provided in
hospital outpatient settings used to calculate the CY 2008 OPPS payment
rates for this final rule with comment period, approximately 103
million claims were of the type of bill potentially appropriate for use
in setting rates for OPPS services (but did not necessarily contain
services payable under the OPPS). Of the 103 million claims,
approximately 45 million were not for services paid under the OPPS or
were excluded as not appropriate for use (for example, erroneous cost-
to-charge ratios (CCRs) or no HCPCS codes reported on the claim). We
were able to use approximately 54 million whole claims of the
approximately 58 million claims that remained to set the OPPS APC
relative weights for the CY 2008 OPPS. From the 54 million whole
claims, we created approximately 97 million single records, of which
approximately 65 million were ``pseudo'' single claims (created from
multiple procedure claims using the process we discuss in this
section). Approximately 926,000 claims trimmed out on cost or units in
excess of +/-3 standard deviations from the geometric mean, yielding
approximately 96 million single bills used for median setting.
Ultimately, we were able to use for CY 2008 ratesetting some portion of
93 ercent of the CY 2006 claims containing services payable under the
OPPS. This is approximately the same percentage of CY 2005 claims where
some portion could be used for CY 2007 ratesetting as described in the
CY 2007 OPPS/ASC final rule with comment period (71 FR 67970).
As proposed, the final APC relative weights and payments for CY
2008 in Addenda A and B to this final rule with comment period were
calculated using claims from this period that were processed before
June 30, 2007, and continue to be based on the median hospital costs
for services in the APC groups. We selected claims for services paid
under the OPPS and matched these claims to the most recent cost report
filed by the individual hospitals represented in our claims data. We
continue to believe that it is appropriate to use the most current full
calendar year claims data and the most recently submitted cost reports
to calculate the median costs which we proposed to convert to relative
payment weights for purposes of calculating the CY 2008 payment rates.
We did not receive any comments on our proposal to base the CY 2008
APC relative weights on the most currently available cost reports and
on claims for services furnished in CY 2006. Therefore, we are
finalizing our data source for the recalibration of the CY 2008 APC
relative payment weights as proposed, without modification, as
described in this section of this final rule with comment period.
b. Use of Single and Multiple Procedure Claims
For CY 2008, in general, we proposed to continue to use single
procedure claims to set the medians on which the APC relative payment
weights would be based, with some exceptions as discussed below. We
generally use single procedure claims to set the median costs for APCs
because we believe that it is important that the OPPS relative weights
on which payment rates are based be appropriate when one and only one
procedure is furnished and because we are, so far, unable to ensure
that packaged costs can be appropriately allocated across multiple
procedures performed on the same date of service. We agree that,
optimally, it is desirable to use the data from as many claims as
possible to recalibrate the APC relative payment weights, including
those claims for multiple procedures. We engaged in several efforts
this year to improve our use of multiple procedure claims for
ratesetting. As we have for several years, we continued to use date of
service stratification and a list of codes to be bypassed to convert
multiple procedure claims to ``pseudo'' single procedure claims. We
also continued our internal efforts to better understand the patterns
of services and costs from multiple bills toward the goal of using more
multiple bill information by assessing the amount of packaging in the
multiple bills and, specifically, by exploring the amount of packaging
for drug administration services in the single and multiple bill
claims. Moreover, in many cases, the packaging approach that we
proposed for the CY 2008 OPPS also allows the use of more claims data
by enabling us to treat claims with multiple procedure codes as single
claims. We refer readers to section II.A.4. of the proposed rule for a
full discussion of the packaging approach for CY 2008.
We received several public comments on our proposed use of single
bills to calculate the APC median costs for ratesetting under the CY
2008 OPPS. A summary of the public comments and our responses follow.
Comment: Some commenters supported the ``natural'' and ``pseudo''
single methodology but asked that CMS continue to refine the approach
in order to improve the accuracy of the estimates because the medians
are used to develop payment rates for services on both single and
multiple procedure claims. Other commenters asserted that continued
reliance on single procedure bills to establish the medians from which
the rates were calculated failed to produce a statistically valid
sample of services for ratesetting, in particular for brachytherapy
services that are often provided in combination with one another in a
single encounter. Other commenters requested that CMS explore
additional revisions to the current methodology to ensure that OPPS
payment would be based on a substantial number of accurate hospital
claims.
Response: We generally base median costs for services on single
procedure claims to ensure that the median cost captures the full cost
of a service when it is the only service furnished. We recognize that
this approach has limitations and, in some cases, prevents us from
using many of the claims for services that are most commonly furnished
at the same time as other services. For this reason, we have developed
a number of different strategies, such as date of service
stratification and the use of the bypass list, that enable us to break
multiple procedure claims into ``pseudo'' single procedure claims where
we have confidence that the ``pseudo'' single claim contains the full
cost of the service, including related packaged costs. In recent years,
however, we have increasingly used multiple procedure claims to develop
median costs for individual services or groups of services. We have
developed these methodologies so that we can use more naturally
occurring claims data in cases in which care is most commonly reported
with multiple major procedure
[[Page 66590]]
codes on the same date, such as observation services, hyperbaric oxygen
therapy (HBOT), and single allergy tests.
Similarly, for CY 2008, we developed and proposed composite APCs
for low dose rate prostate brachytherapy (APC 8001 (LDR Prostate
Brachytherapy Composite)) and cardiac electrophysiology services (APC
8000 (Cardiac Electrophysiologic Evaluation and Ablation Composite)).
These APCs are designed to use multiple procedure claims to establish a
median cost and APC payment for multiple major procedures when they are
furnished together. As we discuss in section II.A.4.d. of this final
rule with comment period, we intend to explore the creation of
additional composite APCs for services that frequently are provided in
the same HOPD encounter. We also plan to continue to develop and refine
methods to increase the amount of claims data that we can use for
setting OPPS payment rates in a manner that gives us the most
confidence that the costs derived from these approaches are valid
reflections of the costs of the services described by HCPCS codes or,
in the case of composite APCs, described by the APCs. We anticipate
that the Data Subcommittee of the APC Panel will continue to provide us
with valuable advice regarding possible methodologies for increasing
the OPPS use of multiple procedure claims for ratesetting.
