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Proposed Rule

Medicare Program: Proposed Changes to the Hospital Outpatient Prospective Payment System and CY 2008 Payment Rates; Proposed Changes to the Ambulatory Surgical Center Payment System and CY 2008 Payment Rates; Medicare and Medicaid Programs: Proposed Changes to Hospital Conditions of Participation; Proposed Changes Affecting Necessary Provider Designations of Critical Access Hospitals

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Start Preamble Start Printed Page 42628

AGENCY:

Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION:

Proposed rule.

SUMMARY:

This proposed rule would revise the Medicare hospital outpatient prospective payment system 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, 2008.

In addition, this proposed rule would update the revised Medicare ambulatory surgical center (ASC) payment system to implement certain related provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). In this proposed rule, we propose the applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which the final policies of the ASC payment system would apply, and other pertinent ratesetting information for the CY 2008 ASC payment system. These changes would be applicable to services furnished on or after January 1, 2008.

In this proposed rule, we also are proposing changes to the policies relating to the necessary provider designations of critical access hospitals (CAHs) that are being recertified when a CAH enters into a new co-location arrangement with another hospital or CAH or when the CAH creates or acquires an off-campus location.

Further, we are proposing changes to several of the current conditions of participation that hospitals must meet to participate in the Medicare and Medicaid programs to require the completion and documentation in the medical record of medical histories and physical examinations of patients conducted after admission and prior to surgery or a procedure requiring anesthesia services and for postanesthesia evaluations of patients before discharge or transfer from the postanesthesia recovery area.

DATES:

To be assured consideration, comments on all sections of the preamble of this proposed rule must be received at one of the addresses provided in the ADDRESSES section no later than 5 p.m. on September 14, 2007.

ADDRESSES:

In commenting, please refer to file code CMS-1392-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of four ways (no duplicates, please):

1. Electronically. You may submit electronic comments on specific issues in this regulation to http://www.cms.hhs.gov/​eRulemaking. Click on the link “Submit electronic comments on CMS regulations with an open comment period.” (Attachments should be in Microsoft Word, WordPerfect, or Excel; however, we prefer Microsoft Word.)

2. By regular mail. You may mail written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1392-P, P.O. Box 8011, Baltimore, MD 21244-1850.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By express or overnight mail. You may send written comments (one original and two copies) to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1392-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

4. By hand or courier. If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to one of the following addresses: Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201; or 7500 Security Boulevard, Baltimore, MD 21244-1850.

If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-9994 in advance to schedule your arrival with one of our staff members.

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp-in clock is available for persons wishing to retain proof of filing by stamping in and retaining an extra copy of the comments being filed.)

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

For information on viewing public comments, see the beginning of the SUPPLEMENTARY INFORMATION section.

Start Further Info

FOR FURTHER INFORMATION CONTACT:

Alberta Dwivedi, (410) 786-0378, Hospital outpatient prospective payment issues.

Dana Burley, (410) 786-0378, Ambulatory surgical center issues.

Suzanne Asplen, (410) 786-4558, Partial hospitalization and community mental health centers issues.

Sheila Blackstock, (410) 786-3502, Reporting of quality data issues.

Mary Collins, (410) 786-3189, and

Jeannie Miller, (410) 786-3164, Necessary provider designations for CAHs Issues.

Scott Cooper, (410) 786-9465, and

Jeannie Miller, (410) 786-3164, Hospital conditions of participation Issues.

End Further Info End Preamble Start Supplemental Information

SUPPLEMENTARY INFORMATION:

Submitting Comments: We welcome comments from the public on all issues set forth in this proposed rule to assist us in fully considering issues and developing policies. You can assist us by referencing file code CMS-1392-P and the specific “issue identifier” that precedes the section on which you choose to comment.

Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. We post all comments received before the close of the comment period on the following Web site as soon as possible after they have been received: http://www.cms.hhs.gov/​eRulemaking. Click on the link “Electronic Comments on CMS Regulations” on that Web site to view public comments.

Comments received timely will also be available for public inspection as they are received, generally beginning approximately 3 weeks after publication Start Printed Page 42629of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, on Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

Electronic Access

This Federal Register document is also available from the Federal Register online database through GPO Access, a service of the U.S. Government Printing Office. Free public access is available on a Wide Area Information Server (WAIS) through the Internet and via asynchronous dial-in. Internet users can access the database by using the World Wide Web; the Superintendent of Documents' home page address is http://www.gpoaccess.gov/​index.html, by using local WAIS client software, or by telnet to swais.access.gpo.gov, then login as guest (no password required). Dial-in users should use communications software and modem to call (202) 512-1661; type swais, then login as guest (no password required).

Alphabetical List of Acronyms Appearing in the Proposed Rule

ACEP American College of Emergency Physicians

AHA American Hospital Association

AHIMA American Health Information Management Association

AMA American Medical Association

APC Ambulatory payment classification

AMP Average manufacturer price

ASC Ambulatory Surgical Center

ASP  Average sales price

AWP Average wholesale price

BBA Balanced Budget Act of 1997, Pub. L. 105-33

BBRA Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999, Pub. L. 106-113

BCA Blue Cross Association

BCBSA Blue Cross and Blue Shield Association

BIPA Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000, Pub. L. 106-554

CAH Critical access hospital

CAP Competitive Acquisition Program

CBSA Core-Based Statistical Area

CCR Cost-to-charge ratio

CERT Comprehensive Error Rate Testing

CMHC  Community mental health center

CMS  Centers for Medicare & Medicaid Services

CoP [Hospital] Condition of participation

CORF Comprehensive outpatient rehabilitation facility

CPT [Physicians'] Current Procedural Terminology, Fourth Edition, 2007, copyrighted by the American Medical Association

CRNA Certified registered nurse anesthetist

CY Calendar year

DMEPOS Durable medical equipment, prosthetics, orthotics, and supplies

DMERC Durable medical equipment regional carrier

DRA Deficit Reduction Act of 2005, Pub. L. 109-171

DSH Disproportionate share hospital

EACH Essential Access Community Hospital

E/M Evaluation and management

EPO Erythropoietin

ESRD End-stage renal disease

FACA Federal Advisory Committee Act, Pub. L. 92-463

FAR Federal Acquisition Regulations

FDA Food and Drug Administration

FFS Fee-for-service

FSS Federal Supply Schedule

FTE Full-time equivalent

FY Federal fiscal year

GAO Government Accountability Office

HCPCS Healthcare Common Procedure Coding System

HCRIS Hospital Cost Report Information System

HHA Home health agency

HIPAA Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191

HOPD Hospital outpatient department

HOP QDRP Hospital Outpatient Quality Data Reporting Program

ICD-9-CM International Classification of Diseases, Ninth Edition, Clinical Modification

IDE Investigational device exemption

IOL Intraocular lens

IPPS [Hospital] Inpatient prospective payment system

IVIG Intravenous immune globulin

MAC Medicare Administrative Contractors

MedPAC Medicare Payment Advisory Commission

MDH Medicare-dependent, small rural hospital

MIEA-TRHCA Medicare Improvements and Extension Act under Division B, Title I of the Tax Relief Health Care Act of 2006, Pub. L. 109-432

MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173

MPFS Medicare Physician Fee Schedule

MSA  Metropolitan Statistical Area

NCCI National Correct Coding Initiative

NCD National Coverage Determination

NTIOL New technology intraocular lens

OCE Outpatient Code Editor

OMB Office of Management and Budget

OPD [Hospital] Outpatient department

OPPS [Hospital] Outpatient prospective payment system

PHP Partial hospitalization program

PM  Program memorandum

PPI Producer Price Index

PPS Prospective payment system

PPV Pneumococcal pneumonia (virus)

PRA Paperwork Reduction Act

QIO Quality Improvement Organization

RFA Regulatory Flexibility Act

RHQDAPU Reporting Hospital Quality Data for Annual Payment Update [Program]

RHHI Regional home health intermediary

SBA Small Business Administration

SCH Sole community hospital

SDP Single Drug Pricer

SI Status indicator

TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97-248

TOPS Transitional outpatient payments

USPDI United States Pharmacopoeia Drug Information

WAC Wholesale acquisition cost

In this document, we address two payment systems under the Medicare program: the hospital outpatient prospective payment system (OPPS) and the revised ambulatory surgical center (ASC) revised payment system. The provisions relating to the OPPS are included in sections I. through XV., XVII., and XIX. through XXII. of this proposed rule and in Addenda A, B, C (Addendum C is available on the Internet only; see section XIX. of this proposed rule), D1, D2, E, L, and M to this proposed rule. The provisions related to the revised ASC payment system are included in sections XVI., XVII., and XIX. through XXII. of this proposed rule and in Addenda AA, BB, DD1, and DD2 to this proposed rule.

Table of Contents

I. Background for the OPPS

A. Legislative and Regulatory Authority for the Hospital Outpatient Prospective Payment System

B. Excluded OPPS Services and Hospitals

C. Prior Rulemaking

D. APC Advisory Panel

1. Authority of the APC Panel

2. Establishment of the APC Panel

3. APC Panel Meetings and Organizational Structure

E. Provisions of the Medicare Improvements and Extension Act under Division B of Title I of the Tax Relief and Health Care Act of 2006 Start Printed Page 42630

F. Summary of the Major Contents of This Proposed Rule

1. Proposed Updates Affecting OPPS Payments

2. Proposed OPPS Ambulatory Payment Classification (APC) Group Policies

3. Proposed OPPS Payment for Devices

4. Proposed OPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals

5. Proposed Estimate of OPPS Transitional Pass-Through Spending for Drugs, Biologicals, and Devices

6. Proposed OPPS Payment for Brachytherapy Sources

7. Proposed OPPS Coding and Payment for Drug Administration Services

8. Proposed OPPS Hospital Coding and Payment for Visits

9. Proposed OPPS Payment for Blood and Blood Products

10. Proposed OPPS Payment for Observation Services

11. Proposed Procedures That Will Be Paid Only as Inpatient Services

12. Proposed Nonrecurring Technical and Policy Changes

13. Proposed OPPS Payment Status and Comment Indicators

14. OPPS Policy and Payment Recommendations

15. Proposed Update of the Revised ASC Payment System

16. Proposed Quality Data for Annual Payment Updates

17. Proposed Changes Affecting Necessary Provider Critical Access Hospitals (CAHs) and Hospital Conditions of Participation (CoPs)

18. Regulatory Impact Analysis

II. Proposed Updates Affecting OPPS Payments

A. Proposed Recalibration of APC Relative Weights

1. Database Construction

a. Database Source and Methodology

b. Proposed Use of Single and Multiple Procedure Claims

(1) Proposed Use of Date of Service Stratification and a Bypass List To Increase the Amount of Data Used To Determine Medians

(2) Exploration of Allocation of Packaged Costs to Separately Paid Procedure Codes

c. Proposed Calculation of CCRs

2. Proposed Calculation of Median Costs

3. Proposed Calculation of OPPS Scaled Payment Weights

4. Proposed Changes to Packaged Services

a. Background

b. Addressing Growth in OPPS Volume and Spending

c. Proposed Packaging Approach

(1) Guidance Services

(2) Image Processing Services

(3) Intraoperative Services

(4) Imaging Supervision and Interpretation Services

(5) Diagnostic Radiopharmaceuticals

(6) Contrast Agents

(7) Observation Services

d. Proposed Development of Composite APCs

(1) Background

(2) Proposed Low Dose Rate (LDR) Prostate Brachytherapy Composite APC

(a) Background

(b) Proposed Payment for LDR Prostate Brachytherapy

(3) Proposed Cardiac Electrophysiologic Evaluation and Ablation Composite APC

(a) Background

(b) Proposed Payment for Cardiac Electrophysiologic Evaluation and Ablation

e. Service-Specific Packaging Issues

B. Proposed Payment for Partial Hospitalization

1. Background

2. Proposed PHP APC Update

3. Proposed Separate Threshold for Outlier Payments to CMHCs

C. Proposed Conversion Factor Update

D. Proposed Wage Index Changes

E. Proposed Statewide Average Default CCRs

F. Proposed OPPS Payments to Certain Rural Hospitals

1. Hold Harmless Transitional Payment Changes Made by Pub. L. 109-171 (DRA)

2. Proposed Adjustment for Rural SCHs Implemented in CY 2006 Related to Pub. L. 108-173 (MMA)

G. Proposed Hospital Outpatient Outlier Payments

H. Calculation of the Proposed National Unadjusted Medicare Payment

I. Proposed Beneficiary Copayments

1. Background

2. Proposed Copayment

3. Calculation of a Proposed Adjusted Copayment Amount for an APC Group

III. Proposed OPPS Ambulatory Payment Classification (APC) Group Policies

A. Proposed Treatment of New HCPCS and CPT Codes

1. Proposed Treatment of New HCPCS Codes Included in the April and July Quarterly OPPS Updates for CY 2007

2. Proposed Treatment of New Category I and III CPT Codes and Level II HCPCS Codes

B. Proposed Changes—Variations Within APCs

1. Background

2. Application of the 2 Times Rule

3. Proposed Exceptions to the 2 Times Rule

C. New Technology APCs

1. Introduction

2. Proposed Movement of Procedures From New Technology APCs to Clinical APCs

a. Positron Emission Tomography (PET)/Computed Tomography (CT) Scans (New Technology APC 1511)

b. IVIG Preadministration-Related Services (New Technology APC 1502)

c. Other Services in New Technology APCs

D. Proposed APC-Specific Policies

1. Hyperbaric Oxygen Therapy (APC 0659)

2. Skin Repair Procedures (APCs 0024, 0025, 0027, and 0686)

3. Cardiac Computed Tomography and Computed Tomographic Angiography (APCs 0282, 0376, 0377, and 0398)

4. Ultrasound Ablation of Uterine Fibroids With Magnetic Resonance Guidance (MRgFUS) (APCs 0195 and 0202)

5. Single Allergy Tests (APC 0381)

6. Myocardial Positron Emission Tomography (PET) Scans (APC 0307)

7. Implantation of Cardioverter-Defibrillators (APCs 0107 and 0108)

8. Implantation of Spinal Neurostimulators (APC 0222)

9. Stereotactic Radiosurgery (SRS) Treatment Delivery Services (APCs 0065, 0066, and 0067)

10. Blood Transfusion (APC 0110)

11. Screening Colonscopies and Screening Flexible Sigmoidoscopies (APCs 0158 and 0159)

IV. Proposed OPPS Payment for Devices

A. Proposed Treatment of Device-Dependent APCs

1. Background

2. Proposed Payment

3. Proposed Payment When Devices Are Replaced With Partial Credit to the Hospital

B. Pass-Through Payments for Devices

1. Expiration of Transitional Pass-Through Payments for Certain Devices

a. Background

b. Proposed Policy

2. Proposed Provisions for Reducing Transitional Pass-Through Payments to Offset Costs Packaged Into APC Groups

a. Background

b. Proposed Policy

V. Proposed OPPS Payment Changes for Drugs, Biologicals, and Radiopharmaceuticals

A. Proposed Transitional Pass-Through Payment for Additional Costs of Drugs and Biologicals

1. Background

2. Drugs and Biologicals with Expiring Pass-Through Status in CY 2007

3. Drugs and Biologicals With Proposed Pass-Through Status in CY 2008

B. Proposed Payment for Drugs, Biologicals, and Radiopharmaceuticals Without Pass-Through Status

1. Background

2. Proposed Criteria for Packaging Payment for Drugs and Biologicals

3. Proposed Payment for Drugs and Biologicals Without Pass-Through Status That Are Not Packaged

a. Payment for Specified Covered Outpatient Drugs

(1) Background

(2) Proposed Payment Policy

(3) Proposed Payment for Blood Clotting Factors

(4) Proposed Payment for Radiopharmaceuticals

(a) Background

(b) Proposed Payment for Diagnostic Radiopharmaceuticals

(c) Proposed Payment for Therapeutic Radiopharmaceuticals

b. Proposed Payment for Nonpass-Through Drugs, Biologicals, and Radiopharmaceuticals With HCPCS Codes, But Without OPPS Hospital Claims Data

VI. Proposed Estimate of OPPS Transitional Pass-Through Spending for Drugs, Biologicals, Radiopharmaceuticals, and Devices

A. Total Allowed Pass-Through Spending

B. Proposed Estimate of Pass-Through Spending

VII. Proposed OPPS Payment for Brachytherapy Sources

A. Background

B. Proposed Payment for Brachytherapy Sources Start Printed Page 42631

VIII. Proposed OPPS Drug Administration Coding and Payment

A. Background

B. Proposed Coding and Payment for Drug Administration Services

IX. Proposed Hospital Coding and Payments for Visits

A. Background

B. Proposed Policies for Hospital Outpatient Visits

1. Clinic Visits: New and Established Patient Visits and Consultations

2. Emergency Department Visits

C. Proposed Visit Reporting Guidelines

1. Background

2. CY 2007 Work on Visit Guidelines

3. Proposed Visit Guidelines

X. Proposed OPPS Payment for Blood and Blood Products

A. Background

B. Proposed Payment for Blood and Blood Products

XI. Proposed OPPS Payment for Observation Services

XII. Proposed Procedures That Will Be Paid Only as Inpatient Procedures

A. Background

B. Proposed Changes to the Inpatient List

XIII. Proposed Nonrecurring Technical and Policy Changes

A. Outpatient Hospital Services and Supplies Incident to a Physician Service

B. Interrupted Procedures

C. Transitional Adjustments Hold Harmless Provisions

D. Reporting of Wound Care Services

E. Reporting of Cardiac Rehabilitation Services

F. Reporting of Bone Marrow and Stem Cell Processing Services

XIV. Proposed OPPS Payment Status and Comment Indicators

A. Proposed Payment Status Indicator Definitions

1. Proposed Payment Status Indicators to Designate Services That Are Paid under the OPPS

2. Proposed Payment Status Indicators to Designate Services That Are Paid Under a Payment System Other Than the OPPS

3. Proposed Payment Status Indicators to Designate Services That Are Not Recognized under the OPPS But That May Be Recognized by Other Institutional Providers

4. Proposed Payment Status Indicators to Designate Services That Are Not Payable by Medicare

B. Proposed Comment Indicator Definitions

XV. OPPS Policy and Payment Recommendations

A. MedPAC Recommendations

B. APC Panel Recommendations

XVI. Proposed Update of the Revised Ambulatory Surgical Center Payment System

A. Legislative and Regulatory Authority for the ASC Payment System

B. Rulemaking for the Revised ASC Payment System

C. Revisions to the ASC Payment System Effective January 1, 2008

1. Covered Surgical Procedures under the Revised ASC Payment System

a. Definition of Surgical Procedure

b. Identification of Surgical Procedures Eligible for Payment under the Revised ASC Payment System

c. Payment for Covered Surgical Procedures under the Revised ASC Payment System

(1) General Policies

(2) Office-Based Procedures

(3) Device-Intensive Procedures

(4) Multiple and Interrupted Procedure Discounting

(5) Transition to Revised ASC Payment Rates

2. Covered Ancillary Services under the Revised ASC Payment System

a. General Policies

b. Payment Policies for Specific Items and Services

(1) Radiology Services

(2) Brachytherapy Sources

(3) Drugs and Biologicals

(4) Implantable Devices with Pass-Through Status under the OPPS

(5) Corneal Tissue Acquisition

3. General Payment Policies

a. Geographic Adjustment

b. Beneficiary Coinsurance

D. Proposed Treatment of New HCPCS Codes

1. Treatment of New CY 2008 Category I and III CPT Codes and Level II HCPCS Codes

2. Proposed Treatment of New Mid-Year Category III CPT Codes

3. Proposed Treatment of Level II HCPCS Codes Released on a Quarterly Basis

E. Proposed Updates to Covered Surgical Procedures and Covered Ancillary Services

1. Identification of Covered Surgical Procedures

a. General Policies

b. Proposed Changes in Designation of Covered Surgical Procedures as Office-Based

c. Proposed Changes in Designation of Covered Surgical Procedures as Device-Intensive

2. Proposed Changes in Identification of Covered Ancillary Services

F. Proposed Payment for Covered Surgical Procedures and Covered Ancillary Services

1. Proposed Payment for Covered Surgical Procedures

a. Proposed Update to Payment Rates

b. Payment Policies When Devices Are Replaced at No Cost or With Credit

(1) Policy When Devices Are Replaced at No Cost or With Full Credit

(2) Proposed Policy When Implantable Devices Are Replaced With Partial Credit

2. Proposed Payment for Covered Ancillary Services

G. Physician Payment for Procedures and Services Provided in ASC

H. Proposed Changes to Definitions of “Radiology and Certain Other Imaging Services” and “Outpatient Prescription Drugs”

I. New Technology Intraocular Lenses

1. Background

2. Changes to the NTIOL Determination Process Finalized for CY 2008

3. NTIOL Application Process for CY 2008 Payment Adjustment

4. Classes of NTIOLS Approved for Payment Adjustment

5. Payment Adjustment

6. Proposed CY 2008 ASC Payment for Insertion of IOLs

J. Proposed ASC Payment and Comment Indicators

K. ASC Policy and Payment Recommendations

L. Proposed Calculation of the ASC Conversion Factor and ASC Payment Rates

1. Overview

2. Budget Neutrality Requirement

3. Calculation of the ASC Payment Rates for CY 2008

4. Calculation of the ASC Payment Rates for CY 2009 and FutureYears

XVII. Reporting Quality Data for Annual Payment Rate Updates

A. Background

1. Reporting Hospital Outpatient Quality Data for Annual Payment Update

2. Reporting ASC Quality Data for Annual Payment Increase

B. Proposed Hospital Outpatient Measures

C. Other Proposed Hospital Outpatient Measures

D. Proposed Implementation of the HOP QDRP

E. Proposed Requirements for HOP Quality Data Reporting for CY 2009 and Subsequent Calendar Years

1. Administrative Requirements

2. Data Collection and Submission Requirements

3. HOP QDRP Validation Requirements

F. Publication of HOP QDRP Data Collected

G. Proposed Attestation Requirement for Future Payment Years

H. HOP QDRP Reconsiderations

I. Reporting of ASC Quality Data

XVIII. Proposed Changes Affecting Critical Access Hospitals (CAHs) and Hospital Conditions of Participation (CoPs)

A. Proposed Changes Affecting CAHs

1. Background

2. Co-Location of Necessary Provider CAHs

3. Provider-Based Facilities of CAHs

4. Termination of Provider Agreement

5. Proposed Regulation Changes

B. Proposed Revisions to Hospital CoPs

1. Background

2. Provisions of the Proposed Regulations

a. Proposed Timeframes for Completion of the Medical History and Physical Examination

b. Proposed Requirements for Preanesthesia and Postanesthesia Evaluations

c. Proposed Technical Amendment to Nursing Services CoP

XIX. Files Available to the Public Via the Internet

A. Information in Addenda Related to the CY 2008 Hospital OPPS

B. Information in Addenda Related to the CY 2008 ASC Payment System

XX. Collection of Information Requirements

XXI. Response to Comments

XXII. Regulatory Impact Analysis

A. Overall Impact

1. Executive Order 12866

2. Regulatory Flexibility Act (RFA)

3. Small Rural Hospitals Start Printed Page 42632

4. Unfunded Mandates

5. Federalism

B. Effects of OPPS Changes in This Proposed Rule

1. Alternatives Considered

2. Limitation of Our Analysis

3. Estimated Impact of This Proposed Rule on Hospitals and CMHCs

4. Estimated Effect of This Proposed Rule on Beneficiaries

5. Conclusion

6. Accounting Statement

C. Effects of ASC Payment System Changes in This Proposed Rule

1. Alternatives Considered

2. Limitations on Our Analysis

3. Estimated Effects of This Proposed Rule on ASCs

4. Estimated Effects of This Proposed Rule on Beneficiaries

5. Conclusion

6. Accounting Statement

D. Effects of the Proposed Requirements for Reporting of Quality Data for Hospital Outpatient Settings

E. Effects of the Proposed Policy on CAH Off-Campus and Co-Location Requirements

F. Effects of Proposed Policy Revisions to the Hospital CoPs

G. Executive Order 12866

Regulation Text

Addenda

Addendum A—Proposed OPPS APCs for CY 2008

Addendum AA—Proposed ASC Covered Surgical Procedures for CY 2008 (Including Surgical Procedures for Which Payment is Packaged)

Addendum B—Proposed OPPS Payment By HCPCS Code for CY 2008

Addendum BB—Proposed ASC Covered Ancillary Services Integral to Covered Surgical Procedures for CY 2008 (Including Ancillary Services for Which Payment Is Packaged)

Addendum D1—Proposed OPPS Payment Status Indicators

Addendum D2—Proposed OPPS Comment Indicators

Addendum DD1—Proposed ASC Payment Indicators

Addendum DD2—Proposed ASC Comment Indicators

Addendum E—Proposed HCPCS Codes That Would Be Paid Only as Inpatient Procedures for CY 2008

Addendum L—Proposed Out-Migration Adjustment

Addendum M—Proposed HCPCS Codes for Assignment to Composite APCs for CY 2008

I. Background for the OPPS

A. Legislative and Regulatory Authority for the Hospital Outpatient Prospective Payment System

When the Medicare statute was originally enacted, Medicare payment for hospital outpatient services was based on hospital-specific costs. In an effort to ensure that Medicare and its beneficiaries pay appropriately for services and to encourage more efficient delivery of care, the Congress mandated replacement of the reasonable cost-based payment methodology with a prospective payment system (PPS). The Balanced Budget Act (BBA) of 1997 (Pub. L. 105-33) added section 1833(t) to the Social Security Act (the Act) authorizing implementation of a PPS for hospital outpatient services (OPPS).

The Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act (BBRA) of 1999 (Pub. L. 106-113) made major changes in the hospital OPPS. The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000 (Pub. L. 106-554) made further changes in the OPPS. Section 1833(t) of the Act was also amended by the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 (Pub. L. 108-173). The Deficit Reduction Act (DRA) of 2005 (Pub. L. 109-171), enacted on February 8, 2006, made additional changes in the OPPS. In addition, the Medicare Improvements and Extension Act under Division B of Title I of the Tax Relief and Health Care Act (MIEA-TRHCA) of 2006 (Pub. L. 109-432), enacted on December 20, 2006, made further changes in the OPPS. A discussion of these provisions is included in sections I.E., VII., and XVII. of this proposed rule.

The OPPS was first implemented for services furnished on or after August 1, 2000. Implementing regulations for the OPPS are located at 42 CFR Part 419.

Under the OPPS, we pay for hospital outpatient services on a rate-per-service basis that varies according to the ambulatory payment classification (APC) group to which the service is assigned. We use the Healthcare Common Procedure Coding System (HCPCS) codes (which include certain Current Procedural Terminology (CPT) codes) and descriptors to identify and group the services within each APC group. The OPPS includes payment for most hospital outpatient services, except those identified in section I.B. of this proposed rule. Section 1833(t)(1)(B)(ii) of the Act provides for Medicare payment under the OPPS for hospital outpatient services designated by the Secretary (which includes partial hospitalization services furnished by community mental health centers (CMHCs)) and hospital outpatient services that are furnished to inpatients who have exhausted their Part A benefits, or who are otherwise not in a covered Part A stay. Section 611 of Pub. L. 108-173 added provisions for Medicare coverage of an initial preventive physical examination, subject to the applicable deductible and coinsurance, as an outpatient department service, payable under the OPPS.

The OPPS rate is an unadjusted national payment amount that includes the Medicare payment and the beneficiary copayment. This rate is divided into a labor-related amount and a nonlabor-related amount. The labor-related amount is adjusted for area wage differences using the hospital inpatient wage index value for the locality in which the hospital or CMHC is located.

All services and items within an APC group are comparable clinically and with respect to resource use (section 1833(t)(2)(B) of the Act). In accordance with section 1833(t)(2) of the Act, subject to certain exceptions, services and items within an APC group cannot be considered comparable with respect to the use of resources if the highest median (or mean cost, if elected by the Secretary) for an item or service in the APC group is more than 2 times greater than the lowest median cost for an item or service within the same APC group (referred to as the “2 times rule”). In implementing this provision, we use the median cost of the item or service assigned to an APC group.

Special payments under the OPPS may be made for New Technology items and services in one of two ways. Section 1833(t)(6) of the Act provides for temporary additional payments, which we refer to as “transitional pass-through payments,” for at least 2 but not more than 3 years for certain drugs, biological agents, brachytherapy devices used for the treatment of cancer, and categories of other medical devices. For New Technology services that are not eligible for transitional pass-through payments, and for which we lack sufficient data to appropriately assign them to a clinical APC group, we have established special APC groups based on costs, which we refer to as New Technology APCs. These New Technology APCs are designated by cost bands which allow us to provide appropriate and consistent payment for designated new procedures that are not yet reflected in our claims data. Similar to pass-through payments, an assignment to a New Technology APC is temporary; that is, we retain a service within a New Technology APC until we acquire sufficient data to assign it to a clinically appropriate APC group.

B. Excluded OPPS Services and Hospitals

Section 1833(t)(1)(B)(i) of the Act authorizes the Secretary to designate the hospital outpatient services that are paid under the OPPS. While most hospital outpatient services are payable under the OPPS, section Start Printed Page 426331833(t)(1)(B)(iv) of the Act excludes payment for ambulance, physical and occupational therapy, and speech-language pathology services, for which payment is made under a fee schedule. Section 614 of Pub. L. 108-173 amended section 1833(t)(1)(B)(iv) of the Act to exclude OPPS payment for screening and diagnostic mammography services. The Secretary exercised the authority granted under the statute to exclude from the OPPS those services that are paid under fee schedules or other payment systems. Such excluded services include, for example, the professional services of physicians and nonphysician practitioners paid under the Medicare Physician Fee Schedule (MPFS); laboratory services paid under the clinical diagnostic laboratory fee schedule (CLFS); services for beneficiaries with end-stage renal disease (ESRD) that are paid under the ESRD composite rate; and services and procedures that require an inpatient stay that are paid under the hospital inpatient prospective payment system (IPPS). We set forth the services that are excluded from payment under the OPPS in § 419.22 of the regulations.

Under § 419.20(b) of the regulations, we specify the types of hospitals and entities that are excluded from payment under the OPPS. These excluded entities include Maryland hospitals, but only for services that are paid under a cost containment waiver in accordance with section 1814(b)(3) of the Act; critical access hospitals (CAHs); hospitals located outside of the 50 States, the District of Columbia, and Puerto Rico; and Indian Health Service hospitals.

C. Prior Rulemaking

On April 7, 2000, we published in the Federal Register a final rule with comment period (65 FR 18434) to implement a prospective payment system for hospital outpatient services. The hospital OPPS was first implemented for services furnished on or after August 1, 2000. Section 1833(t)(9) of the Act requires the Secretary to review certain components of the OPPS, no less often than annually, and to revise the groups, relative payment weights, and other adjustments that take into account changes in medical practices, changes in technologies, and the addition of new services, new cost data, and other relevant information and factors.

Since initially implementing the OPPS, we have published final rules in the Federal Register annually to implement statutory requirements and changes arising from our continuing experience with this system. We published in the Federal Register on November 24, 2006 the CY 2007 OPPS/ASC final rule with comment period (71 FR 67960). In that final rule with comment period, we revised the OPPS to update the payment weights and conversion factor for services payable under the CY 2007 OPPS on the basis of claims data from January 1, 2005, through December 31, 2005, and to implement certain provisions of Pub. L. 108-173 and Pub. L. 109-171. In addition, we responded to public comments received on the provisions of the November 10, 2005 final rule with comment period (70 FR 86516) pertaining to the APC assignment of HCPCS codes identified in Addendum B of that rule with the new interim (NI) comment indicator; and public comments received on the August 23, 2006 OPPS/ASC proposed rule for CY 2007 (71 FR 49506).

D. APC Advisory Panel

1. Authority of the APC Panel

Section 1833(t)(9)(A) of the Act, as amended by section 201(h) of the BBRA, and redesignated by section 202(a)(2) of the BBRA, requires that we consult with an outside panel of experts to review the clinical integrity of the payment groups and their weights under the OPPS. The Act further specifies that the panel will act in an advisory capacity. The Advisory Panel on Ambulatory Payment Classification (APC) Groups (the APC Panel), discussed under section I.D.2. of this proposed rule, fulfills these requirements. The APC Panel is not restricted to using data compiled by CMS, and may use data collected or developed by organizations outside the Department in conducting its review.

2. Establishment of the APC Panel

On November 21, 2000, the Secretary signed the initial charter establishing the APC Panel. This expert panel, which may be composed of up to 15 representatives of providers subject to the OPPS (currently employed full-time, not as consultants, in their respective areas of expertise), reviews clinical data and advises CMS about the clinical integrity of the APC groups and their weights. For purposes of this Panel, consultants or independent contractors are not considered to be full-time employees. The APC Panel is technical in nature, and is governed by the provisions of the Federal Advisory Committee Act (FACA). Since its initial chartering, the Secretary has renewed the APC Panel's charter three times: on November 1, 2002; on November 1, 2004; and effective November 21, 2006. The current charter specifies, among other requirements, that the APC Panel continue to be technical in nature; be governed by the provisions of the FACA; may convene up to three meetings per year; has a Designated Federal Officer (DFO); and is chaired by a Federal official designated by the Secretary.

The current APC Panel membership and other information pertaining to the APC Panel, including its charter, Federal Register notices, meeting dates, agenda topics, and meeting reports can be viewed on the CMS Web site at: http://www.cms.hhs.gov/​FACA/​05_​AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp#TopOfPage.

3. APC Panel Meetings and Organizational Structure

The APC Panel first met on February 27, February 28, and March 1, 2001. Since the initial meeting, the APC Panel has held 11 subsequent meetings, with the last meeting taking place on March 7 and 8, 2007. Prior to each meeting, we publish a notice in the Federal Register to announce the meeting, and when necessary to solicit and announce nominations for the APC Panel's membership.

The APC Panel has established an operational structure that, in part, includes the use of three subcommittees to facilitate its required APC review process. The three current subcommittees are the Data Subcommittee, the Observation and Visit Subcommittee, and the Packaging Subcommittee. The Data Subcommittee is responsible for studying the data issues confronting the APC Panel, and for recommending options for resolving them. The Observation and Visit Subcommittee reviews and makes recommendations to the APC Panel on all technical issues pertaining to observation services and hospital outpatient visits paid under the OPPS (for example, APC configurations and APC payment weights). The Packaging Subcommittee studies and makes recommendations on issues pertaining to services that are not separately payable under the OPPS, but whose payments are bundled or packaged into APC payments. Each of these subcommittees was established by a majority vote from the full APC Panel during a scheduled APC Panel meeting, and their continuation as subcommittees was approved at the March 2007 APC Panel meeting. All subcommittee recommendations are discussed and voted upon by the full APC Panel.

Discussions of the recommendations resulting from the APC Panel's March Start Printed Page 426342007 meeting are included in the sections of this proposed rule that are specific to each recommendation. For discussions of earlier APC Panel meetings and recommendations, we reference previous hospital OPPS final rules or the Web site mentioned earlier in this section.

E. Provisions of the Medicare Improvements and Extension Act Under Division B of Title I of the Tax Relief and Health Care Act of 2006

The Medicare Improvements and Extension Act under Division B of Title I of the Tax Relief and Health Care Act (MIEA-TRHCA) of 2006, Pub. L. 109-432, enacted on December 20, 2006, included the following provisions affecting the OPPS:

1. Section 107(a) of the MIEA-TRHCA amended section 1833(t)(16)(C) of the Act to extend the period for payment of brachytherapy devices based on the hospital's charges adjusted to cost for 1 additional year, through December 31, 2007.

2. Section 107(b)(1) of the MIEA-TRHCA amended section 1833(t)(2)(H) of the Act by adding stranded and non-stranded devices furnished on or after July 1, 2007, as additional classifications of brachytherapy devices for which separate payment groups must be established for payment under the OPPS. Section 107(b)(2) of the MIEA-TRCHA provides that the Secretary may implement the section 107(b)(1) amendment to section 1833(t)(2)(H) of the Act “by program instruction or otherwise.”

3. Section 109(a) of the MIEA-TRHCA added new paragraph (17) to section 1833(t) of the Act which authorizes the Secretary, beginning in 2009 and each subsequent year, to reduce the OPPS full annual update by 2.0 percentage points if a hospital paid under the OPPS fails to submit data as required by the Secretary in the form and manner specified on selected measures of quality of care, including medication errors. In accordance with this provision, the selected measures are those that are appropriate for the measurement of quality of care furnished by hospitals in the outpatient setting, that reflect consensus among affected parties and, to the extent feasible and practicable, that include measures set forth by one or more of the national consensus entities, and that may be the same as those required for reporting by hospitals paid under the IPPS. This provision specifies that a reduction for 1 year cannot be taken into account when computing the OPPS update for a subsequent year. In addition, this provision requires the Secretary to establish a process for making the submitted data available for public review.

F. Summary of the Major Contents of This Proposed Rule

In this proposed rule, we are setting forth proposed changes to the Medicare hospital OPPS for CY 2008. These changes would be effective for services furnished on or after January 1, 2008. We are also setting forth proposed changes to the Medicare ASC payment system for CY 2008. These changes would be effective for services furnished on or after January 1, 2008. The following is a summary of the major changes that we are proposing to make:

1. Proposed Updates Affecting OPPS Payments

In section II. of this proposed rule, we set forth—

  • The methodology used to recalibrate the proposed APC relative payment weights.
  • The proposed payment for partial hospitalization services, including the proposed separate threshold for outlier payments for CMHCs.
  • The proposed update to the conversion factor used to determine payment rates under the OPPS.
  • The proposed retention of our current policy to use the IPPS wage indices to adjust, for geographic wage differences, the portion of the OPPS payment rate and the copayment standardized amount attributable to labor-related cost.
  • The proposed update of statewide average default CCRs.
  • The proposed application of hold harmless transitional outpatient payments (TOPs) for certain small rural hospitals.
  • The proposed payment adjustment for rural SCHs.
  • The proposed calculation of the hospital outpatient outlier payment.
  • The calculation of the proposed national unadjusted Medicare OPPS payment.
  • The proposed beneficiary copayments for OPPS services.

2. Proposed OPPS Ambulatory Payment Classification (APC) Group Policies

In section III. of this proposed rule, we discuss the proposed additions of new procedure codes to the APCs; our proposal to establish a number of new APCs; and our analyses of Medicare claims data and certain recommendations of the APC Panel. We also discuss the application of the 2 times rule and proposed exceptions to it; proposed changes to specific APCs; and the proposed movement of procedures from New Technology APCs to clinical APCs.

3. Proposed OPPS Payment for Devices

In section IV. of this proposed rule, we discuss proposed payment for device-dependent APCs and the pass-through payment for specific categories of devices.

4. Proposed OPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals

In section V. of this proposed rule, we discuss the proposed CY 2008 OPPS payment for drugs, biologicals, and radiopharmaceuticals, including the proposed payment for drugs, biologicals, and radiopharmaceuticals with and without pass-through status.

5. Proposed Estimate of OPPS Transitional Pass-Through Spending for Drugs, Biologicals, and Devices

In section VI. of this proposed rule, we discuss the estimate of CY 2008 OPPS transitional pass-through spending for drugs, biologicals, and devices.

6. Proposed OPPS Payment for Brachytherapy Sources

In section VII. of this proposed rule, we discuss our proposal concerning coding and payment for brachytherapy sources.

7. Proposed OPPS Coding and Payment for Drug Administration Services

In section VIII. of this proposed rule, we set forth our proposed policy concerning coding and payment for drug administration services.

8. Proposed OPPS Hospital Coding and Payments for Visits

In section IX. of this proposed rule, we set forth our proposed changes to policies for the coding and reporting of clinic and emergency department visits and critical care services on claims paid under the OPPS.

9. Proposed OPPS Payment for Blood and Blood Products

In section X. of this proposed rule, we discuss our proposed payment for blood and blood products.

10. Proposed OPPS Payment for Observation Services

In section XI. of this proposed rule, we discuss the proposed payment policies for observation services furnished to patients on an outpatient basis.

11. Proposed Procedures That Will Be Paid Only as Inpatient Services

In section XII. of this proposed rule, we discuss the procedures that we are Start Printed Page 42635proposing to remove from the inpatient list and assign to APCs.

12. Proposed Nonrecurring Technical and Policy Changes

In section XIII. of this proposed rule, we set forth our proposals for nonrecurring technical and policy changes and clarifications relating to outpatient hospital services and supplies incident to a physician service; payment for interrupted procedures prior to and after the administration of anesthesia; transitional adjustments to payments for covered outpatient services furnished by small rural hospitals and SCHs located in rural areas; and reporting requirements for wound care services, cardiac rehabilitation services, and bone marrow and stem cell processing services.

13. Proposed OPPS Payment Status and Comment Indicators

In section XIV. of this proposed rule, we discuss proposed changes to the definitions of status indicators assigned to APCs and present our proposed comment indicators for the OPPS/ASC final rule with comment period.

14. OPPS Policy and Payment Recommendations

In section XV. of this proposed rule, we address recommendations made by MedPAC and the APC Panel regarding the OPPS for CY 2008.

15. Proposed Update of the Revised ASC Payment System

In section XVI. of this proposed rule, we discuss the proposed update of the revised ASC payment system payment rates for CY 2008. We also discuss our proposed changes to our regulations § 414.22 (b)(5)(i)(A) and (B) regarding physician payment for performing noncovered ASC surgical procedures in ASCs. In addition, we are proposing to revise the definitions of “radiology and certain other imaging services” and “outpatient prescription drugs” when provided integral to an ASC covered surgical procedure.

16. Reporting Quality Data for Annual Payment Rate Updates

In section XVII. of this proposed rule, we discuss the proposed quality measures for reporting hospital outpatient quality data for CY 2009 and subsequent years and set forth the requirements for data collection and submission for the annual payment update. We also briefly discuss the legislative provisions of the MIEA-TRHCA that give the Secretary authority to develop quality measures for reporting by ASCs.

17. Proposed Changes Affecting Necessary Provider Critical Access Hospitals (CAHs) and Hospital Conditions of Participation (CoPs)

In section XVIII. of this proposed rule, we discuss our proposed changes affecting necessary provider designations for CAHs that are being recertified when the CAH enters into a new co-location arrangement with another hospital or CAH or when the CAH creates or acquires an off-campus location. We also discuss our proposed changes relating to several hospital CoPs to require the completion of physical examinations and medical histories, and documentation in the medical records, for patients after admission and prior to surgery or a procedure requiring anesthesia services and for postanesthesia evaluations of patients before discharge or transfer from the postanesthesia recovery area.

