CMS-1414-P

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

SUMMARY:  This proposed rule would revise 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 proposed rule, we describe the proposed 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 would be applicable to services furnished on or after January 1, 2010. 

In addition, this proposed rule would update 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 proposed rule, we set forth the applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these proposed changes would apply, and other pertinent ratesetting information for the CY 2010 ASC payment system.  These proposed changes would be applicable to services furnished on or after January 1, 2010.

The proposed rule (CMS-1414-P) is available in the "Related Links Outside CMS" below.  These 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.

TABLE 38. - NEW CATEGORY III CPT CODES IMPLEMENTED IN JULY 2009 AS ASC COVERED SURGICAL PROCEDURES

TABLE 39. - NEW LEVEL II HCPCS CODES FOR COVERED ANCILLARY SERVICES IMPLEMENTED IN APRIL 2009

TABLE 40. - NEW LEVEL II HCPCS CODES FOR COVERED ANCILLARY SERVICES IMPLEMENTED IN JULY 2009

TABLE 41. - PROPOSED NEW ASC COVERED SURGICAL PROCEDURES FOR CY 2010

TABLE 42. - HCPCS CODES PROPOSED FOR DELETION EFFECTIVE CY 2010

TABLE 43. - ASC COVERED SURGICAL PROCEDURES PROPOSED FOR OFFICE-BASED DESIGNATION FOR CY 2010

TABLE 44. - CY 2009 TEMPORARILY DESIGNATED OFFICE-BASED ASC COVERED SURGICAL PROCEDURES PROPOSED FOR PERMANENT OFFICE-BASED DESIGNATION FOR CY 2010

TABLE 45. - CY 2009 TEMPORARILY DESIGNATED OFFICE-BASED ASC COVERED SURGICAL PROCEDURES PROPOSED FOR TEMPORARY OFFICE-BASED DESIGNATION IN CY 2010

TABLE 47. - PROCEDURES PROPOSED FOR EXCLUSION FROM THE ASC LIST OF COVERED PROCEDURES FOR CY 2010 THAT ARE PROPOSED FRO REMOVAL FROM THE OPPS INPATIENT LIST

TABLE 48. - PROPOSED PROCEDURES TO WHICH THE NO COST/FULL CREDIT AND PARTIAL CREDIT DEVICE ADJUSTMENT POLICY WOULD APPLY IN CY 2010

TABLE 49. - PROPOSED 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 50. - INSERTION OF IOL PROCEDURES

TABLE 53. - ESTIMATED CY 2010 IMPACT OF THE UPDATE TO THE ASC PAYMENT SYSTEM ON ESTIMATED 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 54. - ESTIMATED IMPACT OF PROPOSED Update to CY 2010 ASC PAYMENT SYSTEM ON AGGREGATE PAYMENTS FOR SELECTED PROCEDURES

TABLE 55. - ACCOUNTING STATEMENT:  CLASSIFICATION OF ESTIMATED EXPENDITURES FROM CY 2009 TO CY 2010 AS A RESULT OF THE PROPOSED CY 2010 UPDATE TO THE REVISED ASC PAYMENT SYSTEM