After consideration of the public comments received, we are
finalizing our proposal, without modification, to calculate median
costs for APCs using single and ``pseudo'' single procedure claims,
except where otherwise specified.
(1) Use of Date of Service Stratification and a Bypass List To Increase
the Amount of Data Used To Determine Medians
Through bypassing specified codes that we believe do not have
significant packaged costs, we are able to use more data from multiple
procedure claims. In many cases, this enables us to create multiple
``pseudo'' single claims from claims that, as submitted, contained
numerous separately paid procedures reported on the same date on one
claim. We refer to these newly created single procedure claims as
``pseudo'' single claims because they were submitted by providers as
multiple procedure claims. The history of our use of a bypass list to
generate ``pseudo'' single claims is well documented, most recently in
the CY 2007 OPPS/ASC final rule with comment period (71 FR 67969
through 67970).
The date of service stratification (sorting the lines by date of
service and treating all lines with the same date of service as a
separate claim) and bypass list process we used for the CY 2007 OPPS
(combined with the packaging changes we proposed in section II.A.4. of
the proposed rule) resulted in our being able to use some part of
approximately 92 percent of the total claims that were eligible for use
in the OPPS ratesetting and modeling for the proposed rule. This
process enabled us to create, for the CY 2008 proposed rule,
approximately 58 million ``pseudo'' singles and approximately 30
million ``natural'' single bills. For the proposed rule, ``pseudo''
single procedure bills represented 66 percent of all single bills used
to calculate median costs. This compared favorably to the CY 2007 OPPS
final rule data in which ``pseudo'' single bills represented 68 percent
of all single bills used to calculate the median costs on which the CY
2007 OPPS payment rates were based. We believed that the reduction in
the percent of ``pseudo'' single bills and the corresponding increase
in the proportion of ``natural'' single bills observed for the CY 2008
proposed rule occurred largely because of our proposal to increase
packaging as discussed in section II.A.4. of the proposed rule. In many
cases, the packaging proposal for CY 2008 enabled us to use claims that
would otherwise have been considered to be multiple procedure claims
and, absent the proposal for additional packaging, could have been used
for ratesetting only if we had been able to create ``pseudo'' single
claims from them.
For CY 2008, we proposed to bypass 425 HCPCS codes that are
identified in Table 1 of the proposed rule. We proposed to continue the
use of the codes on the CY 2007 OPPS bypass list but to remove codes we
proposed to package for CY 2008. We also proposed to remove codes that
were on the CY 2007 bypass list that ceased to meet the empirical
criteria under the proposed packaging changes when clinical review
confirmed that their removal would be appropriate in the context of the
full proposal for the CY 2008 OPPS. Since the inception of the bypass
list, we have calculated the percent of ``natural'' single bills that
contained packaging for each code and the amount of packaging in each
``natural'' single bill for each code. We retained the codes on the
previous year's bypass list and used the update year's data to
determine whether it would be appropriate to add additional codes to
the previous year's bypass list. The entire list (including the codes
that remained on the bypass list from prior years) was open to public
comment. For the CY 2008 proposed rule, we explicitly reviewed all
``natural'' single bills against the empirical criteria for all codes
on the CY 2007 bypass list because of the proposal for greater
packaging discussed in section II.A.4. of the proposed rule, as this
effort increased the packaging associated with some codes. We removed
106 HCPCS codes from the CY 2007 bypass list for the CY 2008 proposal.
In addition, we note that many of the codes we proposed to newly
package for CY 2008 were on the bypass list used for setting the OPPS
payment rates for CY 2007 and were not proposed for bypass because we
also proposed to package them. We proposed to add to the bypass list
HCPCS codes that, using the proposed rule data, met the same previously
established empirical criteria for the bypass list that are reviewed
below or which our clinicians believed would have little associated
packaging if the services were coded correctly.
The CY 2008 packaging proposal minimally reduced the percentage of
total claims that we were able to use, in whole or in part, from 93
percent for CY 2007 to 92 percent for the proposed rule. The proposed
packaging approach increased the number of ``natural'' single bills, in
spite of reducing the universe of codes requiring single bills for
ratesetting, but reduced the number of ``pseudo'' single bills. More
``natural'' single procedure bills can be created by the packaging of
codes that always appear with another procedure because these dependent
services are supportive of and ancillary to the primary independent
procedures for which payment is being made. A claim containing two
independent procedure codes on the same date of service and not on the
bypass list previously could not be used for ratesetting, but packaging
the cost of one of the codes on the claim frees the claim to be used to
calculate the median cost of the procedure that is not packaged. On the
other hand, our proposed packaging approach reduced the number of codes
eligible for the bypass list because of the limitation on packaging set
by our previously established empirical criteria. A smaller bypass list
and the presence of greater packaging on claims reduced the final
number of ``pseudo'' single claims. In prior years, roughly 68 percent
of single bills were ``pseudo'' single bills, but based on the CY 2008
proposed rule data, 66 percent of single bills were ``pseudo'' singles.
Similarly, for this final rule with comment period,
[[Page 66591]]
66 percent of single bills were ``pseudo'' singles. Moreover, the
numbers of ``natural'' single bills and ``pseudo'' single bills were
reduced by the volume of services that we proposed to package. Hence,
our CY 2008 proposal to package payment for some HCPCS codes with
relatively high frequencies would eliminate for ratesetting the number
of available ``natural'' and ``pseudo'' single bills attributable to
the codes that we proposed to package.
As in prior years, we proposed to use the following empirical
criteria to determine the additional codes to add to the CY 2007 bypass
list to create the CY 2008 bypass list. We assumed that the
representation of packaging in the single claims for any given code was
comparable to packaging for that code in the multiple claims:
There are 100 or more single claims for the code. This
number of single claims ensures that observed outcomes are sufficiently
representative of packaging that might occur in the multiple claims.