18. Regulatory Impact Analysis

In section XXII. of this proposed rule, we set forth an analysis of the impact the proposed changes will have on affected entities and beneficiaries.

II. Proposed Updates Affecting OPPS Payments

A. Proposed Recalibration of APC Relative Weights

(If you choose to comment on issues in this section, please include the caption “APC Relative Weights” at the beginning of your comment.)

1. Database Construction

a. Database Source and Methodology

Section 1833(t)(9)(A) of the Act requires that the Secretary review and revise the relative payment weights for APCs at least annually. In the April 7, 2000 OPPS final rule with comment period (65 FR 18482), we explained in detail how we calculated the relative payment weights that were implemented on August 1, 2000, for each APC group. Except for some reweighting due to a small number of APC changes, these relative payment weights continued to be in effect for CY 2001. This policy is discussed in the November 13, 2000 interim final rule (65 FR 67824 through 67827).

We are proposing to use the same basic methodology that we described in the April 7, 2000 OPPS final rule with comment period to recalibrate the APC relative payment weights for services furnished on or after January 1, 2008, and before January 1, 2009. That is, we are proposing to recalibrate the relative payment weights for each APC based on claims and cost report data for outpatient services. We are proposing to use the most recent available data to construct the database for calculating APC group weights. For the purpose of recalibrating the proposed APC relative payment weights for CY 2008, we used approximately 131 million final action claims for hospital OPD services furnished on or after January 1, 2006, and before January 1, 2007. (For exact counts of claims used, we refer readers to the claims accounting narrative under supporting documentation for this proposed rule on the CMS Web site at http://www.cms.hhs.gov/​HospitalOutpatientPPS/​HORD/​). Of the 131 million final action claims for services provided in hospital outpatient settings, approximately 101 million claims were of the type of bill potentially appropriate for use in setting rates for OPPS services (but did not necessarily contain services payable under the OPPS). Of the 101 million claims, approximately 46 million were not for services paid under the OPPS or were excluded as not appropriate for use (for example, erroneous cost-to-charge ratios (CCRs) or no HCPCS codes reported on the claim). We were able to use approximately 50 million whole claims of the approximately 54 million claims that remained to set the OPPS APC relative weights we are proposing for the CY 2008 OPPS. From the 50 million whole claims, we created approximately 88 million single records, of which approximately 58 million were “pseudo” single claims (created from multiple procedure claims using the process we discuss in this section). Approximately 822,000 claims trimmed out on cost or units in excess of ±3 standard deviations from the geometric mean, yielding approximately 87 million single bills used for median setting. Ultimately, we were able to use for proposed CY 2008 ratesetting some portion of 92 percent of the CY 2006 claims containing services payable under the OPPS.

The proposed APC relative weights and payments for CY 2008 in Addenda A and B to this proposed rule were calculated using claims from this period that were processed before January 1, 2007, and continue to be based on the median hospital costs for services in the APC groups. We selected claims for services paid under the OPPS and matched these claims to the most recent cost report filed by the individual hospitals represented in our claims data. We continue to believe that it is appropriate to use the most current full calendar year claims data and the most Start Printed Page 42636recently submitted cost reports to calculate the median costs which we are proposing to convert to relative payment weights for purposes of calculating the CY 2008 payment rates.

b. Proposed Use of Single and Multiple Procedure Claims

For CY 2008, in general, we are proposing to continue to use single procedure claims to set the medians on which the APC relative payment weights would be based, with some exceptions as discussed below. We have received many requests asking that we ensure that the data from claims that contain charges for multiple procedures are included in the data from which we calculate the relative payment weights. Requesters believe that relying solely on single procedure claims to recalibrate APC relative payment weights fails to take into account data for many frequently performed procedures, particularly those commonly performed in combination with other procedures. They believe that if a service is frequently performed in combination with others, the individual services are more complex and more resource-intensive than if they were performed alone. Stakeholders have suggested that including data from multiple procedure claims could increase the median cost estimates for the individual services. They believe that depending upon single procedure claims alone results in basing relative payment weights on the least costly services that are not representative of the typical services, thereby introducing downward bias to the medians on which the weights are based.

We generally use single procedure claims to set the median costs for APCs because we believe that it is important that the OPPS relative weights on which payment rates are based be appropriate when one and only one procedure is furnished and because we are, so far, unable to ensure that packaged costs can be appropriately allocated across multiple procedures performed on the same date of service. We agree that, optimally, it is desirable to use the data from as many claims as possible to recalibrate the APC relative payment weights, including those claims for multiple procedures. We engaged in several efforts this year to improve our use of multiple procedure claims for ratesetting. As we have for several years, we continue to use date of service stratification and a list of codes to be bypassed to convert multiple procedure claims to “pseudo” single procedure claims. We also continued our internal efforts to better understand the patterns of services and costs from multiple bills toward the goal of using more multiple bill information by assessing the amount of packaging in the multiple bills and, specifically, by exploring the amount of packaging for drug administration services in the single and multiple bill claims. Moreover, in many cases, the proposed expansion of packaging also enables the use of more claims data by enabling us to treat claims with multiple procedure codes as single claims. We refer readers to section II.A.4. of this proposed rule for a full discussion of this proposal for CY 2008.

(1) Proposed Use of Date of Service Stratification and a Bypass List To Increase the Amount of Data Used To Determine Medians

By bypassing specified codes that we believe do not have significant packaged costs, we are able to use more data from multiple procedure claims. In many cases, this enables us to create multiple “pseudo” single claims from claims that, as submitted, contained multiple separately paid procedures on the same claim. We refer to these newly created single procedure claims as “pseudo” single claims because they were submitted by providers as multiple procedure claims. The history of our use of a bypass list to generate “pseudo” single claims is well documented, most recently in the CY 2007 OPPS/ASC final rule with comment period (71 FR 67969 through 67970).

The date of service stratification and bypass list process we used for the CY 2007 OPPS (combined with the packaging changes we are proposing in section II.A.4. of this proposed rule) resulted in our being able to use some part of approximately 92 percent of the total claims that are eligible for use in the OPPS ratesetting and modeling for this proposed rule. This process enabled us to create, for CY 2008 approximately 58 million “pseudo” singles and approximately 30 million “natural” single bills. For this proposed rule, “pseudo” single procedure bills represented 66 percent of all single bills used to calculate median costs. This compares favorably to the CY 2007 OPPS final rule data in which “pseudo” single bills represented 68 percent of all single bills used to calculate the median costs on which the CY 2007 OPPS payment rates were based. We believe that the reduction in the percent of “pseudo” single bills and the corresponding increase in the proportion of “natural” single bills occurred largely because of our proposal to increase packaging as discussed in section II.A.4. of this proposed rule. In many cases, the packaging proposal for CY 2008 enabled us to use claims that would otherwise have been considered to be multiple procedure claims and, absent the proposal for additional packaging, could have been used for ratesetting only if we had been able to create “pseudo” single claims from them.

For CY 2008, we are proposing to bypass 425 HCPCS codes that are identified in Table 1 of this proposed rule. We are proposing to continue the use of the codes on the CY 2007 OPPS bypass list but to remove codes we are proposing to package for CY 2008. We also are proposing to remove codes that were on the CY 2007 bypass list that ceased to meet the empirical criteria under the proposed packaging changes when clinical review confirmed that their removal would be appropriate in the context of the full proposal for the CY 2008 OPPS. Since the inception of the bypass list, we have calculated the percent of natural single bills that contained packaging for each code and the amount of packaging in each “natural” single bill for each code. We retained the codes on the previous year's bypass list and used the update year's data to determine whether it would be appropriate to add additional codes to the previous year's bypass list. The entire list (including the codes that remained on the bypass list from prior years) was open to public comment. For this CY 2008 proposed rule, we explicitly reviewed all “natural” single bills against the empirical criteria for all codes on the CY 2007 bypass list because of the proposal for greater packaging discussed in section II.A.4. of this proposed rule, as this effort increased the packaging associated with some codes. We removed 106 HCPCS codes from the CY 2007 bypass list for the CY 2008 proposal. We note also that many of the codes we are proposing to newly package for CY 2008 were on the bypass list used for setting the OPPS payment rates for CY 2007 and are no longer proposed for bypass because we are proposing to package them, as discussed in more detail below. We also are proposing to add to the bypass list HCPCS codes that, using the proposed rule data, meet the same previously established empirical criteria for the bypass list that are reviewed below or which our clinicians believe would have little associated packaging if the services were correctly coded.

The CY 2008 packaging proposal minimally reduced the percentage of total claims that we were able to use, in whole or in part, from 93 percent for CY 2007 to 92 percent for this proposed rule. The proposed packaging approach increased the number of “natural” single bills, in spite of reducing the Start Printed Page 42637universe of codes requiring single bills for ratesetting, but reduced the number of “pseudo” single bills. More “natural” single procedure bills can be created by the packaging of codes that always appear with another procedure because these dependent services are supportive of and ancillary to the primary independent procedures for which payment is being made. A claim containing two independent procedure codes on the same date of service and not on the bypass list previously could not be used for ratesetting, but packaging the cost of one of the codes on the claim frees the claim to be used to calculate the median cost of the procedure that is not packaged. On the other hand, our proposed packaging approach reduced the number of codes eligible for the bypass list because of the limitation on packaging set by our previously established empirical criteria. A smaller bypass list and the presence of greater packaging on claims reduced the final number of “pseudo” single claims. In prior years, roughly 68 percent of single bills were “pseudo” single bills, but based on the CY 2008 proposed rule data, 66 percent of single bills were “pseudo” singles. Moreover, the number of “natural” single bills and “pseudo” single bills are reduced by the volume of services that we are proposing to package. Hence, our CY 2008 proposal to package payment for some HCPCS codes with relatively high frequencies would eliminate for ratesetting the number of available “natural” and “pseudo” single bills attributable to the codes that we are proposing to package.

As in prior years, we are proposing to use the following empirical criteria to determine the additional codes to add to the CY 2007 bypass list to create the CY 2008 bypass list. We assume that the representation of packaging on the single claims for any given code is comparable to packaging for that code in the multiple claims:

  • There are 100 or more single claims for the code. This number of single claims ensures that observed outcomes are sufficiently representative of packaging that might occur in the multiple claims.
  • Five percent or fewer of the single claims for the code have packaged costs on that single claim for the code. This criterion results in limiting the amount of packaging being redistributed to the payable procedure remaining on the claim after the bypass code is removed and ensures that the costs associated with the bypass code represent the cost of the bypassed service.
  • The median cost of packaging observed in the single claims is equal to or less than $50. This limits the amount of error in redistributed costs.
  • The code is not a code for an unlisted service.

In addition, we are proposing to add to the bypass list codes that our clinicians believe have minimal associated packaging based on their clinical assessment of the full CY 2008 OPPS proposal. We note that this list contains bypass codes that are appropriate to claims for services in CY 2006 and, therefore, includes codes that have been deleted for CY 2007. Moreover, there are codes on the bypass list that are new for CY 2007 and which are appropriate additions to the bypass list in preparation for use of the CY 2007 claims for creation of the CY 2009 OPPS.

In order to keep the established empirical criteria for the bypass list constant, we are seeking public comment on whether we should adjust the $50 packaging cost criterion for inflation each year and, if so, recommendations for the source of the adjustment. Adding an inflation adjustment factor would ensure that the same amount of packaging associated with candidate codes for the bypass list is reviewed each year relative to nominal costs.

Table 1.—Proposed CY 2008 Bypass Codes for Creating “Pseudo” Single Claims for Calculating Median Costs

HCPCS codeShort descriptor
11056Trim skin lesions, 2 to 4.
11057Trim skin lesions, over 4.
11300Shave skin lesion.
11301Shave skin lesion.
11719Trim nail(s).
11720Debride nail, 1-5.
11721Debride nail, 6 or more.
11954Therapy for contour defects.
17003Destruct premalg les, 2-14.
31231Nasal endoscopy, dx.
31579Diagnostic laryngoscopy.
51798Us urine capacity measure.
54240Penis study.
56820Exam of vulva w/scope.
67820Revise eyelashes.
69210Remove impacted ear wax.
69220Clean out mastoid cavity.
70030X-ray eye for foreign body.
70100X-ray exam of jaw.
70110X-ray exam of jaw.
70120X-ray exam of mastoids.
70130X-ray exam of mastoids.
70140X-ray exam of facial bones.
70150X-ray exam of facial bones.
70160X-ray exam of nasal bones.
70200X-ray exam of eye sockets.
70210X-ray exam of sinuses.
70220X-ray exam of sinuses.
70250X-ray exam of skull.
70260X-ray exam of skull.
70328X-ray exam of jaw joint.
70330X-ray exam of jaw joints.
70336Magnetic image, jaw joint.
70355Panoramic x-ray of jaws.
70360X-ray exam of neck.
70370Throat x-ray & fluoroscopy.
70371Speech evaluation, complex.
70450Ct head/brain w/o dye.
70480Ct orbit/ear/fossa w/o dye.
70486Ct maxillofacial w/o dye.
70490Ct soft tissue neck w/o dye.
70544Mr angiography head w/o dye.
70551Mri brain w/o dye.
71010Chest x-ray.
71015Chest x-ray.
71020Chest x-ray.
71021Chest x-ray.
71022Chest x-ray.
71023Chest x-ray and fluoroscopy.
71030Chest x-ray.
71034Chest x-ray and fluoroscopy.
71035Chest x-ray.
71100X-ray exam of ribs.
71101X-ray exam of ribs/chest.
71110X-ray exam of ribs.
71111X-ray exam of ribs/chest.
71120X-ray exam of breastbone.
71130X-ray exam of breastbone.
71250Ct thorax w/o dye.
72010X-ray exam of spine.
72020X-ray exam of spine.
72040X-ray exam of neck spine.
72050X-ray exam of neck spine.
72052X-ray exam of neck spine.
72069X-ray exam of trunk spine.
72070X-ray exam of thoracic spine.
72072X-ray exam of thoracic spine.
72074X-ray exam of thoracic spine.
72080X-ray exam of trunk spine.
72090X-ray exam of trunk spine.
72100X-ray exam of lower spine.
72110X-ray exam of lower spine.
72114X-ray exam of lower spine.
72120X-ray exam of lower spine.
72125Ct neck spine w/o dye.
72128Ct chest spine w/o dye.
72131Ct lumbar spine w/o dye.
72141Mri neck spine w/o dye.
72146Mri chest spine w/o dye.
72148Mri lumbar spine w/o dye.
72170X-ray exam of pelvis.
72190X-ray exam of pelvis.
72192Ct pelvis w/o dye.
72202X-ray exam sacroiliac joints.
72220X-ray exam of tailbone.
73000X-ray exam of collar bone.
73010X-ray exam of shoulder blade.
73020X-ray exam of shoulder.
73030X-ray exam of shoulder.
73050X-ray exam of shoulders.
73060X-ray exam of humerus.
73070X-ray exam of elbow.
73080X-ray exam of elbow.
73090X-ray exam of forearm.
73100X-ray exam of wrist.
73110X-ray exam of wrist.
73120X-ray exam of hand.
Start Printed Page 42638
73130X-ray exam of hand.
73140X-ray exam of finger(s).
73200Ct upper extremity w/o dye.
73218Mri upper extremity w/o dye.
73221Mri joint upr extrem w/o dye.
73510X-ray exam of hip.
73520X-ray exam of hips.
73540X-ray exam of pelvis & hips.
73550X-ray exam of thigh.
73560X-ray exam of knee, 1 or 2.
73562X-ray exam of knee, 3.
73564X-ray exam, knee, 4 or more.
73565X-ray exam of knees.
73590X-ray exam of lower leg.
73600X-ray exam of ankle.
73610X-ray exam of ankle.
73620X-ray exam of foot.
73630X-ray exam of foot.
73650X-ray exam of heel.
73660X-ray exam of toe(s).
73700Ct lower extremity w/o dye.
73718Mri lower extremity w/o dye.
73721Mri jnt of lwr extre w/o dye.
74000X-ray exam of abdomen.
74010X-ray exam of abdomen.
74020X-ray exam of abdomen.
74022X-ray exam series, abdomen.
74150Ct abdomen w/o dye.
74210Contrst x-ray exam of throat.
74220Contrast x-ray, esophagus.
74230Cine/vid x-ray, throat/esoph.
74246Contrst x-ray uppr gi tract.
74247Contrst x-ray uppr gi tract.
74249Contrst x-ray uppr gi tract.
76020X-rays for bone age.
76040X-rays, bone evaluation.
76061X-rays, bone survey.
76062X-rays, bone survey.
76065X-rays, bone evaluation.
76066Joint survey, single view.
76070Ct bone density, axial.
76071Ct bone density, peripheral.
76075Dxa bone density, axial.
76076Dxa bone density/peripheral
76077Dxa bone density/v-fracture.
76078Radiographic absorptiometry.
76100X-ray exam of body section.
76400Magnetic image, bone marrow.
76510Ophth us, b & quant a.
76511Ophth us, quant a only.
76512Ophth us, b w/non-quant a.
76513Echo exam of eye, water bath.
76514Echo exam of eye, thickness.
76516Echo exam of eye.
76519Echo exam of eye.
76536Us exam of head and neck.
76645Us exam, breast(s).
76700Us exam, abdom, complete.
76705Echo exam of abdomen.
76770Us exam abdo back wall, comp.
76775Us exam abdo back wall, lim.
76778Us exam kidney transplant.
76801Ob us < 14 wks, single fetus.
76805Ob us >/= 14 wks, sngl fetus.
76811Ob us, detailed, sngl fetus.
76816Ob us, follow-up, per fetus.
76817Transvaginal us, obstetric.
76830Transvaginal us, non-ob.
76856Us exam, pelvic, complete.
76857Us exam, pelvic, limited.
76870Us exam, scrotum.
76880Us exam, extremity.
76970Ultrasound exam follow-up.
76977Us bone density measure.
76999Echo examination procedure.
77300Radiation therapy dose plan.
77301Radiotherapy dose plan, imrt.
77315Teletx isodose plan complex.
77326Brachytx isodose calc simp.
77327Brachytx isodose calc interm.
77328Brachytx isodose plan compl.
77331Special radiation dosimetry.
77336Radiation physics consult.
77370Radiation physics consult.
77401Radiation treatment delivery.
77402Radiation treatment delivery.
77403Radiation treatment delivery.
77404Radiation treatment delivery.
77407Radiation treatment delivery.
77408Radiation treatment delivery.
77409Radiation treatment delivery.
77411Radiation treatment delivery.
77412Radiation treatment delivery.
77413Radiation treatment delivery.
77414Radiation treatment delivery.
77416Radiation treatment delivery.
77418Radiation tx delivery, imrt.
77470Special radiation treatment.
77520Proton trmt, simple w/o comp.
77523Proton trmt, intermediate.
80500Lab pathology consultation.
80502Lab pathology consultation.
85097Bone marrow interpretation.
86510Histoplasmosis skin test.
86850RBC antibody screen.
86870RBC antibody identification.
86880Coombs test, direct.
86885Coombs test, indirect, qual.
86886Coombs test, indirect, titer.
86890Autologous blood process.
86900Blood typing, ABO.
86901Blood typing, Rh (D).
86903Blood typing, antigen screen.
86904Blood typing, patient serum.
86905Blood typing, RBC antigens.
86906Blood typing, Rh phenotype.
86930Frozen blood prep.
86970RBC pretreatment.
88104Cytopath fl nongyn, smears.
88106Cytopath fl nongyn, filter.
88107Cytopath fl nongyn, sm/fltr.
88108Cytopath, concentrate tech.
88112Cytopath, cell enhance tech.
88160Cytopath smear, other source.
88161Cytopath smear, other source.
88162Cytopath smear, other source.
88172Cytopathology eval of fna.
88173Cytopath eval, fna, report.
88182Cell marker study.
88184Flowcytometry/tc, 1 marker.
88185Flowcytometry/tc, add-on.
88300Surgical path, gross.
88302Tissue exam by pathologist.
88304Tissue exam by pathologist.
88305Tissue exam by pathologist.
88307Tissue exam by pathologist.
88311Decalcify tissue.
88312Special stains.
88313Special stains.
88321Microslide consultation.
88323Microslide consultation.
88325Comprehensive review of data.
88331Path consult intraop, 1 bloc.
88342Immunohistochemistry.
88346Immunofluorescent study.
88347Immunofluorescent study.
88348Electron microscopy.
88358Analysis, tumor.
88360Tumor immunohistochem/manual.
88365Insitu hybridization (fish).
88368Insitu hybridization, manual.
88399Surgical pathology procedure.
89049Chct for mal hyperthermia.
89230Collect sweat for test.
89240Pathology lab procedure.
90761Hydrate iv infusion, add-on.
90766Ther/proph/dg iv inf, add-on.
90801Psy dx interview.
90802Intac psy dx interview.
90804Psytx, office, 20-30 min.
90805Psytx, off, 20-30 min w/e&m.
90806Psytx, off, 45-50 min.
90807Psytx, off, 45-50 min w/e&m.
90808Psytx, office, 75-80 min.
90809Psytx, off, 75-80, w/e&m.
90810Intac psytx, off, 20-30 min.
90812Intac psytx, off, 45-50 min.
90816Psytx, hosp, 20-30 min.
90818Psytx, hosp, 45-50 min.
90826Intac psytx, hosp, 45-50 min.
90845Psychoanalysis.
90846Family psytx w/o patient.
90847Family psytx w/patient.
90853Group psychotherapy.
90857Intac group psytx.
90862Medication management.
92002Eye exam, new patient.
92004Eye exam, new patient.
92012Eye exam established pat.
92014Eye exam & treatment.
92020Special eye evaluation.
92081Visual field examination(s).
92082Visual field examination(s).
92083Visual field examination(s).
92135Opthalmic dx imaging.
92136Ophthalmic biometry.
92225Special eye exam, initial.
92226Special eye exam, subsequent.
92230Eye exam with photos.
92240Icg angiography.
92250Eye exam with photos.
92275Electroretinography.
92285Eye photography.
92286Internal eye photography.
92520Laryngeal function studies.
92541Spontaneous nystagmus test.
92546Sinusoidal rotational test.
92548Posturography.
92552Pure tone audiometry, air.
92553Audiometry, air & bone.
92555Speech threshold audiometry.
Start Printed Page 42639
92556Speech audiometry, complete.
92557Comprehensive hearing test.
92567Tympanometry.
92582Conditioning play audiometry.
92585Auditor evoke potent, compre.
92603Cochlear implt f/up exam 7 >.
92604Reprogram cochlear implt 7 >.
92626Eval aud rehab status.
93005Electrocardiogram, tracing.
93225ECG monitor/record, 24 hrs.
93226ECG monitor/report, 24 hrs.
93231Ecg monitor/record, 24 hrs.
93232ECG monitor/report, 24 hrs.
93236ECG monitor/report, 24 hrs.
93270ECG recording.
93271Ecg/monitoring and analysis.
93278ECG/signal-averaged.
93727Analyze ilr system.
93731Analyze pacemaker system.
93732Analyze pacemaker system.
93733Telephone analy, pacemaker.
93734Analyze pacemaker system.
93735Analyze pacemaker system.
93736Telephonic analy, pacemaker.
93741Analyze ht pace device sngl.
93742Analyze ht pace device sngl.
93743Analyze ht pace device dual.
93744Analyze ht pace device dual.
93786Ambulatory BP recording.
93788Ambulatory BP analysis.
93797Cardiac rehab.
93798Cardiac rehab/monitor.
93875Extracranial study.
93880Extracranial study.
93882Extracranial study.
93886Intracranial study.
93888Intracranial study.
93922Extremity study.
93923Extremity study.
93924Extremity study.
93925Lower extremity study.
93926Lower extremity study.
93930Upper extremity study.
93931Upper extremity study.
93965Extremity study.
93970Extremity study.
93971Extremity study.
93975Vascular study.
93976Vascular study.
93978Vascular study.
93979Vascular study.
93990Doppler flow testing.
94015Patient recorded spirometry.
94690Exhaled air analysis.
95115Immunotherapy, one injection.
95117Immunotherapy injections.
95165Antigen therapy services.
95805Multiple sleep latency test.
95806Sleep study, unattended.
95807Sleep study, attended.
95808Polysomnography, 1-3.
95812Eeg, 41-60 minutes.
95813Eeg, over 1 hour.
95816Eeg, awake and drowsy.
95819Eeg, awake and asleep.
95822Eeg, coma or sleep only.
95869Muscle test, thor paraspinal.
95900Motor nerve conduction test.
95921Autonomic nerv function test.
95925Somatosensory testing.
95930Visual evoked potential test.
95950Ambulatory eeg monitoring.
95953EEG monitoring/computer.
95970Analyze neurostim, no prog.
95972Analyze neurostim, complex.
95974Cranial neurostim, complex.
95978Analyze neurostim brain/1h.
96000Motion analysis, video/3d.
96101Psycho testing by psych/phys.
96111Developmental test, extend.
96116Neurobehavioral status exam.
96118Neuropsych tst by psych/phys.
96119Neuropsych testing by tec.
96150Assess hlth/behave, init.
96151Assess hlth/behave, subseq.
96152Intervene hlth/behave, indiv.
96153Intervene hlth/behave, group.
96415Chemo, iv infusion, addl hr.
96423Chemo ia infuse each addl hr.
96900Ultraviolet light therapy.
96910Photochemotherapy with UV-B.
96912Photochemotherapy with UV-A.
96913Photochemotherapy, UV-A or B.
96920Laser tx, skin < 250 sq cm.
98925Osteopathic manipulation.
98926Osteopathic manipulation.
98927Osteopathic manipulation.
98940Chiropractic manipulation.
98941Chiropractic manipulation.
98942Chiropractic manipulation.
99204Office/outpatient visit, new.
99212Office/outpatient visit, est.
99213Office/outpatient visit, est.
99214Office/outpatient visit, est.
99241Office consultation.
99242Office consultation.
99243Office consultation.
99244Office consultation.
99245Office consultation.
0144TCT heart wo dye; qual calc.
C8951IV inf, tx/dx, each addl hr.
C8955Chemotx adm, IV inf, addl hr.
G0008Admin influenza virus vac.
G0101CA screen;pelvic/breast exam.
G0127Trim nail(s).
G0130Single energy x-ray study.
G0166Extrnl counterpulse, per tx.
G0175OPPS Service,sched team conf.
G0332Preadmin IV immunoglobulin.
G0340Robt lin-radsurg fractx 2-5.
G0344Initial preventive exam.
G0365Vessel mapping hemo access.
G0367EKG tracing for initial prev.
G0376Smoke/tobacco counseling >10.
M0064Visit for drug monitoring.
Q0091Obtaining screen pap smear.

(2) Exploration of Allocation of Packaged Costs to Separately Paid Procedure Codes

During its August 23-24, 2006 meeting, the APC Panel recommended that CMS provide claims analysis of the contributions of packaged costs (including packaged revenue code charges and charges for packaged HCPCS codes) to the median cost of each drug administration service. (We refer readers to Recommendation #28 in the August 23-24, 2006 meeting recommendation summary on the CMS Web site at: http://www.cms.hhs.gov/​FACA/​05_​AdvisoryPanelonAmbulatoryPaymentClassificationGroups.asp#TopOfPage.) In our continued effort to better understand the multiple claims in order to extract single bill information from them, we examined the extent to which the packaging in multiple procedure claims differs from the packaging in the single procedure claims on which we base the median costs both in general and more specifically for drug administration services. We performed this analysis using the claims data on which we based the CY 2007 OPPS/ASC final rule with comment period. We examined the amount of packaging in multiple procedure versus single procedure claims in general and in claims for drug administration services in particular. We conducted this analysis without taking into account the proposed packaging approach presented in this proposed rule. However, we do not expect the services newly proposed for packaged payment to commonly appear with a drug administration service. Therefore, we believe that the analysis conducted on the CY 2007 final rule with comment period data is sufficient to inform our development of this proposed rule.

In general, we do not believe that the proportionate amount of packaged costs in the multiple bills relative to the number of primary services is greater than that in the single bills. The costs in uncoded revenue codes and HCPCS codes with a packaged status indicator account for 22 percent of observed costs in the universe of all CY 2005 claims that we used to model the CY 2007 OPPS (including both the single and multiple procedure bills). Similarly, the costs in uncoded revenue codes and HCPCS codes with a packaged status indicator account for 18 percent of the total cost in the subset of CY 2005 single bills that we used to calculate the median costs on which the relative weights are based.

However, the bypass methodology creates a “pseudo” single bill for all claims for services or items on the bypass list, and these “pseudo” single bills have no associated packaging, by definition of the application of the bypass list. Excluding the total cost associated with bypass codes, 28 percent of observed costs in the single Start Printed Page 42640bills are attributable to packaged services, and 29 percent of observed costs across all claims are attributable to packaged services. Therefore, we conclude that, in general, the extent of packaging in all bills is similar to the amount of packaging in the single procedure bills we use to set median costs for most APCs.

We recognize that aggregate numbers do not address the packaging associated with single and multiple procedure claims for specific services. We have received comments stating that the amount of packaging in the single bills for drug administration services is not representative of the typical packaged costs of these drug administration services, which are usually performed in combination with one another, because the single bills represent less complex and less resource-intensive services than the usual cases.

We published a study in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68120 through 68121) that discussed the amount of packaging on the single bills for drug administration procedure codes, and we promised to replicate that study for the APC Panel. We discussed the results of this study with the APC Panel at its March 2007 meeting, in accordance with the APC Panel's August 2006 recommendation. Table 2 below shows the drug administration HCPCS codes and their descriptors, status indicators, deleted code status, and CY 2007 APC assignments in columns 1, 2, 3, and 4, respectively. HCPCS codes for additional hours of infusion services are not presented because these codes were included on the CY 2007 bypass list and, therefore, we explicitly associated no packaged costs with them, as discussed in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68117 through 68118). Column 6 of the table contains the number of single bills relative to total occurrences of the code in the CY 2005 claims, and column 8 shows the percentage of single bills used to set payment rates. Drug administration services demonstrate reasonable single bill representation in comparison with other OPPS services. Single bills for drug administration constitute, roughly, 30 percent of all observed occurrences of drug administration services, varying by code from 7 to 55 percent. Columns 10 through 13 of the table show measures of central tendency for packaged costs as a percentage of total cost on each single claim. Columns 10 and 11 show the mean and median of all packaged costs as a percentage of total costs, and columns 12 and 13 break out the costs of packaged drug HCPCS codes and uncoded pharmacy revenue code charges for revenue codes in the 0250 series (Pharmacy), 0260 series (IV Therapy), and 0630 series (Pharmacy—Extension). These columns demonstrate that packaged costs substantially contribute to median cost estimates for the majority of drug administration HCPCS codes.

For all single bills for CPT code 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour), on average, packaged costs were 31 percent of total cost (median 27 percent). For the same code, packaged drug and pharmacy costs comprised, on average, 23 percent of total costs (median 15 percent). Single bills make up 34 percent of all line-item occurrences of the service, suggesting that this single bill median cost was fairly robust and probably captured packaging adequately. On the other hand, CPT code 90784 (Therapeutic, prophylactic or diagnostic injection (specify material injected); subcutaneous or intramuscular) demonstrates limited packaging (median 0 percent and mean 17 percent), and the median cost for the code is derived from only 7 percent of all occurrences of the code. Across all drug administration codes, over half show significant median packaged costs largely attributable to packaged drug and pharmacy costs.

Table 2.—Packaged Cost Data for CY 2005 Single Claims for Drug Administration Services

HCPCS codeShort descriptorSIDeleted codeAPCSingle billsTotal frequencyPercent single billsMedian cost ($)All packaged costs as a percent of total costPackaged drug and pharmacy costs as a percent of total cost
MedianMeanMedianMean
(1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)
90780IV infusion therapy, 1 hourSX04401,008,0552,974,78533.9110.4327.130.815.322.6
90782Injection, sc/imSX04371,326,0942,894,23145.824.770.010.10.08.7
90783Injection, iaSX04384273,01214.251.350.010.90.06.8
90784Injection, ivSX0438183,0962,812,2046.549.540.016.70.09.7
90788Injection of antibioticSX043719,400141,29313.745.9624.632.320.730.4
96400Chemotherapy, sc/imS043857,47281,54670.551.980.06.30.04.5
96405Chemo intralesional, up to 7S043814218178.5193.650.012.00.010.5
96406Chemo intralesional over 7S04382728.646.420.00.00.00.0
96408Chemotherapy, push techniqueS043921,113134,44715.796.8510.621.32.413.6
96410Chemotherapy, infusion methodS0441161,872555,17029.2151.5521.427.012.419.6
96414Chemo, infuse method add-onS04412,37014,56116.3182.8915.423.08.615.6
96420Chemo, ia, push tecniqueS043917093318.299.869.627.64.215.4
96422Chemo ia infusion up to 1 hrS04415561,81430.7162.9445.946.531.035.1
96425Chemotherapy, infusion methodS044114955726.8216.6829.433.514.724.4
96440Chemotherapy, intracavitaryS04393810436.537.120.02.10.01.5
96445Chemotherapy, intracavitaryS04394313731.461.9823.825.023.721.1
96450Chemotherapy, into CNSS044139486945.3160.0325.828.72.08.3
96520Port pump refill & mainS04409,77123,92840.8140.6629.031.516.823.6
96530Syst pump refill & mainS04408,33419,28343.2100.007.422.20.713.7
96542Chemotherapy injectionS043851192955.051.560.010.80.06.5

By definition, we are unable to precisely assess the amount of packaging associated with drug administration codes in the multiple bills. As a proxy, we estimated packaging as a percent of total cost on Start Printed Page 42641each claim for two subsets of claims. Both analyses suggest the presence of moderate packaged costs, especially drug and pharmacy costs, associated with drug administration services in the multiple bills. Table 3 below shows measures of central tendency for packaging percentages in the multiple bills or portions of multiple bills remaining after “pseudo” singles have been created. We refer to this group of the multiple bills as the “hardcore” multiple bills. For the first subset of “hardcore” multiple bills with only drug administration codes, that is, where multiple drug administration codes are the only separately paid procedure codes on the claim (defined as procedure codes with a status indicator of “S,” “T,” “V,” “X,” or “P”), we estimate that packaged costs are 22 percent of total costs (27 percent, on average), where total costs consist of costs for all payable codes. Costs for packaged drug HCPCS codes and pharmacy revenue codes comprise 13 percent of total cost at the median (19 percent, on average). For the second subset of “hardcore” multiple bills with any drug administration code, that is, where a drug administration code appears with other payable codes (largely radiology services and visits), we estimate packaged costs are 13 percent of total cost at the median (19 percent, on average). Costs for packaged drugs and pharmacy revenue codes comprise 6 percent of total cost at the median (10 percent, on average). The amount of packaging in both proxy measures, but especially the first subset, closely resembles the packaged costs as a percentage of drug administration costs observed in the single bills for drug administration services. While finding a way to accurately use data from the “hardcore” multiple bills to estimate drug administration median costs undoubtedly would impact medians, these comparisons suggest that the multiple bill data probably would support current median estimates.

Table 3.—Packaged Costs on Multiple Bill Claims for Drug Administration Services

Total frequencyAll packaged costs as a percent of total costPackaged drug and pharmacy costs as a percent of total cost
MedianMeanMedianMean
Subset 1: “Hardcore” Multiple Claims with Only Drug Administration Codes
693,92521.626.812.719.3
Subset 2: “Multiple” Claims with At Least One Drug Administration Code
4,816,33813.219.45.810.0

We have received several comments over the past few years offering algorithms for packaging the costs associated with specific revenue codes or packaged drugs with certain drug administration codes. Because of the complexity of even routine OPPS claims, prior research suggests that such algorithms have limited power to generate additional single bill claims and do little to change median cost estimates. We continue to look for simple, but powerful, methodologies like the bypass list and packaging of HCPCS codes for additional ancillary and supportive services to assign packaged costs to all services within the “hardcore” multiple bills. Ideally, these methodologies should be intuitive to the provider community, easily integrated into the complexity of OPPS median cost estimation, and simple to maintain from year to year. We solicit and will carefully consider methodologies for creation of single bills that meet these criteria.

c. Proposed Calculation of CCRs

We calculate hospital-specific overall CCRs and hospital-specific departmental CCRs for each hospital for which we have claims data in the period of claims being used to calculate the median costs that we convert to scaled relative weights for purposes of setting the OPPS payment rates. We apply the hospital-specific CCR to the hospital's charges at the most detailed level possible, based on a revenue code-to-cost center crosswalk that contains a hierarchy of CCRs used to estimate costs from charges for each revenue code. That crosswalk is available for review and continuous comment on the CMS Web site at: http://www.cms.hhs.gov/​HospitalOutpatientPPS/​03_​crosswalk.asp#TopOfPage. Comments on the proposed configuration of the crosswalk for CY 2008 should be included with comments on this section of this proposed rule. We calculate CCRs for the standard and nonstandard cost centers accepted by the electronic cost report database. In general, the most detailed level at which we calculate CCRs is the hospital-specific departmental level.

Following the expiration of most medical devices from pass-through status in CY 2003, prior to which devices were paid at charges reduced to cost using the hospital's overall CCR, we received comments that our OPPS cost estimates for device implantation procedures systematically underestimate the cost of the devices included in the packaged payment for the procedures. Commenters informed us that hospitals routinely mark up charges for low cost items to a much greater extent than they mark up high cost items, and that these items are often combined in a single cost center on their Medicare cost report. Commenters stated that when items with widely varying costs are combined in a single cost center using that cost center's CCR to estimate costs from charges for those items, this approach will overestimate the cost of low cost items and underestimate the cost of high cost items. This is commonly known as “charge compression.” They stated that, in the case of implantable devices, the charges for both high cost devices and low cost supplies typically are reported under the medical supply revenue code series and that the costs of both typically are reported in the medical supply cost center on the cost report. Commenters stated that the application of one medical supply CCR to charges for all items reported under the medical supply revenue code underestimates the cost of expensive medical supplies and overestimates the cost of inexpensive supplies. They indicated that when these costs are packaged into the costs of the procedures in which they are used, the result is inaccurate median costs for the HCPCS codes and APCs, and thus the standard OPPS ratesetting methodology systematically distorts Start Printed Page 42642relative payment weights for procedures using devices.

In CY 2006, the device industry commissioned a study to interpolate a device-specific CCR from the medical supply CCR, using publicly available hospital claim and Medicare cost report data rather than proprietary data on device costs. After reviewing the device industry's data analysis and study model, CMS contracted with RTI International (RTI) to study the impact of charge compression on the cost-based weight methodology adopted in the FY 2007 IPPS final rule, to evaluate this model and to propose solutions. For more information, interested individuals can view RTI's report on the CMS Web site at: http://www.cms.hhs.gov/​reports/​downloads/​Dalton.pdf.

Any study of cost estimation in general, and charge compression specifically, has obvious importance for both the OPPS and the IPPS. RTI's research explicitly focused on the IPPS for several reasons, which include greater Medicare expenditure under the IPPS, a desire to evaluate the model quickly given IPPS regulation deadlines, and a focus on other components of the new FY 2007 IPPS cost-based weight methodology (CMS Contract No. 500-00-0024-T012, “A Study of Charge Compression in Calculating DRG Relative Weights,” page 5). The study first addressed the possibility of cross-aggregation bias in the CCRs used to estimate costs under the IPPS created by the IPPS methodology of aggregating cost centers into larger departments before calculating CCRs. The report also addressed potential bias created by estimating costs using a CCR that reflects the combined costs and charges of services with wide variation in the amount of hospital markup. In its assessment of the latter, RTI targeted its attempt to identify the presence of charge compression to those cost centers presumably associated with revenue codes demonstrating significant IPPS expenditures and utilization. RTI assessed the correlation between cost report CCRs and the percent of charges in a cost center attributable to a set of similar services represented by a group of revenue codes. RTI did not examine the correlation between CCRs and revenue codes without significant IPPS expenditures or a demonstrated concentration in a specific Diagnosis Related Group (DRG). For example, RTI did not examine revenue code groups within the pharmacy cost center with low proportionate inpatient charges that might be important to the OPPS, such as “Pharmacy Incident to Radiology.” RTI states this limitation in its study and specifically recommends that disaggregated CCRs be reestimated for outpatient hospital charges.

Cost report CCRs combine both inpatient and outpatient services. Ideally, RTI would be able to examine the correlation between CCRs for Medicare inpatient services and inpatient claim charges and the correlation between CCRs for Medicare outpatient services and outpatient claim charges. However, the comprehensive nature of the cost report CCR (which combines inpatient and outpatient services) argues for an analysis of the correlation between CCRs and combined inpatient and outpatient claim charges. As noted, the RTI study accepted some measurement error in its analysis by matching an “all charges” CCR to inpatient estimates of charges for groups of similar services represented by revenue codes because of short timelines and because inpatient costs dominate outpatient costs in many ancillary cost centers. We believe that CCR adjustments used to calculate payment should be based on the comparison of cost report CCRs to combined inpatient and outpatient charges. An “all charges” model would reduce measurement error and estimate adjustments to disaggregated CCRs that could be used in both hospital inpatient and outpatient payment systems.

RTI made several short-term recommendations for improving the accuracy of DRG weight estimates from a cost-based methodology to address bias in combining cost centers and charge compression that could be considered in the context of OPPS policy. We discuss each recommendation within the context of the OPPS and provide our assessment of its application to the OPPS. We do not discuss RTI's recommendations to change cost report policy, which, by definition, would not have an effect on payment weight estimates until several years in the future.

(1) RTI recommends expansion of the number of CCRs used under the IPPS (RTI study, pages 11 and 85). Our OPPS methodology is already more specific than the RTI recommendation. To the extent possible, the OPPS uses hospital-specific cost centers, both standard and nonstandard, to reduce charges to estimated costs and, therefore, the OPPS ratesetting methodology is already more specific than the RTI recommendation.

(2) RTI recommends disaggregation of emergency department and blood products from the “other services” CCR used in the IPPS (RTI study, pages 11 and 85). Because we use standard and nonstandard cost center data, our OPPS methodology already comports with this RTI recommendation. Further, we estimate a CCR for blood that is often higher than that in the cost report based on a special methodology that is discussed further in section X of this proposed rule. Therefore, the OPPS is already meeting, and in several cases exceeding, the RTI recommendation for specificity with regard to estimating the costs associated with emergency department and blood product services.

