CMS-1504-P

TITLE:  Medicare Program:  Proposed Changes to the Hospital Outpatient Prospective Payment System and CY 2011 Payment Rates; Proposed Changes to the Ambulatory Surgical Center Payment System and CY 2011 Payment Rates; Proposed Changes to Payments to Hospitals for Certain Inpatient Hospital Services and for Graduate Medical Education Costs; and Proposed Changes to Physician Self-Referral Rules and Related Changes to Provider Agreement Regulations

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 and to implement certain provisions of the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act of 2010 (Affordable Care Act).  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 proposed changes would be applicable to services furnished on or after January 1, 2011.

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 and to implement certain provisions of the Affordable Care Act.  In this proposed rule, we set forth the proposed 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 2011 ASC payment system.  These proposed changes would be applicable to services furnished on or after January 1, 2011.

This proposed rule also includes proposals to implement provisions of the Affordable Care Act relating to payments to hospitals for direct graduate medical education (GME) and indirect medical education (IME) costs; and new limitations on certain physician referrals to hospitals in which they have an ownership or investment interest.

The proposed rule (CMS-1504-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 2011 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 2011. The data are based on claims for hospital outpatient services provided January 1, 2009 through December 31, 2009.

TABLE 42.--NEW CATEGORY III CPT CODES AND LEVEL II HCPCS CODE IMPLEMENTED IN JULY 2010 AS ASC COVERED SURGICAL PROCEDURES

TABLE 43.--PROPOSED NEW ASC COVERED SURGICAL PROCEDURES FOR CY 2011

TABLE 44.--ASC COVERED SURGICAL PROCEDURES PROPOSED FOR OFFICE-BASED DESIGNATION FOR CY 2011

TABLE 45.--CY 2010 TEMPORARILY DESIGNATED OFFICE-BASED ASC COVERED SURGICAL PROCEDURES PROPOSED FOR PERMANENT OFFICE-BASED FOR CY 2011

TABLE 46.--CY 2010 TEMPORARILY DESIGNATED OFFICE-BASED ASC COVERED SURGICAL PROCEDURES PROPOSED FOR TEMPORARY OFFICE‑BASED DESIGNATION IN CY 2011

TABLE 47.--PROPOSED CY 2011 PAYMENT INDICATORS FOR NEW CY 2010 HCPCS CODES FOR ASC COVERED SURGICAL PROCEDURES DESIGNATED AS TEMPORARILY OFFICE-BASED ON AN INTERIM BASIS IN THE CY 2010 OPPS/ASC FINAL RULE WITH COMMENT PERIOD

TABLE 48.--ASC COVERED SURGICAL PROCEDURES PROPOSED FOR DEVICE-INTENSIVE DESIGNATION FOR CY 2011

TABLE 49.--PROCEDURES PROPOSED FOR EXCLUSION FROM THE ASC LIST OF COVERED PROCEDURES FOR CY 2011 THAT ARE PROPOSED FOR REMOVAL FROM THE CY 2011 OPPS INPATIENT LIST

TABLE 52.--PROPOSED CY 2011 ASC PREVENTIVE SERVICES FOR WHICH COINSURANCE AND DEDUCTIBLE WOULD BE WAIVED IN CY 2011

TABLE 53.--INSERTION OF IOL PROCEDURES

TABLE 54.-- MULTIFACTOR PRODUCTIVITY ADJUSTED PAYMENT UPDATE:  ILLUSTRATIVE EXAMPLES

TABLE 57.--ESTIMATED IMPACT OF THE PROPOSED CY 2011 UPDATE TO THE ASC PAYMENT SYSTEM ON AGGREGATE CY 2011 MEDICARE PROGRAM PAYMENTS BY SURGICAL SPECIALTY OR ANCILLARY ITEMS AND SERVICES GROUP

TABLE 58.--ESTIMATED IMPACT OF THE PROPOSED UPDATE TO CY 2011 ASC PAYMENT SYSTEM ON AGGREGATE PAYMENTS FOR SELECTED PROCEDURES

TABLE 59.--ACCOUNTING STATEMENT:  CLASSIFICATION OF ESTIMATED TRANSFERS FROM CY 2010 TO CY 2011 AS A RESULT OF THE PROPOSED CY 2011 UPDATE TO THE REVISED ASC PAYMENT SYSTEM