Five percent or fewer of the single claims for the code
have packaged costs on that single claim for the code. This criterion
results in limiting the amount of packaging being redistributed to the
separately payable procedure remaining on the claim after the bypass
code is removed and ensures that the costs associated with the bypass
code represent the cost of the bypassed service.
The median cost of packaging observed in the single claims
is equal to or less than $50. This limits the amount of error in
redistributed costs.
The code is not a code for an unlisted service.
In addition, we proposed to add to the bypass list codes that our
clinicians believe have minimal associated packaging based on their
clinical assessment of the complete CY 2008 OPPS proposal. As proposed,
this list contained bypass codes that were appropriate to claims for
services in CY 2006 and, therefore, included codes that were deleted
for CY 2007. Moreover, there were codes on the proposed bypass list
that were new for CY 2007 and which were appropriate additions to the
bypass list in preparation for use of the CY 2007 claims for creation
of the CY 2009 OPPS.
We received a number of public comments on the use of the bypass
list for creation of ``pseudo'' single procedure claims. A summary of
the comments and our responses follow.
Comment: Some commenters objected to the removal of HCPCS codes
from the bypass list because the codes ceased to meet the criteria for
the bypass list as a result of increased packaging in the ``natural''
single claims due to the proposed packaging approach. The commenters
objected to the removal of codes from the bypass list for this reason
because they asserted that it caused claims that would otherwise have
become ``pseudo'' single claims to not be used and, thereby, reduced
the number of single bills that were available for ratesetting for
certain services.
Response: We agree with the commenters, so we have reevaluated the
bypass list for this final rule with comment period and restored a
number of codes on the bypass list prior to the CY 2008 proposal to
maximize the creation of single and ``pseudo'' single procedure bills.
As we discuss later in this section and in section II.A.4. of this
final rule with comment period, we have made changes to the data
process to ensure that we capture as much data as possible for services
assigned status indicator ``Q.'' Although we revised the process to
apply the specific ``Q'' status indicator policies before assessment of
the bypass list so that additional HCPCS codes could be considered for
the bypass list without risk of losing their data regarding packaging,
we determined that no codes with status indicator ``Q'' were
appropriate for addition to the final CY 2008 bypass list because of
their significant associated packaging.
Comment: Several commenters asked that CMS add certain HCPCS codes
to the bypass list so that more single bills would be available for
median setting. Some commenters specifically objected to the removal of
the following radiation oncology services that they indicated should
seldom have any associated packaging: CPT codes 77280 (Therapeutic
radiology simulation-aided field setting; simple); 77285 (Therapeutic
radiology simulation-aided field setting; intermediate); 77290
(Therapeutic radiology simulation-aided field setting; complex); 77295
(Therapeutic radiology simulation-aided field setting; 3-dimensional);
77332 (Treatment devices, design and construction; simple (simple
block, simple bolus)); 77333 (Treatment devices, design and
construction; intermediate (multiple blocks, stents, bite blocks,
special bolus)); 77334 (Treatment devices, design and construction;
complex (irregular blocks, special shields, compensators, wedges, molds
or casts)); and 77417 (Therapeutic radiology port film(s)). One
commenter explained that there was an interaction with the packaging of
image guided radiation therapy codes that reduced the percentage of
single bills for high dose rate (HDR) brachytherapy from 62 percent to
48 percent of the total frequency. The commenter believed that the
payment for APC 0313 (Brachytherapy) dropped from $789.70 in CY 2007 to
$739.46 in the CY 2008 proposed rule because there were packaged costs
on claims that could no longer be used because the multiple procedure
claims included codes that were removed from the bypass list. The
commenter asked that these codes be restored to the bypass list so that
these claims could be used. Other commenters asked that CMS place CPT
code 93017 (Cardiovascular stress test using maximal or submaximal
treadmill or bicycle exercise, continuous electrocardiographic
monitoring, and/or pharmacological stress; tracing only, without
interpretation and report) on the bypass list because it is typically
performed with single photon emission computed tomography (SPECT)
procedures (CPT code 78465 (Myocardial perfusion imaging; tomographic
(SPECT), multiple studies (including attenuation correction when
performed), at rest and/or stress (exercise and/or pharmacologic) and
redistribution and/or rest injection, without or without
quantification)). These commenters believed that significant data from
multiple procedure claims were lost because CPT code 93017 was not
bypassed. Other commenters asked that CMS add the following drug
administration CPT codes to the bypass list because doing so would
enable use of more multiple procedure claims data to establish median
costs for drug administration services: CPT codes 90767 (Intravenous
infusion, for therapy, prophylaxis, or diagnosis (specify substance or
drug); additional sequential infusion, up to 1 hour (List separately in
addition to code for primary procedure)); 90768 (Intravenous infusion,
for therapy, prophylaxis, or diagnosis (specify substance or drug);
concurrent infusion (List separately in addition to code for primary
procedure); 90775 (Therapeutic, prophylactic or diagnostic injection
(specify substance or drug); each additional sequential intravenous
push of a new substance/drug (List separately in addition to code for
primary procedure)); 96411 (Chemotherapy administration; intravenous,
push technique, each additional substance/drug (List separately in
addition to code for primary procedure)); and 96417 (Chemotherapy
administration, intravenous infusion technique; each additional
sequential infusion (different substance/drug), up to 1 hour (List
[[Page 66592]]
separately in addition to code for primary procedure)). A commenter
asked that we add HCPCS code 88307 (Level V Surgical pathology, gross
and microscopic examination) because it is so similar to HCPCS codes
88305 (Level III Surgical pathology, gross and microscopic examination)
and 88306 (Level IV Surgical pathology, gross and microscopic
examination) that were already included on the bypass list.