(3) RTI recommends reclassification of intermediate care charges from the intensive care unit to the routine cost center (RTI study, pages 10 and 85). This recommendation is not relevant to the OPPS because our methodology for calculating costs under the OPPS relies solely on ancillary cost centers and does not use either cost center included in the recommendation to estimate costs for hospital outpatient services.

(4) RTI recommends establishment of regression-based estimates as a temporary or permanent method for disaggregating national average CCRs for medical supplies, drugs, and radiology services under the IPPS (RTI study, pages 11 and 86). With regard to radiology services, RTI estimated significantly lower CCRs for the cost centers for computed tomography (CT) scans and magnetic resonance imaging (MRI) services. RTI triangulated its findings with lower observed CCRs for the one-third of providers reporting nonstandard cost centers, specifically MRI Scan and CT Scan. However, in using CCRs for nonstandard cost centers, including MRI Scan and CT Scan, the OPPS already has partially implemented RTI's recommendation to use lower CCRs to estimate costs for those OPPS services allocated to these two imaging cost centers.

For reasons discussed in more detail below, we are proposing to develop an all-charges model that would compare variation in CCRs with variation in combined inpatient and outpatient charges for sets of similar services and establish disaggregated CCRs that could be applied to both inpatient and outpatient charges. We are proposing to evaluate the results of that methodology for purposes of determining whether the resulting disaggregated CCRs should be proposed for use in developing the CY 2009 OPPS payment rates. The revised all-charges model and resulting disaggregated CCRs will not be available in time for use in the CY 2008 OPPS/ASC final rule with comment period.

There are several reasons that we are not proposing to use the intradepartmental CCRs that RTI estimated using IPPS charges for the CY 2008 OPPS estimation of median costs. We agree with RTI that the Start Printed Page 42643intradepartmental CCRs it calculated for the IPPS would not always be appropriate for application to the OPPS (RTI study, pages 34 and 35). While RTI recommends that the model be recalibrated for outpatient charges before it is applied to the OPPS, we believe that the combined nature of the CCRs available from the cost report prevents an accurate outpatient recalibration that would be appropriate for the OPPS alone. The addition of outpatient charges could change the variability of combined charges for some groups of services. For example, if hospitals use a high volume of less complex devices with lower charges in the outpatient department, the inclusion or omission of the outpatient charges for these high volume and lower cost devices could change the estimated disaggregated device CCR. Furthermore, RTI's analysis excluded some revenue codes with extensive outpatient charges because these revenue codes play a minor role in the IPPS. Therefore, we believe that an all-charges model examining an expanded subset of revenue codes is most appropriate, and that this model must be developed before we could apply the resulting disaggregated CCRs to the charges for supplies paid under the OPPS.

Moreover, to implement the disaggregated IPPS-based CCRs in the OPPS that RTI estimated for CY 2008 could result in greater instability in relative payment weights for CY 2008 than would otherwise occur. Significant changes in CCRs, both increases and decreases, could prompt the reassignment of services to different APCs due to the new estimates of median costs and require modification of the overall APC structure. Not only might there be significant fluctuations in payment between the CY 2007 and CY 2008 OPPS, but a subsequent change to application of the disaggregated CCRs resulting from development of an all-charges model might also result in significant fluctuations in median costs and increased instability in payments from CY 2008 to CY 2009. Therefore, these sequential changes could result in significant increases in median costs in one year and significant declines in median costs in the next year.

Therefore, we are not proposing to adopt the RTI disaggregated CCRs under the CY 2008 OPPS. We will consider whether it would be appropriate to adopt disaggregated CCRs for the OPPS after we analyze the results of the use of both inpatient and outpatient charges across all payers to recalculate disaggregated CCRs.

2. Proposed Calculation of Median Costs

In this section of this proposed rule, we discuss the use of claims to calculate the proposed OPPS payment rates for CY 2008. The hospital OPPS page on the CMS Web site on which this proposed rule is posted provides an accounting of claims used in the development of the proposed rates on the CMS Web site at: http://www.cms.hhs.gov/​HospitalOutpatientPPS. The accounting of claims used in the development of this proposed rule is included on the Web site under supplemental materials for the CY 2008 proposed rule. That accounting provides additional detail regarding the number of claims derived at each stage of the process. In addition, below we discuss the files of claims that comprise the data sets that are available for purchase under a CMS data user contract. Our CMS Web site, http://www.cms.hhs.gov/​HospitalOutpatientPPS, includes information about purchasing the following two OPPS data files: “OPPS Limited Data Set” and “OPPS Identifiable Data Set.”

We used the following methodology to establish the relative weights we are proposing to use in calculating the OPPS payment rates for CY 2008 shown in Addenda A and B to this proposed rule. This methodology is as follows:

We used outpatient claims for the full CY 2006, processed before January 1, 2007, to set the proposed relative weights for CY 2008. To begin the calculation of the relative weights for CY 2008, we pulled all claims for outpatient services furnished in CY 2006 from the national claims history file. This is not the population of claims paid under the OPPS, but all outpatient claims (including, for example, CAH claims and hospital claims for clinical laboratory services for persons who are neither inpatients nor outpatients of the hospital).

We then excluded claims with condition codes 04, 20, 21, and 77. These are claims that providers submitted to Medicare knowing that no payment will be made. For example, providers submit claims with a condition code 21 to elicit an official denial notice from Medicare and document that a service is not covered. We then excluded claims for services furnished in Maryland, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands because hospitals in those geographic areas are not paid under the OPPS.

We divided the remaining claims into the three groups shown below. Groups 2 and 3 comprise the 101 million claims that contain hospital bill types paid under the OPPS.

1. Claims that were not bill types 12X, 13X, 14X (hospital bill types), or 76X (CMHC bill types). Other bill types are not paid under the OPPS and, therefore, these claims were not used to set OPPS payment.

2. Claims that were bill types 12X, 13X, or 14X (hospital bill types). These claims are hospital outpatient claims.

3. Claims that were bill type 76X (CMHC). (These claims are later combined with any claims in item 2 above with a condition code 41 to set the per diem partial hospitalization rate determined through a separate process.)

For the CCR calculation process, we used the same general approach as we used in developing the final APC rates for CY 2007, using the revised CCR calculation which excluded the costs of paramedical education programs and weighted the outpatient charges by the volume of outpatient services furnished by the hospital. We refer readers to the CY 2007 OPPS/ASC final rule with comment period for more information (71 FR 67983 through 67985). We first limited the population of cost reports to only those for hospitals that filed outpatient claims in CY 2006 before determining whether the CCRs for such hospitals were valid.

We then calculated the CCRs for each cost center and the overall CCR for each hospital for which we had claims data. We did this using hospital-specific data from the Healthcare Cost Report Information System (HCRIS). We used the most recent available cost report data, in most cases, cost reports for CY 2005. We used the most recently submitted cost report to calculate the CCRs to be used to calculate median costs for the proposed CY 2008 OPPS rates. If the most recent available cost report was submitted but not settled, we looked at the last settled cost report to determine the ratio of submitted to settled cost using the overall CCR, and we then adjusted the most recent available submitted but not settled cost report using that ratio. We calculated both an overall CCR and cost center-specific CCRs for each hospital. We used the overall CCR calculation discussed in section II.A.1.c. of this proposed rule for all purposes that require use of an overall CCR.

We then flagged CAH claims, which are not paid under the OPPS, and claims from hospitals with invalid CCRs. The latter included claims from hospitals without a CCR; those from hospitals paid an all-inclusive rate; those from hospitals with obviously erroneous CCRs (greater than 90 or less than .0001); and those from hospitals with Start Printed Page 42644overall CCRs that were identified as outliers (3 standard deviations from the geometric mean after removing error CCRs). In addition, we trimmed the CCRs at the cost center (that is, departmental) level by removing the CCRs for each cost center as outliers if they exceeded ±3 standard deviations from the geometric mean. We used a four-tiered hierarchy of cost center CCRs to match a cost center to every possible revenue code appearing in the outpatient claims, with the top tier being the most common cost center and the last tier being the default CCR. If a hospital's cost center CCR was deleted by trimming, we set the CCR for that cost center to “missing,” so that another cost center CCR in the revenue center hierarchy could apply. If no other cost center CCR could apply to the revenue code on the claim, we used the hospital's overall CCR for the revenue code in question. For example, if a visit was reported under the clinic revenue code, but the hospital did not have a clinic cost center, we mapped the hospital-specific overall CCR to the clinic revenue code. The hierarchy of CCRs is available for inspection and comment on the CMS Web site: http://www.cms.hhs.gov/​HospitalOutpatientPPS.

We then converted the charges to costs on each claim by applying the CCR that we believed was best suited to the revenue code indicated on the line with the charge. Table 4 of this proposed rule contains a list of the allowed revenue codes. Revenue codes not included in Table 4 are those not allowed under the OPPS because their services cannot be paid under the OPPS (for example, inpatient room and board charges), and thus charges with those revenue codes were not packaged for creation of the OPPS median costs. One exception is the calculation of median blood costs, as discussed in section X. of this proposed rule.

Thus, we applied CCRs as described above to claims with bill types 12X, 13X, or 14X, excluding all claims from CAHs and hospitals in Maryland, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands and claims from all hospitals for which CCRs were flagged as invalid.

We identified claims with condition code 41 as partial hospitalization services of hospitals and moved them to another file. These claims were combined with the 76X claims identified previously to calculate the partial hospitalization per diem rate.

We then excluded claims without a HCPCS code. We moved to another file claims that contained nothing but influenza and pneumococcal pneumonia (“PPV”) vaccines. Influenza and PPV vaccines are paid at reasonable cost and, therefore, these claims are not used to set OPPS rates. We note that the separate file containing partial hospitalization claims is included in the files that are available for purchase as discussed above. Unlike years past, we did not create a separate file of claims containing observation services because we are proposing to package all observation care for the CY 2008 OPPS.

We next copied line-item costs for drugs, blood, and devices (the lines stay on the claim, but are copied onto another file) to a separate file. No claims were deleted when we copied these lines onto another file. These line-items are used to calculate a per unit mean and median and a per day mean and median for drugs, radiopharmaceutical agents, blood and blood products, and devices, including, but not limited to, brachytherapy sources, as well as other information used to set payment rates, such as a unit-to-day ratio for drugs.

We then divided the remaining claims into the following five groups:

1. Single Major Claims: Claims with a single separately payable procedure (that is, status indicator “S,” “ T,” “V,” or “X”).

2. Multiple Major Claims: Claims with more than one separately payable procedure (that is, status indicator “S,” “T,” “V,” or “X”), or multiple units for one payable procedure. As discussed below, some of these can be used in median setting. We also included in this set claims that contain one unit of one code when the bilateral modifier is appended to the code and the code is one that is conditionally or independently bilateral. In these cases, these claims represent more than one unit of the service described by the code, notwithstanding that only one unit is billed.

3. Single Minor Claims: Claims with a single HCPCS code that is assigned to status indicator “F,” “G,” “H,” “K,” “L,” or “N.”

4. Multiple Minor Claims: Claims with multiple HCPCS codes that are assigned to status indicator “F,” “G,” “H,” “K,” “L,” or “N.”

5. Non-OPPS Claims: Claims that contain no services payable under the OPPS (that is, all status indicators other than those listed for major or minor status). These claims are excluded from the files used for the OPPS. Non-OPPS claims have codes paid under other fee schedules, for example, durable medical equipment or clinical laboratory tests, and do not contain either a code for a separately paid service or a code for a packaged service.

We use status indicator “Q” in Addendum B to this proposed rule to identify services that receive separate HCPCS code-specific payment when specific criteria are met, and payment for the individual service is packaged in all other circumstances. We are proposing several different sets of criteria to determine whether separate payment would be made for specific services. For example, HCPCS code G0379 (Direct admission of patient for hospital observation care) is assigned to status indicator “Q” in Addendum B to this proposed rule because we are proposing that it receive separate payment only if it is billed on the same date of service as HCPCS code G0378 (Hospital observation service, per hour), without any services with status indicator “T” or “V,” or Critical Care (APC 0617). Proposed payment for observation services is discussed in section XI. of this proposed rule. The specific services in the proposed composite APCs discussed in section II.A.4. of this proposed rule also are assigned to status indicator “Q” in Addendum B to this proposed rule because we are proposing that their payment would be bundled into a single composite payment for a combination of major procedures under certain circumstances. These services would only receive separate code-specific payment if certain criteria are met. The same is true for those less intensive outpatient mental health treatment services for which payment is limited to the partial hospitalization per diem rate and which also are assigned to status indicator “Q” in Addendum B to this proposed rule. According to longstanding OPPS payment policy (65 FR 18455), payment for these individual mental health services is bundled into a single payment, APC 0034 (Mental Health Services Composite), when the sum of the individual mental health service payments for all of these mental health services provided on the same day would exceed payment for a day of partial hospitalization services. However, the largest number of specific HCPCS codes identified by status indicator “Q” in Addendum B to this proposed rule are those codes that we identify as “special” packaged codes, where we are proposing that a service receives separate payment when it appears on the same day on a claim without another service that is assigned to status indicator “S,” “T,” “V,” or “X.” We are proposing to package payment for these HCPCS codes when the code appears on the same date of service with any other service that is Start Printed Page 42645assigned to status indicator “S,” “T,” “V,” or “X.”

This last and largest subset of conditionally packaged services have to be integrated into the identification of single and multiple bills to ensure that the costs for these services are appropriately packaged when they appear with any other separately paid service. We handle these conditionally packaged services in the data by assigning the HCPCS code an APC and a data status indicator of “N.” When the conditionally packaged HCPCS code appears with a HCPCS code with a status indicator of “S,” “T,” “V,” or “X” on the same date of service, it is treated as a packaged code. The costs that appear on the line with the code are packaged into the cost of the HCPCS code with a status indicator of “S,” “T,” “V,” or “X.” When the conditionally packaged HCPCS code appears by itself, we change the status indicator on the line to the status indicator of the APC to which the conditionally packaged code is assigned, converting the service from a minor to a major procedure. This creates single bills for these conditionally packaged services that are then used to set the median cost for the conditionally packaged code and for the APC to which it is assigned when it is separately paid.

The claims listed in numbers 1, 2, 3, and 4 above are included in the data files that can be purchased as described above.

In years prior to the CY 2007 OPPS, we made a determination of whether each HCPCS code was a major code or a minor code or a code other than a major or minor code. We used those code-specific determinations to sort claims into the five groups identified above. For the CY 2007 OPPS, we used status indicators to sort the claims into these groups. We defined major procedures as any procedure having a status indicator of “S,” “T,” “V,” or “X;” defined minor procedures as any code having a status indicator of “N;” and classified “other” procedures as any code having a status indicator other than “S,” “T,” “V,” “X,” or “N.” For the CY 2007 OPPS proposed rule limited data set and identifiable data set, these definitions excluded claims on which hospitals billed drugs and devices without also billing separately paid procedure codes and, therefore, these public use files did not contain all claims used to calculate the drug and device frequencies and medians. We corrected this for the CY 2007 OPPS/ASC final rule with comment period limited data set and identifiable data set by extracting claims containing drugs and devices from the set of “other” claims and adding them to the public use files.

At its March 2007 meeting, the APC Panel recommended that CMS edit and return for correction claims that contain a HCPCS code for a separately paid drug or device but that also do not contain a HCPCS code assigned to a procedural APC (that is, those not assigned status indicator “S,” “T,” “V,” or “X”). The APC Panel stated that this edit should improve the claims data and may increase the number of single bills available for ratesetting. We note that such an edit would be broader than the device-to-procedure code edits we implemented for CY 2007 for selected devices. While we encourage hospitals to code correctly in accordance with CPT, CMS, and local contractor guidance, in general we have historically implemented claims processing edits under the OPPS when we believe that these edits help ensure complete claims data for ratesetting. In the case of such Outpatient Code Editor (OCE) edits for drugs and devices that are separately paid, it is unclear to us that these edits would improve our claims data for median cost calculation because the items receive separate payment and do not result in multiple procedure claims when they are reported. We also are uncertain about the clinical circumstances that could result in a hospital submitting an OPPS claim that only reported a separately paid drug or device. We are soliciting comments specifically on the impact of establishing such edits on hospital billing processes and on related potential improvements to claims data used for median setting.

Therefore, in view of the prior public comments and our desire to ensure that the public data files contain all appropriate data, for the CY 2008 OPPS, we are proposing to define major procedures as HCPCS codes that have a status indicator of “S,” “T,” “V,” or “X.” We are proposing to define minor procedures as HCPCS codes that have a status indicator of “F,” “G,” “H,” “K,” “L,” or “N” but, as we discuss above, to make single bills out of any claims for single procedures with a minor code that also has an APC assignment. This ensures that the claims that contain only codes for drugs and biologicals or devices but that do not contain codes for procedures are included in the limited data set and the identifiable data set. It also ensures, as discussed above, that conditionally packaged services that receive separate payment only when they are billed without any other separately payable OPPS services are treated appropriately for purposes of median cost calculations. We are proposing to define “other” services as HCPCS codes that have a status indicator other than those defined as major or minor procedures.

We continue to believe that using status indicators, with the proposed changes, is an appropriate way to sort the claims into these groups and also to make our process more transparent to the public. We further believe that this proposed method of sorting claims would enhance the public's ability to derive useful information for analysis and public comment on this proposed rule.

We set aside the single minor, multiple minor, and non-OPPS claims (numbers 3, 4, and 5 above) because we did not use these claims in calculating median costs of procedural APCs. We then examined the multiple major claims for dates of service to determine if we could break them into single procedure claims using the dates of service on all lines on the claim. If we could create claims with single major procedures by using date of service, we created a single procedure claim record for each separately paid procedure on a different date of service (that is, a “pseudo” single).

We then used the bypass codes listed in Table 1 of this proposed rule and discussed in section II.A.1.b. of this proposed rule to remove separately payable procedures that we determined contain limited costs or no packaged costs or were otherwise suitable for inclusion on the bypass list from a multiple procedure bill. When one of the two separately payable procedures on a multiple procedure claim was on the bypass list, we split the claim into two “pseudo” single procedure claims records. The single procedure claim record that contained the bypass code did not retain packaged services. The single procedure claim record that contained the other separately payable procedure (but no bypass code) retained the packaged revenue code charges and the packaged HCPCS code charges.

We also removed lines that contained multiple units of codes on the bypass list and treated them as “pseudo” single claims by dividing the cost for the multiple units by the number of units on the line. Where one unit of a single, separately paid procedure code remained on the claim after removal of the multiple units of the bypass code, we created a “pseudo” single claim from that residual claim record, which retained the costs of packaged revenue codes and packaged HCPCS codes. This enabled us to use claims that would otherwise be multiple procedure claims and could not be used. We excluded those claims that we were not able to Start Printed Page 42646convert to single claims even after applying all of the techniques for creation of “pseudo” singles. Among those excluded were claims that contain codes that are viewed as independently or conditionally bilateral and that contain the bilateral modifier (Modifier 50, Bilateral procedure) because the line-item cost for the code represents the cost of two units of the procedure, notwithstanding that the code appears with a unit of one. Therefore, the charge on the line represents the charge for two services rather than a single service and using the line as reported would overstate the cost of a single procedure. We then packaged the costs of packaged HCPCS codes (codes with status indicator “N” listed in Addendum B to this proposed rule) and packaged revenue codes into the cost of the single major procedure remaining on the claim.

The list of packaged revenue codes is shown in Table 4 of this proposed rule. At its March 2007 meeting the APC Panel recommended that CMS review the final list of packaged revenue codes for consistency with OPPS policy and ensure that future versions of the OCE edit accordingly. We compared the packaged revenue codes in the OCE to the finalized list of packaged revenue codes for the CY 2007 OPPS (71 FR 67989 through 67990) that we used for packaging costs in median calculation. As a result of that analysis, we are accepting the APC Panel's recommendation and we are proposing to change the list of packaged revenue codes for the CY 2008 OPPS in the following manner. First, we are proposing to remove revenue codes 0274 (Prosthetic/Orthotic devices) and 0290 (Durable Medical Equipment) from the list of packaged revenue codes because we do not permit hospitals to report implantable devices in these revenue codes (Internet Only Manual 100-4, Chapter 4, section 20.5.1.1). We also are proposing to add revenue code 0273 (Take Home Supplies) to the list of packaged revenue codes because we believe that the charges under this revenue code are for the incidental supplies that hospitals sometimes provide for patients who are discharged at a time when it is not possible to secure the supplies needed for a brief time at home. We are proposing to conform the list of packaged revenue codes in the OCE to the OPPS for CY 2008.

We packaged the costs of the HCPCS codes that are shown with status indicator “N” into the cost of the independent service to which the packaged service is ancillary or supportive. We refer readers to section II.A.4. of this proposed rule for a more complete discussion of the packaging changes we are proposing for CY 2008.

After removing claims for hospitals with error CCRs, claims without HCPCS codes, claims for immunizations not covered under the OPPS, and claims for services not paid under the OPPS, approximately 54 million claims were left. Of these 54 million claims, we were able to use some portion of approximately 50 million whole claims (92 percent of approximately 54 million potentially usable claims) to create approximately 88 million single and “pseudo” single claims, of which we used 87 million single bills (after trimming out just over 822,000 claims as discussed below) in the CY 2008 median development and for ratesetting.

We also excluded (1) claims that had zero costs after summing all costs on the claim and (2) claims containing packaging flag number 3. Effective for services furnished on or after July 1, 2004, the OCE assigns packaging flag number 3 to claims on which hospitals submit token charges for a service with status indicator “S” or “T” (a major separately paid service under the OPPS) for which the fiscal intermediary is required to allocate the sum of charges for services with a status indicator equaling “S” or “T” based on the weight for the APC to which each code is assigned. We do not believe that these charges, which were token charges as submitted by the hospital, are valid reflections of hospital resources. Therefore, we deleted these claims. We also deleted claims for which the charges equal the revenue center payment (that is, the Medicare payment) on the assumption that where the charge equals the payment, to apply a CCR to the charge would not yield a valid estimate of relative provider cost.

For the remaining claims, we then standardized 60 percent of the costs of the claim (which we have previously determined to be the labor-related portion) for geographic differences in labor input costs. We made this adjustment by determining the wage index that applied to the hospital that furnished the service and dividing the cost for the separately paid HCPCS code furnished by the hospital by that wage index. As has been our policy since the inception of the OPPS, we are proposing to use the pre-reclassified wage indices for standardization because we believe that they better reflect the true costs of items and services in the area in which the hospital is located than the post-reclassification wage indices and, therefore, would result in the most accurate unadjusted median costs.

We also excluded claims that were outside 3 standard deviations from the geometric mean of units for each HCPCS code on the bypass list (because, as discussed above, we used claims that contain multiple units of the bypass codes).

We used the remaining claims to calculate the CY 2008 proposed median costs for each separately payable HCPCS code and each APC. The comparison of HCPCS and APC medians determines the applicability of the “2 times” rule. Section 1833(t)(2) of the Act provides that, subject to certain exceptions, the items and services within an APC group cannot be considered comparable with respect to the use of resources if the highest median (or mean cost, if elected by the Secretary) for an item or service in the group is more than 2 times greater than the lowest median cost for an item or service within the same group (“the 2 times rule”). Finally, we reviewed the medians and reassigned HCPCS codes to different APCs where we believed that it was appropriate. Section III. of this proposed rule includes a discussion of certain proposed HCPCS code assignment changes that resulted from examination of the medians and for other reasons. The APC medians were recalculated after we reassigned the affected HCPCS codes. Both the HCPCS medians and the APC medians were weighted to account for the inclusion of multiple units of the bypass codes in the creation of “pseudo” single bills.

In our review of median costs for HCPCS codes and their assigned APCs, we have frequently noticed that some services are consistently rarely performed in the hospital outpatient setting for the Medicare population. In particular, there are a number of services, such as several procedures related to the care of pregnant women, that have annual Medicare claims volume of 100 or fewer occurrences. By definition, these services also have a small number of single bills from which to estimate median costs. In addition, in some cases, these codes have been historically assigned to clinical APCs where all the services are low volume. Therefore, the median costs for these services and APCs often fluctuate from year to year, in part due to the variability created by such a small number of claims. One of the benefits of basing payment on the median cost of many HCPCS codes with sufficient single bill representation in an APC is that such fluctuation is moderated by the increased number of observations for similar services on which the APC median cost is also based. We considered proposing a distinct methodology for calculation of the Start Printed Page 42647median cost of low total volume APCs in order to provide more stability in payment from year to year for these low total volume services. However, after examination of the low total volume OPPS services and their assigned APCs, we concluded that there were other clinical APCs with higher volumes of total claims to which these low total volume services could be reassigned, while ensuring the continued clinical and resource homogeneity of the clinical APCs to which they would be newly reassigned. Therefore, we believe that it is more appropriate to reconfigure clinical APCs to eliminate most of the low total volume APCs. These low volume services differ from other OPPS services only because they are not often furnished to the Medicare population. Therefore, we are proposing to reconfigure certain clinical APCs for CY 2008 as a way to promote stability and appropriate payment for the services assigned to them, including low total volume services. We believe that these proposed reconfigurations maintain APC clinical and resource homogeneity. We are proposing these changes as an alternative to developing specific quantitative approaches to treating low total volume APCs differently for purposes of median calculation. As a result of this proposal, 3 APCs proposed for CY 2008 (all of which are New Technology APCs) have a total volume of services less than 100, and only 17 APCs have a total volume of less than 1,000, in comparison with CY 2007 where 9 APCs (including 3 New Technology APCs) had a total volume of less than 100 and 36 APCs had a total volume of less than 1,000.

A detailed discussion of the medians for blood and blood products is included in section X. of this proposed rule. A discussion of the medians for APCs that require one or more devices when the service is performed is included in section IV.A. of this proposed rule. A discussion of the median for partial hospitalization is included below in section II.B. of this proposed rule.

Table 4.—Proposed CY 2008 Packaged Revenue Codes

Revenue codeDescription
0250PHARMACY.
0251GENERIC.
0252NONGENERIC.
0254PHARMACY INCIDENT TO OTHER DIAGNOSTIC.
0255PHARMACY INCIDENT TO RADIOLOGY.
0257NONPRESCRIPTION DRUGS.
0258IV SOLUTIONS.
0259OTHER PHARMACY.
0260IV THERAPY, GENERAL CLASS.
0262IV THERAPY/PHARMACY SERVICES.
0263SUPPLY/DELIVERY.
0264IV THERAPY/SUPPLIES.
0269OTHER IV THERAPY.
0270M&S SUPPLIES.
0271NONSTERILE SUPPLIES.
0272STERILE SUPPLIES.
0273TAKE HOME SUPPLIES.
0275PACEMAKER DRUG.
0276INTRAOCULAR LENS SOURCE DRUG.
0278OTHER IMPLANTS.
0279OTHER M&S SUPPLIES.
0280ONCOLOGY.
0289OTHER ONCOLOGY.
0343DIAGNOSTIC RADIOPHARMS.
0344THERAPEUTIC RADIOPHARMS.
0370ANESTHESIA.
0371ANESTHESIA INCIDENT TO RADIOLOGY.
0372ANESTHESIA INCIDENT TO OTHER DIAGNOSTIC.
0379OTHER ANESTHESIA.
0390BLOOD STORAGE AND PROCESSING.
0399OTHER BLOOD STORAGE AND PROCESSING.
0560MEDICAL SOCIAL SERVICES.
0569OTHER MEDICAL SOCIAL SERVICES.
0621SUPPLIES INCIDENT TO RADIOLOGY.
0622SUPPLIES INCIDENT TO OTHER DIAGNOSTIC.
0624INVESTIGATIONAL DEVICE (IDE).
0630DRUGS REQUIRING SPECIFIC IDENTIFICATION, GENERAL CLASS.
0631SINGLE SOURCE.
0632MULTIPLE.
0633RESTRICTIVE PRESCRIPTION.
0681TRAUMA RESPONSE, LEVEL I.
0682TRAUMA RESPONSE, LEVEL II.
0683TRAUMA RESPONSE, LEVEL III.
0684TRAUMA RESPONSE, LEVEL IV.
0689TRAUMA RESPONSE, OTHER.
0700CAST ROOM.
0709OTHER CAST ROOM.
0710RECOVERY ROOM.
0719OTHER RECOVERY ROOM.
0720LABOR ROOM.
Start Printed Page 42648
0721LABOR.
0762OBSERVATION ROOM.
0810ORGAN ACQUISITION.
0819OTHER ORGAN ACQUISITION.
0942EDUCATION/TRAINING.

3. Proposed Calculation of OPPS Scaled Payment Weights

Using the median APC costs discussed previously, we calculated the proposed relative payment weights for each APC for CY 2008 shown in Addenda A and B to this proposed rule. In years prior to CY 2007, we standardized all the relative payment weights to APC 0601 (Mid Level Clinic Visit) because it is one of the most frequently performed services in the hospital outpatient setting. We assigned APC 0601 a relative payment weight of 1.00 and divided the median cost for each APC by the median cost for APC 0601 to derive the relative payment weight for each APC.

Beginning with the CY 2007 OPPS, we standardized all of the relative payment weights to APC 0606 (Level 3 Clinic Visits) because we deleted APC 0601 as part of the reconfiguration of the visit APCs. We chose APC 0606 as the base because under our proposal to reconfigure the APCs where clinic visits are assigned for CY 2007, APC 0606 is the middle level clinic visit APC (that is, Level 3 of five levels). We have historically used the median cost of the middle level clinic visit APC (that is APC 0601 through CY 2006) to calculate unscaled weights because mid-level clinic visits are among the most frequently performed services in the hospital outpatient setting. Therefore, to maintain consistency in using a median for calculating unscaled weights representing the median cost of some of the most frequently provided services, we proposed to continue to use the median cost of the mid-level clinic APC, proposed APC 0606, to calculate unscaled weights. Following our standard methodology, but using the CY 2007 median for APC 0606, for CY 2007 we assigned APC 0606 a relative payment weight of 1.00 and divided the median cost of each APC by the median cost for APC 0606 to derive the unscaled relative payment weight for each APC. The choice of the APC on which to base the relative weights for all other APCs does not affect the payments made under the OPPS because we scale the weights for budget neutrality. We are again proposing to use APC 0606 as the base for the CY 2008 OPPS relative weights.

Section 1833(t)(9)(B) of the Act requires that APC reclassification and recalibration changes, wage index changes, and other adjustments be made in a manner that assures that aggregate payments under the OPPS for CY 2008 are neither greater than nor less than the aggregate payments that would have been made without the changes. To comply with this requirement concerning the APC changes, we compared aggregate payments using the CY 2007 relative weights to aggregate payments using the CY 2008 proposed relative weights. This year, we included payments to CMHCs in our comparison. Based on this comparison, we adjusted the relative weights for purposes of budget neutrality. The unscaled relative payment weights were adjusted by a weight scaler of 1.3665 for budget neutrality. In addition to adjusting for increases and decreases in weight due to the recalibration of APC medians, the scaler also accounts for any change in the base, other than changes in volume, which are not a factor in the weight scaler.

The proposed relative payment weights listed in Addenda A and B to this proposed rule incorporate the recalibration adjustments discussed in sections II.A.1. and 2. of this proposed rule.

Section 1833(t)(14)(H) of the Act, as added by section 621(a)(1) of Pub. L. 108-173, states that “Additional expenditures resulting from this paragraph shall not be taken into account in establishing the conversion factor, weighting and other adjustment factors for 2004 and 2005 under paragraph (9) but shall be taken into account for subsequent years.” Section 1833(t)(14) of the Act provides the payment rates for certain “specified covered outpatient drugs.” Therefore, the cost of those specified covered outpatient drugs (as discussed in section V. of this proposed rule) is included in the budget neutrality calculations for the CY 2008 OPPS.

4. Proposed Changes to Packaged Services

(If you choose to comment on the issues in this section, please include the caption “OPPS: Packaged Services” at the beginning of your comment.)

a. Background

When the Medicare program was first implemented, it paid for hospital services (inpatient and outpatient) based on hospital-specific reasonable costs attributable to furnishing services to Medicare beneficiaries. Later the law was amended to limit payment to the lesser of the hospital's reasonable cost or customary charges for services furnished to Medicare beneficiaries. Specific service-based methodologies were then developed for certain types of services, such as clinical laboratory tests and durable medical equipment, while payments for outpatient surgical procedures and other diagnostic tests were based on a blend of the hospital's aggregate Medicare costs for these services and Medicare's payment for similar services in other ambulatory settings. While this mix of different payment methodologies was in use, hospital outpatient services were growing rapidly following the implementation of the IPPS in 1983. The brisk increase in hospital outpatient services led to an interest in creating payment incentives to promote more efficient delivery of hospital outpatient services through a Medicare prospective payment system for hospital outpatient services, and the final statutory requirements for the OPPS were established by the BBA and the BBRA. During the period of time when different approaches to prospective payment for hospital outpatient services were being considered, a variety of reports to Congress (June 1988, September 1990, and March 1995) discussed three major issues related to defining the unit of payment for the payment system, specifically the extent to which clinically similar procedures should be grouped for payment purposes and the logic that should be used for the groupings; the extent to which payment for minor, ancillary services associated with a significant Start Printed Page 42649procedure should be packaged into a single payment for the procedure (which we refer to as “packaging”); and the extent to which payment for multiple significant procedures related to an outpatient encounter or to an episode of care should be bundled into a single unit of payment (which we refer to as “bundling”). Both packaging and bundling were presented as approaches to creating incentives for efficiency, with their potential policy disadvantages including inconsistency with other ambulatory fee schedules, reduced transparency of service-specific payment, and the potential for hospitals shifting the delivery of packaged or bundled services to delivery settings other than the hospital outpatient department (HOPD).

The OPPS, like other prospective payment systems, relies on the concept of averaging, where the payment may be more or less than the estimated costs of providing a service or package of services for a particular patient, but with the exception of outlier cases, it is adequate to ensure access to appropriate care. Decisions about packaging and bundling payment involve a balance between ensuring some separate payment for individual services and establishing incentives for efficiency through larger units of payment. In many situations, the final payment rate for a package of services may do a better job of balancing variability in the relative costs of component services compared to individual rates covering a smaller unit of service without packaging or bundling. Packaging payments into larger payment bundles promotes the stability of payment for services over time, a characteristic that reportedly is very important to hospitals. Unlike packaged services, the costs of individual services typically show greater variation because the higher variability for some component items and services cannot be balanced with lower variability for others and because relative weights are typically estimated using a smaller set of claims. When compared to service-specific payment, packaging or bundling payment for component services may change payment at the hospital level to the extent that there are systematic differences across hospitals in their performance of the services included in that unit of payment. Hospitals spending more per case than payment received would be encouraged to review their service patterns to ensure that they furnish services as efficiently as possible. Similarly, we believe that unpackaging services heightens the hospital's focus on pricing individual services, rather than the efficient delivery of those services. Over the past several years of the OPPS, greater unpackaging of payment has occurred simultaneously with continued tremendous growth in OPPS expenditures as a result of increasing volumes of individual services, as discussed in further detail below. Also discussed in further detail below, most recently in its comments to the CY 2007 OPPS/ASC proposed rule and in the context of this rapid spending growth, the Medicare Payment Advisory Commission (MedPAC) encouraged CMS to broaden the payment bundles under the OPPS to encourage providers to use resources efficiently.

As permitted under section 1833(t)(2)(B) of the Act, the OPPS establishes groups of covered HOPD services, namely APC groups, and uses them as the basic unit of payment. During the evolution of the OPPS over the past 7 years, significant attention has been concentrated on service-specific payment for services furnished to particular patients, rather than on creating incentives for the efficient delivery of services through encounter or episode-of-care-based payment. Overall packaging included in the clinical APCs has decreased, and the procedure groupings have become smaller as the focus has shifted to refining service-level payment. Specifically, in the CY 2003 OPPS, there were 569 APCs, but by CY 2007, the number of APCs had grown to 862, a 51-percent increase in 4 years. Similarly, the percentage of CPT codes for procedural services that receive packaged payment declined by over 10 percent between CY 2003 and CY 2007.

Currently, the APC groups reflect a modest degree of packaging, including packaged payment for minor ancillary services, inexpensive drugs, medical supplies, implantable devices, capital-related costs, operating and recovery room use, and anesthesia services. Bundling payment for multiple significant services provided in the same hospital outpatient encounter or during an episode of care is not currently a common OPPS payment practice, because the APC groups generally reflect only the modest packaging associated with individual procedures or services. Unconditionally packaged services with HCPCS codes are identified by the status indicator “N.” Conditionally packaged services, specifically those services whose payment is packaged unless specific criteria for separate payment are met, are assigned to status indicator “Q.” To the extent possible, hospitals may use HCPCS codes to report any packaged services that were performed, consistent with CPT or CMS coding guidelines, but packaged costs also may be uncoded and included in specific revenue code charges. Hospitals include charges for packaged services on their claims, and the costs associated with those packaged services are then added into the costs of separately payable procedures on the same claims in establishing payment rates for the separately payable services.

Packaging and bundling payment for multiple interrelated services into a single payment creates incentives for providers to furnish services in the most efficient way by enabling hospitals to manage their resources with maximum flexibility, thereby encouraging long-term cost containment. For example, where there are a variety of supplies that could be used to furnish a service, some of which are more expensive than others, packaging encourages hospitals to use the least expensive item that meets the patient's needs, rather than to routinely use a more expensive item. Packaging also encourages hospitals to negotiate carefully with manufacturers and suppliers to reduce the costs of purchased items and services or to explore alternative group purchasing arrangements, thereby encouraging the most economical health care. Similarly, packaging encourages hospitals to establish protocols that ensure that services are furnished only when they are important and to carefully scrutinize the services ordered by practitioners to maximize the efficient use of hospital resources. Finally, packaging payments into larger payment bundles promotes the stability of payment for services over time. Packaging also may reduce the importance of refining service-specific payment because there is more opportunity for hospitals to average payment across higher cost cases requiring many ancillary services and lower cost cases requiring fewer ancillary services.

b. Addressing Growth in OPPS Volume and Spending

Creating additional incentives for providing only necessary services in the most efficient manner is of vital importance to Medicare today, in view of the recent explosion of growth in program expenditures for hospital outpatient services paid under the OPPS. As illustrated in Table 5 below, total spending has been growing at a rate of roughly 10 percent per year under the OPPS, and the Medicare Trustees project that total spending under the OPPS will increase by more than $3 billion from CY 2007 through CY 2008 to nearly $35 billion. Implementation of the OPPS has not Start Printed Page 42650slowed outpatient spending growth over the past few years; in fact, double-digit spending growth has generally been occurring. We are greatly concerned with this rate of increase in program expenditures under the OPPS.

Table 5.—Growth in Expenditures Under OPPS From CY 2001-CY 2008

[Projected Expenditures for CY 2006-CY 2008, in Billions]

OPPS growthCY 2001CY 2002CY 2003CY 2004CY 2005CY 2006CY 2007CY 2008
Incurred Cost17.70219.56121.15623.86626.57229.33831.64134.960
Percent Increase10.58.212.811.310.47.810.5
Source: CY 2007 Medicare Trustees' Report.

As with the other Medicare fee-for-service payment systems that are experiencing rapid spending growth, brisk growth in the intensity and utilization of services is the major reason for the current rates of growth in the OPPS, rather than general price or enrollment changes. Table 6 below illustrates the increases in the volume and intensity of hospital outpatient services over the past several years.

Table 6.—Percent Increase in Volume and Intensity of Hospital Outpatient Services

CY 2002CY 2003CY 2004CY 2005CY 2006 (Est.)CY 2007 (Est.)CY 2008 (Est.)
Percent Increase3.52.57.67.48.66.45.8
Source: CY 2007 Medicare Trustees' Report.

For hospital outpatient services, the volume and intensity of services are estimated to have continued to increase significantly in recent years, at a rate of 8.6 percent between CY 2005 and CY 2006, the last two completed calendar years. As we discussed in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68189 through 68190), the rapid growth in utilization of services under the OPPS shows that Medicare is paying mainly for more services each year, regardless of their quality or impact on beneficiary health. In its March 2007 Report to Congress (pages 55 and 56), MedPAC confirmed that much of the growth in service volume from 2003 to 2005 resulted from increases in the number of services per beneficiary who received care, rather than from increases in the number of beneficiaries served. The MedPAC found that while the rate of growth in service volume declined over that time period, the complexity of services, defined as the sum of the relative payment weights of all OPPS services divided by the volume of all services, increased, and that most of the growth was attributable to the insertion of devices and the provision of complex imaging services. The MedPAC further found that regression analysis suggested that relatively complex hospital outpatient services may be more profitable for hospitals than less complex services. In addition, its analysis indicated that favorable payments for complex services give hospitals an incentive to provide more of those complex services rather than fewer basic services, which increases overall service complexity. The MedPAC expressed concern about this relationship and concluded that the historically large increases in outpatient volume and service complexity suggest a need to recalibrate the OPPS. In the future, MedPAC plans to examine options for recalibrating the payment system to accurately match payments to the costs of individual services (Medicare Payment Advisory Commission Report to the Congress: Medicare Payment Policy, March 2007, pages 55 and 56).

As proposed for the CY 2007 OPPS and finalized for the CY 2009 OPPS, we developed a plan to promote higher quality services under the OPPS, so that Medicare spending would be directed toward those higher quality services (71 FR 68189 through 68197). We believe that Medicare payments should encourage physicians and other providers in their efforts to achieve better health outcomes for Medicare beneficiaries at a lower cost. In the CY 2007 OPPS/ASC final rule with comment period, we discussed the concept of “value-based purchasing” in the OPPS as well as in other Medicare payment systems. “Value-based purchasing” may use a range of incentives to achieve identified quality and efficiency goals, as a means of promoting better quality of care and more effective resource use in the Medicare payment systems. In developing the concept of value-based purchasing for Medicare, we have been working closely with stakeholder partners.

We continue to believe that the collection and submission of performance data and the public reporting of comparative information are strong incentives for hospital accountability in general and quality improvement in particular, while encouraging the most efficient and effective care. Measurement and reporting can focus the attention of hospitals and consumers on specific goals and on hospitals' performance relative to those goals. Development and implementation of performance measurement and reporting by hospitals can thus produce quality improvement in health care delivery. Hospital performance measures may also provide a foundation for performance-based rather than volume-based payments.

