On July 3, 2008, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that will update payment rates paid under both the Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) Payment System for calendar year (CY) 2009. The ruling is available for download from CMS’ web site (PDF, 3.6M) while publication is pending in the Federal Register.

CMS will accept comments on the proposed rule until September 2, 2008 and will respond to those comments in a final rule to be issued by November 1, 2008. The revised policies and payment rates will be applicable to services furnished on or after January 1, 2009.

Highlights of the Proposed Rule

• CMS projects that proposed CY 2009 payment rates under the OPPS will result in a 3.2% increase in Medicare payment for providers paid under the OPPS. Outpatient hospital departments are projected to receive $28.7 billion in payments for services furnished to Medicare beneficiaries. CMS also expects to make payments of almost $3.9 billion for services performed in an ASC.
• The update to ASC rates constitutes the second year of a four-year transition to align payment rates with those paid to hospital outpatient departments and minimize the impact of financial incentives on decisions about treatment settings.

For OPPS, CMS is proposing to:

• Continue using the composite APC (8000) methodology to reimburse for electrophysiologic evaluation and ablation services, as established for CY 2008 at a rate of $9,190.24, which is an increase compared to the CY 2008 payment of $8,542.57
• Maintain the unconditionally packaged status for CPT code 93662 (ICE), despite the APC Panel’s recommendation to reinstate separate payment for this service.
• Refine the definitions of new and established patients as they relate to reporting hospital outpatient visits to enable more accurate cost estimates for APCs 0604 through 0608.
• Continue reducing OPPS payment by 100 percent of the device offset amount when a hospital furnishes pacemakers and ICDs without cost or with a full credit, and by 50 percent of the device offset amount when the hospital receives partial credit in the amount of 50 percent or more of the cost for the device.
• Create three new status indicators (Q1 for STVX-Packaged Codes, Q2 for T-Packaged Codes, or Q3 for Codes that may be paid through a composite APC) to further refine the different types of conditionally packaged procedure codes that were previously assigned status indicator “Q” (Packaged Services Subject to Separate Payment under OPPS Payment Criteria).
• Establish five imaging composite APCs (ultrasound, CT/CTA without contrast, CT/CTA with contrast, MRI/MRA without contrast and MRI/MRA with contrast) based on the families of codes used in the Medicare Physician Fee Schedule for multiple imaging procedure payment reductions.
  

For ASC, CMS is proposing to:

• Update the payment amounts for device-intensive procedures (33206, 33207, 33208, 33212, 33213, 33214, 33224, 33225, 33240, 33249 and 33282) based on the CY 2009 OPPS proposal for device-dependent procedures.
• Adopt the OPPS policy for reduced payment to providers when a device is furnished without cost or with full credit for the cost of the device.

Heart rhythm management APCs, status indicators and payment rates will be published at a later date.