CMS-1414-FC

Medicare Program:  Changes to the Hospital Outpatient Prospective Payment System and CY 2010 Payment Rates; Changes to the Ambulatory Surgical Center Payment System and CY 2010 Payment Rates

Summary:  This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system.  In this final rule with comment period, 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, 2010.

In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system.  In this final rule with comment period, we set forth the applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these changes will apply, and other pertinent ratesetting information for the CY 2010 ASC payment system.  These changes are applicable to services furnished on or after January 1, 2010.

The final rule (CMS-1414-FC) is available in the "Related Links Outside CMS" below.  These data files are located in the "Downloads" section below:

Addendum AA - a list of covered surgical procedures under the revised ASC payment system, including Category I and Category III CPT and Level II HCPCS codes.  Included are surgical procedures that receive packaged payment through the payment for covered surgical procedures, as well as those that are paid separately. Payment indicators (defined in Addendum DD1) designate each procedure's payment status.

Addendum BB - a list of radiology services and other covered ancillary services eligible for ASC payment under the revised ASC payment system when provided integral to an ASC covered surgical procedure. Included are ancillary services that receive packaged payment through the payment for covered surgical procedures, as well as those that are paid separately. Payment indicators (defined in Addendum DD1) designate each service's payment status.

Addendum DD1 - a list of ASC payment indicators used in Addenda AA and BB to provide payment information regarding covered surgical procedures and covered ancillary services, respectively, under the revised ASC payment system. The payment indicators represent policy-relevant characteristics of HCPCS codes related to their payment status in ASCs; for example, whether a code is designated as packaged, office-based, or device-intensive.

Addendum DD2 - a list of ASC comment indicators.

Addendum EE - a list of surgical procedures excluded from Medicare payment in ASCs. The surgical procedures on that exclusionary list are those that are on the OPPS inpatient list, CPT unlisted codes, surgical procedures that are not recognized for payment under Medicare, and those that CMS medical advisors determined pose a significant risk to beneficiary safety or would be expected to require an overnight stay when provided in ASCs.

Addendum A - This Excel file lists, in APC order, the proposed name, payment status indicator, relative weight, payment rate, and copayment amount(s) for the 2010 APC groups.

Median Costs for Hospital Outpatient Services, by ambulatory payment classification (APC) group - This Excel file displays proposed median costs, by APC group, for services payable under the OPPS in calendar year 2010. The data are based on claims for hospital outpatient services provided January 1, 2008 through December 31, 2008.

ASC Preamble Table Descriptions:

TABLE 60.-- SURGICAL PROCEDURES REQUESTED FOR ADDITION TO THE CY 2010 ASC LIST OF COVERED SURGICAL PROCEDURES

TABLE 61.-- SPECIFIC CPT UNLISTED CODES REQUESTED FOR ADDITION TO ASC LIST OF COVERED SURGICAL PROCEDURES

TABLE 62. -- NEW ASC COVERED SURGICAL PROCEDURES FOR CY 2010

TABLE 63.-- HCPCS CODES DELETED EFFECTIVE CY 2010

TABLE 64. -- CY 2010 FINAL DESIGNATIONS OF ASC COVERED SURGICAL PROCEDURES NEWLY DESIGNATED AS OFFICE-BASED

TABLE 65. -- CY 2009 TEMPORARILY DESIGNATED OFFICE-BASED ASC COVERED SURGICAL PROCEDURES THAT ARE DESIGNATED AS PERMANENTLY OFFICE-BASED FOR CY 2010

TABLE 66. -- CY 2009 TEMPORARILY OFFICE-BASED PROCEDURES THAT ARE DESIGNATED AS TEMPORARILY OFFICE‑BASED FOR CY 2010

TABLE 67. -- FINAL CY 2010 PAYMENT INDICATORS FOR NEW CY 2010 HCPCS CODES FOR ASC COVERED SURGICAL PROCEDURES DESIGNATED AS TEMPORARILY OFFICE-BASED ON AN INTERIM BASIS

TABLE 68.-- ASC COVERED SURGICAL PROCEDURES DESIGNATED AS DEVICE-INTENSIVE FOR CY 2010

TABLE 69.-- PROCEDURES EXCLUDED FROM THE ASC LIST OF COVERED SURGICAL PROCEDURES FOR CY 2010 THAT WERE REMOVED FROM THE CY 2010 OPPS INPATIENT LIST

TABLE 70.-- CY 2010 PROCEDURES TO WHICH THE NO COST/FULL CREDIT AND PARTIAL CREDIT DEVICE ADJUSTMENT POLICY APPLIES

TABLE 71.-- DEVICES FOR WHICH THE "FB" OR "FC" MODIFIER MUST BE REPORTED WITH THE PROCEDURE CODE IN CY 2010 WHEN FURNISHED AT NO COST OR WITH FULL OR PARTIAL CREDIT

TABLE 72.-- INSERTION OF IOL PROCEDURES

TABLE 75 -- ESTIMATED IMPACT OF THE FINAL CY 2010 ASC PAYMENT SYSTEM ON AGGREGATE CY 2010 MEDICARE PROGRAM PAYMENTS UNDER THE 25/75 TRANSITION BLEND AND WITHOUT A TRANSITION, BY SURGICAL SPECIALTY OR ANCILLARY ITEMS AND SERVICES GROUP

TABLE 76.-- ESTIMATED IMPACT OF THE FINAL CY 2010 ASC PAYMENT SYSTEM ON AGGREGATE PAYMENTS FOR SELECTED PROCEDURES

TABLE 77.-- ACCOUNTING STATEMENT:  CLASSIFICATION OF ESTIMATED EXPENDITURES FROM CY 2009 TO CY 2010 AS A RESULT OF THE CY 2010 UPDATE TO THE REVISED ASC PAYMENT SYSTEM

PLEASE NOTE:

Updated CY 2010 ASC addenda files that reflect the payment rates under current law for January 1 through February 28, 2010 are available at http://www.cms.hhs.gov/ASCPayment/11_Addenda_Updates.asp . The hyperlink will connect to the ASC Addenda Updates Page.

We are reposting Addenda AA and BB to reflect technical corrections to the relative value units and the CY 2010 conversion factor under the Medicare Physician Fee Schedule (see http://www.federalregister.gov/OFRUpload/OFRData/2009-26502_PI.pdf.) that affect the CY 2010 third year transition payment rates for ASC covered services for which payments are based on the MPFS nonfacility practice expense amounts, including some office-based procedures and some ancillary radiology procedures. The affects ASC rates have been updated in the revised versions of Addenda AA and BB for the CY 2010 OPPS/ASC final rule with comment period. A correction notice will also be published in Federal Register regarding these corrections.

The revised rates continue to reflect the negative update to the MPFS for CY 2010 authorized under current law.