In the CY 2007 OPPS/ASC final rule with comment period, as a first step in the OPPS toward value-based purchasing, we finalized a policy that would employ our equitable adjustment authority under section 1833(t)(2)(E) of the Act to establish an OPPS Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program based on measures specifically developed to characterize the quality of outpatient care (71 FR 68197). We finalized implementation of the program for CY 2009, when we would implement a 2.0 point reduction to the OPPS conversion factor update for those hospitals that do not meet the specific requirements of the CY 2009 OPPS RHQDAPU program. We described the Start Printed Page 42651CY 2009 program which would be based upon CY 2008 hospital reporting of appropriate measures of the quality of hospital outpatient care that have been carefully developed and evaluated, and endorsed as appropriate, with significant input from stakeholders. We reiterated our belief that ensuring that Medicare beneficiaries receive the care they need and that such services are of high quality are the necessary initial steps to incorporating value-based purchasing into the OPPS. We explained that we are specifically seeking to encourage care that is both efficient and of high quality in the HOPD.

Subsequent to the publication of the CY 2007 OPPS/ASC final rule with comment period, section 109(b) of the MIEA-TRHCA specifies that in the case of a subsection (d) hospital (defined under section 1886(d)(1)(B) of the Act as hospitals that are located in the 50 States or the District of Columbia other than those categories of hospitals or hospital units that are specifically excluded from the IPPS, including psychiatric, rehabilitation, long-term care, children's, and cancer hospitals or hospital units) that does not submit to the Secretary the quality reporting data required for CY 2009 and each subsequent year, the OPPS annual update factor shall be reduced by 2.0 percentage points. The quality reporting program proposed for CY 2008 according to this provision is referred to as the Hospital Outpatient Quality Data Reporting Program (HOP QDRP) and is discussed in detail in section XVII. of this proposed rule.

As the next step in our movement toward value-based purchasing under the OPPS and to complement the HOP QDRP for CY 2009, with measure reporting beginning in CY 2008, we believe it is important to initiate specific payment approaches to explicitly encourage efficiency in the hospital outpatient setting that we believe will control future growth in the volume of OPPS services. While the HOP QDRP will encourage the provision of higher quality hospital outpatient services that lead to improved health outcomes for Medicare beneficiaries, we believe that more targeted approaches are also necessary to encourage increased hospital efficiency. Two alternatives we have considered that would be feasible under current law include establishing a methodology to measure the growth in volume and reduce OPPS payment rates to account for unnecessary increases in volume or developing payment incentives for hospitals to ensure that they provide necessary services as efficiently as possible.

With respect to the first alternative, section 1833(t)(2)(F) of the Act requires us to establish a methodology for controlling unnecessary increases in the volume of covered OPPS services, and section 1833(t)(9)(C) of the Act authorizes us to adjust the update to the conversion factor if, under section 1833(t)(2)(F) of the Act, we determine that there is growth in volume that exceeds established tolerances. As we indicated in the September 8, 1998 proposed rule proposing the establishment of the OPPS (63 FR 47585), we considered creating a system that mirrors the sustainable growth rate (SGR) methodology applied to the MPFS update to control unnecessary growth in service volume. However, implementing such a system could have the potentially undesirable effect of escalating service volume as payment rates stagnate and hospital costs rise, thus actually resulting in a growth in volume rather than providing an incentive to control volume. Therefore, this approach to addressing the volume growth under the OPPS could inadvertently result in the exact opposite of our desired outcome.

The second alternative we considered is to expand the packaging of supportive ancillary services and ultimately bundle payment for multiple independent services into a single OPPS payment. We believe that this would create incentives for hospitals to monitor and adjust the volume and efficiency of services themselves, by enabling them to manage their resources with maximum flexibility. Instead of external controls on volume, we believe that it is preferable for the OPPS to create payment incentives for hospitals to carefully scrutinize their service patterns to ensure that they furnish only those services that are necessary for high quality care and to ensure that they provide care as efficiently as possible. Specifically, we believe that increased packaging and bundling are the most appropriate payment strategies to establish such incentives in a prospective payment system, and that this approach is clearly preferable to the establishment of an SGR or other methodology that seeks to control spending by addressing significant growth in volume and program spending with lower payments.

In its October 6, 2006 letter of comment on the CY 2007 OPPS/ASC proposed rule, MedPAC urged us to establish broader payment bundles in both the revised ASC and hospital outpatient prospective payment systems to promote efficient resource use and better align the two payment systems. In particular, our proposal for the CY 2008 revised ASC payment system proposed to package payment for all items and services directly related to the provision of covered surgical procedures into the ASC facility payment for the associated surgical procedure (71 FR 49468). These other items and services included all drugs, biologicals, contrast agents, implantable devices, and diagnostic services such as imaging. Because a number of these items and services are separately paid under the OPPS and the proposal included the establishment of most ASC payment weights based on the procedures' corresponding OPPS payment weights, MedPAC encouraged us to align the payment bundles in the two payment systems by increasing the size of the payment bundles under the OPPS.

Moreover, MedPAC staff indicated in testimony at the January 9, 2007 MedPAC public meeting that the growth in OPPS spending and volume raises questions about whether the OPPS should be changed to encourage greater efficiency (page 390 of the January 9, 2007 MedPAC meeting transcript available at http://www.medpac.gov). MedPAC staff explained at that time that MedPAC intends to perform a long-term assessment of the design of the OPPS, including considering the bundling of payments for procedures and visits furnished over a period of time into a single payment, assessing whether there should be an expenditure target for hospital outpatient services, evaluating whether payments for multiple imaging services provided in the same session should be discounted, and reviewing the methodology used by CMS to determine relative payment weights for hospital outpatient services. We welcome MedPAC's study of these areas, particularly with regard to how we might develop appropriate payment rates for larger bundles of services.

Because we believe it is important that the OPPS create enhanced incentives for hospitals to provide only necessary, high quality care and to provide that care as efficiently as possible, we have given considerable thought to how we could increase packaging under the OPPS in a manner that would not place hospitals at substantial financial risk but which would create incentives for efficiency and volume control, while providing hospitals with flexibility to provide care in the most appropriate way for each Medicare beneficiary. We are considering the possibility of greater bundling of payment for major hospital outpatient services, which could result in establishing OPPS payments for episodes of care, and for this reason we particularly welcome MedPAC's Start Printed Page 42652exploration of how such an approach might be incorporated into the OPPS payment methodology. We are particularly concerned about the potential for shifting higher cost bundled services to other ambulatory settings, and we welcome ideas on deterring such activity. We are currently considering the complex policy issues related to the possible development and implementation of a bundled payment policy for hospital outpatient services that involves significant services provided over a period of time which could be paid through an episode-based payment methodology, but we consider this possible approach to be a long-term policy objective. We encourage public comments regarding the specific hospital outpatient services, clinical and financial issues, ratesetting methodologies, and operational challenges we should consider in our exploratory work in this area.

We also are examining how we might possibly establish payments for same-day care encounters, building upon the current use of APCs for payment through greater packaging of supportive ancillary services. This could include conditional packaging of supportive ancillary services into payment for the procedure that is the reason for the OPPS encounter (for example, diagnostic tests performed on the day of a scheduled procedure). Another approach could include creation of composite APCs for frequently performed combinations of surgical procedures (for example, one APC payment for multiple cardiac electrophysiologic procedures performed on the same date). Not only could these encounter-based payment groups create enhanced incentives for efficiency, but they may also enable us to utilize for ratesetting many of the multiple procedure claims that are not now used in our establishment of OPPS rates for single procedures. (We refer readers to section II.A.1.b. of this proposed rule for a more detailed discussion of the treatment of multiple procedure claims in the ratesetting process.) For CY 2008, we are proposing two new composite APCs for CY 2008 payment of combinations of services in two clinical care areas, as discussed under section II.A.4.d. of this proposed rule. We look forward to receiving public comment on this proposal as we explore the possibility of moving toward basing OPPS payment on larger packages and bundles of services provided in a single hospital outpatient encounter.

We intend to involve the APC Panel in our future exploration of how we can develop encounter-based and episode-based payment groups, and we look forward to the findings and recommendations of MedPAC in this area. This is a significant change in direction for the OPPS, and we specifically seek the recommendations of all stakeholders with regard to which ancillary services could be packaged and those combinations of services provided in a single encounter or over time that could be bundled together for payment. We are hopeful that expanded packaging and, ultimately, greater bundling under the OPPS may result in sufficient moderation of growth in volume and spending that further controls would not be needed. However, if spending were to continue to escalate at the current rates, even after we have exhausted our options for increased packaging and bundling, we are considering multiple options under our authority to address these issues, including the possibility of imposing external controls that could link growth in volume to reduced payments under the OPPS in the future.

c. Proposed Packaging Approach

With the exception of the two composite APCs that we are proposing for CY 2008 and discuss in detail in section II.A.4.d. of this proposed rule, we are not currently prepared to propose an episode-based or fully developed encounter-based payment methodology for CY 2008 as our next step in value-based purchasing for the OPPS. However, in reviewing our approach to revising payment packages and bundles, we have examined services currently provided under the OPPS, looking for categories of ancillary items and services for which we believe payment could be appropriately packaged into larger payment packages for the encounter. For this first step in creating larger payment groups, we examined the HCPCS code definitions (including CPT code descriptors) to see whether there were categories of codes for which packaging would be a logical expansion of the longstanding packaging policy that has been a part of the OPPS since its inception. In general, we have often packaged the costs of selected HCPCS codes into payment for services reported with other HCPCS codes where we believed that one code reported an item or service that was integral to the provision of care that was reported by another HCPCS code.

As an example of a previous change in the OPPS packaging status for a HCPCS code that is ancillary and supportive, under the CY 2007 OPPS, we note that CPT code 93641 (Electrophysiologic evaluation of single or dual chamber pacing cardioverter defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluate of sensing an pacing for arrhythmia termination) at the time of initial implantation or replacement; with testing of single chamber or dual chamber cardioverter defibrillator) went from separate to packaged payment. This service is only performed during the course of a surgical procedure for implantation or replacement of implantable cardioverter-defibrillator (ICD) leads, and these surgical implantation procedures are currently assigned to APC 0106 (Insertion/Replacement/Repair of Pacemaker and/or Electrodes) and APC 0108 (Insertion/Replacement/Repair of Cardioverter-Defibrillator Leads). We considered the electrophysiologic evaluation service (CPT code 93641) to be an ancillary supportive service that may be performed only in the same operative session as a procedure that could otherwise be performed independently of the electrophysiologic evaluation service. In this particular case, the APC Panel recommended for CY 2007 that we package payment for this diagnostic test and we adopted that recommendation for the CY 2007 OPPS. Making this payment change in this specific case resulted in the availability of significantly more claims data and, therefore, establishment of more valid and representative estimated median costs for the lead insertion and electrophysiologic evaluation services furnished in the single hospital encounter.

In the case of much of the care furnished in the HOPD, we believe that it is appropriate to view a complete service as potentially being reported by a combination of two or more HCPCS codes, rather than a single code, and to establish payment policy that supports this view. Ideally, we would consider a complete HOPD service to be the totality of care furnished in a hospital outpatient encounter or in an episode of care. In general, we believe that it is particularly appropriate to package payment for those items and services that are typically ancillary and supportive into the payment for the primary diagnostic or therapeutic modalities in which they are used. As a significant first step towards creating payment units that represent larger units of service, we examined whether there are categories of HCPCS codes that are typically ancillary and supportive to diagnostic and therapeutic modalities.

Specifically, as our initial substantial step toward creating larger payment groups for hospital outpatient care, we are proposing to package payment for Start Printed Page 42653items and services in the seven categories listed below into the payment for the primary diagnostic or therapeutic modality to which we believe these items and services are typically ancillary and supportive. We specifically chose these categories of HCPCS codes for packaging because we believe that the items and services described by the codes in these categories are the HCPCS codes that are typically ancillary and supportive to a primary diagnostic or therapeutic modality and, in those cases, are an integral part of the primary service they support. We are proposing to assign status indicator “N” to those HCPCS codes that we believe are always integral to the performance of the primary modality and to package their costs into the costs of the separately paid primary services with which they are billed. We are proposing to assign status indicator “Q” to those HCPCS codes that we believe are typically integral to the performance of the primary modality and to package payment for their costs into the costs of the separately paid primary services with which they are usually billed but to pay them separately in those uncommon cases in which no other separately paid primary service is furnished in the hospital outpatient encounter.

For ease of reference in our subsequent discussion in each of the seven areas, we refer to the HCPCS codes for which we are proposing to package (or conditionally package) payment as dependent services. We use the term “independent service” to refer to the HCPCS codes that represent the primary therapeutic or diagnostic modality into which we are proposing to package payment for the dependent service. We note that, in future years as we consider the development of larger payment groups that more broadly reflect services provided in an encounter or episode of care, it is possible that we might propose to bundle payment for a service that we now refer to as “independent” in this proposed rule.

Specifically, we are proposing to package the payment for HCPCS codes describing the dependent items and services in the following seven categories into the payment for the independent services with which they are furnished:

  • Guidance services.
  • Image processing services.
  • Intraoperative services.
  • Imaging supervision and interpretation services.
  • Diagnostic radiopharmaceuticals.
  • Contrast media and.
  • Observation services.

We identify the HCPCS codes we are proposing to package for CY 2008, explain our rationale for proposing to package the codes in these categories, provide examples of how HCPCS and APC median costs and payments would change under these proposals, and discuss the impact of these changes in the discussion below under each category.

The median costs of services at the HCPCS level for many separately paid procedures change as a result of this proposal because we are proposing to change the composition of the payment packages associated with the HCPCS codes. Moreover, as a result of changes to the HCPCS median costs, we are proposing to reassign some HCPCS codes to different clinical APCs for CY 2008 to avoid 2 times violations and to ensure continuing clinical and resource homogeneity of the APCs. Therefore, the APC median costs change not only as a result of the increased packaging itself but also as a result of the migration of HCPCS codes into and out of APCs through APC reconfiguration. The file of HCPCS code and APC median costs resulting from our proposal is found under supporting documentation for this proposed rule on the CMS Web site at http://www.cms.hhs.gov/​HospitalOutpatientPPS/​HORD/​list.asp#TopOfPage.

Review of the HCPCS median costs indicates that, while the proposed median costs rise for some HCPCS codes as a result of increased packaging that expands the costs included in the payment packages, there are also cases in which the proposed median costs decline as a result of these proposed changes. While it seems intuitive to believe that the proposed median costs of the remaining separately paid services should rise when the costs of services previously paid separately are packaged into larger payment groups, it is more challenging to understand why the proposed median costs of separately paid services would not change or would decline when the costs of previously paid services are packaged.

Medians are generally more stable than means because they are less sensitive to extreme observations, but medians typically do not reflect subtle changes in cost distributions. The OPPS' use of medians rather than means usually results in relative weight estimates being less sensitive to packaging decisions. Specifically, the median cost for a particular independent procedure generally will be higher as a result of added packaging, but also could change little or be lower because median costs typically do not reflect small distributional changes and also because changes to the packaged HCPCS codes affect both the number and composition of single bills and the mix of hospitals contributing those single bills. Such a decline, no change, or an increase in the median cost at the HCPCS code level could result from a change in the number of single bills used to set the median cost. With greater packaging, more “natural” single bills are created for some codes but fewer “pseudo” single bills are created. Thus, some APCs gain single bills and some lose single bills due to packaging changes, as well as to the reassignment of some codes to different APCs. When more claims from a different mix of providers are used to set the median cost for the HCPCS code, the median cost could move higher or lower within the array of per claim costs.

Similarly, proposed revisions to APC assignments that are necessary to resolve 2 times violations that could arise as a result of changes in the HCPCS median cost for one or more codes due to additional packaging may also result in increases or decreases to APC median costs and, therefore, to increases or decreases in the payments for HCPCS codes that would not be otherwise affected except for the CY 2008 proposed packaging approach for the seven categories of items and services.

We have examined the proposed aggregate impact of making these changes on payment for CY 2008. Because the OPPS is a budget neutral payment system in which the amount of payment weight in the system is annually adjusted for changes in expenditures created by changes in APC weights and codes (but is not currently adjusted based on estimated growth in service volume), the effects of the packaging changes we are proposing result in changes to scaled weights and, therefore, to the payment rates for all separately paid procedures. These changes result from both shifts in median costs as a result of increased packaging, changes in multiple procedure discounting patterns, and a higher weight scaler that is applied to all unscaled APC weights. (We refer readers to section II.A.3. of this proposed rule for an explanation of the weight scaler.) In a budget neutral system, the monies previously paid for services that are now proposed to be packaged are not lost, but are redistributed to all other services. A higher weight scaler would increase payment rates relative to observed median costs for independent services by redistributing the lost weight of packaged items that historically have Start Printed Page 42654been paid separately and the lost weight when the median costs of independent services do not completely reflect the full incremental cost of the packaged services. The impact of this proposed change on proposed CY 2008 OPPS payments is discussed in section XXII B. of this proposed rule, and the impact on various classifications of hospitals is shown in Column 2B in Table 67 in that section.

We estimate that our CY 2008 proposal would redistribute approximately 1.2 percent of the estimated CY 2007 base year expenditures under the OPPS. The monies associated with this redistribution would be in addition to any increase that would otherwise occur due to a proposed higher median cost for the APC as a result of the expanded payment package. If the relative weight for a particular APC decreases as a result of the proposed packaging approach, the increased weight scaler may or may not result in a relative weight that is equal to or greater than the relative weight that would occur without the proposed packaging approach. In general, the packaging that we are proposing would have more effect on payment for some services than on payment for others because the dependent items and services that we are proposing for packaging are furnished more often with some independent services than with others. However, because of the amount of payment weight that would be redistributed by this proposal, there would be some impact on payments for all OPPS services whose rates are set based on payment weights, and the impact on any given hospital would vary based on the mix of services furnished by the hospital.

The following discussion separately addresses each of the seven categories of items and services for which we are proposing to package payment under the CY 2008 OPPS as part of our packaging proposal. Many codes that we are proposing to package for CY 2008 could fit into more than one of those seven categories. For example, CPT code 93325 (Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography)) could be included in both the intraoperative and image processing categories. Therefore, for organizational purposes, both to ensure that each code appears in only one category and to facilitate discussion of our CY 2008 proposal, we have created a hierarchy of categories that determines which category each code appropriately falls into. This hierarchy is organized from the most clinically specific to the most general type of category. The hierarchy of categories is as follows: guidance services, image processing services, intraoperative services, and imaging supervision and interpretation services. Therefore, while CPT code 93325 may logically be grouped with either imaging processing services or intraoperative services, it is treated as an image processing service because that group is more clinically specific and precedes intraoperative services in the hierarchy. We did not believe it was necessary to include diagnostic radiopharmaceuticals, contrast media, or observation categories in this list because those services generally map to only one of those categories. We note that there is no cost estimation or payment implications related to the assignment of a HCPCS code for purposes of discussion to any specific category.

(1) Guidance Services

We are proposing to package payment for HCPCS guidance codes for CY 2008, specifically those codes that are reported for supportive guidance services, such as ultrasound, fluoroscopic, and stereotactic navigation services, that aid the performance of an independent procedure. We performed a broad search for such services, relying upon the American Medical Association's (AMA's) CY 2007 book of CPT codes and the CY 2007 book of Level II HCPCS codes, which identified specific HCPCS codes as guidance codes. Moreover, we performed a clinical review of all HCPCS codes to capture additional codes that are not necessarily identified as “guidance” services but describe services that provide directional information during the course of performing an independent procedure. For example, we are proposing to package CPT code 61795 (Stereotactic computer-assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal (List separately in addition to code for primary procedure)) because we consider it to be a guidance service that provides three-dimensional information to direct the performance of intracranial or other diagnostic or therapeutic procedures. We also included HCPCS codes that existed in CY 2006 but were deleted and were replaced in CY 2007. We included the CY 2006 HCPCS codes because we are proposing to use the CY 2006 claims data to calculate the CY 2008 OPPS median costs on which the CY 2008 payment rates would be based. Many, although not all, of the CPT guidance codes we identified are designated by CPT as add-on codes that are to be reported in addition to the CPT code for the primary procedure. We also note that there are a number of CPT codes describing independent surgical procedures but which the code descriptors indicate that guidance is included in the code reported for the surgical procedure if it is used and, therefore, packaged payment is already made for the associated guidance service under the OPPS. For example, the independent procedure described by CPT code 55873 (Cryosurgical ablation of the prostate (includes ultrasonic guidance for interstitial cryosurgical probe placement)) already includes the ultrasound guidance that may be used. We believe packaging payment for every guidance service under the OPPS would provide consistently packaged payment for all these services that are used to direct independent procedures, even if they are currently separately reported.

Because these dependent guidance procedures support the performance of an independent procedure and they are generally provided in the same operative session as the independent procedure, we believe that it would be appropriate to package their payment into the OPPS payment for the independent procedure performed. However, guidance services differ from some of the other categories of services that we are proposing to package for CY 2008. Hospitals sometimes may have the option of choosing whether to perform a guidance service immediately preceding or during the main independent procedure, or not at all, unlike many of the imaging supervision and interpretation services, for example, which are generally always reported when the independent procedure is performed. Once a hospital decides that guidance is appropriate, the hospital may have several options regarding the type of guidance service that can be performed. For example, when inserting a central venous access device, hospitals have the option of using no guidance, ultrasound guidance, or fluoroscopic guidance, and the selection in any specific case will depend upon the specific clinical circumstances of the device insertion procedure. In fact, the historical hospital claims data demonstrate that various guidance services for the insertion of these devices, which have historically received packaged payment under the OPPS, are used frequently for the insertion of vascular access devices.

Thus, we recognize hospitals have several options regarding the performance and types of guidance services they use. However, we believe that hospitals utilize the most appropriate form of guidance for the specific procedure that is performed. Start Printed Page 42655We do not want to create payment incentives to use guidance for all independent procedures or to provide one form of guidance instead of another. Therefore, by proposing to package payment for all forms of guidance, we are specifically encouraging hospitals to utilize the most cost effective and clinically advantageous method of guidance that is appropriate in each situation by providing them with the maximum flexibility associated with a single payment for the independent procedure. Similarly, hospitals may appropriately not utilize guidance services in certain situations based on clinical indications.

Because guidance services can be appropriately reported in association with many independent procedures, under our proposed packaging of guidance services for CY 2008, the costs associated with guidance services would be mapped to a larger number of independent procedures than some other categories of codes that we are proposing to package. For example, CPT code 76001 (Fluoroscopy, physician time more than one hour, assisting a non-radiologic physician (e.g., nephrostolithotomy, ERCP, bronchoscopy, transbronchial biopsy)) can be reported with a wide range of services. According to the CPT code descriptor, these procedures include nephrostolithotomy, which may be reported with CPT code 50080 (Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm), and endoscopic retrograde cholangiopancreatography, which may be reported with CPT code 43260 (Endoscopic retrograde cholangiopancreatography (ERCP); diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)). Therefore, the cost of the fluoroscopic guidance would be reflected in the payment for each of these independent services, in addition to numerous other procedures, rather than in the payment for only one or two independent services, as is the case for some of the other categories of codes that we are proposing to package for CY 2008.

In addition, because independent procedures such as CPT code 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa)) may be reported with or without guidance, the cost for the guidance will be reflected in the median cost for the independent procedure as a function of the frequency that guidance is reported with that procedure. As we stated previously, the median cost for a particular independent procedure generally will be higher as a result of added packaging, but also could change little or be lower because median costs typically do not reflect small distributional changes and because changes to the packaged HCPCS codes affect both the number and composition of single bills and the mix of hospitals contributing those single bills. In fact, the CY 2007 CPT book indicates that if guidance is performed with CPT code 20610, it may be appropriate to bill CPT code 76942 (Ultrasonic guidance for needle placement (e.g. biopsy, aspiration, injection, localization device), imaging supervision and interpretation); 77002 (Fluoroscopic guidance for needle placement (e.g. biopsy, aspiration, injection, localization device)); 77012 (Computed tomography guidance for needle placement (e.g. biopsy, aspiration, injection, localization device), radiological supervision and interpretation); or 77021 (Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation). The CY 2007 CPT book also implies that it is not always clinically necessary to use guidance in performing an arthrocentesis described by CPT code 20610.

The guidance procedures that we are proposing to package for CY 2008 vary in their resource costs. Resource cost was not a factor we considered when proposing to package guidance procedures. Notably, most of the guidance procedures are relatively low cost in comparison to the independent services they frequently accompany.

The codes we are proposing to identify as guidance codes for CY 2008 that would receive packaged payment are listed in Table 8 below.

Several of these codes, including CPT code 76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure)), are already unconditionally (that is, always) packaged under the CY 2007 OPPS, where they have been assigned to status indicator “N.” Payment for these services is currently made as part of the payment for the separately payable, independent services with which they are billed. No separate payment is made for services that we have assigned to status indicator “N.” We are not proposing status indicator changes for the five guidance procedures that were unconditionally packaged for CY 2007.

We are proposing to change the status indicators for 31 guidance procedures from separately paid to unconditionally packaged (status indicator “N”) for the CY 2008 OPPS. We believe that these services are always integral to and dependent upon the independent services that they support and, therefore, their payment would be appropriately packaged because they would generally be performed on the same date and in the same hospital as the independent services.

We are proposing to change the status indicator for 1 guidance procedure from separately paid to conditionally packaged (status indicator “Q”), and we will treat it as a “special” packaged code for the CY 2008 OPPS, specifically, CPT code 76000 (Fluoroscopy (separate procedure), up to 1 hour physician time, other than 71023 or 71034 (e.g. cardiac fluoroscopy)). This code was discussed in the past with the Packaging Subcommittee of the APC Panel which determined that, consistent with its code descriptor as a separate procedure, this procedure could sometimes be provided alone, without any other services on the claim. We believe that this procedure would usually be provided by a hospital as guidance in conjunction with another significant independent procedure on the same date of service but may occasionally be provided without another independent service. As a “special” packaged code, if the fluoroscopy service were billed without any other service assigned to status indicator “S,” “T,” “V,” or “X” reported on the same date of service, under our proposal we would not treat the fluoroscopy procedure as a dependent service for purposes of payment. If we were to unconditionally package payment for this procedure, treating it as a dependent service, hospitals would receive no payment at all when providing this service alone, although the procedure would not be functioning as a guidance service in that case. However, according to our proposal, its conditionally packaged status with its designation as a “special” packaged code would allow payment to be provided for this “Q” status fluoroscopy procedure, in which case it would be treated as an independent service under these limited circumstances. On the other hand, when the fluoroscopy service is furnished as a guidance procedure on the same day and in the same hospital as independent, separately paid services that are assigned to status indicator “S,” Start Printed Page 42656“T,” “V,” or “X,” we are proposing to package payment for it as a dependent service. In all cases, we are proposing that hospitals that furnish independent services on the same date as dependent guidance services must bill them all on the same claim. We believe that when dependent guidance services and independent services are furnished on the same date and in the same facility, they are part of a single complete hospital outpatient service that is reported with more than one HCPCS code, and no separate payment should be made for the guidance service which supports the independent service.

We have calculated the median costs on which the proposed CY 2008 payment rates are based using the packaging status of each code as provided in Table 8 below. As we discussed earlier in more detail, this has the effect of both changing the median cost for the independent service into which the cost of the dependent service is packaged and also of redistributing payment that would otherwise have been made separately for the service we are proposing to newly package for CY 2008.

For example, CPT code 76940 (Ultrasound guidance for, and monitoring of, parenchymal tissue ablation) is assigned to APC 0268 (Level I Ultrasound Guidance Procedures) for CY 2007. We are proposing to discontinue APC 0268 for CY 2008 and to provide packaged payment for the HCPCS codes that were previously assigned to APC 0268. CPT code 76940 was billed with CPT code 47382 (Ablation, one or more liver tumor(s), percutaneous, radiofrequency) 148 times in the CY 2008 OPPS proposed rule claims data, and 42 percent of the claims for CPT code 76940 reported CPT code 47382 on the same date of service. Similarly, we note that almost 19 percent of the claims for CPT code 47382 also reported the ultrasound guidance service described by CPT code 76940. Under our proposed policy for the CY 2008 OPPS, we are proposing to expand the packaging associated with CPT code 47382 so that payment for the ultrasound guidance, if performed, would be packaged into the payment for the liver tumor ablation. Specifically, we would package payment for CPT code 76940 so that under the CY 2008 OPPS, the dependent procedure, in this case ultrasound guidance, would receive packaged payment through the separate OPPS payment for the independent procedure, in this case, the liver tumor ablation. The payment rates for this example associated with our CY 2008 proposal are outlined in Table 7 below.

In this case, the proposed CY 2008 median cost for APC 0423 (Level II Percutaneous Abdominal and Biliary Procedures) to which CPT code 47382 is assigned is $2,775.33, while the CY 2007 median cost of APC 0423 is $2,283.08 and of APC 0268 is $72.61. However, as discussed in section II.A.4.c. of this proposed rule concerning our general proposed packaging approach, the added effect of the budget neutrality adjustment that would result from the aggregate effects of the CY 2008 packaging proposal (were there no further budget neutrality adjustment for other reasons) significantly changes the final payment rates relative to median cost estimates. Table 7 presents a comparison of the CY 2007 payment for CPT codes 47382 and 76940, where CPT code 76940 is paid separately, to the CY 2008 payment we are proposing for CPT codes 47382 and 76940, where payment for CPT code 76940 would be packaged. This example cannot demonstrate the overall impact of packaging guidance services on payment to any given hospital because each individual hospital's case-mix and billing patterns would be different. The overall impact of packaging payment for CPT code 76940, as well as all the other proposed packaging changes we are proposing for CY 2008, can only be assessed in the aggregate for classes of hospitals. Section XXII.B. of this proposed rule displays the overall impact of APC weight recalibration and packaging changes we are proposing by classes of hospitals, and the OPPS Hospital-Specific Impacts—Provider-Specific Data file presents our estimates of CY 2008 hospital payment for those hospitals we include in our ratesetting and payment simulation database. The hospital-specific impacts file can be found on the CMS Web site at http://www.cms.hhs.gov/​HospitalOutpatientPPS/​ under supporting documentation for this proposed rule.

Table 7.—Example of the Effects of the CY 2008 Packaging Proposal on Payment for CPT Codes 76940 and 47382

HCPCS codeShort descriptorSum of CY 2007 payment (76940 paid separately)Sum of CY 2008 proposed payment (76940 packaged)
76940Us guide, tissue ablation spine (dependent service)$73.04$0.00
47382Percut ablate liver rf (independent service)2,296.472,810.08
Total Payment2,369.512,810.08

The estimated overall impact of these changes presented in section XXII.B. of this proposed rule is based on the assumption that hospital behavior would not change with regard to when these dependent services are performed on the same date and by the same hospital that performs the independent services. To the extent that hospitals could change their behavior and perform the guidance services more or less frequently, on subsequent dates, or at settings outside of the hospital, the data would show such a change in practice in future years and that change would be reflected in future budget neutrality adjustments. However, with respect to guidance services in particular, we believe that hospitals are limited in the extent to which they could change their behavior with regard to how they furnish these services. By their definition, these guidance services generally must be furnished on the same date and at the same operative location as the independent procedure in order for the guidance service to meaningfully contribute to the treatment of the patient in directing the performance of the independent procedure. We do not believe the clinical characteristics of the guidance services reported with the guidance HCPCS codes listed in Table 8 below will change in the immediate future.

As we indicated earlier, in all cases we are proposing that hospitals that furnish the guidance service on the same date as the independent service Start Printed Page 42657must bill both services on the same claim. We expect to carefully monitor any changes in billing practices on a service-specific and hospital-specific basis to determine whether there is reason to request that Quality Improvement Organizations (QIOs) review the quality of care furnished or to request that Program Safeguard Contractors review the claims against the medical record.

Table 8.—Guidance HCPCS Codes Proposed for Packaged Payment in CY 2008

HCPCS codeShort descriptorCY 2007 SICY 2007 APCProposed CY 2008 SIProposed CY 2008 APCInactive HCPCS Code effective 1/1/2008 or earlier (listed on the same line as its replacement code)Short descriptor of the inactive HCPCS code
19295Place breast clip, precutS0657Nn/a
61795Brain surgery using computerS0302Nn/a
62160Neuroendoscopy add-onT0122Nn/a
76000Fluoroscope examinationX0272Q0272
76001Fluoroscope exam, extensiveNn/aNn/a
76930Echo guide, cardiocentesisS0268Nn/a
76932Echo guide for heart biopsyS0309Nn/a
76936Echo guide for artery repairS0309Nn/a
76937Us guide, vascular accessNn/aNn/a
76940Us guide, tissue ablationS0268Nn/a
76941Echo guide for transfusionS0268Nn/a
76942Echo guide for biopsyS0268Nn/a
76945Echo guide, villus samplingS0268Nn/a
76946Echo guide for amniocentesisS0268Nn/a
76948Echo guide, ova aspirationS0309Nn/a
76950Echo guidance radiotherapyS0268Nn/a
76965Echo guidance radiotherapyS0308Nn/a
76975GI endoscopic ultrasoundS0266Nn/a
76998Us guide, intraopS0266Nn/a76986Ultrasound guide intraoper.
77001Fluoro guide for vein deviceNn/aNn/a75998Fluoro guide for vein device.
77002Needle localization by xrayNn/aNn/a76003Needle localization by xray.
77003Fluoroguide for spine injectNn/aNn/a76005Fluoroguide for spine inject.
77011Ct scan for localizationS0283Nn/a76355Ct scan for localization.
77012Ct scan for needle biopsyS0283Nn/a76360Ct scan for needle biopsy.
77013Ct guide for tissue ablationS0333Nn/a76362Ct guide for tissue ablation.
77014Ct scan for therapy guideS0282Nn/a76370Ct scan for therapy guide.
77021Mr guidance for needle placeS0335Nn/a76393Mr guidance for needle place.
77022Mri for tissue ablationS0335Nn/a76394Mri for tissue ablation.
77031Stereotact guide for brst bxX0264Nn/a76095Stereotactic breast biopsy.
77032Guidance for needle, breastX0263Nn/a
77417Radiology port film(s)X0260Nn/a
77421Stereoscopic x-ray guidanceS0257Nn/a
95873Guide nerv destr, elec stimS0215Nn/a
95874Guide nerv destr, needle emgS0215Nn/a
0054TBone surgery using computerS0302Nn/a
0055TBone surgery using computerS0302Nn/a
0056TBone surgery using computerS0302Nn/a

(2) Image Processing Services

We are proposing to package payment for “image processing” HCPCS codes for CY 2008, specifically those codes that are reported as supportive dependent services to process and integrate diagnostic test data in the development of images, performed concurrently or after the independent service is complete. We performed a broad search for such services, relying upon the AMA's CY 2007 book of CPT codes and the CY 2007 book of Level II HCPCS codes, which identified specific codes as “processing” codes. In addition, we performed a clinical review of all HCPCS codes to capture additional codes that we consider to be image processing. For example, we are proposing to package payment for CPT code 93325 (Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography)) because it is an image processing procedure, even though the code descriptor does not specifically indicate it as such.

An image processing service processes and integrates diagnostic test data that were captured during another independent procedure, usually one that is separately payable under the OPPS. The image processing service is not necessarily provided on the same date of service as the independent procedure. In fact, several of the image processing services that we are proposing to package for CY 2008 do not need to be provided face-to-face with the patient in the same encounter as the independent service. While this approach to service delivery may be administratively advantageous from a hospital's perspective, providing separate payment for each image processing service whenever it is performed is not consistent with encouraging value-based purchasing under the OPPS. We believe it is important to package payment for supportive dependent services that accompany independent services but that may not need to be provided face-to-face with the patient in the same Start Printed Page 42658encounter because the supportive services utilize data that were collected during the preceding independent services and packaging their payment encourages the most efficient use of hospital resources. We are particularly concerned with any continuance of current OPPS payment policies that could encourage certain inefficient and more costly service patterns. As stated above, packaging encourages hospitals to establish protocols that ensure that services are furnished only when they are medically necessary and to carefully scrutinize the services ordered by practitioners to minimize unnecessary use of hospital resources. Our standard methodology to calculate median costs packages the costs of dependent services with the costs of independent services on “natural” single claims across different dates of service, so we are confident that we would capture the costs of the supportive image processing services for ratesetting when they are packaged according to our CY 2008 proposal, even if they were provided on a different date than the independent procedure.

We list the image processing services that would be packaged for CY 2008 in Table 10 below. As these services support the performance of an independent service, we believe it would be appropriate to package their payment into the OPPS payment for the independent service provided.

As many independent services may be reported with or without image processing services, the cost of the image processing services will be reflected in the median cost for the independent HCPCS code as a function of the frequency that image processing services are reported with that particular HCPCS code. Again, while the median cost for a particular independent procedure generally will be higher as a result of added packaging, it could also change little or be lower because median costs typically do not reflect small distributional changes and because changes to the packaged HCPCS codes affect both the number and composition of single bills and the mix of hospitals contributing those single bills. For example, CPT code 70450 (Computed tomography, head or brain; without contrast material) may be provided alone or in conjunction with CPT code 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resource imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation). In fact, CPT code 70450 was provided approximately 1.5 million times based on CY 2008 proposed rule claims data. CPT code 76376 was provided with CPT code 70450 less than 2 percent of the total instances that CPT code 70450 was billed. Therefore, as the frequency of CPT code 76376 provided in conjunction with CPT code 70450 increases, the median cost for CPT code 70450 would be more likely to reflect that additional cost.

The image processing services that we are proposing to package vary in their hospital resource costs. Resource cost was not a factor we considered when proposing to package supportive image processing services. Notably, the majority of image processing services that we are proposing to package have modest median costs in relationship to the cost of the independent service that they typically accompany.

Several of these codes, including CPT code 76350 (Subtraction in conjunction with contrast studies), are already unconditionally (that is, always) packaged under the CY 2007 OPPS, where they have been assigned to status indicator “N.” Payment for these services is made as part of the payment for the separately payable, independent services with which they are billed. No separate payment is made for services that we have assigned to status indicator “N.” We are not proposing status indicator changes for the four image processing services that were unconditionally packaged for CY 2007.

We are proposing to change the status indicator for seven image processing services from separately paid to unconditionally packaged (status indicator “N”) for the CY 2008 OPPS. We believe that these services are always integral to and dependent upon the independent service that they support and, therefore, their payment would be appropriately packaged. We have calculated the median costs on which the proposed CY 2008 payment rates are based using the packaging status of each code as provided in Table 10 below. As we discuss above in more detail, this has the effect of both changing the median cost for the independent service into which the cost of the dependent service is packaged and also of redistributing payment that would otherwise have been made separately for the service we are proposing to newly package for CY 2008.

For example, CPT code 93325 (Doppler echocardiography color flow velocity mapping (List separately in addition to codes for echocardiography)) is assigned to APC 0697 (Level I Echocardiogram Except Transesophageal) for CY 2007. The proposed CY 2008 median cost of APC 0697 is $302.40. CPT code 93325 was billed with CPT code 93350 (Echocardiography, transthoracic, real-time with image documentation (2D), with or without M-mode recording, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report) approximately 43,000 times in the CY 2008 OPPS proposed rule data, and 5 percent of the claims for CPT code 93325 reported CPT code 93350 on the same date of service. Similarly, we note that almost 35 percent of the claims for CPT code 93350 also reported the image processing service described by CPT code 93325. Because CPT code 93350 is designated by CPT as an add-on code to a stress test service, as would be expected, we also observed that a CPT code for a stress test, most commonly CPT code 93017 (Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report) was also frequently reported on the same claim on the same day as both of the other two CPT codes. CPT code 93017 is assigned to APC 0100 (Cardiac Stress Tests) with a proposed CY 2008 median cost of $180.10. Under our proposed policy for the CY 2008, we are proposing to expand the packaging associated with the independent stress test and echocardiography services so that payment for the echocardiography color flow velocity mapping, if performed, would be packaged. Specifically, we would package payment for CPT code 93325, the echocardiography color flow velocity mapping, so that this dependent procedure would receive packaged payment through the separate OPPS payments for the independent procedures, here the stress test and echocardiography services. The payment rates for this example associated with our CY 2008 proposal are outlined in Table 9 below.

In this case, the proposed CY 2008 median cost for APC 0100 to which CPT code 93017 is assigned is $180.10. The proposed CY 2008 median cost for APC 0697, to which CPT code 93350 is assigned, is $302.40. The CY 2007 median cost for APC 0100 is $154.83 and the median cost for APC 0697 is $97.61. However, as discussed in section II.A.4.c. of this proposed rule concerning our general proposed packaging approach, the added effect of the budget neutrality adjustment that would result from the aggregate effects of the CY 2008 packaging proposal Start Printed Page 42659(were there no further budget neutrality adjustment for other reasons) significantly changes the final payment rates relative to the median cost estimates. Table 9 presents a comparison of payments for CPT codes 93017, 93350, and 93325 in CY 2007, where payment for CPT code 93325 is made separately, to our CY 2008 proposed payments for CPT codes 93017, 93350, and 93325, where payment for CPT code 93325 would be packaged. This example cannot demonstrate the overall impact of packaging image processing services on payment to any given hospital because each individual hospital's case-mix and billing patterns would be different. The overall impact of packaging payment for CPT code 93325, as well as the proposed packaging changes that we are proposing for CY 2008, can only be assessed in the aggregate for classes of hospitals. Section XXII.B. of this proposed rule displays the overall impact of APC weight recalibration and packaging changes that we are proposing by classes of hospitals, and the OPPS Hospital-Specific Impacts—Provider-Specific Data file presents our estimates of CY 2008 hospital payment for those hospitals we include in our ratesetting and payment simulation database. The hospital-specific impacts file can be found on the CMS Web site at http://www.cms.hhs.gov/​HospitalOutpatientPPS/​ under supporting documentation for this proposed rule.

Table 9.—Example of the Effects of the CY 2008 Packaging Proposal on Payment for CPT Codes 93325, 93350, and 93017

HCPCS codeShort descriptorSum of CY 2007 payment (93325 paid separately)Sum of CY 2008 proposed payment (93325 Packaged)
93325Doppler color flow add-on (dependent service)$98.18$0.00
93350Echo transthoracic (independent service)197.64306.18
93017Cardiovascular stress test (independent service)155.74182.36
Total Payment451.56488.54

The estimated overall impact of these proposed changes presented in section XXII.B. of this proposed rule is based on the assumption that hospital behavior would not change with regard to how often these dependent image processing services are performed in conjunction with the independent services. To the extent that hospitals could change their behavior and perform the image processing services more or less frequently, the data would show such a change in practice in future years and that change would be reflected in future budget neutrality adjustments.

