TITLE: Medicare Program: Proposed Changes to the Hospital Outpatient Prospective Payment System and CY 2012 Payment Rates; Proposed Changes to the Ambulatory Surgical Center Payment System and CY 2012 Payment Rates; Proposed Additional Changes to the Hospital Inpatient Quality Reporting Program and the Hospital Value-Based Purchasing Program
Medicare and Medicaid Programs: Proposed Changes to Physician Self-Referral Rules and Provider Agreement Regulations on Patient Safety
PUBLICATION DATE: July 18, 2011
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 OPPS. These proposed changes would be applicable to services furnished on or after January 1, 2012.
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 proposed relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these proposed changes would apply, and other proposed ratesetting information for the CY 2012 ASC payment system. These proposed changes would be applicable to services furnished on or after January 1, 2012.
We are proposing to revise the requirements for the Hospital Outpatient Quality Reporting (IQR) Program, add new requirements for ASC Quality Reporting System, and make additional changes to provisions of the Hospital Inpatient Quality Reporting (IQR) Program and the Hospital Inpatient Value-Based Purchasing (VBP) Program.
We also are proposing to allow eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot.
In addition, we are proposing to make changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreements relating to patient safety.
The proposed rule (CMS-1525-P) is available in the "Related Links Outside CMS" below. The supporting 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 proposed 2012 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 2012. The data are based on claims for hospital outpatient services provided January 1, 2010 through December 31, 2010.
TABLE 41. - PROPOSED COMMENT TIMEFRAME FOR NEW HCPCS CODES
TABLE 42. - NEW LEVEL II HCPCS CODES FOR COVERED ANCILLARY SERVICES IMPLEMENTED IN APRIL 2011
TABLE 43. - NEW LEVEL II HCPCS CODES FOR COVERED ANCILLARY SERVICES IMPLEMENTED IN JULY 2011
TABLE 44. - NEW CATEGORY III CPT CODES IMPLEMENTED IN JULY 2011 AS ASC COVERED SURGICAL PROCEDURES
TABLE 45. - ASC COVERED SURGICAL PROCEDURES PROPOSED FOR PERMANENT OFFICE-BASED DESIGNATION FOR 2012
TABLE 46. - PROPOSED CY 2012 PAYMENT INDICATORS FOR ASC COVERED SURGICAL PROCEDURES DESIGNATED AS TEMPORARILY OFFICE-BASED IN THE CY 2011 OPPS/ASC FINAL RULE WITH COMMENT PERIOD
TABLE 47. - ASC COVERED SURGICAL PROCEDURES PROPOSED FOR DEVICE-INTENSIVE DESIGNATION FOR CY 2012
TABLE 48. - PROCEDURES PROPOSED FOR EXCLUSION FROM THE ASC LIST OF COVERED PROCEDURES FOR CY 2012 THAT ARE PROPOSED FOR REMOVAL FROM THE CY 2012 OPPS INPATIENT LIST
TABLE 49. - PROPOSED CY 2012 PROCEDURES TO WHICH THE NO COST/FULL CREDIT AND PARTIAL CREDIT DEVICE ADJUSTMENT POLICY WOULD APPLY
TABLE 50. - PROPOSED DEVICES FOR WHICH THE "FB" OR "FC" MODIFIER MUST BE REPORTED WITH THE PROCEDURE CODE IN CY 2012 WHEN FURNISHED AT NO COST OR WITH FULL OR PARTIAL CREDIT