Response: We have reviewed the requests to add these codes to the
bypass list and we have made the following decisions for CY 2008 for
the reasons stated below:
We have added the radiation oncology services listed above, with
the exception of CPT code 77417, to the bypass list because we agree
that they are of the type that should not have packaging associated
with them. We recognize that including them on the bypass list may
yield significantly more single procedure bills and may also increase
the number of claims that we can use for calculation of the low dose
rate prostate brachytherapy composite APC (APC8001). We have not added
CPT code 77417 to the CY 2008 bypass list because, based on its final
CY 2008 unconditionally packaged status, the code would not be a
candidate for the bypass list. Unconditionally packaged codes are not
included on the bypass list because their presence on a claim does not
make that claim a multiple procedure bill.
We have added CPT code 93017 to the bypass list because we agree
that it should not have significant associated packaging, and we
recognize that including it on the bypass list may yield significantly
more single procedure bills for median setting.
We have not added the drug administration services listed above to
the bypass list. Four of these five codes are for sequential drug
infusion services or injections of additional drugs and, therefore, by
definition, new drugs and medical supplies that are associated with
these codes should be reported in all cases in which the services are
furnished. We note that, beginning in CY 2007, we placed the CPT codes
for additional hours of infusion on the bypass list, recognizing that
all packaging related to these hours would be associated with the
initial services on the claim. We proposed and finalized this approach
for CY 2007, because we were unable to accurately assign representative
portions of packaged costs to multiple different drug administration
services. We expected that the packaging related to additional hours of
infusion of drugs that spanned several hours would be appropriately
assigned to the code for the first hour of infusion on the same claim.
If we had not placed the codes for additional hours of infusion on the
bypass list, we would have had a substantial set of drug administration
multiple procedure claims that were unusable for ratesetting purposes.
However, adding the sequential drug administration services to the
bypass list too would force all of the costs of the associated
additional drugs and supplies to be packaged into the payment for the
initial drug administration service for another drug, which we do not
believe is an appropriate allocation of packaging. While we understand
the concerns of the commenters regarding the challenges associated with
setting appropriate payment rates for these sequential services
reported on multiple procedure claims, we have very little CY 2006
claims data for the four codes because they were not recognized for
payment under the CY 2006 OPPS. We will reconsider the treatment of
these CPT codes for the CY 2009 OPPS update when CY 2007 data, where
these codes were separately paid under the OPPS, are available. We have
not added CPT code 90768 to the bypass list because our final CY 2008
policy unconditionally packages payment for this service and,
therefore, it is not a candidate for the bypass list.
We agree that HCPCS code 88307 (which was on the proposed bypass
list for the CY 2008 OPPS) is appropriate and we have added it to the
final CY 2008 bypass list.
In addition to these responses to comments, we have added six other
HCPCS codes to the final CY 2008 bypass list that met the empirical
criteria for inclusion using the final rule data, and we have also
added three HCPCS codes for clinical consistency with codes that are
already on the bypass list. New bypass codes for this final rule with
comment period are identified in Table 1 with an asterisk.
Comment: One commenter objected to the use of the bypass list to
create ``pseudo'' single claims for median setting on the basis that it
artificially lowers the median cost of the services on the bypass list
by sending all packaging on the claim to the other major separately
paid service on the claim. Specifically, the commenter believed that
inclusion of CPT code 93880 (Duplex scan of extracranial arteries;
complete bilateral study) on the bypass list resulted in the use of the
cost data for the lowest cost services and, thereby, lowered the cost
of this service. The commenter stated that CMS should work with
stakeholders on use of the bypass list, its impact on median costs, and
ways that CMS could use data that were more reflective of the real
costs for these procedures. The commenter believed that the median cost
of CPT code 93880 should be based on the cost of the typical patient
and not the least expensive patient because the OPPS payment caps
payment in the physician's office for the service. The commenter
explained that using the bypass list to generate more ``pseudo'' single
claims without any packaging resulted in stagnation in payment that
encouraged hospitals to pressure physicians to order more expensive
tests and threatened access to care for beneficiaries who would be
served well by simpler tests that were being underpaid as a result of
inclusion of CPT code 93880 on the bypass list.
One commenter asked that CMS provide a code-specific analysis of
the impact of bypassing each code on the bypass list because the
commenter believed that removing and using the line item costs for the
bypass codes to set the median costs for the APCs to which the bypass
codes are assigned results in understatement of the median costs for
those APCs.
Response: The bypass list has been very effective in enabling us to
use claims data that would not otherwise be available for median
calculation. Since its origin for the CY 2004 OPPS, we have been very
careful in determining the codes to be placed on the bypass list. As
described above, we use a standard set of criteria to select claims
that seldom have packaging (that is, fewer than 5 percent of
``natural'' single bills); that have little packaging (that is, less
than $50); for which we have at least 100 ``natural'' single bills; and
that are not unlisted codes (for which there is no specified service).
In addition to codes that pass these criteria, we also have added HCPCS
codes to the bypass list that have been recommended to us by members of
the public, including the specialty societies that are most familiar
with them, as services with which packaging should be seldom, if ever,
associated. Therefore, we believe that we have been very prudent with
regard to our selection of the codes to be added to the bypass list and
with our use of the list. Moreover, we open the criteria and the list
to public comment each year and we respond to comments in the final
rule for the update year.
We also make available the claims data used to calculate the median
costs on which the relative weights are based, and we provide an
extensive narrative description of our data process. Hence, we provide
commenters with the tools to conduct any further analyses they chose
with regard to the codes on the
[[Page 66593]]
bypass list or otherwise. In the case of CPT code 93880, the median
packaged cost on ``natural'' single procedure claims (of which there
were 403,106) was $0 and the percent of natural single procedure claims
on which there was any packaging was 0.47 percent (1,899 claims out of
403,106 ). Therefore, the code meets the criteria for inclusion on the
bypass list and will remain on it for CY 2008. We have no evidence that
physicians or hospitals are billing more expensive tests as a result of
the OPPS payment rate for CPT code 93880, and our data show there is
very little packaging associated with the service in the typical case.