As we indicated earlier, in all cases we are proposing that hospitals that furnish the image processing procedure in association with the independent service must bill both services on the same claim. We expect to carefully monitor any changes in billing practices on a service-specific and hospital-specific basis to determine whether there is reason to request that QIOs review the quality of care furnished or to request that Program Safeguard Contractors review the claims against the medical record.

Table 10.—Image Processing HCPCS Codes Proposed for Packaged Payment in CY 2008

HCPCS codeShort descriptorCY 2007 SICY 2007 APCProposed CY 2008 SIInactive CPT code effective 1/1/08 or earlier (listed on the same line as its replacement codeShort descriptor of the inactive CPT code
76125Cine/video x-rays add-onX0260N
76350Special x-ray contrast studyNn/aN
763763d render w/o postprocessX0340N
763773d rendering w/postprocessS0282N
93325Doppler color flow add-onS0697N
93613Electrophys map 3d, add-onT0087N
95957EEG digital analysisS0214N
0159TCad breast MRINn/aN
0174TCad cxr remoteNn/aN0152TComputer chest add-on.
0175TCad cxr with interpNn/aN0152TComputer chest add-on.
G0288Recon, CTA for surg planS0417N

(3) Intraoperative Services

We are proposing to package payment for “intraoperative” HCPCS codes for CY 2008, specifically those codes that are reported for supportive dependent diagnostic testing or other minor procedures performed during independent procedures. We performed a broad search for possible intraoperative HCPCS codes, relying upon the AMA's CY 2007 book of CPT codes and the CY 2007 book of Level II HCPCS codes, to identify specific codes as “intraoperative” codes. Furthermore, we performed a clinical review of all HCPCS codes to capture additional supportive diagnostic testing or other minor intraoperative or intraprocedural codes that are not necessarily identified as “intraoperative” codes. For example, we are proposing to package payment for CPT code 95955 (Electroencephalogram (EEG) during Start Printed Page 42660nonintracranial surgery (e.g., carotid surgery)) because it is a minor intraoperative diagnostic testing procedure even though the code descriptor does not indicate it as such. Although we use the term “intraoperative” to categorize these procedures, we also have included supportive dependent services in this group that are provided during an independent procedure, although that procedure may not necessarily be a surgical procedure. These dependent services clearly fit into this category because they are provided during, and are integral to, an independent procedure, like all the other intraoperative codes, but the independent procedure they accompany may not necessarily be a surgical procedure. For example, we are proposing to package HCPCS code G0268 (Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing). While specific audiologic function testing procedures are not surgical procedures performed in an operating room, they are independent procedures that are separately payable under the OPPS, and HCPCS code G0268 is a supportive dependent service always provided in association with one of these independent services. All references to “intraoperative” below refer to services that are usually or always provided during a surgical procedure or other independent procedure.

By definition, a service that is performed intraoperatively is provided during and, therefore, on the same date of service as another procedure that is separately payable under the OPPS. Because these intraoperative services support the performance of an independent procedure and they are provided in the same operative session as the independent procedure, we believe it would be appropriate to package their payment into the OPPS payment for the independent procedure performed. Therefore, we are not proposing to package payment for CY 2008 for those diagnostic services, such as CPT code 93005 (Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report) that are sometimes or only rarely performed and reported as supportive services in association with other independent procedures. Instead, we are proposing to include those HCPCS codes that are usually or always performed intraoperatively, based upon our review of the codes described above. The intraoperative services that we are proposing to package vary in hospital resource costs. Resource cost was not a factor we considered when determining which supportive intraoperative procedures to package.

The codes we are proposing to identify as intraoperative services for CY 2008 that would receive packaged payment under the OPPS are listed in Table 12 below.

Several of these codes, including CPT code 93640 (Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia, evaluation of sensing and pacing for arrhythmia termination) at the time of initial implantation or replacement), are already unconditionally (that is, always) packaged under the CY 2007 OPPS, where they have been assigned to status indicator “N.” Payment for these services is made through the payment for the separately payable, independent services with which they are billed. No separate payment is made for services that we have assigned to status indicator “N.” We are not proposing status indicator changes for the five diagnostic intraoperative services that were unconditionally packaged for CY 2007.

We are proposing to change the status indicator for 34 intraoperative services from separately paid to unconditionally packaged (status indicator “N”) for the CY 2008 OPPS. We believe that these services are always integral to and dependent upon the independent services that they support and, therefore, their payment would be appropriately packaged because they would generally be performed on the same date and in the same hospital as the independent services.

We are also proposing to change the status indicator for one intraoperative procedure from unconditionally packaged to conditionally packaged (status indicator “Q”) as a “special” packaged code for the CY 2008 OPPS, specifically, CPT code 0126T (Common carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor assessment). This code was discussed in the past with the Packaging Subcommittee of the APC Panel which determined that, consistent with its code descriptor as a separate procedure, this procedure could sometimes be provided alone, without any other OPPS services on the claim. We believe that this procedure would usually be provided by a hospital in conjunction with another independent procedure on the same date of service but may occasionally be provided without another independent service. As a “special” packaged code, if the study were billed without any other service assigned to status indicator “S,” “T,” “V,” or “X” reported on the same date of service, under our proposal we would not treat the IMT study as a dependent service for purposes of payment. If we were to continue to unconditionally package payment for this procedure, treating it as a dependent service, hospitals would receive no payment at all when providing this service alone, although the procedure would not be functioning as an intraoperative service in that case. However, according to our proposal, its conditionally packaged status as a “special” packaged code would allow payment to be provided for this “Q” status IMT study when provided alone, in which case it would be treated as an independent service under these limited circumstances. On the other hand, when this service is furnished as an intraoperative procedure on the same day and in the same hospital as independent, separately paid services that are assigned to status indicator “S,” “T,” “V,” or “X,” we are proposing to package payment for it as a dependent service. In all cases, we are proposing that hospitals that furnish independent services on the same date as this IMT procedure must bill them all on the same claim. We believe that when dependent and independent services are furnished on the same date and in the same facility, they are part of a single complete hospital outpatient service that is reported with more than one HCPCS code, and no separate payment should be made for the intraoperative procedure that supports the independent service.

We have calculated the median costs on which the proposed CY 2008 payment rates are based using the packaging status of each code as provided in Table 12 below. As we discuss above in more detail, this has the effect of both changing the median cost for the independent service into which the cost of the dependent service is packaged and also of redistributing payment that would otherwise have been made separately for the service we are proposing to newly package for CY 2008.

For example, CPT code 92547 (Use of vertical electrodes (List separately in addition to code for primary procedure)) is assigned to APC 0363 (Level I Otorhinolaryngologic Function Tests) for CY 2007. The proposed CY 2008 median cost of APC 0363 is $53.73. CPT code 92547 was billed with CPT code 92541 (Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording) 6,056 times in the CY 2008 OPPS proposed rule data, and 97 Start Printed Page 42661percent of the claims for CPT code 92547 reported CPT code 92541 on the same date of service. Similarly, we note that over half of the claims for CPT code 92541 also reported the service described by CPT code 92547. Under our proposed policy for the CY 2008 OPPS, we are proposing to expand the packaging associated with the independent nystagmus test so that payment for the use of vertical electrodes, if used, would be packaged. Specifically, we would package payment for CPT code 92547 so that under the CY 2008 OPPS the commonly billed dependent procedure, the use of vertical electrodes, would receive packaged payment through the separate OPPS payment for the independent procedure, in this case the nystagmus test. The payment rates for this example associated with our CY 2008 proposal are outlined in Table 11 below.

In this case, the proposed CY 2008 median cost for APC 0363, to which CPT code 92541 is assigned, is $53.73, while the CY 2007 median cost of this APC with status indicator “S” and to which both CPT codes 92547 and 02541 are assigned is $52.09. However, as discussed in the section II.A.4. of this proposed rule concerning our general proposed packaging approach, the added effect of the budget neutrality adjustment that would result from the aggregate effects of the complete CY 2008 packaging proposal (were there no further budget neutrality adjustment for other reasons) significantly changes the final payment rates relative to median cost estimates. Table 11 presents a comparison of payment for CPT codes 92541 and 92547 in CY 2007, where CPT code 92547 is paid separately, to our CY 2008 proposed payment for CPT codes 92541 and 92547, where payment for CPT code 92547 would be packaged. This example cannot demonstrate the overall impact of packaging intraoperative services on payment to any given hospital because each individual hospital's case-mix and billing patterns would be different. The overall impact of packaging payment for CPT code 92547, as well as all other packaging changes we are proposing for CY 2008, can only be assessed in the aggregate for classes of hospitals. Section XXII.B. of this proposed rule displays the overall impact of APC weight recalibration and packaging changes we are proposing by classes of hospitals, and the OPPS Hospital-Specific Impacts—Provider-Specific Data file presents our estimates of CY 2008 hospital payment for those hospitals we include in our ratesetting and payment simulation database. The hospital-specific impacts file can be found on the CMS Web site at http://www.cms.hhs.gov/​HospitalOutpatientPPS/​ under supporting documentation for this proposed rule.

 Table 11.— Example of the Effects of the CY 2008 Packaging Proposal on Payment for CPT Codes 92541 and 92547

HCPCS CodeShort descriptorSum of CY 2007 payment (92547 paid separately)Sum of CY 2008 proposed payment (92547 packaged)
92541Spontaneous nystagmus study (independent service)$52.40$54.41
92547Supplemental electrical test (dependent service)52.400.00
Total Payment104.8054.41

The estimated overall impact of these proposed changes is based on the assumption that hospital behavior would not change with regard to when these dependent intraoperative services are performed on the same date and by the same hospital that performs the independent services. To the extent that hospitals could change their behavior and perform the intraoperative services more or less frequently, on subsequent dates, or at settings outside of the hospital, the data would show such a change in practice in future years and that change would be reflected in future budget neutrality adjustments. However, with respect to intraoperative services in particular, we believe that hospitals are limited in the extent to which they could change their behavior with regard to how they furnish these services. By their definition, these intraoperative services generally must be furnished on the same date and at the same operative location as the independent procedure in order to be considered intraoperative. For these codes, we assume that both the dependent and independent services would be furnished on the same date in the same hospital, and hospitals should bill them on the same claim with the same date of service.

As we indicated earlier, in all cases we are proposing that hospitals that furnish the intraoperative procedure on the same date as the independent service must bill both services on the same claim. We expect to carefully monitor any changes in billing practices on a service-specific and hospital-specific basis to determine whether there is reason to request that QIOs review the quality of care furnished or to request that Program Safeguard Contractors review the claims against the medical record.

Table 12.—Intraoperative HCPCS Codes Proposed for Packaged Payment in CY 2008

HCPCS CodeShort descriptorCY 2007 SICY 2007 APCProposed CY 2008 SI
20975Electrical bone stimulationX0340N
31620Endobronchial us add-onS0670N
37250Iv us first vessel add-onS0416N
37251Iv us each add vessel add-onS0416N
58110Bx done w/colposcopy add-onT0188N
67299Eye surgery procedureT0235N
73530X-ray exam of hipX0261N
74300X-ray bile ducts/pancreasX0263N
Start Printed Page 42662
74301X-rays at surgery add-onX0263N
75898Follow-up angiographyX0263N
78020Thyroid met uptakeS0399N
78478Heart wall motion add-onS0399N
78480Heart function add-onS0399N
78496Heart first pass add-onS0399N
92547Supplemental electrical testX0363N
92978Intravasc us, heart add-onS0670N
92979Intravasc us, heart add-onS0416N
93320Doppler echo exam, heartS0697N
93321Doppler echo exam, heartS0697N
93571Heart flow reserve measureS0670N
93572Heart flow reserve measureS0416N
93609Map tachycardia, add-onT0087N
93613Electrophys map 3d, add-onT0087N
93621Electrophysiology evaluationT0085N
93622Electrophysiology evaluationT0085N
93623Stimulation, pacing heartT0087N
93631Heart pacing, mappingT0087N
93640Evaluation heart deviceNn/aN
93641Electrophysiology evaluationNn/aN
93662Intracardiac ecg (ice)S0670N
95829Surgery electrocorticogramS0214N
95920Intraop nerve test add-onS0216N
95955EEG during surgeryS0213N
95999Neurological procedureS0215N
96020Functional brain mappingX0373N
0126TChd risk imt studyNn/aQ
0173TIop monit io pressureNn/aN
G0268Removal of impacted wax mdX0340N
G0275Renal angio, cardiac cathNn/aN
G0278Iliac art angio, cardiac cathNn/aN

(4) Imaging Supervision and Interpretation Services

We are proposing to change the packaging status of many imaging supervision and interpretation codes for CY 2008. We define “imaging supervision and interpretation codes” as HCPCS codes for services that are defined as “radiological supervision and interpretation” in the radiology series, 70000 through 79999, of the AMA's CY 2007 book of CPT codes, with the addition of some services in other code ranges of CPT, Category III CPT tracking codes, or Level II HCPCS codes that are clinically similar or directly crosswalk to codes defined as radiological supervision and interpretation services in the CPT radiology range. We also included HCPCS codes that existed in CY 2006 but were deleted and were replaced in CY 2007. We included the CY 2006 HCPCS codes because we are proposing to use the CY 2006 claims data to calculate the CY 2008 OPPS median costs on which the CY 2008 payment rates would be based.

In its discussion of “radiological supervision and interpretation,” CPT indicates that “when a procedure is performed by two physicians, the radiologic portion of the procedure is designated as ‘radiological supervision and interpretation’.” In addition, CPT guidance notes that, “When a physician performs both the procedure and provides imaging supervision and interpretation, a combination of procedure codes outside the 70000 series and imaging supervision and interpretation codes are to be used.” In the hospital outpatient setting, the concept of one or more than one physician performing related procedures does not apply to the reporting of these codes, but the radiological supervision and interpretation codes clearly are established for reporting in association with other procedural services outside the CPT 70000 series. Because these imaging supervision and interpretation codes are always reported for imaging services that support the performance of an independent procedure and they are, by definition, always provided in the same operative session as the independent procedure, we believe that it would be appropriate to package their payment into the OPPS payment for the independent procedure performed.

In addition to radiological supervision and interpretation codes in the radiology range of CPT codes, there are CPT codes in other series that describe similar procedures that we are proposing to include in the group of imaging supervision and interpretation codes proposed for packaging under the CY 2008 OPPS. For example, CPT code 93555 (Imaging supervision, interpretation and report for injection procedure(s) during cardiac catheterization; ventricular and/or atrial angiography) whose payment under the OPPS is currently packaged, is commonly reported with an injection procedure code, such as CPT code 93543 (Injection procedure during cardiac catheterization; for selective left ventricular or left atrial angiography), whose payment is also currently packaged under the OPPS, and a cardiac catheterization procedure code, such as CPT code 93526 (Combined right heart catheterization and retrograde left heart catheterization), that is separately paid. In the case of cardiac catheterization, CPT code 93555 describes an imaging supervision and interpretation service in support of the cardiac catheterization procedure, and this dependent service is clinically quite similar to radiological supervision and interpretation codes in the radiology range of CPT. Payment for the cardiac catheterization imaging Start Printed Page 42663supervision and interpretation services has been packaged since the beginning of the OPPS. Therefore, in developing this proposal for the CY 2008 proposed rule, we conducted a comprehensive clinical review of all Category I and Category III CPT codes and Level II HCPCS codes to identify all codes that describe imaging supervision and interpretation services. The codes we are proposing to identify as imaging supervision and interpretation codes for CY 2008 that would receive packaged payment are listed in Table 14 below.

Several of these codes, including CPT code 93555 discussed above, are already unconditionally (that is, always) packaged under the CY 2007 OPPS, where they have been assigned to status indicator “N.” Payment for these services is made as part of the payment for the separately payable, independent services with which they are billed. No separate payment is made for services that we have assigned to status indicator “N.” We are not proposing status indicator changes for the six imaging supervision and interpretation services that were unconditionally packaged for CY 2007.

We are proposing to change the status indicator for 33 imaging supervision and interpretation services from separately paid to unconditionally packaged (status indicator “N”) for the CY 2008 OPPS. We believe that these services are always integral to and dependent upon the independent services that they support and, therefore, their payment would be appropriately packaged because they would generally be performed on the same date and in the same hospital as the independent services.

We are proposing to change the status indicator for 93 imaging supervision and interpretation services from separately paid to conditionally packaged (status indicator “Q”) as “special” packaged codes for the CY 2008 OPPS. These services may occasionally be provided at the same time and at the same hospital with one or more other procedures for which payment is currently packaged under the OPPS, most commonly injection procedures, and in these cases we would not treat the imaging supervision and interpretation services as dependent services for purposes of payment. If we were to unconditionally package payment for these imaging supervision and interpretation services as dependent services, hospitals would receive no payment at all for providing the imaging supervision and interpretation service and the other minor procedure(s). However, according to our proposal, their conditional packaging status as “special” packaged codes would allow payment to be provided for these “Q” status imaging supervision and interpretation services as independent services in these limited circumstances, and for which payment for the accompanying minor procedure would be packaged. However, when these imaging supervision and interpretation dependent services are furnished on the same day and in the same hospital as independent separately paid services, specifically, any service assigned to status indicator “S,” “T,” “V,” or “X,” we are proposing to package payment for them as dependent services. In all cases, we are proposing that hospitals that furnish the independent services on the same date as the dependent services must bill them all on the same claim. We believe that when the dependent and independent services are furnished on the same date and in the same hospital, they are part of a single complete hospital outpatient service that is reported with more than one HCPCS code, and no separate payment should be made for the imaging supervision and interpretation service that supports the independent service.

In the case of services for which we are proposing conditional packaging, we would expect that, although these services would always be performed in the same session as another procedure, in some cases that other procedure's payment would also be packaged. For example, CPT code 73525 (Radiological examination, hip, arthrography, radiological supervision and interpretation) and CPT code 27093 (Injection procedure for hip arthrography; without anesthesia) could be provided in a single hospital outpatient encounter and reported as the only two services on a claim. In the case where only these two services were performed, the conditionally packaged status of CPT code 73525 would appropriately allow for its separate payment as an independent imaging supervision and interpretation arthrography service, into which payment for the dependent injection procedure would be packaged.

We have calculated the median costs on which the proposed CY 2008 payment rates are based using the packaging status of each code as provided in Table 14 below. As we discuss above in more detail, this has the effect of both changing the median cost for the independent service into which the cost of the dependent service is packaged and also of redistributing payment that would otherwise have been made separately for the service we are proposing to newly package for CY 2008.

For example, CPT code 72265 (Myelography, lumbosacral, radiological supervision and interpretation) is assigned to APC 0274 (Myelography) for CY 2007. The proposed CY 2008 median cost of APC 0274 is $245.38. CPT code 72265 was billed with CPT code 72132 (Computed tomography, lumbar spine; with contrast material) 20,233 times in the CY 2008 OPPS proposed rule data, and 62 percent of the claims for CPT code 72265 reported CPT code 72132 on the same date of service. Similarly, we note that over half of the claims for CPT code 72132 also reported the myelography service described by CPT code 72265. As would be expected, we also observed that a CPT code for the clinically necessary intrathecal injection, specifically CPT code 62284 (Injection procedure for myelography and/or computed tomography, spinal (other than C1-C2 and posterior fossa)) was also frequently reported on the same claim on the same day as both of the other two CPT codes. Payment for CPT code 62284 is already packaged under the OPPS for CY 2007, as is payment for most HCPCS codes that describe dependent injection procedures that accompany independent procedures. Under our proposed policy for the CY 2008 OPPS, we are proposing to expand the packaging associated with the independent spinal computed tomography (CT) scan so that payment for both the associated injection procedure and the related myelography service, if performed, would be packaged. Specifically, we would package payment for CPT code 72265 when it appears on the same claim with a separately paid service such as CPT code 72132, so that, under the CY 2008 OPPS, both commonly billed dependent procedures, the injection procedure and the myelography service, would receive packaged payment through the separate OPPS payment for the independent procedure, the CT scan. The payment rates for this example associated with our CY 2008 proposal are outlined in Table 13 below. The proposed conditionally packaged status for CPT code 72265 would ensure that if lumbosacral myelography was performed alone, separate payment for the myelography service would be made under the OPPS as the myelography service would not be a dependent service in that situation.

The proposed policy would result in no separate payment for CPT code 72265 when it is billed on the same day and by the same hospital as any separately paid service, such as CPT code 72132. Moreover, as discussed Start Printed Page 42664later in this section, the proposed policy would provide packaged payment for the contrast agent that is required to perform the independent computed tomography service. For purposes of the example in Table 13 below, we include the payment for HCPCS code Q9947 (Low osmolar contrast material 200-249 mg/ml iodine concentration, per ml) which was reported on about one-third of the CY 2008 proposed rule claims for CPT code 72132. To calculate the CY 2007 payment for the contrast agent, we multiplied the mean number of units per day from our CY 2008 proposed rule data (48.3) by the April 2007 per unit payment rate for HCPCS code Q9947 ($1.33).

In this case, the proposed CY 2008 median cost for APC 0316 (Level II Computed Tomography with Contrast) to which CPT code 72132 is assigned is $741.80. The CY 2007 median cost for APC 0283 to which CPT code 72132 is assigned is $249.48 and the median cost of APC 0274 to which CPT code 72265 is assigned is $156.10. However, as discussed in section II.A.4.c. of this proposed rule concerning our general proposed packaging approach, the added effect of the budget neutrality adjustment that would result from the aggregate effects of the CY 2008 packaging proposal (were there no further budget neutrality adjustment for other reasons) significantly changes the final payment rates relative to median cost estimates. Table 13 presents a comparison of payment for CPT codes 72132 and 72265 and HCPCS code Q9947 in CY 2007, where CPT code 72265 and HCPCS code Q9947 are paid separately, to our CY 2008 proposed payment for CPT codes 72132 and 77265 and HCPCS code Q9947, where payment for CPT code 72265 and HCPCS code Q9947 would be packaged. This example cannot demonstrate the overall impact of packaging imaging supervision and interpretation services on payment to any given hospital because each individual hospital's case-mix and billing patterns would be different. The overall impact of packaging payment CPT code 77265 when it appears with any other separately paid service, as well as all other packaging changes that we are proposing for CY 2008, can only be assessed in aggregate for classes of hospitals. Section XXII.B. of this proposed rule displays the overall impact of APC weight recalibration and packaging changes we are proposing by classes of hospitals, and the OPPS Hospital-Specific Impacts—Provider-Specific Data file presents our estimates of CY 2008 hospital payment for those hospitals we include in our ratesetting and payment simulation database. The hospital-specific impacts file can be found on the CMS Web site at http://www.cms.hhs.gov/​HospitalOutpatientPPS/​ under supporting documentation for this proposed rule.

Table 13.—Example of the Effects of the CY 2008 Packaging Proposal on Payment for CPT Codes 72265 and 72132 and HCPCS Code Q9947

HCPCS codeShort descriptorSum of CY 2007 payment (72265 paid separately)Sum of CY 2008 proposed payment (72265 packaged)
62284Injection for myelogram (dependent service)$0.00$0.00
Q9947*LOCM 200-249mg/ml iodine, 1ml (dependent service)64.240.00
72265Contrast x-ray lower spine (dependent service)157.010.00
72132CT lumbar spine w/dye (independent service)250.94751.09
Total Payment472.14751.09
* Based on the mean number of units per day from our CY 2008 proposed rule data (48.3) and the April 2007 per unit payment rate for Q9947 ($1.33).

The estimated overall impact of these changes presented in XXII.B. of this proposed rule is based on the assumption that hospital behavior would not change with regard to when these dependent services are performed on the same date and by the same hospital that performs the independent services. To the extent that hospitals could change their behavior and perform the imaging supervision and interpretation services more or less frequently, on subsequent dates, or at settings outside of the hospital, the data would show such a change in practice in future years and that change would be reflected in future budget neutrality adjustments. However, with respect to the imaging supervision and interpretation services in particular, we believe that hospitals are limited in the extent to which they could change their behavior with regard to how they furnish these services. By their definition, these imaging and supervision services generally must be furnished on the same date and at the same operative location as the independent procedure in order for the imaging service to meaningfully contribute to the diagnosis or treatment of the patient. For those radiological supervision and interpretation codes in the radiology range of CPT in particular, if the same physician is able to perform both the procedure and the supervision and interpretation as stated by CPT, we assume that both the dependent and independent services would be furnished on the same date in the same hospital, and hospitals should bill them on the same claim with the same date of service.

As we indicated earlier in this section, in all cases we are proposing that hospitals that furnish the imaging supervision and interpretation service on the same date as the independent service must bill both services on the same claim. We expect to carefully monitor any changes in billing practices on a service-specific and hospital-specific basis to determine whether there is reason to request that QIOs review the quality of care furnished or to request that Program Safeguard Contractors review the claims against the medical record. Start Printed Page 42665

Table 14.—Imaging Supervision and Interpretation HCPCS Codes Proposed for Packaged Payment in CY 2008

HCPCS codeShort descriptorCY 2007 SICY 2007 APCProposed CY 2008 SIProposed CY 2008 APCInactive CPT code effective 1/1/2008 or earlier (listed on the same line as its replacement code)Short descriptor of the inactive CPT code
70010Contrast x-ray of brainS0274Q0274
70015Contrast x-ray of brainS0274Q0274
70170X-ray exam of tear ductX0264Q0264
70332X-ray exam of jaw jointS0275Q0275
70373Contrast x-ray of larynxX0263Q0263
70390X-ray exam of salivary ductX0263Q0263
71040Contrast x-ray of bronchiX0263Q0263
71060Contrast x-ray of bronchiX0263Q0263
71090X-ray & pacemaker insertionX0272Nn/a
72240Contrast x-ray of neck spineS0274Q0274
72255Contrast x-ray, thorax spineS0274Q0274
72265Contrast x-ray, lower spineS0274Q0274
72270Contrast x-ray, spineS0274Q0274
72275EpidurographyS0274Nn/a
72285X-ray c/t spine diskS0388Q0388
72291Perq vertebroplasty, fluorS0274Nn/a76012Perq vertebroplasty, fluor.
72292Perq vertebroplasty, ctS0274Nn/a76013Perq vertebroplasty, ct.
72295X-ray of lower spine diskS0388Q0388
73040Contrast x-ray of shoulderS0275Q0275
73085Contrast x-ray of elbowS0275Q0275
73115Contrast x-ray of wristS0275Q0275
73525Contrast x-ray of hipS0275Q0275
73542X-ray exam, sacroiliac jointS0275Q0275
73580Contrast x-ray of knee jointS0275Q0275
73615Contrast x-ray of ankleS0275Q0275
74190X-ray exam of peritoneumS0264Q0264
74235Remove esophagus obstructionS0257Nn/a
74305X-ray bile ducts/pancreasX0263Nn/a
74320Contrast x-ray of bile ductsX0264Q0264
74327X-ray bile stone removalS0296Nn/a
74328X-ray bile duct endoscopyNn/aNn/a
74329X-ray for pancreas endoscopyNn/aNma
74330X-ray bile/panc endoscopyNn/aNn/a
74340X-ray guide for GI tubeX0272Nn/a
74350X-ray guide, stomach tubeX0263Nn/a
74355X-ray guide, intestinal tubeX0263Nn/a
74360X-ray guide, GI dilationS0257Nn/a
74363X-ray, bile duct dilationS0297Nn/a
74425Contrast x-ray, urinary tractS0278Q0278
74430Contrast x-ray, bladderS0278Q0278
74440X-ray, male genital tractS0278Q0278
74445X-ray exam of penisS0278Q0278
74450X-ray, urethra/bladderS0278Q0278
74455X-ray, urethra/bladderS0278Q0278
74470X-ray exam of kidney lesionX0263Q0263
74475X-ray control, cath insertS0297Q0297
74480X-ray control, cath insertS0296Q0296
74485X-ray guide, GU dilationS0296Q0296
74740X-ray, female genital tractX0264Q0264
74742X-ray, fallopian tubeX0264N
75600Contrast x-ray exam of aortaS0280Q0280
75605Contrast x-ray exam of aortaS0280Q0280
75625Contrast x-ray exam of aortaS0280Q0280
75630X-ray aorta, leg arteriesS0280Q0280
75635Ct angio abdominal arteriesS0662Q0662
75650Artery x-rays, head & neckS0280Q0280
75658Artery x-rays, armS0279Q0279
75660Artery x-rays, head & neckS0668Q0668
75662Artery x-rays, head & neckS0280Q0280
75665Artery x-rays, head & neckS0280Q0280
75671Artery x-rays, head & neckS0280Q0280
Start Printed Page 42666
75676Artery x-rays, neckS0280Q0280
75680Artery x-rays, neckS0280Q0280
75685Artery x-rays, spineS0280Q0280
75705Artery x-rays, spineS0668Q0668
75710Artery x-rays, arm/legS0280Q0280
75716Artery x-rays, arms/legsS0280Q0280
75722Artery x-rays, kidneyS0280Q0280
75724Artery x-rays, kidneysS0280Q0280
75726Artery x-rays, abdomenS0280Q0280
75731Artery x-rays, adrenal glandS0280Q0280
75733Artery x-rays, adrenalsS0668Q0668
75736Artery x-rays, pelvisS0280Q0280
75741Artery x-rays, lungS0279Q0279
75743Artery x-rays, lungsS0280Q0280
75746Artery x-rays, lungS0279Q0279
75756Artery x-rays, chestS0279Q0279
75774Artery x-ray, each vesselS0279Nn/a
75790Visualize A-V shuntS0279Q0279
75801Lymph vessel x-ray, arm/legX0264Q0264
75803Lymph vessel x-ray,arms/legsX0264Q0264
75805Lymph vessel x-ray, trunkX0264Q0264
75807Lymph vessel x-ray, trunkX0264Q0264
75809Nonvascular shunt, x-rayX0263Q0263
75810Vein x-ray, spleen/liverS0279Q0279
75820Vein x-ray, arm/legS0668Q0668
75822Vein x-ray, arms/legsS0668Q0668
75825Vein x-ray, trunkS0279Q0279
75827Vein x-ray, chestS0279Q0279
75831Vein x-ray, kidneyS0279Q0279
75833Vein x-ray, kidneysS0279Q0279
75840Vein x-ray, adrenal glandS0280Q0280
75842Vein x-ray, adrenal glandsS0280Q0280
75860Vein x-ray, neckS0668Q0668
75870Vein x-ray, skullS0668Q0668
75872Vein x-ray, skullS0279Q0279
75880Vein x-ray, eye socketS0668Q0668
75885Vein x-ray, liverS0280Q0280
75887Vein x-ray, liverS0279Q0279
75889Vein x-ray, liverS0280Q0280
75891Vein x-ray, liverS0279Q0279
75893Venous sampling by catheterQ0668Q0668
75894X-rays, transcath therapyS0298Nn/a
75896X-rays, transcath therapyS0263Nn/a
75901Remove cva device obstructX0263Nn/a
75902Remove cva lumen obstructX0263Nn/a
75940X-ray placement, vein filterS0298Nn/a
75945Intravascular usS0267Q0267
75946Intravascular us add-onS0266Nn/a
75960Transcath iv stent rs&iS0668Nn/a
75961Retrieval, broken catheterS0668Nn/a
75962Repair arterial blockageS0668Q0668
75964Repair Artery blockage, eachS0668Nn/a
75966Repair arterial blockageS0668Q0668
75968Repair Artery blockage, eachS0668Nn/a
75970Vascular biopsyS0668Nn/a
75978Repair venous blockageS0668Q0668
75980Contrast xray exam bile ductS0297Nn/a
75982Contrast xray exam bile ductS0297Nn/a
75984Xray control catheter changeX0263Nn/a
75989Abscess drainage under x-rayNNn/a
75992Atherectomy, x-ray examS0668Nn/a
75993Atherectomy, x-ray examS0668Nn/a
75994Atherectomy, x-ray examS0668Nn/a
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75995Atherectomy, x-ray examS0668Nn/a
75996Atherectomy, x-ray examS0668Nn/a
76080X-ray exam of fistulaX0263Q0263
76975GI endoscopic ultrasoundS0266Q0266
77053X-ray of mammary ductX0263Q026376086X-ray of mammary duct.
77054X-ray of mammary ductsX0263Q026376088X-ray of mammary ducts.
93555Imaging, cardiac cathNn/aNn/a
93556Imaging, cardiac cathNn/aNn/a

(5) Diagnostic Radiopharmaceuticals

For CY 2008, we are proposing to change the packaging status of diagnostic radiopharmaceuticals as part of our overall enhanced packaging approach for the CY 2008 OPPS. Packaging costs into a single aggregate payment for a service, encounter, or episode of care is a fundamental principle that distinguishes a prospective payment system from a fee schedule. In general, packaging the costs of supportive items and services into the payment for the independent procedure or service with which they are associated encourages hospital efficiencies and also enables hospitals to manage their resources with maximum flexibility. As we stated in the CY 2007 OPPS/ASC final rule with comment period, we believe that a policy to package payment for additional radiopharmaceuticals (other than those already packaged when their per day costs are below the packaging threshold for OPPS drugs, biologicals, and radiopharmaceuticals based on data for the update year) is consistent with OPPS packaging principles and would provide greater administrative simplicity for hospitals (71 FR 68094).

All nuclear medicine procedures require the use of at least one radiopharmaceutical, and there are only a small number of radiopharmaceuticals that may be appropriately billed with each diagnostic nuclear medicine procedure. While examining the CY 2005 hospital claims data in preparation for the CY 2007 OPPS/ASC proposed rule, we identified a significant number of diagnostic nuclear medicine procedure claims that were missing HCPCS codes for the associated radiopharmaceutical. At that time, we believed that there could be two reasons for the presence of these claims in the data. One reason could be that the radiopharmaceutical used for the procedure was packaged under the OPPS and, therefore, some hospitals may have decided not to include the specific radiopharmaceutical HCPCS code and an associated charge on the claim. A second reason could be that the hospitals may have incorporated the cost of the radiopharmaceutical into the charges for the associated nuclear medicine procedures. A third possibility not offered in the CY 2007 OPPS/ASC proposed rule is that hospitals may have included the charges for radiopharmaceuticals on an uncoded revenue code line.

In the CY 2007 OPPS/ASC proposed rule, we did not propose packaging payment for radiopharmaceuticals with per day costs above the $55 CY 2007 packaging threshold because we indicated that we were concerned that payments for certain nuclear medicine procedures could potentially be less than the costs of some of the packaged radiopharmaceuticals, especially those that are relatively expensive. At the same time, we also noted the GAO's comment in reference to the CY 2006 OPPS proposed rule that stated a methodology that includes packaging all radiopharmaceutical costs into the payments for the nuclear medicine procedures may result in payments that exceed hospitals' acquisition costs for certain radiopharmaceuticals because there may be more than one radiopharmaceutical that may be used for a particular procedure. We also expressed concern that packaging payment for additional radiopharmaceuticals could provoke treatment decisions that may not reflect use of the most clinically appropriate radiopharmaceutical for a particular nuclear medicine procedure in any specific case (71 FR 68094).

After considering this issue further and examining our CY 2006 claims data for the CY 2008 OPPS update, we believe that it is most appropriate to package payment for some radiopharmaceuticals, specifically diagnostic radiopharmaceuticals, into the payment for diagnostic nuclear medicine procedures for CY 2008. We expect that packaging would encourage hospitals to use the most cost efficient diagnostic radiopharmaceutical products that are clinically appropriate. We anticipate that hospitals would continue to provide care that is aligned with the best interests of the patient. Furthermore, we believe that it would be the intent of most hospitals to provide both the diagnostic radiopharmaceutical and the associated diagnostic nuclear medicine procedure at the time the diagnostic radiopharmaceutical is administered and not to send patients to a different provider for administration of the radiopharmaceutical. We do not believe that our packaging proposal would limit beneficiaries' ability to receive clinically appropriate diagnostic procedures. Again, the OPPS is a system of averages, and payment in the aggregate is intended to be adequate, although payment for any one service may be higher or lower than a hospital's actual costs in that case.

For CY 2008, we have separated radiopharmaceuticals into two groupings. The first group includes diagnostic radiopharmaceuticals, while Start Printed Page 42668the second group includes therapeutic radiopharmaceuticals. We identified all diagnostic radiopharmaceuticals as those Level II HCPCS codes that include the term “diagnostic” along with a radiopharmaceutical in their long code descriptors. Therefore, we were able to distinguish therapeutic radiopharmaceuticals from diagnostic radiopharmaceuticals as those Level II HCPCS codes that have the term “therapeutic” along with a radiopharmaceutical in their long code descriptors. There currently are no HCPCS C-codes used to report radiopharmaceuticals under the OPPS. For CY 2008, we are proposing to package payment for all diagnostic radiopharmaceuticals that are not otherwise packaged according to the proposed CY 2008 packaging threshold for drugs, biologicals, and radiopharmaceuticals. We are proposing this packaging approach for diagnostic radiopharmaceuticals, while we are proposing to continue to pay separately for therapeutic radiopharmaceuticals with an average per day cost of more than $60 as discussed in section V.B.3. of this proposed rule. In that section, we review our reasons for treating diagnostic radiopharmaceuticals (as well as contrast media) differently from other types of specified covered outpatient drugs identified in section 1833(t)(B) of the Act.

Diagnostic radiopharmaceuticals are always intended to be used with a diagnostic nuclear medicine procedure. In examining our CY 2006 claims data, we were able to match most diagnostic radiopharmaceuticals to their associated diagnostic procedures and most diagnostic nuclear medicine procedures to their associated diagnostic radiopharmaceuticals in the vast majority of single bills used for ratesetting. We estimate that less than 5 percent of all claims with a diagnostic radiopharmaceutical had no corresponding diagnostic nuclear medicine procedure. In addition, we found that only about 13 percent of all single bills with a diagnostic nuclear medicine procedure code had no corresponding diagnostic radiopharmaceutical billed. These statistics indicate that, in a majority of our single bills for diagnostic nuclear medicine procedures, a diagnostic radiopharmaceutical HCPCS code is included on the single bill. Table 15 presents the top 20 diagnostic nuclear medicine procedures in terms of the overall frequency with which they are reported in the OPPS claims data. Among these high volume diagnostic nuclear medicine procedures, their single bills include a HCPCS code for a diagnostic radiopharmaceutical at least 84 percent of the time for 19 out of the top 20 procedures. More specifically, 84 to 86 percent of the single bills for 4 diagnostic nuclear medicine procedures include a diagnostic radiopharmaceutical, 87 to 89 percent of the single bills for 8 diagnostic nuclear medicine procedures include a diagnostic radiopharmaceutical, and 90 percent or more of the single bills for 7 diagnostic nuclear medicine procedures include a diagnostic radiopharmaceutical.

Table 15.—Top 20 Diagnostic Nuclear Medicine Procedures Sorted by CY 2006 OPPS Total Volume

HCPCS codeShort descriptorSIAPCTotal line-item frequencySingle bills with a radiopharmaceutical as a percent of all single billsSingle bills as a percent of total line-item frequency
78465Heart image (3d), multipleS0377566,252889
78306Bone imaging, whole bodyS0396368,4529076
78815Tumorimage pet/ct skul-thighS0308122,12610084
78223Hepatobiliary imagingS039469,0668590
78315Bone imaging, 3 phaseS039656,5248988
78464Heart image (3d), singleS039835,8669329
78472Gated heart, planar, singleS039832,1548980
78264Gastric emptying studyS039531,1908894
78812Tumor image (pet)/skul-thighS030827,34510086
78007Thyroid image, mult uptakesS039123,7038496
78195Lymph system imagingS040020,1878918
78585Lung V/Q imagingS037820,0369148
78070Parathyroid nuclear imagingS039118,7529484
78006Thyroid imaging with uptakeS039018,6138695
78300Bone imaging, limited areaS039618,3338990
78320Bone imaging (3D)S039616,7108435
78588Perfusion lung imageS037814,3238848
78707K flow/funct image w/o drugS040413,8208990
78580Lung perfusion imagingS040113,0116619
78816Tumor image pet/ct full bodyS030812,34910086

Among the lower volume diagnostic nuclear medicine procedures (which are outside the top 20 in terms of volume), there is still good representation of diagnostic radiopharmaceutical HCPCS codes on the single bills for most procedures. About 40 percent of the low volume diagnostic nuclear medicine procedures have at least 80 percent of the single bills for that diagnostic procedure that include a diagnostic radiopharmaceutical HCPCS code; about 37 percent of the low volume diagnostic procedures have between 50 to 79 percent of the single bills that include a diagnostic radiopharmaceutical HCPCS code; and about 23 percent of the low volume diagnostic procedures have less than 50 percent of the single bills that include a diagnostic radiopharmaceutical HCPCS code. For the few diagnostic nuclear medicine procedures where less than 50 percent of the single bills include a diagnostic radiopharmaceutical HCPCS code, we believe there could be several reasons why the percentage of single bills for the diagnostic nuclear medicine procedure with a diagnostic radiopharmaceutical HCPCS code is low.

As noted earlier, it is possible that hospitals may be including the charge for the radiopharmaceutical in the Start Printed Page 42669charge for the diagnostic nuclear medicine procedure itself or on an uncoded revenue code line instead of reporting charges for a specific diagnostic radiopharmaceutical HCPCS code. We found that 24 percent of all single bills for a diagnostic nuclear medicine procedure but without a coded diagnostic radiopharmaceutical had uncoded costs in a revenue code that might contain diagnostic radiopharmaceutical costs, specifically, revenue codes 0254 (Drugs Incident to Other Diagnostic Services), 0255 (Drugs Incident to Radiology), 0343 (Diagnostic Radiopharmaceuticals), 0621 (Supplies Incident to Radiology), and 0622 (Supplies Incident to Other Diagnostic Services). In comparison, we found that only 2 percent of diagnostic nuclear medicine single bills with a nuclear medicine procedure and a coded diagnostic radiopharmaceutical had uncoded costs in these revenue codes. It is also possible that some of these procedures typically use a diagnostic radiopharmaceutical subject to packaged payment under the CY 2006 OPPS, and hospitals may have chosen not to report a separate charge for the diagnostic radiopharmaceutical. Payment for diagnostic radiopharmaceuticals commonly used with some diagnostic nuclear medicine procedures would already be packaged because these diagnostic radiopharmaceuticals' average per day cost were less than $50 in CY 2006. The CY 2008 proposal to package additional diagnostic radiopharmaceuticals would have little impact on the payment for those diagnostic procedures that typically use inexpensive diagnostic radiopharmaceuticals that would be packaged under our proposed CY 2008 packaging threshold of $60, except to the extent that the budget neutrality adjustment due to the broader packaging proposal leads to an increase in the scaler and an increase in the payment for procedures in general.

At its March 2007 meeting, the APC Panel recommended that CMS work with stakeholders on issues related to payment for radiopharmaceuticals, including evaluating claims data for different classes of radiopharmaceuticals and ensuring that a nuclear medicine procedure claim always includes at least one reported radiopharmaceutical agent. We are accepting the APC Panel's recommendation, and we specifically welcome public comment on the hospitals' burden involved should we require such precise reporting. We also are seeking comment on the importance of such a requirement in light of our above discussion on the representation of diagnostic radiopharmaceuticals in the single bills for diagnostic nuclear medicine procedures, the presence of uncoded revenue code charges specific to diagnostic radiopharmaceuticals on claims without a coded diagnostic radiopharmaceutical, and our proposal to package payment for all diagnostic radiopharmaceuticals.

It has come to our attention that several diagnostic radiopharmaceuticals may be used for multiple day studies; that is, a particular diagnostic radiopharmaceutical may be administered on one day and a related diagnostic nuclear medicine procedure may be performed on a subsequent day. While we understand that multiple day episodes for diagnostic radiopharmaceuticals and the related diagnostic nuclear medicine procedures occur, we expect that this would be a small proportion of all diagnostic nuclear medicine imaging procedures. We estimate that, roughly, 15 diagnostic radiopharmaceuticals have a half-life longer than one day such that they could support diagnostic nuclear medicine scans on different days. We believe these diagnostic radiopharmaceuticals would be concentrated in a specific set of diagnostic procedures. Excluding the 5 percent of diagnostic radiopharmaceutical claims with no matching diagnostic nuclear medicine scan for the same beneficiary, we found that a diagnostic nuclear medicine scan was reported on the same day as a coded diagnostic radiopharmaceutical 90 percent or more of the time for 10 of these 15 diagnostic radiopharmaceuticals. Further, between 80 and 90 percent single bills for each of the remaining 5 diagnostic radiopharmaceuticals had a diagnostic nuclear medicine scan on the same day. In the “natural” single bills we use for ratesetting, we package payment across dates of service. In light of such high percentages of extended half-life diagnostic radiopharmaceuticals with same day diagnostic nuclear medicine scans and the ability of “natural” singles to package costs across days, we believe that our standard OPPS ratesetting methodology of using median costs calculated from claims data adequately captures the costs of diagnostic radiopharmaceuticals associated with diagnostic nuclear medicine procedures that are not provided on the same date of service.

This packaging proposal reduces the overall frequency of single bills for diagnostic nuclear medicine procedures, but the percent of single bills out of total claims remains robust for the majority of diagnostic nuclear medicine procedures. Typically, packaging more procedures should improve the number of single bill claims from which to derive median cost estimates because packaging reduces the number of separately paid procedures on a claim, thereby creating more single procedure bills. In the case of diagnostic nuclear medicine procedures, packaging diagnostic radiopharmaceuticals reduces the overall number of single bills available to calculate median costs by increasing packaged costs that previously were ignored in the bypass process. In prior years, we did not consider the costs of radiopharmaceuticals when we used our bypass methodology to extract “pseudo” single claims because we assumed that the cost of radiopharmaceutical overhead and handling would be included in the line-item charge for the radiopharmaceutical, and the diagnostic radiopharmaceuticals were subject to potential separate payment if their mean per day cost fell above the packaging threshold. The bypass process sets empirical and clinical criteria for minimal packaging for a specific list of procedures and services in order to assign packaged costs to other procedures on a claim and is discussed at length in section II.A.1. of this proposed rule. Generally, changing the status of diagnostic radiopharmaceuticals to packaged increases packaging on each claim. This could make it both harder for nuclear medicine procedures to qualify for the bypass list and more difficult to assign packaging to individual diagnostic nuclear medicine procedures, resulting in a possible reduction of the number of “pseudo” singles that are produced by the bypass process. Notwithstanding this potentiality, diagnostic nuclear medicine procedures continue to have good representation in the single bills. On average, single bills as a percent of total occurrences remains substantial at 55 percent for individual procedures. We discuss our process for ratesetting, including the construction and use of single and multiple bills, in greater detail in section II.A.1. of this proposed rule.

We believe our CY 2006 claims data support our CY 2008 proposal to package payment for all diagnostic radiopharmaceuticals and lead to proposed payment rates for diagnostic nuclear medicine procedures that appropriately reflect payment for the costs of the diagnostic radiopharmaceuticals that are administered to carry out those diagnostic nuclear medicine procedures. Among the top 20 high volume Start Printed Page 42670diagnostic nuclear medicine procedures, at least 84 percent of the single bills for almost every diagnostic nuclear medicine procedure included a diagnostic radiopharmaceutical HCPCS code. While a diagnostic radiopharmaceutical, by definition, would be anticipated to accompany 100 percent of the diagnostic nuclear medicine procedures, it is not unexpected that while percentages in our claims data are high, they are less than 100 percent. As noted previously, we have heard anecdotal reports that some hospitals may include the charges for diagnostic radiopharmaceuticals in their charge for the diagnostic nuclear medicine procedure or on an uncoded revenue code line, rather than reporting a HCPCS code for the diagnostic radiopharmaceutical. Thus, it is likely that the frequency of diagnostic radiopharmaceutical costs reflected in our claims data are even higher than the percentages indicate. Furthermore, we note that the OPPS ratesetting methodology is based on medians, which are less sensitive to extremes than means and typically do not reflect subtle changes in cost distributions. Therefore, to the extent that the vast majority of single bills for a particular diagnostic nuclear medicine procedure include a diagnostic radiopharmaceutical HCPCS code, the fact that the percentage is somewhat less than 100 percent is likely to have minimal impact on the median cost of the procedure in most cases. Even in those few instances where we have a low total number of single bills, largely because of low overall volume, we have ample representation of diagnostic radiopharmaceutical HCPCS codes on the single bills for the majority of lower volume nuclear medicine procedures. We also continue to have reasonable representation of single bills out of total claims in general. Finally, as noted previously, to the extent that the diagnostic radiopharmaceuticals commonly used with a particular diagnostic nuclear medicine procedure are already packaged, the proposal to package additional diagnostic radiopharmaceuticals would have little impact on the payment for these procedures.

We have calculated the median costs on which we are proposing to base the CY 2008 payment rates using the packaging status of each diagnostic radiopharmaceutical HCPCS code as provided in Table 17 below. As we discussed earlier in more detail, this has the effect of both changing the median cost for the independent service (the diagnostic nuclear medicine procedure) into which the cost of the dependent service (the diagnostic radiopharmaceutical) is packaged and also of redistributing payment that would otherwise have been made separately for the service we are proposing to newly package for CY 2008.

For example, HCPCS code A9552 (Fluorodeoxyglucose F-18 FDG, Diagnostic, per study dose, up to 45 millicuries) that describes the diagnostic radiopharmaceutical commonly called FDG is frequently billed with CPT code 78815 (Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid-thigh). HCPCS code A9552 is assigned to APC 1651 (F18 fdg) for CY 2007. HCPCS code A9552 was billed with CPT code 78815 101,242 times in the single bills available for this CY 2008 proposed rule, and 97 percent of the single bills for CPT code 78815 also reported HCPCS code A9552. Under our proposed policy for CY 2008, we are proposing to package payment for HCPCS code A9552 into the payment for separately payable procedures that are provided in conjunction with HCPCS code A9552. In this example, HCPCS code A9552 would receive packaged payment through the separate OPPS payment for CPT code 78815. CPT code 78815 is assigned to APC 1511 (New Technology—Level XI ($900-$1000)) for CY 2007 with a CY 2007 median cost for PET/CT procedures of $850.36 and to APC 0308 (Non-Myocardial Positron Emission Tomography (PET) Imaging) for CY 2008 with a proposed CY 2008 APC median cost of $1,093.52.

The proposed CY 2008 payment rates associated with this example are outlined in Table 16 below. The table indicates that the proposed CY 2008 payment rate for the skull base to mid-thigh PET/CT scan would be substantially higher than the CY 2007 payment amount for that code. The proposed increase for the PET/CT scan is slightly more than the estimated average CY 2007 payment for the separately payable FDG (paid in CY 2007 at charges reduced to cost).

This example cannot demonstrate the overall impact of packaging diagnostic radiopharmaceuticals on payment to any given hospital because each individual hospital's case mix and billing patterns would be different. The overall impact of packaging diagnostic radiopharmaceuticals, as well as all other packaging changes proposed for CY 2008, can only be assessed in the aggregate for each hospital. Section XXII.B. of this proposed rule displays the overall impact of APC weight recalibration and packaging changes that we are proposing by classes of hospitals, and the OPPS Hospital-Specific Impacts—Provider-Specific Data file presents our estimates of CY 2008 hospital payment for those hospitals we include in our ratesetting and payment simulation database. The hospital-specific impacts file can be found on the CMS Web site at http://www.cms.hhs.gov/​HospitalOutpatientPPS/​ under supporting documentation for this proposed rule.

Table 16.—Example of the Effects of the CY 2008 Packaging Proposal on Payment for HCPCS Code A9552 and CPT Code 78815

HCPCS codeShort descriptorSum of CY 2007 payment (A9552 paid separately at cost)Sum of CY 2008 proposed payment (A9552 packaged)
A9552F18 fdg (dependent service)*$279.290.00
78815Tumor image pet/ct skul-thigh (independent service)950.001,107.22
Total Payment1,229.291,107.22
*Estimated average CY 2007 payment at charges reduced to cost.
Start Printed Page 42671

The estimated overall impact of these changes that we are proposing for CY 2008 is based on the assumption that hospital behavior would not change with regard to when the dependent diagnostic radiopharmaceuticals are provided by the same hospital that performs the independent services. In order to provide diagnostic nuclear medicine procedures under this proposal, hospitals would either need to administer the necessary diagnostic radiopharmaceuticals themselves or refer patients elsewhere for the administration of the diagnostic radiopharmaceuticals. In the latter case, claims data would show such a change in practice in future years and that change would be reflected in future ratesetting. However, with respect to diagnostic radiopharmaceuticals, we believe that hospitals are limited in the extent to which they could change their behavior with regard to how they furnish these items because diagnostic radiopharmaceuticals are typically provided on the same day as a diagnostic nuclear medicine procedure. It would be difficult for Hospital A to send patients to receive diagnostic radiopharmaceuticals from Hospital B and then have the patients return to Hospital A for the diagnostic nuclear medicine procedure in the appropriate timeframe (given the radiopharmaceutical's half life) to perform a high quality study. We would expect that hospitals would always bill the diagnostic radiopharmaceutical on the same claim as the other independent services for which the radiopharmaceutical was administered.

As we indicate above, in all cases, we are proposing that hospitals that furnish diagnostic radiopharmaceuticals in association with diagnostic nuclear medicine procedures bill both the item and the procedure on the same claim so that the costs of the diagnostic radiopharmaceuticals can be appropriately packaged into payment for the diagnostic nuclear medicine procedure. We expect to carefully monitor any changes in billing practices on a service-specific and hospital-specific basis to determine whether there is reason to request that QIOs review the quality of care furnished or to request that Program Safeguard Contractors review the claims against the medical record.

Table 17.—Diagnostic Radiopharmaceutical HCPCS Codes Proposed for Packaged Payment in CY 2008

HCPCS codeShort descriptorCY 2007 SICY 2007 APCCY 2008 proposed SI
A4641Radiopharm dx agent nocNn/aN
A4642In111 satumomabH0704N
A9500Tc99m sestamibiH1600N
A9502Tc99m tetrofosminH0705N
A9503Tc99m medronateNn/aN*
A9504Tc99m apcitideNn/aN*
A9505TL201 thalliumH1603N
A9507In111 capromabH1604N
A9508I131 iodobenguate, dxH1045N
A9510Tc99m disofeninNn/aN*
A9512Tc99m pertechnetateNn/aN*
A9516I123 iodide cap, dxH9148N
A9521Tc99m exametazimeH1096N
A9524I131 serum albumin, dxH9100N
A9526Nitrogen N-13 ammoniaH0737N
A9528Iodine I-131 iodide cap, dxH1088N
A9529I131 iodide sol, dxNn/aN
A9531I131 max 100uCiNn/aN*
A9532I125 serum albumin, dxNn/aN
A9536Tc99m depreotideH0739N
A9537Tc99m mebrofeninNn/aN*
A9538Tc99m pyrophosphateNn/aN*
A9539Tc99m pentetateH0722N*
A9540Tc99m MAANn/aN*
A9541Tc99m sulfur colloidNn/aN*
A9542In111 ibritumomab, dxH1642N
A9544I131 tositumomab, dxH1644N
A9546Co57/58H0723N
A9547In111 oxyquinolineH1646N
A9548In111 pentetateH1647N
A9550Tc99m gluceptateH0740N
A9551Tc99m succimerH1650N
A9552F18 fdgH1651N
A9553Cr51 chromateH0741N
A9554I125 iothalamate, dxNn/aN
A9555Rb82 rubidiumH1654N
A9556Ga67 galliumH1671N
A9557Tc99m bicisateH1672N
A9558Xe133 xenon 10mciNn/aN*
A9559Co57 cyanoH0724N
A9560Tc99m labeled rbcH0742N
A9561Tc99m oxidronateNn/aN*
A9562Tc99m mertiatideH0743N
A9565In111 pentetreotideH1677N
A9566Tc99m fanolesomabH1678N
A9567Technetium TC-99m aerosolH0829N*
Start Printed Page 42672
A9568Tc99m arcitumomabH1648N
* Indicates that the radiopharmaceutical would have been packaged under the $60 packaging threshold methodology in CY 2008, even in the absence of the broader packaging proposal for radiopharmaceuticals.

(6) Contrast Agents

For CY 2008, we are proposing to package payment for all contrast media into their associated independent diagnostic and therapeutic procedures as part of our proposed packaging approach for the CY 2008 OPPS. As noted in section II.A.4.c. of this proposed rule, packaging the costs of supportive items and services into the payment for the independent procedure or service with which they are associated encourages hospital efficiencies and also enables hospitals to manage their resources with maximum flexibility. We believe that contrast agents are particularly well suited for packaging because they are always provided in support of an independent diagnostic or therapeutic procedure that involves imaging, and thus payment for contrast agents can be packaged into the payment for the associated separately payable procedures.

Contrast agents are generally considered to be those substances introduced into or around a structure that, because of the differential absorption of x-rays, alteration of magnetic fields, or other effects of the contrast medium in comparison with surrounding tissues, permit visualization of the structure through an imaging modality. The use of certain contrast agents is generally associated with specific imaging modalities, including x-ray, computed tomography (CT), ultrasound, and magnetic resonance imaging (MRI), for purposes of diagnostic testing or treatment. They are most commonly administered through an oral or intravascular route in association with the performance of the independent procedures involving imaging that are the basis for their administration. Even in the absence of this proposal to package payment for all contrast agents, we would propose to package the majority of HCPCS codes for contrast agents recognized under the OPPS in CY 2008. We consider contrast agents to be drugs under the OPPS, and as a result they are packaged if their estimated mean per day cost is equal to or less than $60 for CY 2008. (For more discussion of our drug packaging criteria, we refer readers to section V.B.2 of this proposed rule.) Seventy-five percent of contrast agents HCPCS codes have an estimated mean per day cost equal to or less than $60 based on our CY 2006 claims data.

Contrast agents are described by those Level II HCPCS codes in the range from Q9945 through Q9964. There currently are no HCPCS C-codes or other Level II HCPCS codes outside the range specified above used to report contrast agents under the OPPS. As shown in Table 19, in CY 2007, we packaged 7 out of 20 of these contrast agent HCPCS codes based on the $55 packaging threshold. For CY 2008, we are proposing to package all drugs with a per day mean cost of $60 or less. For CY 2008, the vast majority of contrast agents would be packaged under the traditional OPPS packaging methodology using the $60 packaging threshold, based on the CY 2006 claims data available for this proposed rule. In fact, of the 20 contrast agent HCPCS codes we are including in our proposed packaging approach, 15 would have been proposed to be packaged for CY 2008 under our drug packaging methodology. These 15 codes represent 94 percent of all occurrences of contrast agents billed under the OPPS. We believe that this shift in the packaging status for several of these agents between CYs 2007 and 2008 may be because, in CY 2007, a number of the contrast agents exceeded the $55 threshold by only a small amount and, based on our latest claims data for CY 2008, a number of these products have now fallen below the proposed $60 threshold. Given that the vast majority of contrast agents billed would already be packaged under the OPPS in CY 2008, we believe it would be desirable to package payment for the remaining contrast agents as it promotes efficiency and results in a consistent payment policy across products that may be used in many of the same independent procedures. We also note that the significant costs associated with these 15 contrast agents would already be reflected in the proposed median costs for those independent procedures and, if we were to pay for the 5 remaining agents separately, we would be treating these 5 agents differently than the others. If the 5 agents remained separately payable, there would effectively be two payments for contrast agents when these 5 agents were billed—a separate payment and a payment for packaged contrast agents that was part of the procedure payment. This could potentially provide a payment incentive to administer certain contrast agents that might not be the most clinically appropriate or cost effective. Moreover, as noted previously, contrast agents are always provided with independent procedures and, under a consistent approach to packaging in keeping with our enhanced efforts to encourage hospital efficiency and promote value-based purchasing under the OPPS, their payment would be appropriately packaged for CY 2008.

We have calculated the median costs on which the proposed CY 2008 payment rates are based using the packaging status of each contrast agent HCPCS code as provided in Table 19 below. As we discussed earlier in more detail, this has the effect of both changing the median cost for the independent service (the diagnostic or therapeutic procedure requiring imaging) into which the cost of the dependent service (the contrast agent) is packaged and also of redistributing payment that would otherwise have been made separately for the service we are proposing to newly package for CY 2008.

For example, HCPCS code Q9947 (Low osmolar contrast material, 200-249 mg/ml iodine concentration, per ml) is one of the contrast agents that we are proposing to package that would not otherwise be packaged in CY 2008 under the proposed $60 packaging threshold. HCPCS code Q9947 is sometimes billed with CPT code 71260 (Computed tomography, thorax; with contrast material(s)). HCPCS code Q9947 is assigned to APC 9159 (LOCM 200-249 mg/ml iodine, 1ml) for CY 2007. HCPCS code Q9947 was billed with CPT code 71260 8,172 times in the single bills available for this CY 2008 proposed rule, and 2 percent of the single bills for CPT code 71260 also reported HCPCS code Q9947. Under our proposed policy for CY 2008, we are proposing to package payment for Start Printed Page 42673HCPCS code Q9947 into the payment for separately payable procedures that are provided in conjunction with the contrast agent. Specifically, we would package payment for HCPCS code Q9947 so that, in this example, HCPCS code Q9947 would receive packaged payment through the separate OPPS payment for CPT code 71260. CPT code 71260 is assigned to APC 0283 (Computed Tomography with Contrast) for CY 2007 with a CY 2007 median cost of $249.48. The procedure is assigned to APC 0283, with a proposed APC name change to “Level I Computed Tomography with Contrast” for CY 2008 and a proposed CY 2008 median cost of $286.13.

The proposed CY 2008 payment rates associated with this example are outlined in Table 18 below. The table indicates that the CY 2008 payment that we are proposing for CPT code 71260 is higher than the CY 2007 payment amount for that code. The proposed increase in the payment rate for CPT code 71260 in CY 2008 is slightly greater than the estimated CY 2007 payment for the separately payable HCPCS code Q9947. Notably, a number of low osmolar contrast agents other than HCPCS code Q9947 that were separately paid in CY 2007 also are proposed for packaged payment in CY 2008 because their mean per day cost falls below the $60 packaging threshold for drugs, biologicals, and radiopharmaceuticals for CY 2008. Packaging the costs of these contrast media also affects the proposed payment rate for CPT code 71260. For another example of packaging contrast agents, we refer readers to the example included in Table 13 of section II.A.4.c.(4) of this proposed rule on packaging imaging supervision and interpretation services. That example illustrates the effect of packaging both a supervision and interpretation service (CPT code 72265 (Myelography, lumbosacral, radiological supervision and interpretation)) and a contrast agent (HCPCS code Q9947 (low osmolar contrast material, 200-249 mg/ml iodine, per ml)) into the payment for an imaging procedure (CPT code 72132 (Computed tomography, lumbar spine; with contrast material)).

This example cannot demonstrate the overall impact of packaging contrast agents on any given hospital because each individual hospital's case mix and billing pattern differs. The overall impact of packaging contrast agents, as well as all the other proposed packaging changes, can only be assessed in the aggregate for classes of hospitals. Section XXII.B. of this proposed rule displays the overall impact of APC weight recalibration and packaging changes we are proposing by classes of hospitals, and the OPPS Hospital-Specific Impacts—Provider-Specific Data file presents our estimates of CY 2008 hospital payment for those hospitals we include in our ratesetting and payment simulation database. The hospital-specific impact file can be found on the CMS Web site at http://www.cms.hhs.gov/​HospitalOutpatientPPS/​ under supporting documentation for this proposed rule.

Table 18.—Example of the Effects of the CY 2008 Packaging Proposal on Payment for CPT Code 72160 and HCPCS Code Q9947

HCPCS codeShort descriptorSum of CY 2007 payment (Q9947 paid separately)Sum of CY 2008 proposed payment (Q9947 packaged)
Q9947LOCM 200-249 mg/ml iodine, 1 ml (dependent service)*$64.24$0.00
71260Ct thorax w/dye (independent service)250.94289.71
Total Payment315.18289.71
*Based on the mean number of units per day from our CY 2008 proposed rule data (48.3) and the April 2007 per unit payment rate for Q9947 ($1.33).

The estimated overall impact of these changes that we are proposing fo r CY 2008 is based on the assumption that hospital behavior would not change with regard to when the contrast agents are provided by the same hospital that performs the imaging procedure. Under this proposal, in order to provide imaging procedures requiring contrast agents, hospitals would either need to administer the necessary contrast agent themselves or refer patients elsewhere for the administration of the contrast agent. In the latter case, claims data would show such a change in practice in future years and that change would be reflected in future ratesetting. However, with respect to contrast agents, we believe that hospitals are limited in the extent to which they could change their behavior with regard to how they furnish these services because contrast agents are typically provided on the same day immediately prior to an imaging procedure being performed. We would expect that hospitals would always bill the contrast agent on the same claim as the other independent services for which the contrast agent was administered.

As we indicated earlier, in all cases we are proposing that hospitals that furnish the supportive contrast agent in association with independent procedures involving imaging must bill both services on the same claim so that the cost of the contrast agent can be appropriately packaged into payment for the significant independent procedure. We expect to carefully monitor any changes in billing practices on a service-specific and hospital specific basis to determine whether there is reason to request that QIOs review the quality of care furnished or to request that Program Safeguard Contractors review the claims against the medical record.

Table 19.—Contrast Media HCPCS Codes Proposed for Packaged Payment in CY 2008

HCPCS codeShort descriptorCY 2007 SICY 2007 APCProposed CY 2008 SI
Q9945LOCM <=149 mg/ml iodine, 1 mlK9157N*
Q9946LOCM 150-199 mg/ml iodine, 1 mlK9158N*
Q9947LOCM 200-249 mg/ml iodine, 1 mlK9159N
Start Printed Page 42674
Q9948LOCM 250-299 mg/ml iodine, 1 mlK9160N*
Q9949LOCM 300-349 mg/ml iodine, 1 mlK9161N*
Q9950LOCM 350-399 mg/ml iodine, 1 mlK9162N*
Q9951LOCM >= 400 mg/ml iodine, 1 mlK9163N*
Q9952Inj Gad-base MR contrast, 1 mlK9164N*
Q9953Inj Fe-based MR contrast, 1 mlK1713N
Q9954Oral MR contrast, 100 mlK9165N*
Q9955Inj perflexane lip micros, mlK9203N*
Q9956Inj octafluoropropane mic, mlK9202N
Q9957Inj perflutren lip micros, mlK9112N
Q9958HOCM <=149 mg/ml iodine, 1 mlNn/aN*
Q9959HOCM 150-199 mg/ml iodine, 1 mlNn/aN
Q9960HOCM 200-249 mg/ml iodine, 1 mlNn/aN*
Q9961HOCM 250-299 mg/ml iodine, 1 mlNn/aN*
Q9962HOCM 300-349 mg/ml iodine, 1 mlNn/aN*
Q9963HOCM 350-399 mg/ml iodine, 1 mlNn/aN*
Q9964HOCM>= 400 mg/ml iodine, 1 mlNn/aN*
*Indicates that the contrast agent would have been packaged under the $60 packaging threshold methodology in CY 2008, even in the absence the broader packaging proposal for contrast agents.

(7) Observation Services

We are proposing to package payment for all observation care, reported under HCPCS code G0378 (Hospital observation services, per hour) for CY 2008. Payment for observation would be packaged as part of the payment for the separately payable services with which it is billed. We have defined observation care as a well-defined set of specific, clinically appropriate services that include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation status is commonly assigned to patients who present to the emergency department and who then require a significant period of treatment or monitoring before a decision is made concerning their next placement or to patients with unexpectedly prolonged recovery after surgery. Throughout this proposed rule, as well as in our manuals and guidance documents, we use both of the terms “observation services” and “observation care” in reference to the services defined above.

Payment for all observation care under the OPPS was packaged prior to CY 2002. Since CY 2002, separate payment of a single unit of an observation APC for an episode of observation care has been provided in limited circumstances. Effective for services furnished on or after April 1, 2002, separate payment for observation was made if the beneficiary had chest pain, asthma, or congestive heart failure and met additional criteria for diagnostic testing, minimum and maximum limits to observation care time, physician care, and documentation in the medical record (66 FR 59856, 59879). Payment for observation care that did not meet these specified criteria was packaged. Between CY 2003 and CY 2006, several more changes were made to the OPPS policy regarding separate payment for observation services, such as: Clarification that observation is not separately payable when billed with “T” status procedures on the day of or day before observation care; development of specific Level II HCPCS codes for hospital observation services and direct admission to observation care; and removal of the initially established diagnostic testing requirements for separately payable observation (67 FR 66794, 69 FR 65828, and 70 FR 68688). Throughout this time period, we maintained separate payment for observation care only for the three specified medical conditions, and OPPS payment for observation for all other clinical conditions remained packaged.

Since January 1, 2006, hospitals have reported observation services based on an hourly unit of care using HCPCS code G0378. This code has a status indicator of “Q” under the CY 2007 OPPS, meaning that the OPPS claims processing logic determines whether the observation is packaged or separately payable. The OCE's current logic determines whether observation services billed under HCPCS code G0378 are separately payable through APC 0339 (Observation) or whether payment for observation services will be packaged into the payment for other separately payable services provided by the hospital in the same encounter based on criteria discussed subsequently. (We note that if an HOPD directly admits a patient to observation, Medicare currently pays separately for that direct admission reported under HCPCS code G0379 (Direct admission of patient for hospital observation care) in situations where payment for the actual observation care reported under HCPCS code G0378 is packaged.) For CY 2008, as discussed in more detail later in this proposed rule (section XI.), we are proposing to continue the coding and payment methodology for direct admission to observation status, with the exception of the requirement that HCPCS code G0379 is only eligible for separate payment if observation care reported under HCPCS code G0378 does not qualify for separate payment. This requirement would no longer be applicable under our proposal to package all observation services reported under HCPCS code G0378.

Currently, separate OPPS payment may be made for observation services reported under HCPCS code G0378 provided to a patient when all of the following requirements are met. The hospital would receive a single separate payment for an episode of observation care (APC 0339) when:

1. Diagnosis Requirements

a. The beneficiary must have one of three medical conditions: congestive heart failure, chest pain, or asthma.

b. Qualifying ICD-9-CM diagnosis codes must be reported in Form Locator (FL) 76, Patient Reason for Visit, or FL 67, principal diagnosis, or both in order for the hospital to receive separate payment for APC 0339. If a qualifying ICD-9-CM diagnosis code(s) is reported in the secondary diagnosis field, but is Start Printed Page 42675not reported in either the Patient Reason for Visit field (FL 76) or in the principal diagnosis field (FL 67), separate payment for APC 0339 is not allowed.

2. Observation Time

a. Observation time must be documented in the medical record.

b. A beneficiary's time in observation (and hospital billing) begins with the beneficiary's admission to an observation bed.

c. A beneficiary's time in observation (and hospital billing) ends when all clinical or medical interventions have been completed, including followup care furnished by hospital staff and physicians that may take place after a physician has ordered the patient be released or admitted as an inpatient.

d. The number of units reported with HCPCS code G0378 must equal or exceed 8 hours.

3. Additional Hospital Services

a. The claim for observation services must include one of the following services in addition to the reported observation services. The additional services listed below must have a line-item date of service on the same day or the day before the date reported for observation:

  • An emergency department visit (APC 0609, 0613, 0614, 0615, or 0616); or
  • A clinic visit (APC 0604, 0605, 0606, 0607, or 0608); or
  • Critical care (APC 0617); or
  • Direct admission to observation reported with HCPCS code G0379 (APC 0604).

b. No procedure with a “T” status indicator can be reported on the same day or day before observation care is provided.

4. Physician Evaluation

a. The beneficiary must be in the care of a physician during the period of observation, as documented in the medical record by admission, discharge, and other appropriate progress notes that are timed, written, and signed by the physician.

b. The medical record must include documentation that the physician explicitly assessed patient risk to determine that the beneficiary would benefit from observation care.

In the context of our proposed CY 2008 packaging approach, for several reasons we believe that it is appropriate to package payment for all observation services reported with HCPCS code G0378 under the CY 2008 OPPS. Primarily, observation services are ideal for packaging because they are always provided as a supportive service in conjunction with other independent separately payable hospital outpatient services such as an emergency department visit, surgical procedure, or another separately payable service, and thus observation costs can logically be packaged into OPPS payment for independent services. As discussed extensively earlier in this section, packaging payment into larger payment bundles creates incentives for providers to furnish services in the most efficient way that meets the needs of the patient, encouraging long-term cost containment.

As we discussed in the general overview of the CY 2008 packaging approach earlier in this section (section II.A.4.b. of this proposed rule), there has been substantial growth in program expenditures for hospital outpatient services under the OPPS in recent years. The primary reason for this upsurge is growth in the intensity and utilization of services rather than the general price of services or enrollment changes. This observed trend is notably reflected in the frequency and costs of separately payable observation care for the last few years. While median costs for an episode of observation care that would meet the criteria for separate payment have remained relatively stable between CY 2003 and CY 2006, the frequency of claims for separately payable observation services has rapidly increased. Comparing claims data for separately payable observation care available for proposed rules spanning from CY 2005 to CY 2008 (that is, claims data reflecting services furnished from CY 2003 to CY 2006), we see substantial growth in separately payable observation care billed under the OPPS over that time. In CY 2003, the full first year when observation care was separately payable, there were approximately 56,000 claims for separately payable observation care. In CY 2004, there were approximately 77,000 claims for separately payable observation care. In CY 2005, that number increased to approximately 124,300 claims, representing about a 61 percent increase in one year. In addition, in the CY 2006 data available for this proposed rule, the frequency of claims for separately payable observation services increased again, to more than 271,200 claims, about a 118-percent increase over CY 2005 and more than triple the number of claims from 2 years earlier. While it is not possible to discern the specific factors responsible for the growth in claims for separately payable observation services, as there have been minor changes in both the process and criteria for separate payment for these services over this time period, the substantial growth by itself is noteworthy.

We are also concerned that the current criteria for separate payment for observation services may provide disincentives for efficiency. In order for observation services to be separately payable, they must last at least 8 hours. While this criterion was put in place to ensure that separate payment is made only for observation services of a substantial duration, it may create a financial disincentive for an HOPD to make a timely determination regarding a patient's safe disposition after observation care ends. By packaging payment for all observation services, regardless of their duration, we would provide incentives for more efficient delivery of services and timely decision-making. The current criterion also prohibits separate payment for observation services when a “T” status procedure (generally a surgical procedure) is provided on the same day or the previous day by the HOPD to the same Medicare beneficiary. Again, this may create a financial disincentive for hospitals to provide minor surgical procedures during a patient's observation stay, unless those procedures are essential to the patient's care during that time period, even if the most efficient and effective performance of those procedures could be during the single HOPD encounter.

Currently, the OPPS pays separately for observation care for only the three original medical conditions designated in CY 2002, specifically chest pain, asthma, and congestive heart failure. As discussed in more detail in the observation section (section XI.) of this proposed rule, the APC Panel recommended at its March 2007 meeting that we consider expanding separate payment for observation services to include two additional diagnoses, syncope and dehydration. As mentioned previously, we have defined observation care as a well-defined set of specific, clinically appropriate services, which include ongoing, short-term treatment, assessment, and reassessment, that are furnished while a decision is being made regarding whether a patient will require further treatment as a hospital inpatient or if the individual is able to be discharged from the hospital. Given the definition of observation services, it is clear that, in certain circumstances, observation care could be appropriate for patients with a range of diagnoses. Both the APC Panel and numerous commenters to prior OPPS proposed rules have confirmed their agreement with this perspective. In addition, the June 2006 Start Printed Page 42676Institute of Medicine (IOM) Report entitled, “Hospital-Based Emergency Care: At the Breaking Point,” encourages hospitals to apply tools to improve the flow of patients through emergency departments, including developing clinical decisions units where observation care is provided. The IOM's Committee on the Future of Emergency Care in the United States Health System recommended that CMS remove the current limitations on the medical conditions that are eligible for separate observation care payment in order to encourage the development of such observation units.

As packaging payment provides desirable incentives for greater efficiency in the delivery of health care and provides hospitals with significant flexibility to manage their resources, we believe it is most appropriate to treat observation care for all diagnoses similarly by packaging its costs into payment for the separately payable independent services with which the observation is associated. This consistent payment methodology would provide hospitals with the flexibility to assess their approaches to patient care and patient flow and provide observation care for patients with a variety of clinical conditions when hospitals conclude that observation services would improve their treatment of those patients. Approximately 70 percent of the occurrences of observation care billed under the OPPS are currently packaged, and this proposal would extend the incentives for efficiency already present for the vast majority of observation services that are already packaged under the OPPS to the remaining 30 percent of observation services for which we currently make separate payment.

We have calculated the median costs on which the proposed CY 2008 payment rates are based according to our proposed packaging approach under which payment for HCPCS code G0378 would always be packaged (status indicator “N”). As we discussed previously in more detail, in this section, this has the effect of both changing the median costs for the independent services into which the costs of the dependent and supportive observation services are packaged and also of redistributing payment that would otherwise have been made separately for the observation services we are proposing to newly package for CY 2008.

For example, separately payable observation care is frequently billed with CPT code 99285 (Emergency department visit for the evaluation and management of a patient (Level 5)). In the CY 2008 OPPS proposed rule claims data, CPT code 99285 was billed 157,668 times on claims with HCPCS code G0378 that meet our current criteria for separate payment for observation care. In addition, about 57 percent of the claims for HCPCS code G0378 that meet our current criteria for separate payment also reported CPT code 99285. Under our proposed policy for CY 2008, we are proposing to package payment for HCPCS code G0378 into the payment for separately payable procedures that are provided in conjunction with HCPCS code G0378. Specifically, we would package payment for HCPCS code G0378 when it is provided with a separately paid service such as CPT code 99285, so that in this example observation would receive packaged payment through the separate OPPS payment for the Level 5 emergency department visit. CPT code 99285 is assigned to APC 0616 (Level 5 Emergency Visits), with a CY 2007 APC median cost of $323.36 and a proposed CY 2008 median cost of $344.50. The CY 2007 median cost of APC 0339 for separately payable observation is $440.22.

The proposed CY 2008 payment rates associated with this example are outlined in Table 20 below. The table indicates that the proposed CY 2008 payment for a Level 5 emergency department visit is higher than the CY 2007 payment amount for that code. However, the proposed increase in the Level 5 emergency department visit payment rate for CY 2008 is significantly less than the CY 2007 payment for separately payable observation. This is due to the fact that, although observation services are commonly billed with a Level 5 emergency department visit, the proportion of all Level 5 emergency department visits that include observation (12 percent) is relatively small. Thus, when observation care that would have met the CY 2007 criteria for separate payment is packaged into payment for separately payable services such as a Level 5 emergency department visit, it raises the payment rate for that separately payable service for all occurrences of the service, even those occurrences where observation care is not provided. As a result, the payment rate for the separately payable service, the Level 5 emergency department visit, does not increase by the full amount of the former payment rate for separately payable observation care as that amount is spread over many more occurrences of Level 5 emergency department visits. In addition, OPPS' use of medians leads relative weight estimates to be less sensitive to packaging decisions.

Table 20.—Example of the Effects of the CY 2008 Packaging Proposal on Payment for Observation Care (HCPCS Code G0378) and CPT Code 99295

HCPCS codeShort descriptorSum of CY 2007 payment (some G0378 paid separately)Sum of CY 2008 proposed payment (G0378 packaged)
G0378 (under criteria for separately paid observation care)Hospital observation per hr (dependent service)$442.81$0.00
99285Emergency dept visit (independent service)325.26348.81
Total Payment768.07348.81

This example cannot demonstrate the overall impact of packaging observation services on any given hospital because each individual hospital's case-mix and billing pattern would be different. The overall impact of packaging HCPCS code G0378, as well as all other packaging changes that we are proposing for CY 2008, can only be assessed in the aggregate for classes of hospitals. Section XXII.B. of this proposed rule displays the overall impact of APC weight recalibration and packaging changes that we are proposing by classes of hospitals, and the OPPS Hospital-Specific Impacts—Provider-Specific Data file presents our estimates of CY 2008 hospital payment Start Printed Page 42677for those hospitals we include in our ratesetting and payment simulation database. The hospital-specific impact file can be found at http://www.cms.hhs.gov/​HospitalOutpatientPPS/​ under supporting documentation for this proposed rule.

The estimated overall impact of these changes that we are proposing for CY 2008 presented in section XXII.B. of this proposed rule is based on the assumption that hospital behavior would not change with regard to when the dependent observation care is provided in the same encounter and by the same hospital that performs the independent services. To the extent that hospitals could change their behavior and cease providing observation services, refer patients elsewhere for that care, or increase the frequency of observation services, the data would show such a change in practice in future years and that change would be reflected in future budget neutrality adjustments. However, with respect to observation care, we believe that hospitals are limited in the extent to which they could change their behavior with regard to how they furnish these services because observation care, by definition, is short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital after receiving the independent services. We believe it is unlikely that hospitals would cease providing medically necessary observation care or refer patients elsewhere for that care if they were unable to reach a decision that the patient could be safely discharged from the outpatient department. We would expect that hospitals would always bill the supportive observation care on the same claim as the other independent services provided in the single hospital encounter.

As we indicated earlier, in all cases we are proposing that hospitals that furnish the observation care in association with independent services must bill those services on the same claim so that the costs of the observation care can be appropriately packaged into payment for the independent services. We expect to carefully monitor any changes in billing practices on a service-specific and hospital-specific basis to determine whether there is reason to request that QIOs review the quality of care furnished or to request that Program Safeguard Contractors review the claims against the medical record.

In summary, we are proposing to package payment for all observation services reported with HCPCS code G0378 for CY 2008. Payment for observation services would be made as part of the payment for the separately payable independent services with which they are billed. As part of this proposal, we would change the status indicator for HCPCS code G0378 from “Q” to “N.” In addition, we would no longer require the current criteria for separate payment related to hospital visits and “T” status procedures, minimum number of hours, and qualifying diagnoses. However, we would retain as general reporting requirements those criteria related to physician evaluation, documentation, and observation beginning and ending time as listed in sections II.A.2.a., b., and c., and 4.a. and b. of this proposed rule. Those are more general requirements that encourage hospitals to provide medically reasonable and necessary care and help to ensure the proper reporting of observation services on correctly coded hospital claims that reflect the full charges associated with all hospital resources utilized to provide the reported services.

d. Proposed Development of Composite APCs

(1) Background

As we discuss above in regard to our reasons for our proposed packaging approach for the CY 2008 OPPS, we believe that it is crucial that the payment approach of the OPPS create incentives for hospitals to seek ways to provide services more efficiently than exist under the current OPPS structure and allow hospitals maximum flexibility to manage their resources. The current OPPS structure usually provides payment for individual services which are generally defined by individual HCPCS codes. We currently package the costs of some items and services (such as drugs and biologicals with an average per day cost of less than $55) into the payment for separately payable individual services. However, because the extent of packaging in the OPPS is currently modest, furnishing many individual separately payable services increases total payment to the hospital. We believe that this aspect of the current OPPS structure is a significant factor in the growth in volume and spending that we discuss in our general overview and provides a primary rationale for our proposed packaging approach for services in the CY 2008 OPPS. While packaging payment for supportive dependent services into the payment for the independent services which they accompany promotes greater efficiency and gives hospitals some flexibility to manage their resources, we believe that payment for larger bundles of major separately paid services that are commonly performed in the same hospital outpatient encounter or as part of a multi-day episode of care would create even more incentives for efficiency, as discussed earlier. Moreover, defining the “service” paid under the OPPS by combinations of HCPCS codes for component services that are commonly performed in the same encounter and that result in the provision of a complete service would enable us to use more claims data and to establish payment rates that we believe more appropriately capture the costs of services paid under the OPPS.

Section 1833(t)(1)(B) of the Act permits us to define what constitutes a “service” for purposes of payment under the OPPS and is not restricted to defining a “service” as a single HCPCS code. For example, the OPPS currently packages payment for certain items and services reported with HCPCS codes into the payment for other separately payable services on the claim. Consistent with our statutory flexibility to define what constitutes a service under the OPPS, we are proposing to view a service, in some cases, as not just the diagnostic or treatment modality identified by one individual HCPCS code but as the totality of care provided in a hospital outpatient encounter that would be reported with two or more HCPCS codes for component services.

In view of this statutory flexibility to define what constitutes a “service” for purposes of OPPS payment, our desire to encourage efficiency in HOPD care, our focus on value-based purchasing, and our desire to use as much claims data as possible to set payment rates under the OPPS, we examined our claims data to determine how we could best use the multiple procedure claims (“hardcore” multiples) that are otherwise not available for ratesetting because they include multiple separately payable procedures furnished on the same date of service. As discussed in more detail in our discussion of single and multiple procedure claims in section II.A.1.b. of this proposed rule, we have focused in recent years on ways to convert multiple procedure claims to single procedure claims to maximize our use of the claims data in setting median costs for separately payable procedures. We have been successful in using the bypass list to generate “pseudo” single procedure claims for use in median setting, but this approach generally does not enable us to use the hardcore multiple claims that contain multiple separately payable Start Printed Page 42678procedures, all with associated packaging that cannot be split among them. We believe that we could use the data from many more multiple procedure claims by creating APCs for payment of those services defined as frequently occurring common combinations of HCPCS codes for component services that we see in correctly coded multiple procedure claims.