In order to keep the established empirical criteria for the bypass
list constant, we specifically solicited public comment on whether we
should adjust the $50 packaging cost criterion for inflation each year
and, if so, recommendations for the source of the adjustment. We
believed that adding an inflation adjustment factor would ensure that
the same amount of packaging associated with candidate codes for the
bypass list was reviewed each year relative to nominal costs.
We received one public comment on the appropriateness of updating
the $50 packaging cost criteria for inclusion of a code on the bypass
list to account for annual inflation. A summary of the comment and our
response follow.
Comment: One commenter stated that CMS should update the $50
maximum ``natural'' single bill median packaging cost criterion for
including HCPCS codes on the bypass list on the basis of empirical
criteria. The commenter did not suggest a methodology we might use for
the update.
Response: We have not changed the $50 maximum ``natural'' bill
median packaging cost criterion for this final rule with comment
period. However, we will consider whether to update the criterion and,
if so, what methodology would be used, as part of the development of
the proposals for the CY 2009 OPPS.
After consideration of the public comments received, we are
adopting, as final, the proposed ``pseudo'' single claims process and
the CY 2008 bypass codes listed in Table 1 below. This list has been
modified from the CY 2008 proposed list, with the addition of HCPCS
codes that meet the empirical criteria based on updated claims data and
certain HCPCS codes recommended by commenters, as discussed above. As
stated earlier, the new bypass codes for this final rule with comment
period are identified in Table 1 with an asterisk.
Table 1.--CY 2008 Final Bypass Codes for Creating ``Pseudo'' Single
Claims for Calculating Median Costs
------------------------------------------------------------------------
Added for
HCPCS code Short description this final
rule
------------------------------------------------------------------------
11056...................... Trim skin lesions, 2 to 4....
11057...................... Trim skin lesions, over 4....
11300...................... Shave skin lesion............
11301...................... Shave skin lesion............
11719...................... Trim nail(s).................
11720...................... Debride nail, 1-5............
11721...................... Debride nail, 6 or more......
11954...................... Therapy for contour defects..
17003...................... Destruct premalg les, 2-14...
31231...................... Nasal endoscopy, dx..........
31579...................... Diagnostic laryngoscopy......
51798...................... Us urine capacity measure....
53661...................... Dilation of urethra.......... *
54240...................... Penis study..................
56820...................... Exam of vulva w/scope........
57150...................... Treat vagina infection....... *
67820...................... Revise eyelashes.............
69210...................... Remove impacted ear wax......
69220...................... Clean out mastoid cavity.....
70030...................... X-ray eye for foreign body...
70100...................... X-ray exam of jaw............
70110...................... X-ray exam of jaw............
70120...................... X-ray exam of mastoids.......
70130...................... X-ray exam of mastoids.......
70140...................... X-ray exam of facial bones...
70150...................... X-ray exam of facial bones...
70160...................... X-ray exam of nasal bones....
70200...................... X-ray exam of eye sockets....
70210...................... X-ray exam of sinuses........
70220...................... X-ray exam of sinuses........
70250...................... X-ray exam of skull..........
70260...................... X-ray exam of skull..........
70328...................... X-ray exam of jaw joint......
70330...................... X-ray exam of jaw joints.....
70336...................... Magnetic image, jaw joint....
70355...................... Panoramic x-ray of jaws......
70360...................... X-ray exam of neck...........
70370...................... Throat x-ray & fluoroscopy...
70371...................... Speech evaluation, complex...
70450...................... Ct head/brain w/o dye........
70480...................... Ct orbit/ear/fossa w/o dye...
70486...................... Ct maxillofacial w/o dye.....
70490...................... Ct soft tissue neck w/o dye..
70544...................... Mr angiography head w/o dye..
70551...................... Mri brain w/o dye............
71010...................... Chest x-ray..................
71015...................... Chest x-ray..................
71020...................... Chest x-ray..................
71021...................... Chest x-ray..................
71022...................... Chest x-ray..................
71023...................... Chest x-ray and fluoroscopy..
71030...................... Chest x-ray..................
71034...................... Chest x-ray and fluoroscopy..
71035...................... Chest x-ray..................
71100...................... X-ray exam of ribs...........
71101...................... X-ray exam of ribs/chest.....
71110...................... X-ray exam of ribs...........
71111...................... X-ray exam of ribs/chest.....
71120...................... X-ray exam of breastbone.....
71130...................... X-ray exam of breastbone.....
71250...................... Ct thorax w/o dye............
72010...................... X-ray exam of spine..........
72020...................... X-ray exam of spine..........
72040...................... X-ray exam of neck spine.....
72050...................... X-ray exam of neck spine.....
72052...................... X-ray exam of neck spine.....
72069...................... X-ray exam of trunk spine....
72070...................... X-ray exam of thoracic spine.
72072...................... X-ray exam of thoracic spine.
72074...................... X-ray exam of thoracic spine.
72080...................... X-ray exam of trunk spine....
72090...................... X-ray exam of trunk spine....
72100...................... X-ray exam of lower spine....
72110...................... X-ray exam of lower spine....
72114...................... X-ray exam of lower spine....
72120...................... X-ray exam of lower spine....
[[Page 66594]]
72125...................... Ct neck spine w/o dye........
72128...................... Ct chest spine w/o dye.......
72131...................... Ct lumbar spine w/o dye......
72141...................... Mri neck spine w/o dye.......
72146...................... Mri chest spine w/o dye......
72148...................... Mri lumbar spine w/o dye.....
72170...................... X-ray exam of pelvis.........
72190...................... X-ray exam of pelvis.........
72192...................... Ct pelvis w/o dye............
72202...................... X-ray exam sacroiliac joints.
72220...................... X-ray exam of tailbone.......
73000...................... X-ray exam of collar bone....
73010...................... X-ray exam of shoulder blade.
73020...................... X-ray exam of shoulder.......
73030...................... X-ray exam of shoulder.......
73050...................... X-ray exam of shoulders......
73060...................... X-ray exam of humerus........
73070...................... X-ray exam of elbow..........