Our examination of data for multiple procedure claims identified two specific sets of services that we believe are good candidates for payment based on the naturally occurring common combinations of component codes that we see on the multiple procedure claims. These are low dose rate (LDR) prostate brachytherapy and cardiac electrophysiologic evaluation and ablation services.

Specifically, we have been told (and our data support) that claims for LDR prostate brachytherapy, when correctly coded, report at least two major separately payable procedure codes the majority of the time. For reasons discussed below, we are proposing to use these correctly coded claims that would otherwise be unusable hardcore multiples as the basis for an encounter-based composite APC that would make a single payment when both codes are reported with the same date of service. We also are proposing to pay separately for these procedure codes in cases where only one of the two procedures is provided in a hospital encounter, through the APC associated with that component procedure code that is furnished.

Similarly, we have been told (and our data support) that multiple cardiac electrophysiologic evaluation, mapping, and ablation services are typically furnished on the same date of service and that the correctly coded claims are typically the multiple procedure claims that include several component services and that we are unable to use in our current claims process. The CY 2007 CPT book introductory discussion in the section entitled “Intracardiac Electrophysiological Procedures/Studies” notes that, in many circumstances, patients with arrhythmias are evaluated and treated at the same encounter. Therefore, as discussed in detail below, we are also proposing to establish an encounter based composite APC for these services that would provide a single payment for certain common combinations of component cardiac electrophysiologic services that are reported on the same date of service.

These composite APCs reflect an evolution in our approach to payment under the OPPS. Where the claims data show that combinations of services are commonly furnished together, in the future we will actively examine whether it would be more appropriate to establish a composite APC under which we would pay a single rate for the service reported with a combination of HCPCS codes on the same date of service (or different dates of service) than to continue to pay for these individual services under service-specific APCs. We are proposing these specific encounter-based composite APCs for CY 2008 because we believe that this approach could move the OPPS toward possible payment based on an encounter or episode-of-care basis, enable us to use more valid and complete claims data, create hospital incentives for efficiency, and provide hospitals with significant flexibility to manage their resources that do not exist when we pay for services on a per service basis. As such, these proposed composite APCs may serve as a prototype for future creation of more composite APCs, through which we could provide OPPS payment for other types of services in the future. We note that while these proposed composite APCs for CY 2008 are based on observed combinations of component HCPCS codes reported on the same date of service for a single encounter, we also will be exploring in the future how we could set payments based on episodes of care involving services that extend beyond the same date but which are all supportive of a single, related course of treatment. While we are not proposing to implement multi-day episode-of-care APCs in CY 2008, we welcome comments on the concept of developing these APCs to provide payment for such episodes in order to inform our future analyses in this area.

While we have never previously used the term “composite” APC under the OPPS, we do have one historical payment policy that resembles the CY 2008 proposed composite APC policy. Since the inception of the OPPS, CMS has limited the aggregate payment for specified less intensive mental health services furnished on the same date to the payment for a day of partial hospitalization, which we considered to be the most resource intensive of all outpatient mental health treatment (65 FR 18455). The costs associated with administering a partial hospitalization program represent the most resource intensive of all outpatient mental health treatment, and we do not believe that we should pay more for a day of individual mental health services under the OPPS. Through the OCE, when the payment for specified mental health services provided by one hospital to a single beneficiary on one date of service based on the payment rates associated with the APCs for the individual services would exceed the per diem partial hospitalization payment (listed as APC 0033 (Partial Hospitalization)), those specified mental health services are assigned to APC 0034, which has the same payment rate as APC 0033, and the hospital is paid one unit of APC 0034. This longstanding policy regarding payment of APC 0034 for combinations of independent services provided in a single hospital encounter resembles the payment policy for composite APCs that we are proposing for LDR prostate brachytherapy and cardiac electrophysiologic evaluation and ablation services for CY 2008. Similar to the logic for the proposed composite APCs, the OCE determines whether to pay these specified mental health services individually or to make a single payment at the same rate as the per diem rate for partial hospitalization for all of the specified mental health services furnished on that date of service. However, we note this established policy for payment of APC 0034 differs from the proposed policies for the new CY 2008 composite APCs because APC 0034 is only paid if the sum of the individual payment rates for the specified mental health services provided on one date of service exceeds the APC 0034 payment rate, which equals the per diem rate of APC 0033 for partial hospitalization.

We are not proposing to change this mental health services payment policy for CY 2008. However, we are proposing to change the status indicator from “S” to “Q” for the HCPCS codes for the specified mental health services to which APC 0034 applies because those codes are conditionally packaged when the sum of the payment rates for the single code APCs to which they are assigned exceeds the per diem payment rate for partial hospitalization. While we have not published APC 0034 in Addendum A in the past, we are including it in Addendum A to this proposed rule entitled “Mental Health Composite,” consistent with our naming taxonomy and publication of the two other proposed composite APCs. We are also including the mental health composite APC 0034 and its member HCPCS codes in Addendum M to this proposed rule in the same way that we show the HCPCS codes to which the LDR Prostate Brachytherapy Composite APC and Cardiac Electrophysiologic Evaluation and Ablation Composite APC apply. Start Printed Page 42679

In summary, we are not proposing a change to the longstanding payment policy under which the OPPS pays one unit of APC 0034 in cases in which the total payments for specified mental health services provided on the same date of service would otherwise exceed the payment rate for APC 0033. However, we are proposing to change the status indicator to “Q” for the HCPCS codes for mental health services to which this policy applies and which comprise this existing composite APC, because payment for these services would be packaged unless the sum of the individual payments assigned to the codes would be less than the payment for APC 0034.

We look forward to public comments on the concept of composite APCs in general and, specifically, the two new proposed encounter-based composite APCs for CY 2008, and we hope to involve the public and the APC Panel in the creation of additional composite APCs. Our goal would be to use the many naturally occurring multiple procedure claims that cannot currently be incorporated under the existing APC structure, regardless of whether the naturally occurring pattern of multiple procedure claims prevents the development of single bills.

(2) Proposed Low Dose Rate (LDR) Prostate Brachytherapy Composite APC (a) Background

LDR prostate brachytherapy is a treatment for prostate cancer in which needles or catheters are inserted into the prostate, and then radioactive sources are permanently implanted into the prostate through the hollow needles or catheters. The needles or catheters are then removed from the body, leaving the radioactive sources in the prostate forever, where they slowly give off radiation to destroy the cancer cells until the sources are no longer radioactive. At least two CPT codes are used to report the composite treatment service because there are separate codes that describe placement of the needles or catheters and application of the brachytherapy sources. LDR prostate brachytherapy cannot be furnished without the services described by both of these codes. Generally, the component services represented by both codes occur in the same operative session in the same hospital on the same date of service. However, we have been told of uncommon cases in which they are furnished in different locations, with the patient being transported from one location to another for application of the sources. In addition, other services, commonly CPT code 76965 (Ultrasonic guidance for interstitial radioelement application) and CPT code 77290 (Therapeutic radiology simulation-aided field setting; complex) are often provided in the same hospital encounter.

CPT code 55875 (Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy) reports the placement of the needles or catheters for services furnished on or after January 1, 2007. Before this date, including in the claims for services furnished in CY 2006 that were used to develop this proposed rule, CPT code 55859 (Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy) reported this service. All of the claims for CPT code 55859 (as reported in the CY 2006 claims data) are for the placement of needles or catheters for prostate brachytherapy, although not all are related to permanent brachytherapy source application.

CPT code 77778 (Interstitial radiation source application; complex) reports the application of brachytherapy sources and, when billed with CPT code 55859 (or CPT code 55875 after January 1, 2007) for the same encounter, reports placement of the sources in the prostate. We have been told that application of brachytherapy sources to the prostate is estimated to be about 85 percent of all occurrences of CPT code 77778 under the OPPS, consistent with our CY 2006 claims data used for CY 2008 ratesetting. CPT code 77778 is also used to report the application of sources of brachytherapy to body sites other than the prostate.

Historical coding, APC assignments, and payment rates for CPT codes 55859 (CPT code 55875 beginning in CY 2007) and 77778 are shown below in Table 21.

Table 21.—Historical Payment Rates for Complex Interstitial Application of Brachytherapy Sources

OPPS CYCombination APCPayment rate for CPT code 77778APC for HCPCS code 77778Payment rate for CPT codes 55859/55875APC for HCPCS code 55859Brachytherapy source
2000N/A$198.31APC 0312$848.04APC 0162Pass-through.
2001N/A205.49APC 0312878.72APC 0162Pass-through.
2002N/A6,344.67APC 03122,068.23APC 0163Pass-through with pro rata reduction.
2003 (prostate brachytherapy with iodine sources)G0261, APC 648, $5,154.34n/an/an/an/aPackaged.
2003 (prostate brachytherapy with palladium sources)G0256, APC 649, $5,998.24n/an/an/an/aPackaged.
2003 (not prostate brachytherapy, not including sources)N/A2,853.58APC 06511,479.60APC 0163Separate payment based on scaled median cost per source.
2004N/A558.24APC 06511,848.55APC 0163Cost.
2005N/A1,248.93APC 06512,055.63APC 0163Cost.
2006N/A666.21APC 06511,993.35APC 0163Cost.
2007N/A1,035.50APC 06512,146.84APC 0163Cost.

Payment rates for CPT code 77778, in particular, have fluctuated over the years. We have frequently been informed by the public that reliance on single procedure claims to set the median costs for these services results in use of only incorrectly coded claims for LDR prostate brachytherapy because, for application of brachytherapy sources to the prostate, a correctly coded claim is a multiple procedure claim. Specifically, we have been informed that a correctly coded claim for LDR prostate brachytherapy should include, for the same date of service, both CPT Start Printed Page 42680codes 55859 and 77778, brachytherapy sources reported with Level II HCPCS codes, and typically separately coded imaging and radiation therapy planning services, and that we should use correctly coded claims to set the median for APC 0651 (Complex Interstitial Radiation Source Application) in particular (where CPT code 77778 is assigned). In presentations to the APC Panel in its March 2006 meeting, and in response to the CY 2006 and CY 2007 OPPS proposed rules, commenters urged us to set the payment rate for LDR prostate brachytherapy services using only multiple procedure claims. Specifically for CY 2007, they urged us to sum the costs on multiple procedure claims containing CPT codes 77778 and 55859 (and no other separately payable services not on the bypass list) and, excluding the costs of sources, split the resulting aggregate median cost on the multiple procedure claim according to a preestablished attribution ratio between CPT codes 77778 and 55859. They indicated that any claim for a brachytherapy service that did not also report a brachytherapy source should be considered to be incorrectly coded and thus not reflective of the hospital's resources required for the interstitial source application procedure. The presenters to the APC Panel believed that claims that did not contain both brachytherapy source and source application codes should be excluded from use in establishing the median cost for APC 0651. They believed that hospitals that reported the brachytherapy sources on their claims were more likely to report complete charges for the associated brachytherapy source application procedure than hospitals that did not report the separately payable brachytherapy sources.

As a result of those comments, for both CY 2006 and CY 2007, we used multiple procedure claims containing both CPT codes 55859 and 77778 to determine a median cost for the totality of both services (with both packaging and bypassing of the other commonly furnished services). We compared the median calculated from this subset of claims reflecting the most common clinical scenario to the single bill median costs for CPT codes 55859 and 77778 as a method of determining whether the total payment to the hospital for both services furnished to provide LDR prostate brachytherapy would be reasonable. In both years, we found that the sum of the single bill medians was reasonably close to the median cost of both services from multiple claims when they were treated as a single procedure and the supporting services were either packaged or bypassed for purposes of calculating the median for the combined pair of codes. (We refer readers to the CY 2006 final rule with comment period (70 FR 68596) and the CY 2007 final rule with comment period (71 FR 68043) for specific discussion of these findings.) Hence, we concluded that the single bill median costs were reasonable and, for both the CY 2006 OPPS and CY 2007 OPPS, we based payment for CPT codes 55859 and 77778 on single procedure claims.

(b) Proposed Payment for LDR Prostate Brachytherapy

For the CY 2008 OPPS, we are proposing to create a composite APC 8001, titled “LDR Prostate Brachytherapy Composite,” that would provide one bundled payment for LDR prostate brachytherapy when the hospital bills both CPT codes 55875 and 77778 as component services provided during the same hospital encounter. It is shown in Addendum A to this proposed rule as APC 8001 (LDR Prostate Brachytherapy Composite). As discussed in detail in section VII. of this proposed rule, we are proposing to continue to pay sources of brachytherapy separately in accordance with the requirements of the statute.

In the CY 2006 claims used to calculate the proposed CY 2008 median costs, CPT code 55859 was reported 14,083 times. The proposed rule median cost for CPT code 55859, calculated from 2,232 single and “pseudo” single bills, is $2,328.56. The CY 2008 proposed rule median cost for APC 0163 (Level IV Cystourethroscopy and other Genitourinary Procedures) to which CPT code 55859 was assigned for CY 2006 and to which CPT code 55875 is assigned for CY 2007 is $2,322.30. In the set of claims used to calculate the median cost for APC 0651, to which CPT code 77778 is the only assigned service, CPT code 77778 was reported 11,850 times. The CY 2008 proposed rule median cost for APC 0651 (and, therefore, for CPT code 77778) based on 339 single and “pseudo” single procedure bills is $969.73.

In examining the claims data used to calculate the median costs for this proposed rule, we found 9,807 claims on which both CPT code 55859 and CPT code 77778 were billed on the same date of service. These data suggest that LDR prostate brachytherapy constituted at least 70 percent of CY 2006 claims for CPT code 55859, with the remainder of claims representing the insertion of needles or catheters for high dose rate prostate brachytherapy or unusual clinical situations where the LDR sources were not applied in the same operative session as the insertion of the needles or catheters. These data are consistent with our understanding of current clinical practice for prostate brachytherapy, and we believe that those multiple claims are correctly coded claims for this common clinical scenario. Similarly, 83 percent of the claims for complex interstitial brachytherapy source application CPT code 77778 also included the CPT code for inserting needles or catheters into the prostate, consistent with our understanding that the vast majority of cases of complex interstitial brachytherapy source application procedures are specifically for the treatment of prostate cancer, rather than other types of cancer.

Using the proposed packaging approach for imaging supervision and interpretation services and guidance services for CY 2008, we were able to identify 1,343 claims, 14 percent of all OPPS claims that reported these two procedures on the same date, that contain both CPT codes 55859 and 77778 on the same date of service and no other separately paid procedure code. We were not able to use more claims to develop this composite APC median cost because there are several radiation therapy planning codes that are commonly reported with CPT codes 55859 and 77778 and that are both separately paid and not on the bypass list because the amount of their associated packaging exceeds the threshold for inclusion on the bypass list. A complete discussion of the bypass list under our CY 2008 packaging proposal is provided in section II.A. of this proposed rule.

We packaged the costs of packaged revenue codes and packaged HCPCS codes into the sum of the costs for CPT codes 55859 and 77778 to derive a total proposed median cost of $3,127.35 for the composite LDR prostate brachytherapy service based upon the 1,343 claims that contained both CPT codes and no other separately paid procedure codes. This is reasonably comparable to $3,298.29, the sum of the CPT median costs we calculated using the single procedure bills for CPT codes 55859 and 77778 (($2,328.56 plus $969.73). We believe that the difference between the composite APC median cost based upon those claims that contain both codes and the sum of the median costs for the APCs to which the two individual CPT codes map is minimal and may be attributable to efficiencies in furnishing the services together during a single encounter. Start Printed Page 42681

We believe that creation of the composite APC for the payment of LDR prostate brachytherapy is consistent with the statute and with our desire to use more claims data for ratesetting, particularly data from correctly coded claims that reflect typical clinical practice, and to make payment for larger packages and bundles of services to provide enhanced incentives for efficiency and cost containment under the OPPS and to maximize hospital flexibility in managing resources.

Under our proposal, hospitals that furnish LDR prostate brachytherapy would report CPT codes 55875 and 77778 and the codes for the applicable brachytherapy sources in the same manner that they currently report these items and services (in addition to reporting any other services provided), using the same HCPCS codes and reporting the same charges. We would require that hospitals report both CPT codes resulting in the composite APC payment on the same claim when they are furnished to a single Medicare beneficiary in the same facility on the same date of service, and we would make any necessary conforming changes to the billing instructions to ensure that they do not present an obstacle to correct reporting. We may implement edits to ensure that hospitals do not submit two separate claims for these two procedures when furnished on the same date in the same facility. When this combination of codes is reported, the OCE would assign the composite APC 8001 and the Pricer would pay based on the payment rate for the composite APC. The OCE would assign APC 0163 or APC 0651 only when both codes are not reported on the same claim with the same date of service, and we would expect this to be the atypical case. The composite APC would have a status indicator of “T” so that payment for other procedures also assigned to status indicator “T” with lower payment rates would be reduced by 50 percent when furnished on the same date of service as the composite service, in order to reflect the efficiency that occurs when multiple procedures are furnished to a Medicare beneficiary in a single operative session. We would not expect that the composite APC payment would be commonly reduced because we believe that it is unlikely that a higher paid procedure would be performed on the same date.

We are proposing to continue to establish separate payment rates for APC 0651 (to which only CPT code 77778 is assigned) and for APC 0163 (to which we are proposing to continue to assign CPT code 55875). In some cases, CPT 55875 may be reported for the insertion of needles or catheters for high dose rate prostate brachytherapy, and the low dose rate brachytherapy source application procedure (CPT code 77778) would not be reported. In high dose rate prostate brachytherapy, the sources are applied temporarily several times over a few days while the needles or catheters remain in the prostate, and the needles or catheters are removed only after all the treatment fractions have been completed. We have also been told by hospitals that, even when LDR prostate brachytherapy is planned, there are occasions in which the needles or catheters are inserted in one facility and the patient is moved to another facility for the application of the sources. In those cases, we would need to be able to appropriately pay the hospital that inserted the needles or catheters before the patient was discharged prior to source application. Moreover, there are cases in which the needles or catheters are inserted but it is not possible to proceed to the application of the sources and, therefore, the hospital would correctly report only CPT code 55875. Similarly, more than 10 brachytherapy sources can be applied interstitially (as described by CPT code 77778) to sites other than the prostate and it is, therefore, necessary to have a separate payment rate for CPT code 77778. Hence, for CY 2008 we are proposing to continue to pay for CPT code 55875 (the successor to CPT code 55859) through APC 0163 and to pay for CPT code 77778 through APC 0651 when the services are individually furnished other than on the same date of service in the same facility.

In summary, we are proposing to establish a composite APC, shown in Addendum A as APC 8001, to provide payment for LDR prostate brachytherapy when the composite service, billed as CPT codes 55875 and 77778, is furnished in a single hospital encounter and to base the payment for the composite APC on the median cost derived from claims that contain both codes. These two CPT codes are assigned to status indicator “Q” in Addendum B to this proposed rule to signify their conditionally packaged status, and their composite APC assignments are noted in Addendum M. This proposal would permit us to base payment on claims for the most common clinical scenario for interstitial radiation source application to the prostate. We note that this payment bundle would also include payment for the commonly associated imaging guidance services, which would be newly packaged under our proposed CY 2008 packaging approach. Most importantly, this composite APC payment methodology that we are proposing would contribute to our goal of providing payment under the OPPS for a larger bundle of component services provided in a single hospital outpatient encounter, creating additional hospital incentives for efficiency and cost containment, while providing hospitals with the most flexibility to manage their resources.

(3) Proposed Cardiac Electrophysiologic Evaluation and Ablation Composite APC

(a) Background

During its March 2007 meeting, members of the APC Panel indicated that the reason we found so few single bills for procedures assigned to APC 0087 (Cardiac Electrophysiologic Recording/Mapping), specifically 72 of 11,834 or 0.61 percent of all proposed rule CY 2006 claims, is that most of the services assigned to APCs 0085 (Level II Electrophysiologic Evaluation), 0086 (Ablate Heart Dysrhythm Focus), and 0087 are performed in varying combinations with one another. Therefore, correctly coded claims would most often include multiple codes for component services that are reported with different CPT codes and that are now paid separately through different APCs. There would never be many single bills and those that are reported as single bills would likely represent atypical cases or incorrectly coded claims.

We examined the combinations of services observed in our claims data across these three APCs to see whether there was the potential for handling the data differently so that we could use more claims data to set the payment rates for these procedures, particularly those services assigned to APC 0087 where we have had a persistent concern regarding the limited and reportedly unrepresentative single bills available for use in calculating the median cost according to our standard OPPS methodology. We initially developed and examined frequency distributions of unique combinations of codes on claims which contained at least one unit of any code assigned to APC 0085, 0086, or 0087 and then broadened these analysis to any combination of an electrophysiologic evaluation and ablation code.

Our initial frequency distributions supported the APC Panel members' description of their experiences. We identified and enumerated the most commonly appearing unique occurrences (either single procedures or combinations) of codes for services Start Printed Page 42682assigned to status indicator “S,” “T,” “V,” or “X” that contained at least one code assigned to APC 0085, 0086, or 0087. There were 7,379 claims in the top 100 occurrence types. Table 22 shows the 10 most common unique occurrences from CY 2006 claims available for this proposed rule.

Table 22.—Ten Most Frequently Occurring Unique Occurrences of Cardiac Electrophysiologic Evaluation, Mapping, and Ablation Procedures and Other Separately Payable Services

Combination numberFrequencyHCPCS codeShort descriptorCY 2007 APCCY 2007 SI
176393620Electrophysiology evaluation0085T
250993609Map tachycardia, add-on0087T
93620Electrophysiology evaluation0085T
93621Electrophysiology evaluation0085T
93623Stimulation, pacing heart0087T
93651Ablate heart dysrhythm focus0086T
339893609Map tachycardia, add-on0087T
93620Electrophysiology evaluation0085T
93621Electrophysiology evaluation0085T
93651Ablate heart dysrhythm focus0086T
438193650Ablate heart dysrhythm focus0086T
537693620Electrophysiology evaluation0085T
93623Stimulation, pacing heart0087T
624893005Electrocardiogram, tracing0099S
93609Map tachycardia, add-on0087T
93620Electrophysiology evaluation0085T
93621Electrophysiology evaluation0085T
93623Stimulation, pacing heart0087T
93651Ablate heart dysrhythm focus0086T
722593005Electrocardiogram, tracing0099S
93609Map tachycardia, add-on0087T
93620Electrophysiology evaluation0085T
93621Electrophysiology evaluation0085T
93651Ablate heart dysrhythm focus0086T
822593613Electrophys map 3d, add-on0087T
93620Electrophysiology evaluation0085T
93621Electrophysiology evaluation0085T
93651Ablate heart dysrhythm focus0086T
921793005Electrocardiogram, tracing0099S
93620Electrophysiology evaluation0085T
1018593613Electrophys map 3d, add-on0087T
93620Electrophysiology evaluation0085T
93621Electrophysiology evaluation0085T
93623Stimulation, pacing heart0087T
93651Ablate heart dysrhythm focus0086T

Although the number of claims for each unique occurrence was modest, we were able to determine that there were certain combinations of codes that occurred most often together. Based on our review of the most frequently occurring combinations of codes on claims that also contained at least one code assigned to APC 0085, 0086 or 0087 and our clinical review of the codes, we proceeded to study combination claims that contained at least one code from group A for evaluation services and at least one code from group B for ablation services reported on the same date of service on an individual claim, as specified in Table 23 below.

Table 23.—Groups of Cardiac Electrophysiologic Evaluation and Ablation Procedures for Further Analysis

Codes used in combinations: at least one in Group A and one in Group BHCPCS codeCY 2007 APCCY 2007 SI
Group A:
Electrophysiology evaluation936190085T
Electrophysiology evaluation936200085T
Group B:
Ablate heart dysrhythm focus936500086T
Ablate heart dysrhythm focus936510086T
Ablate heart dysrhythm focus936520086T

When we studied claims that contained a code in group A and also a code in group B, we found that there were 5,118 claims that met these criteria, and that of these 5,118 claims, 4,552 (89 percent) contained both CPT code 93620 (Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple Start Printed Page 42683electrode catheters with induction or attempted induction of arrhythmia; with right atrial pacing and recording, right ventricular pacing and recording, His bundle recording) from APC 0085 and CPT code 93651 (Intracardiac catheter ablation of arrhythmogenic focus; for treatment of supraventricular tachycardia by ablation of fast or slow atrioventricular pathways, accessory atrioventricular connections or other atrial foci, singly or in combination) from APC 0086 with the same date of service. Given that CPT code 93651 had a total frequency of 8,091, this means that more than 55 percent of the claims for CPT code 93651 also contained CPT code 93620. CPT code 93620 had a total frequency of 12,624, approximately 50 percent higher than the total frequency for CPT code 93651, which is consistent with our expectations because CPT code 93620 describes a diagnostic service and CPT code 93651 is a treatment service that may be provided based upon the findings of the evaluation described by CPT code 93620. In addition to the codes for group A and group B services, the combination claims also contained costs for packaged services that were reported under revenue codes without HCPCS codes and under packaged HCPCS codes. As we discuss in considerable detail above, we lack a methodology that could be used to allocate these packaged costs to major separately paid procedures in a manner which gives us confidence that the costs would be attributed correctly. We have explored and will continue to explore an alternative strategy that would enable us to use these correctly coded multiple procedure claims for ratesetting.

In our review of these claims, not only did we find a high number of claims on which there was one code from group A and one code from group B, but we also found that claims for procedures assigned to APC 0087 for CY 2007 usually appeared on claims that contained a code from APC 0085 or APC 0086, or both. The most frequently appearing CPT codes that were assigned to APC 0087 for CY 2007 were, as shown above, 93609 (Intraventricular and/or intra-atrial mapping of tachycardia site(s), with catheter manipulation to record from multiple sites to identify origin of tachycardia (List separately in addition to code for primary procedure)), 93613 (Intracardiac electrophysiologic 3-dimensional mapping (List separately in addition to code for primary procedure)), 93621 (Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left atrial pacing and recording from coronary sinus or left atrium (List separately in addition to code for primary procedure)), 93622 (Comprehensive electrophysiologic evaluation including insertion and repositioning of multiple electrode catheters with induction or attempted induction of arrhythmia; with left ventricular pacing and recording (List separately in addition to code for primary procedure)), and 93623 (Programmed simulation and pacing after intravenous drug infusion (List separately in addition to code for primary procedure)). These codes are all CPT add-on codes that CPT indicates are to be reported in addition to the code for the primary procedure. Our clinical review of the services described by these five CPT codes determined that they are supportive dependent services that are provided most often as supplemental to procedures assigned to APCs 0085 and 0086. The procedures in APCs 0085 and 0086 can be performed without these supportive add-on procedures, but these dependent services cannot be done except as a supplement to another electrophysiologic procedure. Therefore, we are proposing to unconditionally package all of these five CPT codes under the grouping of intraoperative services for the CY 2008 OPPS. We discuss the packaging of intraoperative services in general, including these services, above.

However, packaging these supportive ancillary services that are so often reported with the cardiac electrophysiologic evaluation and ablation services does not enable us to use many more claims because, as we noted previously, the claims on which these codes most commonly appeared typically also contained at least one separately paid code from APC 0085 and one code from APC 0086. Although the most common combination of codes from APCs 0085 and 0086 is the pair of CPT codes 93620 and 93651, there are numerous other combinations of services from APCs 0085 and 0086 that are performed and, while not as frequent, these combinations are also reflected in the multiple claims.

In order to use more claims and adequately reflect the varied, common combinations of electrophysiologic evaluation and ablation CPT codes, we calculated a composite median cost from all claims containing at least one code from group A and at least one code from group B as if they were a single service. We selected multiple procedure claims that contained at least one code in group A and one code in group B on the same date of service and calculated a median cost from the total costs on these claims. Some claims had more than one code from each group. Although the claim was required to contain at least one code from each group to be included, the claim could also contain any number of codes from either group and any number of units of those codes. In addition, the costs of the five supportive intraoperative services previously assigned to APC 0087 that we identify above were packaged, as well as the costs of the other items and services proposed to be packaged for the CY 2008 OPPS. This selection process yielded 5,118 claims to use for the calculation. The proposed composite median cost for these claims using the CY 2008 proposed rule data is $8,528.83. We believe that this cost is attributable largely to the 4,552 claims that contain one unit each of CPT code 93620 and CPT code 93651 (and some unknown numbers and combinations of packaged services). In comparison, the sum of the CY 2008 proposed rule CPT code median costs for CPT code 93620 (which is $3,111.76) and CPT code 93651 (which is $5,643.95) is $8,755.71. If the 50 percent multiple procedure discount is applied to the CPT code median cost for the lower cost procedure based on its assignment to an APC with a “T” status, the adjusted sum of the median costs is $7,199.83 ($5,643.95 + $1,555.88). These medians were calculated using only claims that contain correct devices and do not contain token charges or the “FB” modifier. We believe the significant positive difference between the composite and discounted costs still reflects efficiencies, as the sum of the discounted median costs does not take into account the cost of other procedures also provided that are assigned to APCs 0085 and 0086, while the composite median cost of $8,528.83 does, to some extent, reflect the cost of other multiple procedures in APCs 0085 and 0086 that were also reported on the claims used to develop the composite median cost. In addition, these two calculations are based upon two different sets of claims, single procedure claims in one case (which do not represent the way the service is typically furnished) and the specified subset of clinically common combination claims in the second case. Moreover, while the 50 percent multiple procedure reduction is our best aggregate estimate of the overall degree of efficiency applicable to multiple surgeries, it may or may not be specifically appropriate to this particular combination of procedures. Start Printed Page 42684

By selecting the multiple procedure claims that contained at least one code in each group, we were able to use many more claims than were available to establish the individual APC medians. The percents by CPT code for the composite configuration below in Table 24 represent the sum of the frequency of single bills used to set the medians for APCs 0085 and 0086 with packaging of the five intraoperative services and the frequency of multiple bills used to set the medians for the composite claims containing at least one code from each group and with packaging of the costs of the five intraoperative services, divided by the total frequency of each CPT code.

Table 24.—Percentage of Claims Used To Calculate Median Costs for Cardiac Electrophysiologic Evaluation and Ablation Procedures

Codes used in combinations: at least one in group A and one in Group BHCPCS codeProposed CY 2008 APCSIStandard configuration (with packaging of intraoperative services)Composite configuration (with packaging of intra- operative services)
CPT percentage of single claimsOverall APC percentage of single claimsCPT percentage of single and combination claims
Group A:
Electrophysiology evaluation936190085T38.9925.4763.96
Electrophysiology evaluation936200085T22.3025.4761.77
Group B:
Ablate heart dysrhythm focus936500085T39.5825.4752.50
Ablate heart dysrhythm focus936510086T4.594.6863.30
Ablate heart dysrhythm focus936520086T7.534.6858.78

Moreover, by packaging CPT codes 93609, 93613, 93621, 93622, and 93623, we use many more of the claims for these codes from the most common clinical scenarios than would otherwise be possible if the supportive intraoperative services were separately paid. Wherever any of these codes appears on a claim that can be used for median setting, the cost data for these codes are packaged in the calculation of the median cost for the separately paid services on the claim.

(b) Proposed Payment for Cardiac Electrophysiologic Evaluation and Ablation

In view of our findings with regard to how often the codes in groups A and B appear together on the same claim, we are proposing to establish one composite APC, shown in Addendum A as APC 8000 (Cardiac Electrophysiologic Evaluation and Ablation Composite), for CY 2008 that would pay for a composite service made up of any number of services in groups A and B when at least one code from group A and at least one code from group B appear on the same claim with the same date of service. The five CPT codes involved in this composite APC are assigned to status indicator “Q” in Addendum B to this proposed rule to identify their conditionally packaged status, and their composite APC assignments are identified in Addendum M. We are proposing to use the composite median cost of $8,528.83 as the basis for establishing the relative weight for this newly created APC for the composite electrophysiologic evaluation and ablation service. Under this composite APC, unlike most other APCs, we would make a single payment for all services reported in groups A and B. We are proposing that hospitals would continue to code using CPT codes to report these services and that the OCE would recognize when the criteria for payment of the composite APC are met and would assign the composite APC instead of the single procedure APCs as currently occurs. The Pricer would make a single payment for the composite APC that would encompass the program payment for the code in group A, the code in group B, and any other codes reported in groups A or B, as well as the packaged services furnished on the same date of service. The proposed composite APC would have a status indicator of “T” so that payment for other procedures also assigned to status indicator “T” with lower payment rates would be reduced by 50 percent when furnished on the same date of service as the composite service, in order to reflect the efficiency that occurs when multiple procedures are furnished to a Medicare beneficiary in a single operative session. We would not expect that the proposed composite APC payment would be commonly reduced because we believe that it is unlikely that a higher paid procedure would be performed on the same date. We are proposing to continue to pay separately for other separately paid services that are not reported under the codes in groups A and B (such as chest x-rays and electrocardiograms).

Moreover, where a service in group A is furnished on a date of service that is different from the date of service for a code in group B for the same beneficiary, we are proposing that payments would be made under the single procedure APCs and the composite APC would not apply. Given our CY 2008 proposal to unconditionally package payment for five cardiac electrophysiologic CPT codes as members of the category of intraoperative services that were previously assigned to APCs 0085 and 0087, we are also proposing to reconfigure APCs 0084 through 0087, where many of the cardiac electrophysiologic procedures that will be separately paid when they are not paid according to the composite APC are assigned. Specifically, we are proposing to discontinue APC 0087, and reconfigure APCs 0084, 0085, and 0086, with proposed titles and median costs of Level I Electrophysiologic Procedures (APC 0084) at $647.41; Level II Electrophysiologic Procedures (APC 0085) at $3,059.46; and Level III Electrophysiologic Procedures (APC 0086) at $5,709.52, respectively. We refer readers to section IV.A.2. of this proposed rule for a discussion of Start Printed Page 42685calculation of median costs for device-dependent APCs. We believe this reconfiguration improves the clinical and resource homogeneity of these APCs which would provide payment for cardiac electrophysiologic procedures that would be individually paid when they do not meet the criteria for payment of the composite APC.

We believe that creation of the proposed composite APC for cardiac electrophysiologic evaluation and ablation services is the most efficient and effective way to use the claims data for the majority of these services and best represents the hospital resources associated with performing the common combinations of these services that are clinically typical. We believe that this proposed ratesetting methodology results in an appropriate median cost for the composite service when at least one evaluation service in group A is furnished on the same date as at least one ablation service in group B. This approach creates incentives for efficiency by providing a single payment for a larger bundle of major procedures when they are performed together, in contrast to continued separate payment for each of the individual procedures. We expect to develop additional composite APCs in the future as we learn more about major currently separately paid services that are commonly furnished together during the same hospital outpatient encounter.

e. Service-Specific Packaging Issues

As a result of requests from the public, a Packaging Subcommittee to the APC Panel was established to review all the procedural CPT codes with a status indicator of “N.” Commenters to past rules have suggested that certain packaged services could be provided alone, without any other separately payable services on the claim, and requested that these codes not be assigned status indicator “N.” In deciding whether to package a service or pay for a code separately, we have historically considered a variety of factors, including whether the service is normally provided separately or in conjunction with other services; how likely it is for the costs of the packaged code to be appropriately mapped to the separately payable codes with which it was performed; and whether the expected cost of the service is relatively low. As discussed above regarding our proposed packaging approach for CY 2008, we have modified the historical considerations outlined above in developing our proposal for the CY 2008 OPPS. The Packaging Subcommittee discussed many HCPCS codes during the March 2007 APC Panel meeting, prior to development of the proposed packaging approach discussed above, and we have summarized and responded to the APC Panel's packaging-related recommendations below. Three of the codes reviewed by the Packaging Subcommittee at the March 2007 APC Panel meeting are included in the seven categories of services identified for packaging under the CY 2008 OPPS. For those three codes, we specifically applied the proposed CY 2008 criteria for determining whether a code should be proposed as packaged or separately payable for CY 2008. Specifically, we determined whether the service is a dependent service falling into one of the seven specified categories that is always or almost always provided integral to an independent service. For those four codes that were reviewed during the March 2007 APC Panel meeting but that do not fit into any of the seven categories of codes that are part of our CY 2008 proposed packaging approach, we applied the packaging criteria described above that were historically used under the OPPS. Moreover, we took into consideration our interest in expanding the size of payment groups for component services to provide encounter-based and episode-of-care-based payment in the future in order to encourage hospital efficiency and provide hospitals with maximal flexibility to manage their resources.

In accordance with a recommendation of the APC Panel, for the CY 2007 OPPS, we implemented a new policy that designates certain codes as “special” packaged codes, assigned to status indicator “Q” under the OPPS, where separate payment is provided if the code is reported without any other services that are separately payable under the OPPS on the same date of service. Otherwise, payment for the “special” packaged code is packaged into payment for the separately payable services provided by the hospital on the same date. We note that these “special” packaged codes are a subset of those HCPCS codes that are assigned to status indicator “Q,” which means that their payment is conditionally packaged under the OPPS. We are proposing to update our criteria to determine packaged versus separate payment for “special” packaged HCPCS codes assigned to status indicator “Q” for CY 2008. For CY 2008, payment for “special” packaged codes would be packaged when these HCPCS codes are billed on the same date of service as a code assigned to status indicator “S,” “T,” “V,” or “X.” When one of the “special” packaged codes assigned to status indicator “Q” is billed on a date of service without a code that is assigned to any of the four status indicators noted above, the “special” packaged code assigned to status indicator “Q” would be separately payable.

The Packaging Subcommittee identified areas for change for some currently packaged CPT codes that it believed could frequently be provided to patients as the sole service on a given date and that required significant hospital resources as determined from hospital claims data. Based on the comments received, additional issues, and new data that we shared with the Packaging Subcommittee concerning the packaging status of codes for CY 2008, the Packaging Subcommittee reviewed the packaging status of numerous HCPCS codes and reported its findings to the APC Panel at its March 2007 meeting. The APC Panel accepted the report of the Packaging Subcommittee, heard several presentations on certain packaged services, discussed the deliberations of the Packaging Subcommittee, and recommended that—

1. CMS place CPT code 76937 (Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle entry, with permanent recording and reporting (list separately in addition to code for primary procedure)) on the list of “special” packaged codes (status indicator “Q”). (Recommendation 1)

2. CMS evaluate providing separate payment for trauma activation when it is reported on a claim for an ED visit, regardless of the level of the emergency department visit. (Recommendation 2)

3. CMS place CPT code 0175T (Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed remote from primary interpretation) on the list of “special” packaged codes (status indicator “Q”). (Recommendation 3)

4. CMS place CPT code 0126T (Common carotid intima-media thickness (IMT) study for evaluation of atherosclerotic burden or coronary heart disease risk factor assessment) on the list of “special” packaged codes (status indicator “Q”) and that CMS consider mapping the code to APC 340 (Minor Ancillary Procedures). (Recommendation 4) Start Printed Page 42686

5. CMS place CPT code 0069T (Acoustic heart sound recording and computer analysis only) on the list of “special” packaged codes (status indicator “Q”) and that CMS exclude APC 0096 (Non-Invasive Vascular Studies) as a potential placement for this CPT code. (Recommendation 5)

6. CMS maintain the packaged status of HCPCS code A4306 (Disposable drug delivery system, flow rate of less than 50 ml per hour) and that CMS present additional data on this system to the APC Panel when available. (Recommendation 6)

7. CMS reevaluate the packaged OPPS payment for CPT code 99186 (Hypothermia; total body) based on current research and availability of new therapeutic modalities. (Recommendation 7)

8. The Packaging Subcommittee remains active until the next APC Panel meeting. (Recommendation 8)

We address each of these recommendations in turn in the discussion that follows.

Recommendation 1

For CY 2008, we are proposing to maintain CPT code 76937 as a packaged service. We are not adopting the APC Panel's recommendation to pay separately for this code in some circumstances as a “special” packaged code. In the CY 2006 OPPS final rule with comment period (70 FR 68544 through 68545), in response to several public comments, we reviewed in detail the claims data related to CPT code 76937. During its March 2006 APC Panel meeting, after reviewing data pertinent to CPT code 76937, the APC Panel recommended that CMS maintain the packaged status of this code for CY 2007, and we accepted that recommendation. During the March 2007 APC Panel meeting, after reviewing current data and listening to a public presentation, the Panel recommended that we treat this code as a “special” packaged code for CY 2008, noting that certain uncommon clinical scenarios could occur where it would be possible to bill this service alone on a claim, without any other separately payable OPPS services.

We are proposing to maintain CPT code 76937 as an unconditionally packaged service for CY 2008, fully consistent with the proposed packaging approach for the CY 2008 OPPS, as discussed above. Because CPT code 76937 is a guidance procedure and we are proposing to package payment for all guidance procedures for CY 2008, we believe it is appropriate to maintain the unconditionally packaged status of this code, which is a CPT designated add-on procedure that we would expect to be generally provided only in association with other independent services. We applied the updated criteria for determining whether this service should receive packaged or separately payment under the CY 2008 OPPS. Specifically, we determined that this service is a supportive ancillary service that is integral to an independent service, resulting in our CY 2008 proposal to packaged payment for the service.

We discussed this code extensively in both the CY 2006 and CY 2007 final rules with comment period (70 FR 68544 through 68545; 71 FR 67996 through 67997). Our hospital claims data demonstrate that guidance services are used frequently for the insertion of vascular access devices, and we have no evidence that patients lack appropriate access to guidance services necessary for the safe insertion of vascular access devices in the hospital outpatient setting. Because we believe that ultrasound guidance would almost always be provided with one or more separately payable independent procedures, its costs would be appropriately bundled with the handful of vascular access device insertion procedures with which it is most commonly performed. We further believe that hospital staff chooses whether to use no guidance or fluoroscopic guidance or ultrasound guidance on an individual basis, depending on the clinical circumstances of the vascular access device insertion procedure.

Therefore, we do not believe that CPT code 76937 is an appropriate candidate for designation as a “special” packaged code. The CY 2007 CPT book indicates that this code is an add-on code and should be reported in addition to the code reported for the primary procedure. According to our CY 2006 claims data available for this proposed rule, this code was billed over 60,000 times, yet less than one-tenth of 1 percent of all claims for the procedure were billed without any separately payable OPPS service on the claim. Because this code is provided alone only extremely rarely, we believe this code would not be appropriately treated as a “special” packaged code. Therefore, we are proposing to continue to unconditionally package CPT code 76937 for CY 2008.