73080...................... X-ray exam of elbow..........
73090...................... X-ray exam of forearm........
73100...................... X-ray exam of wrist..........
73110...................... X-ray exam of wrist..........
73120...................... X-ray exam of hand...........
73130...................... X-ray exam of hand...........
73140...................... X-ray exam of finger(s)......
73200...................... Ct upper extremity w/o dye...
73218...................... Mri upper extremity w/o dye..
73221...................... Mri joint upr extrem w/o dye.
73510...................... X-ray exam of hip............
73520...................... X-ray exam of hips...........
73540...................... X-ray exam of pelvis & hips..
73550...................... X-ray exam of thigh..........
73560...................... X-ray exam of knee, 1 or 2...
73562...................... X-ray exam of knee, 3........
73564...................... X-ray exam, knee, 4 or more..
73565...................... X-ray exam of knees..........
73590...................... X-ray exam of lower leg......
73600...................... X-ray exam of ankle..........
73610...................... X-ray exam of ankle..........
73620...................... X-ray exam of foot...........
73630...................... X-ray exam of foot...........
73650...................... X-ray exam of heel...........
73660...................... X-ray exam of toe(s).........
73700...................... Ct lower extremity w/o dye...
73718...................... Mri lower extremity w/o dye..
73721...................... Mri jnt of lwr extre w/o dye.
74000...................... X-ray exam of abdomen........
74010...................... X-ray exam of abdomen........
74020...................... X-ray exam of abdomen........
74022...................... X-ray exam series, abdomen...
74150...................... Ct abdomen w/o dye...........
74210...................... Contrast x-ray exam of throat
74220...................... Contrast x-ray, esophagus....
74230...................... Cine/vid x-ray, throat/esoph.
74246...................... Contrast x-ray uppr gi tract.
74247...................... Contrst x-ray uppr gi tract..
74249...................... Contrst x-ray uppr gi tract..
76020...................... X-rays for bone age..........
76040...................... X-rays, bone evaluation......
76061...................... X-rays, bone survey..........
76062...................... X-rays, bone survey..........
76065...................... X-rays, bone evaluation......
76066...................... Joint survey, single view....
76070...................... Ct bone density, axial.......
76071...................... Ct bone density, peripheral..
76075...................... Dxa bone density, axial......
76076...................... Dxa bone density/peripheral..
76077...................... Dxa bone density/v-fracture..
76078...................... Radiographic absorptiometry..
76100...................... X-ray exam of body section...
76400...................... Magnetic image, bone marrow..
76510...................... Ophth us, b & quant a........
76511...................... Ophth us, quant a only.......
76512...................... Ophth us, b w/non-quant a....
76513...................... Echo exam of eye, water bath.
76514...................... Echo exam of eye, thickness..
76516...................... Echo exam of eye.............
76519...................... Echo exam of eye.............
76536...................... Us exam of head and neck.....
76645...................... Us exam, breast(s)...........
76700...................... Us exam, abdom, complete.....
76705...................... Echo exam of abdomen.........
76770...................... Us exam abdo back wall, comp.
76775...................... Us exam abdo back wall, lim..
76778...................... Us exam kidney transplant....
76801...................... Ob us < 14 wks, single fetus.
76805...................... Ob us >/= 14 wks, sngl fetus.
76811...................... Ob us, detailed, sngl fetus..
76816...................... Ob us, follow-up, per fetus..
76817...................... Transvaginal us, obstetric...
76830...................... Transvaginal us, non-ob......
76856...................... Us exam, pelvic, complete....
76857...................... Us exam, pelvic, limited.....
76870...................... Us exam, scrotum.............
76880...................... Us exam, extremity...........
76970...................... Ultrasound exam follow-up....
76977...................... Us bone density measure......
76999...................... Echo examination procedure...
77280...................... Set radiation therapy field.. *
77285...................... Set radiation therapy field.. *
77290...................... Set radiation therapy field.. *
77295...................... Set radiation therapy field.. *
77300...................... Radiation therapy dose plan..
[[Page 66595]]
77301...................... Radiotherapy dose plan, imrt.
77315...................... Teletx isodose plan complex..
77326...................... Brachytx isodose calc simp...
77327...................... Brachytx isodose calc interm.
77328...................... Brachytx isodose plan compl..
77331...................... Special radiation dosimetry..
77332...................... Radiation treatment aid(s)... *
77333...................... Radiation treatment aid(s)... *
77334...................... Radiation treatment aid(s)... *
77336...................... Radiation physics consult....
77370...................... Radiation physics consult....
77401...................... Radiation treatment delivery.
77402...................... Radiation treatment delivery.
77403...................... Radiation treatment delivery.
77404...................... Radiation treatment delivery.
77407...................... Radiation treatment delivery.
77408...................... Radiation treatment delivery.
77409...................... Radiation treatment delivery.
77411...................... Radiation treatment delivery.
77412...................... Radiation treatment delivery.
77413...................... Radiation treatment delivery.
77414...................... Radiation treatment delivery.
77416...................... Radiation treatment delivery.
77418...................... Radiation tx delivery, imrt..
77470...................... Special radiation treatment..
77520...................... Proton trmt, simple w/o comp.
77523...................... Proton trmt, intermediate....
80500...................... Lab pathology consultation...
80502...................... Lab pathology consultation...
85097...................... Bone marrow interpretation...
86510...................... Histoplasmosis skin test.....
86850...................... RBC antibody screen..........
86870...................... RBC antibody identification..
86880...................... Coombs test, direct..........
86885...................... Coombs test, indirect, qual..
86886...................... Coombs test, indirect, titer.
86890...................... Autologous blood process.....
86900...................... Blood typing, ABO............
86901...................... Blood typing, Rh (D).........
86903...................... Blood typing, antigen screen.
86904...................... Blood typing, patient serum..
86905...................... Blood typing, RBC antigens...
86906...................... Blood typing, Rh phenotype...
86930...................... Frozen blood prep............
86970...................... RBC pretreatment.............
88104...................... Cytopath fl nongyn, smears...
88106...................... Cytopath fl nongyn, filter...
88107...................... Cytopath fl nongyn, sm/fltr..
88108...................... Cytopath, concentrate tech...
88112...................... Cytopath, cell enhance tech..
88160...................... Cytopath smear, other source.
88161...................... Cytopath smear, other source.
88162...................... Cytopath smear, other source.
88172...................... Cytopathology eval of fna....
88173...................... Cytopath eval, fna, report...
88182...................... Cell marker study............
88184...................... Flowcytometry/ tc, 1 marker..
88185...................... Flowcytometry/tc, add-on.....
88300...................... Surgical path, gross.........
88302...................... Tissue exam by pathologist...
88304...................... Tissue exam by pathologist...
88305...................... Tissue exam by pathologist...
88307...................... Tissue exam by pathologist...
88311...................... Decalcify tissue.............
88312...................... Special stains...............
88313...................... Special stains...............
88321...................... Microslide consultation......
88323...................... Microslide consultation......
88325...................... Comprehensive review of data.
88331...................... Path consult intraop, 1 bloc.
88342...................... Immunohistochemistry.........
88346...................... Immunofluorescent study......
88347...................... Immunofluorescent study......
88348...................... Electron microscopy..........
88358...................... Analysis, tumor..............
88360...................... Tumor immunohistochem/manual.
88361...................... Tumor immunohistochem/comput. *
88365...................... Insitu hybridization (fish)..
88368...................... Insitu hybridization, manual.
88399...................... Surgical pathology procedure.
89049...................... Chct for mal hyperthermia....
89230...................... Collect sweat for test.......
89240...................... Pathology lab procedure......
90761...................... Hydrate iv infusion, add-on..
90761...................... Hydrate iv infusion, add-on.. *
90766...................... Ther/proph/dg iv inf, add-on. *
90801...................... Psy dx interview.............
90802...................... Intac psy dx interview.......
90804...................... Psytx, office, 20-30 min.....
90805...................... Psytx, off, 20-30 min w/e&m..
90806...................... Psytx, off, 45-50 min........
90807...................... Psytx, off, 45-50 min w/e&m..
90808...................... Psytx, office, 75-80 min.....
90809...................... Psytx, off, 75-80, w/e&m.....
90810...................... Intac psytx, off, 20-30 min..
90812...................... Intac psytx, off, 45-50 min..
90816...................... Psytx, hosp, 20-30 min.......
90818...................... Psytx, hosp, 45-50 min.......
90826...................... Intac psytx, hosp, 45-50 min. *
90845...................... Psychoanalysis...............
90846...................... Family psytx w/o patient.....
90847...................... Family psytx w/patient.......
[[Page 66596]]
90853...................... Group psychotherapy..........
90857...................... Intac group psytx............
90862...................... Medication management........
92002...................... Eye exam, new patient........
92004...................... Eye exam, new patient........
92012...................... Eye exam established pat.....
92014...................... Eye exam & treatment.........
92020...................... Special eye evaluation.......
92081...................... Visual field examination(s)..
92082...................... Visual field examination(s)..
92083...................... Visual field examination(s)..
92135...................... Ophth dx imaging post seg....
92136...................... Ophthalmic biometry..........
92225...................... Special eye exam, initial....
92226...................... Special eye exam, subsequent.
92230...................... Eye exam with photos.........
92240...................... Icg angiography..............
92250...................... Eye exam with photos.........
92275...................... Electroretinography..........
92285...................... Eye photography..............
92286...................... Internal eye photography.....
92520...................... Laryngeal function studies...
92541...................... Spontaneous nystagmus test...
92546...................... Sinusoidal rotational test...
92548...................... Posturography................
92552...................... Pure tone audiometry, air....
92553...................... Audiometry, air & bone.......
92555...................... Speech threshold audiometry..
92556...................... Speech audiometry, complete..
92557...................... Comprehensive hearing test...
92567...................... Tympanometry.................
92582...................... Conditioning play audiometry.
92585...................... Auditor evoke potent, compre.
92603...................... Cochlear implt f/up exam 7 >.
92604...................... Reprogram cochlear implt 7 >.
92626...................... Eval aud rehab status........
93005...................... Electrocardiogram, tracing...
93017...................... Cardiovascular stress test... *
93225...................... ECG monitor/record, 24 hrs...
93226...................... ECG monitor/report, 24 hrs...
93231...................... Ecg monitor/record, 24 hrs...
93232...................... ECG monitor/report, 24 hrs...
93236...................... ECG monitor/report, 24 hrs...
93270...................... ECG recording................
93271...................... Ecg/monitoring and analysis..
93278...................... ECG/signal-averaged..........
93727...................... Analyze ilr system...........
93731...................... Analyze pacemaker system.....
93732...................... Analyze pacemaker system.....
93733...................... Telephone analy, pacemaker...
93734...................... Analyze pacemaker system.....
93735...................... Analyze pacemaker system.....
93736...................... Telephonic analy, pacemaker..
93741...................... Analyze ht pace device sngl..
93742...................... Analyze ht pace device sngl..
93743...................... Analyze ht pace device dual..
93744...................... Analyze ht pace device dual..
93786...................... Ambulatory BP recording......
93788...................... Ambulatory BP analysis.......
93797...................... Cardiac rehab................
93798...................... Cardiac rehab/monitor........
93875...................... Extracranial study...........
93880...................... Extracranial study...........
93882...................... Extracranial study...........
93886...................... Intracranial study...........
93888...................... Intracranial study...........
93922...................... Extremity study..............
93923...................... Extremity study..............
93924...................... Extremity study..............
93925...................... Lower extremity study........
93926...................... Lower extremity study........
93930...................... Upper extremity study........
93931...................... Upper extremity study........
93965...................... Extremity study..............
93970...................... Extremity study..............
93971...................... Extremity study..............
93975...................... Vascular study...............
93976...................... Vascular study...............
93978...................... Vascular study...............
93979...................... Vascular study...............
93990...................... Doppler flow testing.........
94015...................... Patient recorded spirometry..
94690...................... Exhaled air analysis.........
95115...................... Immunotherapy, one injection.
95117...................... Immunotherapy injections.....
95165...................... Antigen therapy services.....
95250...................... Glucose monitoring, cont..... *
95805...................... Multiple sleep latency test..
95806...................... Sleep study, unattended......
95807...................... Sleep study, attended........
95808...................... Polysomnography, 1-3.........
95812...................... Eeg, 41-60 minutes...........
95813...................... Eeg, over 1 hour.............
95816...................... Eeg, awake and drowsy........
95819...................... Eeg, awake and asleep........
95822...................... Eeg, coma or sleep only......
95869...................... Muscle test, thor paraspinal.
95872...................... Muscle test, one fiber....... *
95900...................... Motor nerve conduction test..
95921...................... Autonomic nerv function test.
95925...................... Somatosensory testing........
95926...................... Somatosensory testing........ *
95930...................... Visual evoked potential test.
95950...................... Ambulatory eeg monitoring....
95953...................... EEG monitoring/computer......
95970...................... Analyze neurostim, no prog...
95972...................... Analyze neurostim, complex...
95974...................... Cranial neurostim, complex...
95978...................... Analyze neurostim brain/1h...
96000...................... Motion analysis, video/3d....
96101...................... Psycho testing by psych/phys.
[[Page 66597]]
96111...................... Developmental test, extend...
96116...................... Neurobehavioral status exam..
96118...................... Neuropsych tst by psych/phys.
96119...................... Neuropsych testing by tec....
96150...................... Assess hlth/behave, init.....
96151...................... Assess hlth/behave, subseq...
96152...................... Intervene hlth/behave, indiv.
96153...................... Intervene hlth/behave, group.
96415...................... Chemo, iv infusion, addl hr..
96423...................... Chemo ia infuse each addl hr.
96900...................... Ultraviolet light therapy....
96910...................... Photochemotherapy with UV-B..
96912...................... Photochemotherapy with UV-A..
96913...................... Photochemotherapy, UV-A or B.
96920...................... Laser tx, skin < 250 sq cm...
98925...................... Osteopathic manipulation.....
98926...................... Osteopathic manipulation.....
98927...................... Osteopathic manipulation.....
98940...................... Chiropractic manipulation....
98941...................... Chiropractic manipulation....
98942...................... Chiropractic manipulation....
99204...................... Office/outpatient visit, new.
99212...................... Office/outpatient visit, est.
99213...................... Office/outpatient visit, est.
99214...................... Office/outpatient visit, est.
99241...................... Office consultation..........
99242...................... Office consultation..........
99243...................... Office consultation..........
99244...................... Office consultation..........
99245...................... Office consultation..........
0144T...................... CT heart wo dye; qual calc...
C8951...................... IV inf, tx/dx, each addl hr..
C8955...................... Chemotx adm, IV inf, addl hr.
G0008...................... Admin influenza virus vac....
G0101...................... CA screen; pelvic/breast exam
G0127...................... Trim nail(s).................
G0130...................... Single energy x-ray study....
G0166...................... Extrnl counterpulse, per tx..
G0175...................... OPPS Service,sched team conf.
G0332...................... Preadmin IV immunoglobulin...
G0340...................... Robt lin-radsurg fractx 2-5..
G0344...................... Initial preventive exam......
G0365...................... Vessel mapping hemo access...
G0367...................... EKG tracing for initial prev.
G0376...................... Smoke/tobacco counseling >10.
M0064...................... Visit for drug monitoring....
Q0091...................... Obtaining screen pap smear...
------------------------------------------------------------------------
(2) Exploration of Allocation of Packaged Costs to Separately Paid
Procedure Codes
During its August 23-24, 2006 meeting, the APC Panel recommended
that CMS provide claims analysis of the contributions of packaged costs
(including packaged revenue code charges and charges for packaged HCPCS
codes) to the median cost of each drug administration service. (We
refer readers to Recommendation 28 in the August 23-24, 2006
meeting recommendation summary on the CMS Web site at: http://www.cms.hhs.gov/FACA/05_AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp#TopOfPage.
) In
our continued effort to better understand the multiple claims in order
to extract single bill information from them, we examined the extent to
which the packaging in multiple procedure claims differs from the
packaging in the single procedure claims on which we base the median
costs both in general and more specifically for drug administration
services. We performed this analysis using the claims data on which we
based the CY 2007 OPPS/ASC final rule with comment period. We examined
the amount of packaging in multiple procedure versus single procedure
claims in general and in claims for drug administration services in
particular. We conducted this analysis without taking into account the
proposed packaging approach presented in the CY 2008 OPPS/ASC proposed
rule. However, we did not expect the services newly proposed for
packaged payment to commonly appear with a drug administration service.
Therefore, we believed that the analysis conducted on the CY 2007 final
rule with comment period data was sufficient to inform our development
of the CY 2008 OPPS/ASC proposed rule.
In general, we did not believe that the proportionate amount of
packaged costs in the multiple bills relative to the number of primary
services would be greater than that in the single bills. Our findings
supported our hypothesis. The costs in uncoded revenue codes and HCPCS
codes with a packaged status indicator accounted for 22 percent of
observed costs in the universe of all CY 2005 claims that we used to
model the CY 2007 OPPS (including both the single and multiple
procedure bills). Similarly, the costs in uncoded revenue codes and
HCPCS codes with a packaged status indicator accounted for 18 percent
of the total cost in the subset of CY 2005 single bills that we used to
calculate the median costs on which the relative weights were based.
However, the bypass methodology creates a ``pseudo'' single bill
for all claims for services or items on the bypass list, and these
``pseudo'' single bills have no associated packaging, by definition of
the application of the bypass list. Excluding the total cost associated
with bypass codes, 28 percent of observed costs in the single bills
were attributable to packaged services, and 29 percent of obs