Recommendation 2

For CY 2008, we are proposing to maintain the packaged status of revenue code 068x, trauma response, when the trauma response is provided without critical care services. During the August 2006 APC Panel meeting, the APC Panel encouraged CMS to pay differentially for critical care services provided with and without trauma activation. For CY 2007, as a result of the APC Panel's August 2006 discussion and our own data analysis, we finalized a policy to pay differentially for critical care provided with and without trauma activation. The CY 2007 payment rate for critical care unassociated with trauma activation is $405.04 (APC 0617, Critical Care), while the payment rate for critical care associated with trauma activation is $899.58 (APC 0617 and APC 0618 (Trauma Response with Critical Care)). During the March 2007 APC Panel meeting, a presenter requested that CMS also pay differentially for emergency department visits provided with and without trauma activation. Two organizations that submitted comment letters for the APC Panel's review specifically requested separate payment for revenue code 068x every time it appears on a claim, regardless of the other services that were billed on that claim. The APC Panel recommended that CMS evaluate providing separate payment for trauma activation when it is reported on a claim for an emergency department visit, regardless of the level of the emergency department visit.

After accepting the APC Panel's recommendation and evaluating this issue, we continue to believe that, while it is currently appropriate to pay separately for trauma activation when billed in association with critical care services, it is also currently appropriate to maintain the packaged payment status of revenue code 068x when trauma response services are provided in association with both clinic and emergency department visits under the CY 2008 OPPS. As mentioned above, it is our general objective to expand the size of the payment groups under the OPPS to move toward encounter-based and episode-of-care-based payments in order to encourage maximum hospital efficiency with a focus on value-based purchasing. Because trauma activation in association with emergency department or clinic visits would always be provided in the same hospital outpatient encounter as the visit for care of the injured Medicare beneficiary, packaging payment for trauma activation when billed in association with both clinic and emergency department visits is most consistent with our proposed packaging approach. We are also concerned that unpackaging payment for trauma activation in those circumstances where the trauma response would be less likely to be essential to appropriately treating a Start Printed Page 42687Medicare beneficiary would reduce the incentive for hospitals to provide the most efficient and cost-effective care. We note that, while we are proposing for CY 2008 to continue to provide separate payment for trauma activation in association with critical care services, we may reconsider this payment policy for future OPPS updates as we further develop encounter-based and episode-of-care-based payment approaches.

Furthermore, continued packaged payment for trauma activation when unassociated with critical care is consistent with the principles of a prospective payment system, where hospitals receive payment based on the median cost related to all of the hospital resources associated with the main service provided. In various situations, each hospital's costs may be higher or lower than the median cost used to set payment rates. In light of our proposed packaging approach for the CY 2008 OPPS, we believe it is particularly important not to make any changes in our payment policies for other services that are not fully aligned with promoting efficient, judicious, and deliberate care decisions by hospitals that allow them maximum flexibility to manage their resources through encouraging the most cost-effective use of hospital resources in providing the care necessary for the treatment of Medicare beneficiaries. Packaging payment encourages hospitals to establish protocols that ensure that services are furnished only when they are medically necessary and to carefully scrutinize the services ordered by practitioners to minimize unnecessary use of hospital resources.

Therefore, we are adopting the APC Panel's recommendation that we evaluate providing separate payment for revenue code 068x when provided in association with emergency department visits. For CY 2008, after our thorough assessment, we are proposing to maintain the packaged status of revenue code 068x, except when revenue code 068x is billed in association with critical care services.

Recommendation 3

For CY 2008, we are proposing to maintain the unconditionally packaged status of CPT codes 0174T (Computer aided detection (CAD) (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation and report, with or without digitization of film radiographic images, chest radiograph(s), performed concurrent with primary interpretation) and 0175T. These services involve the application of computer algorithms and classification technologies to chest x-ray images to acquire and display information regarding chest x-ray regions that may contain indications of cancer. CPT code 0152T (Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images; chest radiograph(s) (List separately in addition to code for primary procedure)), the predecessor code to CPT codes 0174T and 0175T, was indicated as an add-on code to chest x-ray CPT codes for CY 2006, according to the AMA's CY 2006 CPT book. However, on July 1, 2006, the AMA released to the public an update that deleted CPT codes 0152T and replaced it with the two new Category III CPT codes 0174T and 0175T.

In its March 2006 presentation to the APC Panel, before the AMA had released the CY 2007 changes to CPT code 0152T, a presenter requested that we pay separately for this service and assign it to a New Technology APC with a payment rate of $15, based on its estimated cost, clinical considerations, and similarity to other image post processing services that are paid separately. We proposed to accept the APC Panel's recommendation to package CPT code 0152T for CY 2007.

In its August 2006 presentation to the APC Panel, after the AMA had released the CY 2007 code changes, the same presenter requested that we assign both of the two new codes to a New Technology APC with a payment rate of $15. The APC Panel members discussed these codes extensively. They considered the possibility of treating CPT code 0175T as a “special” packaged code, thereby assigning payment to the code only when it was performed by a hospital without any other separately payable OPPS service also provided on the same day. They questioned the meaning of the word “remote” in the code descriptor for CPT code 0175T, noting that was unclear as to whether remote referred to time, geography, or a specific provider. They believed it was likely that a hospital without a CAD system that performed a chest x-ray and sent the x-ray to another hospital for performance of the CAD would be providing the CAD service under arrangement and, therefore, would be providing at least one other service (chest x-ray) that would be separately paid. Thus, even in these cases, payment for the CAD service could be appropriately packaged. After significant and lengthy deliberation, the APC Panel recommended that we package payment for both of the new CPT codes, 0174T and 0175T, for CY 2007.

In its March 2007 presentation to the APC Panel, the same presenter requested that we pay separately for CPT codes 0174T and 0175T, mapping them to New Technology APC 1492, with a payment rate of $15. The presenter indicated that chest x-ray CAD is not a screening tool and should only be billed to Medicare when applied to chest x-rays suspicious for lung cancer. The presenter also explained that additional and distinct hospital resources are required for chest x-ray CAD that are not required for a standard chest x-ray. In addition, remote chest x-ray CAD described by CPT code 0175T can be performed at a different time or location or by a different provider than the chest x-ray service. The presenter expressed concern that if hospitals were not paid separately for this technology, hospitals would not be able to provide it, thereby limiting beneficiary access to chest x-ray CAD. The APC Panel recommended conditional packaging as a “special” packaged code for CPT code 0175T, but did not recommend a change to the unconditionally packaged status of CPT code 0174T. We are not adopting the APC Panel's recommendation for designation of CPT code 0175T as a “special” packaged code under the CY 2008 OPPS.

We believe that packaged payment for diagnostic chest x-ray CAD under a prospective payment methodology for outpatient hospital services is most appropriate. We are proposing to maintain CPT codes 0174T and 0175T as unconditionally packaged services for CY 2008, fully consistent with the proposed packaging approach for the CY 2008 OPPS, as discussed above. Because CPT codes 0174T and 0175T are supportive ancillary services that fit into the “image processing” category, and we are proposing to package payment for all image processing services for CY 2008, we believe it is appropriate to maintain the packaged status of these codes. We applied the updated criteria for determining whether these two CAD services should receive packaged or separate payment. Specifically, we determined that this service is a dependent service that is integral to an independent service, in this case, the chest x-ray or other OPPS service that we would expect to be provided in addition to the CAD service.

After hearing many public presentations and discussions regarding the use of chest x-ray CAD, we continue to believe that even the remote service would almost always be provided by a hospital either in conjunction with other separately payable services or Start Printed Page 42688under arrangement. For example, if a physician orders a chest x-ray and CAD service to be performed at hospital A, and hospital A, which does not have the CAD technology, sends the chest-ray to hospital B for the performance of chest x-ray CAD, hospital B could only provide the CAD service if it were provided under arrangement, to avoid the OPPS unbundling prohibition. Assuming that the CAD service was provided under arrangement, hospital A would bill for the chest x-ray CAD that was performed by hospital B and would pay hospital B for the service provided. In that case, hospital A would also bill the chest x-ray service that it provided. In another scenario that has been described to us, if a physician were to send a patient to a hospital clinic with the patient's chest x-ray for consultation, we believe that the patient would likely receive a visit service, in addition to the chest x-ray CAD. Therefore, in both of these circumstances, payment for the chest x-ray CAD would be appropriately packaged into payment for the separately payable services with which it was provided.

We also do not believe that CPT code 0175T should be treated as a “special” packaged code. As discussed earlier in this section with regard to our packaging proposal for image processing services for CY 2008, we are concerned with establishing payment policies that could encourage certain inefficient and more costly service patterns, particularly for those services that do not need to be provided as a face-to-face encounter with the patient. If we were to assign CPT code 0175T to “special” packaged status, we would likely create an incentive for hospitals to perform chest x-ray CAD remotely, for example, several days after performance of the initial chest x-ray, rather than immediately following the chest x-ray on the same day, to enable the hospital to receive separate payment for the service. In CY 2005, there were approximately 7.3 million claims for all chest x-ray services in the HOPD, so a payment policy that could induce such changes in service delivery would be problematic in light of our commitment to encouraging the most efficient and cost-effective care for Medicare beneficiaries. Creating such perverse payment incentives through conditional packaging is a particular problem for those services that do not need a face-to-face encounter with the patient. In fact, as part of our proposed CY 2008 packaging approach, we are also proposing to unconditionally package payment in CY 2008 for several other image processing services that are not always performed face-to-face, including HCPCS code G0288 (Reconstruction, computer tomographic angiography of aorta for surgical planning for vascular surgery) and CPT code 76377 (3D rendering with interpretation and reporting of computed tomography, magnetic resource imaging, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation).

The proposed unconditionally packaged treatment of the two CPT codes for chest x-ray CAD is fully consistent with the proposed packaging approach for the CY 2008 OPPS, as discussed above, and the principles and incentives for efficiency inherent in a prospective payment system based on groups of services. Packaging these services creates incentives for providers to furnish services in the most cost-effective way and provides them with the most flexibility to manage their resources. As stated above, packaging encourages hospitals to establish protocols that ensure that services are furnished only when they are medically necessary and to carefully scrutinize the services ordered by practitioners to minimize unnecessary use of hospital resources. Therefore, we are proposing to continue to unconditionally package payment for CPT codes 0174T and 0175T for CY 2008.

Recommendation 4

For CY 2008, we are adopting the APC Panel's recommendation and proposing to add CPT code 0126T to the list of “special” packaged codes and assign this code to APC 0340 (Minor Ancillary Procedures).

This service describes an ultrasound procedure that measures common carotid intima-media thickness to evaluate a patient's degree of atherosclerosis. This code became effective January 1, 2006. We received a comment to the CY 2007 proposed rule requesting that this code become separately payable for CY 2007. At that point, we had no cost data for the service and, as discussed in the CY 2007 OPPS/ASC final rule with comment period (71 FR 67998), we reviewed this code with the Packaging Subcommittee, as is our standard procedure for codes that we are asked to review during the comment period. The APC Panel noted that this service could sometimes be provided to a patient without any other separately payable services. Therefore, the APC Panel recommended that we add this code to the list of “special” packaged codes and pay for it separately when it is provided without any other separately payable services on the same day. For circumstances when this code is paid separately, the APC Panel recommended that we consider assigning this code to APC 0340.

While we continue to believe that this procedure would not commonly be provided alone, we are adopting the APC Panel recommendation and are proposing to treat this code as a “special” packaged code subject to conditional packaging, mapping to APC 0340 for CY 2008 when it would be separately paid. This is fully consistent with the proposed packaging approach for the CY 2008 OPPS, as discussed above. Because CPT code 0126T is almost always performed during another procedure, and we are proposing to package payment for all intraoperative procedures for CY 2008, we believe it is appropriate to designate this CPT code as a “special” packaged code. We applied the updated criteria for determining whether this service should receive packaged or separate payment. Specifically, we determined that this service is usually a dependent service that is integral to an independent service, but that it could sometimes be provided without an independent service.

As with all “special” packaged codes, we will closely monitor cost data and frequency of separate payment for this procedure as soon as we have more claims data available.

Recommendation 5

For CY 2008, we are proposing to maintain the packaged status of CPT code 0069T, and we are not adopting the APC Panel's recommendation to designate this service as a “special” packaged code. This service uses signal processing technology to detect, interpret, and document acoustical activities of the heart through special sensors applied to a patient's chest. This code was a new Category III CPT code implemented in the CY 2005 OPPS. CPT code 0069T was an add-on code to an electrocardiography (EKG) service for CYs 2005 and 2006. However, effective January 1, 2007, the AMA changed the code descriptor to remove the add-on code designation for CPT code 0069T. This code has been packaged under the OPPS since CY 2005.

During the August 2005 APC Panel meeting, the APC Panel recommended packaging CPT code 0069T for CY 2005. In its March 2006 presentation to the APC Panel, a presenter requested that we pay separately for CPT code 0069T and assign it to APC 0099 (Electrocardiograms) based on its estimated cost and clinical characteristics. The presenter stated that Start Printed Page 42689the acoustic heart sound recording and analysis service may be provided with or without a separately reportable electrocardiogram. Members of the APC Panel engaged in extensive discussion of clinical scenarios as they considered whether CPT code 0069T could or could not be appropriately reported alone or in conjunction with several different procedure codes. Ultimately, the APC Panel recommended assigning this service to a separately payable status indicator. However, during the August 2006 meeting, the APC Panel further discussed CMS' proposal to package payment for CPT code 0069T for CY 2007 and considered the CY 2007 code descriptor change, finally recommending that CMS continue to package this code for CY 2007.

During the March 2007 APC Panel meeting, the same presenter requested that we pay separately for this service and assign it to APC 0096 (Non-Invasive Vascular Studies) or to APC 0097 (Cardiac and Ambulatory Blood Pressure Monitoring), with CY 2007 payment rates of $94.06 and $62.85, respectively. The presenter stated that the estimated true cost of this service lies between $62 and $94. The presenter clarified that this service is usually provided with an EKG, but noted that the test is sometimes provided without an EKG, according to its revised code descriptor for CY 2007. The presenter agreed that it would be rare for the acoustic heart sound procedure to be performed alone without any other separately payable OPPS services. The APC Panel recommended that we place CPT code on the list of “special” packaged codes and that we exclude APC 0096 as a potential placement for this CPT code.

Because this service does not fit into one of the seven identified categories of packaged codes proposed for the CY 2008 OPPS, we followed our historical packaging guidelines to determine whether to maintain the packaged status of this code or to pay for it separately. Based on the clinical uses that were described during the March 2007 and earlier APC Panel meetings, APC Panel discussions, and our claims data review, we continue to believe that it is highly unlikely that CPT code 0069T would be performed in the HOPD as a sole service without other separately payable OPPS services. In addition, our data indicate that this service is estimated to require only minimal hospital resources. Based on CY 2006 claims, we had only 8 single claims for CPT code 0069T, with a median line-item cost of $5.21, consistent with its low expected cost. Therefore, we believe that payment for CPT code 0069T is appropriately packaged because it would usually be closely linked to the performance of an EKG or other separately payable cardiac service, would rarely, if ever, be the only OPPS service provided to a patient in an encounter, and has a low estimated resource cost. The proposed packaged treatment of this code is consistent with the principles and incentives for efficiency inherent in a prospective payment system based on groups of services. Therefore, we are proposing to continue to package payment for CPT code 0069T for CY 2008.

Recommendation 6

For CY 2008, we are proposing to adopt the APC Panel's recommendation and maintain the packaged status of HCPCS code A4306. As requested by the APC Panel, we will also present to the APC Panel additional data on this system when available.

HCPCS code A4306 describes a disposable drug delivery system with a flow rate of less than 50 ml per hour. As discussed in a presentation at the March 2007 APC Panel meeting, there is a particular disposable drug delivery system that is specifically used to treat postoperative pain. Since the implementation of the OPPS, this code was assigned to status indicator “A,” indicating that it was payable according to another fee schedule, in this case, the Durable Medical Equipment (DME) fee schedule. There were discussions during CYs 2005 and 2006 between CMS and a manufacturer, and it was determined that this code should be removed from the DME fee schedule as this code does not describe DME. For CY 2007, HCPCS code A4306 is payable under the OPPS, with status indicator “N” indicating that its payment is unconditionally packaged.

One presenter to the APC Panel requested that we pay separately for this supply under the OPPS. For CY 2007, we packaged payment for this code because it is considered to be a supply, and since the inception of the OPPS the established payment policy packages payment for supplies because they are directly related and integral to an independent service furnished under the OPPS.

Our CY 2006 claims data indicate that HCPCS code A4306 was billed on OPPS claims 1,773 times, yielding a line-item median cost of approximately $3. The APC Panel and a presenter believe that this code may not always be appropriately billed by hospitals as the data also show that this code was billed together with computed tomography (CT) scans of the thorax, abdomen, and pelvis approximately 40 percent of the time that this supply was reported. The APC Panel speculated that this code may be currently reported when other types of drug delivery devices are utilized for nonsurgical procedures or for purposes other than the treatment of postoperative pain. Therefore, the APC Panel requested that we share additional data when available.

In summary, because HCPCS code A4306 represents a supply and payment of supplies is packaged under the OPPS according to longstanding policy, we are proposing to maintain the packaged status of HCPCS code A4306 for CY 2008.

Recommendation 7

For CY 2008, we are proposing to maintain the packaged status of CPT code 99186, consistent with the APC Panel's recommendation that we reevaluate the packaged OPPS payment for CPT code 99186 based on current research and the availability of new therapeutic modalities.

This service describes induced total body hypothermia that is performed on some post-cardiac arrest patients to avoid or lessen brain damage. The service has been packaged since the implementation of the OPPS. One presenter to the APC Panel at the March 2007 meeting requested that this code be assigned a separately payable status indicator under the OPPS. The presenter expressed concern that hospitals that provide this service and subsequently transfer the patient to another hospital prior to admission are not adequately paid for their services.

Because this service does not fit into one of the seven identified categories of packaged codes proposed for the CY 2008 OPPS, we followed our historical packaging guidelines to determine whether to maintain the packaged status of this code or to pay for it separately. Claims data indicate that this code was billed 39 times under the OPPS in CY 2006 and was never billed without another separately payable service on the same date. The proposed CY 2008 median cost for this code is $35, with individual costs ranging from $17 to $69, likely reflecting the costs associated with traditional methods of inducing total body hypothermia, such as ice packs applied to the body. In fact, the presenter noted that a technologically advanced total body hypothermia system costs $30,000, with an additional cost of $1,600 per disposable body suit. As expected, our claims data show that this service was provided most frequently with high level emergency department visits and critical care services. Start Printed Page 42690

We believe that the circumstances in which total body hypothermia would be provided to a Medicare beneficiary and billed under the OPPS are extremely rare, as patients requiring this therapy would almost always be admitted as inpatients if they survive. We believe that, in the uncommon situation where a patient presents to one hospital and then is cooled and transported to another hospital without admission to the first hospital, payment for the hypothermia service would be most appropriately packaged into payment for the many other separately payable services that it most likely accompanied and that would be paid to the first hospital under the OPPS.

In addition, consistent with the principles and incentives for efficiency inherent in a prospective payment system based on groups of services, packaging payment for this procedure that is highly integrated with other services provided in the hospital outpatient encounter creates incentives for providers to furnish services in the most cost-effective way. In situations where there are a variety of supplies that could be used to furnish a service, some of which are more expensive than others, packaging encourages hospitals to use the most cost-effective item that meets the patient's needs.

Recommendation 8

In response to the APC Panel's recommendation for the Packaging Subcommittee to remain active until the next APC meeting, we note that the APC Panel Packaging Subcommittee remains active, and additional issues and new data concerning the packaging status of codes will be shared for its consideration as information becomes available. We continue to encourage submission of common clinical scenarios involving currently packaged HCPCS codes to the Packaging Subcommittee for its ongoing review, and we also encourage recommendations of specific services or procedures whose payment would be most appropriately packaged under the OPPS. Additional detailed suggestions for the Packaging Subcommittee should be submitted to APCPanel@cms.hhs.gov, with “Packaging Subcommittee” in the subject line.

B. Proposed Payment for Partial Hospitalization

(If you choose to comment on issues in this section, please include the caption “OPPS: Partial Hospitalization” at the beginning of your comment.)

1. Background

Partial hospitalization is an intensive outpatient program of psychiatric services provided to patients as an alternative to inpatient psychiatric care for beneficiaries who have an acute mental illness. A partial hospitalization program (PHP) may be provided by a hospital to its outpatients or by a Medicare-certified community mental health center (CMHC). Section 1833(t)(1)(B)(i) of the Act provides the Secretary with the authority to designate the hospital outpatient services to be covered under the OPPS. The Medicare regulations at 42 CFR 419.21 that implement this provision specify that payments under the OPPS will be made for partial hospitalization services furnished by CMHCs as well as those furnished to hospital outpatients. Section 1833(t)(2)(C) of the Act requires that we establish relative payment weights based on median (or mean, at the election of the Secretary) hospital costs determined by 1996 claims data and data from the most recent available cost reports. Payment to providers under the OPPS for PHPs represents the provider's overhead costs associated with the program. Because a day of care is the unit that defines the structure and scheduling of partial hospitalization services, we established a per diem payment methodology for the PHP APC, effective for services furnished on or after August 1, 2000. For a detailed discussion, we refer readers to the April 7, 2000 OPPS final rule with comment period (65 FR 18452).

Historically, the median per diem cost for CMHCs greatly exceeded the median per diem cost for hospital-based PHPs and has fluctuated significantly from year to year, while the median per diem cost for hospital-based PHPs has remained relatively constant ($200-$225). We believe that CMHCs may have increased and decreased their charges in response to Medicare payment policies. As discussed in more detail in section II.B.2. of this proposed rule and in the CY 2004 OPPS final rule with comment period (68 FR 63470), we also believe that some CMHCs manipulated their charges in order to inappropriately receive outlier payments.

For CY 2005, the PHP per diem amount was based on 12 months of hospital and CMHC PHP claims data (for services furnished from January 1, 2003, through December 31, 2003). We used data from all hospital bills reporting condition code 41, which identifies the claim as partial hospitalization, and all bills from CMHCs because CMHCs are Medicare providers only for the purpose of providing partial hospitalization services. We used CCRs from the most recently available hospital and CMHC cost reports to convert each provider's line-item charges as reported on bills to estimate the provider's cost for a day of PHP services. Per diem costs were then computed by summing the line-item costs on each bill and dividing by the number of days on the bill.

In the CY 2005 OPPS update, the CMHC median per diem cost was $310, the hospital-based PHP median per diem cost was $215, and the combined CMHC and hospital-based median per diem cost was $289. We believed that the reduction in the CY 2005 CMHC median per diem cost compared to prior years indicated that the use of updated CCRs had accounted for the previous increase in CMHC charges and represented a more accurate estimate of CMHC per diem costs for PHP.

For the CY 2006 OPPS final rule with comment period, we analyzed 12 months of the most current claims data available for hospital and CMHC PHP services furnished between January 1, 2004, and December 31, 2004. We also used the most currently available CCRs to estimate costs. The median per diem cost for CMHCs dropped to $154, while the median per diem cost for hospital-based PHPs was $201. Based on the CY 2004 claims data, the average charge per day for CMHCs was $760, considerably greater than hospital-based per day costs but significantly lower than what it was in CY 2003 ($1,184). We believed that a combination of reduced charges and slightly lower CCRs for CMHCs resulted in a significant decline in the CMHC median per diem cost between CY 2003 and CY 2004.

Following the methodology used for the CY 2005 OPPS update, the CY 2006 OPPS updated combined hospital-based and CMHC median per diem cost was $161, a decrease of 44 percent compared to the CY 2005 combined median per diem amount.

As we were concerned that this amount may not cover the cost for PHPs, as stated in the CY 2006 OPPS final rule with comment period (70 FR 68548 and 68549), we applied a 15-percent reduction to the combined hospital-based and CMHC median per diem cost to establish the CY 2005 PHP APC. (We refer readers to the CY 2006 OPPS final rule with comment period for a full discussion of how we established the CY 2006 PHP rate (70 FR 68548).) We stated our belief that a reduction in the CY 2005 median per diem cost would strike an appropriate balance between using the best available data and providing adequate payment for a program that often spans 5-6 hours a Start Printed Page 42691day. We stated that 15 percent was an appropriate reduction because it recognized decreases in median per diem costs in both the hospital data and the CMHC data, and also reduced the risk of any adverse impact on access to these services that might result from a large single-year rate reduction. However, we adopted this policy as a transitional measure, and stated in the CY 2006 OPPS final rule with comment period that we would continue to monitor CMHC costs and charges for these services and work with CMHCs to improve their reporting so that payments can be calculated based on better empirical data, consistent with the approach we have used to calculate payments in other areas of the OPPS (70 FR 68548).

To apply this methodology for CY 2006, we reduced the CY 2005 combined unscaled hospital-based and CMHC median per diem cost of $289 by 15 percent, resulting in a combined median per diem cost of $245.65 for CY 2006.

For the CY 2007 final rule with comment period, we analyzed 12 months of more current data for hospital and CMHC PHP claims for services furnished between January 1, 2005, and December 31, 2005. We also used the most currently available CCRs to estimate costs. Using these updated data, we recreated the analysis performed for the CY 2007 proposed rule to determine if the significant factors we used in determining the proposed PHP rate had changed. The median per diem cost for CMHCs increased $8 to $173, while the median per diem cost for hospital-based PHPs decreased $19 to $190. The CY 2005 average charge per day for CMHCs was $675, similar to the figure noted in the CY 2007 proposed rule ($673) but still significantly lower than what was noted as the average charge for CY 2003 ($1,184).

The combined hospital-based and CMHC median per diem cost would have been $175 for CY 2007. Rather than allowing the PHP median per diem cost to drop to this level, we proposed to reduce the PHP median cost by 15 percent, similar to the methodology used for the CY 2006 update. However, after considering all public comments received concerning the proposed CY 2007 PHP per diem rate and results obtained using the more current data, we modified our proposal to continue using the 15 percent reduction methodology as the basis for calculating the combined hospital based and CMHC median per diem cost for CY 2007. Instead, we made a 5 percent reduction to the CY 2006 median per diem rate to provide a transitional path to the per diem cost indicated by the data. We believed that this approach accounted for the downward direction of the data and addressed concerns raised by commenters about the magnitude of another 15 percent reduction in 1 year. Thus, to calculate the CY 2007 APC PHP per diem cost, we reduced $245.65 (the CY 2005 combined hospital-based and CMHC median per diem cost of $289 reduced by 15 percent) by 5 percent, which resulted in a combined per diem cost of $233.37.

2. Proposed PHP APC Update

For the past 2 years, we were concerned that we did not have sufficient evidence to support using the median per diem cost produced by the most current year's PHP data. After extensive analysis, we now believe we have determined the appropriate level of cost for the type of day services that is being provided. This analysis included an examination of revenue-to-cost center mapping, refinements to the per diem methodology, and an in-depth analysis of the number of units of service per day.

In the CY 2006 and CY 2007 OPPS updates, the data have produced median costs that we believe were too low to cover the cost of a program that typically spans 5 to 6 hours per day. However, we continued to observe a clear downward trend in the data. We stated that if the data continue to reflect a low PHP per diem cost in CY 2008, we expect to continue the transition of decreasing the PHP median per diem cost to an amount that is more reflective of the data.

We received a comment on the CY 2007 proposed rates that CMS understated the PHP median cost by not using a hospital-specific CCR for partial hospitalization. In our response to this comment in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68000), we noted that, although most hospitals do not have a cost center for partial hospitalization, we used the CCR as specific to PHP as possible. The following CMS Web site contains the revenue-code-to-cost-center crosswalk: http://www.cms.hhs.gov/​HospitalOutpatientPPS/​03_​crosswalk.asp#TopOfPage.

This crosswalk indicates how charges on a claim are mapped to a cost center for the purpose of converting charges to cost. One or more cost centers are listed for most revenue codes that are used in the OPPS median calculations, starting with the most specific, and ending with the most general. Typically, we map the revenue code to the most specific cost center with a provider-specific CCR. However, if the hospital does not have a CCR for any of the listed cost centers, we consider the overall hospital CCR as the default. For partial hospitalization, the revenue center codes billed by PHPs are mapped to Primary Cost Center 3550 “Psychiatric/Psychological Services”. If that cost center is not available, they are mapped to the Secondary Cost Center 6000 “Clinic.” We use the overall facility CCR for CMHCs because PHPs are CMHCs' only Medicare cost, and CMHCs do not have the same cost structure as hospitals. Therefore, for CMHCs, we use the CCR from the outpatient provider-specific file.

Closer examination of the revenue-code-to-cost-center crosswalk revealed that 10 of the revenue center codes (shown in the table below) that are common among hospital based PHP claims did not map to a Primary Cost Center 3550 “Psychiatric/Psychological Services” or a Secondary Cost Center of 6000 “Clinic.”

Revenue center codeRevenue center description
0430Occupational Therapy.
0431Occupational Therapy: Visit charge.
0432Occupational Therapy: Hourly charge.
0433Occupational Therapy: Group rate.
0434Occupational Therapy: Evaluation/re-evaluation.
0439Occupational Therapy: Other occupational therapy.
0904Psychiatric/Psychological Treatment: Activity therapy.
0940Other Therapeutic Services.
0941Other Therapeutic Services: Recreation Rx.
0942Other Therapeutic Services: Education/training.

We believe these 10 revenue center codes did not map to either a Primary Cost Center 3550 “Psychiatric/Psychological Services” or a Secondary Cost Center 6000 “Clinic” because these codes may be used for services that are not PHP or psychiatric related. For example, many Occupational Therapy claims are not furnished to PHP patients and, therefore, should be appropriately mapped to a Primary Cost Center 5100 “Occupation Therapy” (the general Occupational Therapy Cost Center). Another example would be claims for Diabetes Education, which is also not furnished to PHP patients.

In order to more accurately estimate costs for PHP claims, for purposes of our analysis, we remapped these 10 revenue center codes to a Primary Cost Center 3550 “Psychiatric/Psychological Services” or a Secondary Cost Center 6000 “Clinic”. Once we remapped the Start Printed Page 42692codes, we computed an alternate cost for each line item of the CY 2006 hospital-based PHP claims. There are a total of 638,652 line items in the CY 2006 hospital-based PHP claims. Prior to remapping, there were 282,871 line items where a default CCR was used to estimate costs. After the remapping, there were 141,682 line items left defaulting to the hospitals' overall CCR. While this remapping creates a more accurate estimate of PHP per diem costs for a significant number of claims, there was not a large change in the resulting median per diem cost. The median per diem costs for hospital-based PHPs increased by $5.20 (from $191.80 to $197).

As part of our effort to produce the most accurate per diem cost estimate, we have reexamined our methodology for computing the PHP per diem cost. Section 1833(t)(2)(C) of the Act requires that we establish relative payment weights based on median (or mean, at the election of the Secretary) hospital costs determined by 1996 claims data and data from the most recent available cost reports. As explained in section II.B.1 of this proposed rule, payment to providers under OPPS for PHP services represents the provider's overhead costs associated with the program. Because a day of care is the unit that defines the structure and scheduling of partial hospitalization services, we established a per diem payment methodology for the PHP APC. Other than being a per diem payment, we use the general OPPS ratesetting methodology for determining median cost.

As we have described in prior Federal Register notices, our current method for computing per diem costs is as follows: we use data from all hospital bills reporting condition code 41, which identifies the claim as partial hospitalization, and all bills from CMHCs. We use CCRs from the most recently available hospital and CMHC cost reports to convert each provider's line-item charges as reported on bills to estimate the provider's cost for a day of PHP services. Per diem costs are then computed by summing the line-item costs on each bill and dividing by the number of days of PHP care provided on the bill. These computed per diem costs are arrayed from lowest to highest and the middle value of the array is the median per diem cost.

We have developed an alternate way to determine median cost by computing a separate per diem cost for each day rather than for each bill. Under this method, a cost is computed separately for each day of PHP care. When there are multiple days of care entered on a claim, a unique cost is computed for each day of care. All of these costs are then arrayed from lowest to highest and the middle value of the array would be the median per diem cost.

We believe this alternative method of computing a per diem median cost produces a more accurate estimate because each day gets an equal weight towards computing the median. We have considered this alternative method for several years, but in light of the volatility of the data, we have not believed it would provide a reasonable and appropriate median per diem cost. In light of the stabilizing trend in the data, and in light of the robustness of recent data analysis, we now believe it is appropriate to propose the adoption of this method. We believe this method for computing a PHP per diem median cost more accurately reflects the costs of a PHP and uses all available PHP data. Therefore, for CY 2008, we are proposing to adopt this alternate method for computing PHP median per diem costs.

As noted previously, for the past 2 years, the data have produced median costs that we believe were too low to cover the cost of a program that typically spans 5 to 6 hours per day. This length of day would include 5 or 6 services with a break for lunch. We looked at the number of units of service being provided in a day of care, as a possible explanation for the low per diem cost for PHP. Our analysis revealed that both hospital-based and CMHC PHPs have a significant number of days where less than 4 units of service were provided.

Specifically, 64 percent of the days that CMHCs were paid were for days where 3 or less units of services were provided, and 34 percent of the days that hospital-based PHPs were paid were for days where 3 or less units of service were provided. We believe these findings are significant because they may explain a lower per diem cost. Therefore, based on these findings, we computed median per diem costs in two categories:

(a) All days.

(b) Days with 4 units of service or more (removing days with 3 services or less).

These median per diem costs were computed separately for CMHCs and hospital based PHPs and are shown in the table below:

CMHCsHospital-based PHPs
All Days$178$186
Days with 4 units or more$191$218

As expected, excluding the low unit days resulted in a higher median per diem cost estimate. However, if the programs have many “low unit days,” their cost and Medicare payment should reflect this level of service. It would not be appropriate to set the PHP rate to exclude the “low unit days” because these days are covered PHP days. We believe the analysis of the number of units of service per day supports a lower per diem cost. Therefore, including all days supports the data trend towards a lower per diem cost and we believe more accurately reflects the costs of providing these PHP services.

Although the minimum number of PHP services required in a PHP day is three, it was never our intention that this represented the typical number of services to be provided in a typical PHP day. Our intention was to cover days that consisted of only three services, generally because a patient was transitioning towards discharge. Rather than set separate rates for half-days and full-days, we believed it was appropriate to set one rate that would be paid for all PHP days, including those for patients transitioning towards discharge. We intend that the PHP benefit is for a full day, with shorter days only occurring while a patient transitions out of the PHP.

However, as indicated in the data, many programs have these “low unit days,” and we believe their cost and Medicare payment should reflect this level of service. It would not be appropriate to set the PHP rate excluding the low unit days because these days are covered. Again, we believe the data support the estimated per diem cost under $200 that we have observed in the data.

At this time, we believe the most appropriate payment rate for PHPs is computed using both hospital-based and CMHC PHP data, including the remapped data for all days, resulting in a median per diem cost of $178. Therefore, we are proposing a CY 2008 APC PHP per diem cost of $178.

3. Proposed Separate Threshold for Outlier Payments to CMHCs

In the November 7, 2003 final rule with comment period (68 FR 63469), we indicated that, given the difference in PHP charges between hospitals and CMHCs, we did not believe it was appropriate to make outlier payments to CMHCs using the outlier percentage target amount and threshold established for hospitals. There was a significant difference in the amount of outlier payments made to hospitals and CMHCs for PHP. In addition, further analysis indicated that using the same OPPS Start Printed Page 42693outlier threshold for both hospitals and CMHCs did not limit outlier payments to high cost cases and resulted in excessive outlier payments to CMHCs. Therefore, beginning in CY 2004, we established a separate outlier threshold for CMHCs. For CYs 2004 and 2005, we designated a portion of the estimated 2.0 percent outlier target amount specifically for CMHCs, consistent with the percentage of projected payments to CMHCs under the OPPS in each of those years, excluding outlier payments. For CY 2006, we set the estimated outlier target at 1.0 percent and allocated a portion of that 1.0 percent, 0.6 percent (or 0.006 percent of total OPPS payments), to CMHCs for PHP services. For CY 2007, we set the estimated outlier target at 1.0 percent and allocated a portion of that 1.0 percent, an amount equal to 0.15 percent of outlier payments and 0.0015 percent of total OPPS payments to CMHCS for PHP service outliers. The CY 2007 CMHC outlier threshold is met when the cost of furnishing services by a CMHC exceeds 3.40 times the PHP APC payment amount. The CY 2007 OPPS outlier payment percentage is 50 percent of the amount of costs in excess of the threshold.

The separate outlier threshold for CMHCs became effective January 1, 2004, and has resulted in more commensurate outlier payments. In CY 2004, the separate outlier threshold for CMHCs resulted in $1.8 million in outlier payments to CMHCs. In CY 2005, the separate outlier threshold for CMHCs resulted in $0.5 million in outlier payments to CMHCs. In contrast, in CY 2003, more than $30 million was paid to CMHCs in outlier payments. We believe this difference in outlier payments indicates that the separate outlier threshold for CMHCs has been successful in keeping outlier payments to CMHCs in line with the percentage of OPPS payments made to CMHCs.

As noted in section II.G. of this proposed rule, for CY 2008, we are proposing to continue our policy of setting aside 1.0 percent of the aggregate total payments under the OPPS for outlier payments. We are proposing that a portion of that 1.0 percent, an amount equal to 0.03 percent of outlier payments and 0.0003 percent of total OPPS payments, would be allocated to CMHCs for PHP service outliers. As discussed in section II.G. of this proposed rule, we again are proposing to set a dollar threshold in addition to an APC multiplier threshold for OPPS outlier payments. However, because the PHP is the only APC for which CMHCs may receive payment under the OPPS, we would not expect to redirect outlier payments by imposing a dollar threshold. Therefore, we are not proposing to set a dollar threshold for CMHC outliers. As noted above, we are proposing to set the outlier threshold for CMHCs for CY 2008 at 3.40 times the APC payment amount and the CY 2008 outlier payment percentage applicable to costs in excess of the threshold at 50 percent.

C. Proposed Conversion Factor Update

(If you choose to comment on issues in this section, please include the caption “OPPS: Conversion Factor” at the beginning of your comment.)

Section 1833(t)(3)(C)(ii) of the Act requires us to update the conversion factor used to determine payment rates under the OPPS on an annual basis. Section 1833(t)(3)(C)(iv) of the Act provides that, for CY 2008, the update is equal to the hospital inpatient market basket percentage increase applicable to hospital discharges under section 1886(b)(3)(B)(iii) of the Act.

The proposed hospital market basket increase for FY 2008 published in the IPPS proposed rule on May 3, 2007, is 3.3 percent (72 FR 24835). To set the OPPS proposed conversion factor for CY 2008, we increased the CY 2007 conversion factor of $61.468, as specified in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68003), by 3.3 percent.

In accordance with section 1833(t)(9)(B) of the Act, we further adjusted the conversion factor for CY 2007 to ensure that the revisions that we are proposing to make to our updates for a revised wage index and rural adjustment are made on a budget neutral basis. We calculated an overall budget neutrality factor of 1.0025 for wage index changes by comparing total payments from our simulation model using the FY 2008 IPPS proposed wage index values to those payments using the current (FY 2007) IPPS wage index values. This adjustment reflects an adjustment of 1.0009 for changes to the wage index and an additional 1.0016 to accommodate the IPPS budget neutrality adjustment for inclusion of the rural floor. As discussed further in section II.D. of this proposed rule, for the first time, the proposed FY 2008 IPPS wage indices include a blanket budget neutrality adjustment for including the rural floor provision, which previously had been applied to the IPPS standardized amount. For further discussion of this proposed policy in its entirety, we refer readers to the FY 2008 IPPS proposed rule (72 FR 24787 through 24792). This proposed adjustment is specific to the IPPS. For the OPPS, we have increased the conversion factor by the proportional amount of the rural floor budget neutrality adjustment to accommodate this proposed change.

We estimated the rural adjustment for CY 2008 to reflect the proposed extension of the adjustment to payment for brachytherapy sources as discussed in section II.F.2. of this proposed rule, but as the impact of the proposed extension was negligible, we did not change the proposed rural adjustment. Therefore, we calculated a budget neutrality factor of 1.000 for the rural adjustment. For CY 2008, we estimate that allowed pass through spending for both drugs and devices would equal approximately $54 million, which represents 0.15 percent of total OPPS projected spending for CY 2008. The proposed conversion factor also is adjusted by the difference between the 0.21 percent pass through dollars set aside in CY 2007 and the 0.15 percent estimate for CY 2008 pass through spending. Finally, proposed payments for outliers remain at 1.0 percent of total payments for CY 2008.

The proposed market basket increase update factor of 3.3 percent for CY 2008, the required wage index and rural budget neutrality adjustment of approximately 1.0025, and the proposed adjustment of 0.06 percent for the difference in the pass-through set aside result in a proposed standard OPPS conversion factor for CY 2008 of $63.693.

D. Proposed Wage Index Changes

(If you choose to comment on issues in this section, please include the caption “OPPS: Wage Index” at the beginning of your comment.)

Section 1833(t)(2)(D) of the Act requires the Secretary to determine a wage adjustment factor to adjust, for geographic wage differences, the portion of the OPPS payment rate and the copayment standardized amount attributable to labor and labor related cost. Since the inception of the OPPS, CMS policy has been to wage adjust 60 percent of the OPPS payment, based on a regression analysis that determined that approximately 60 percent of the costs of services paid under the OPPS were attributable to wage costs. We confirmed that this labor related share for outpatient services is still appropriate during our regression analysis for the payment adjustment for rural hospitals in the CY 2006 OPPS final rule with comment period (70 FR 68553). We are not proposing to revise this policy for the CY 2008 OPPS. We refer readers to section II.H. of this proposed rule for a description and example of how the wage index for a Start Printed Page 42694particular hospital is used to determine the payment for the hospital. This adjustment must be made in a budget neutral manner. (As we have done in prior years, we are proposing to adopt the final IPPS wage indices for the OPPS and to extend these wage indices to hospitals that participate in the OPPS but not the IPPS (referred to in this section as “non IPPS” hospitals).)

As discussed in section II.A. of this proposed rule, we standardize 60 percent of estimated costs (labor-related costs) for geographic area wage variation using the IPPS pre-reclassified wage indices in order to remove the effects of differences in area wage levels in determining the national unadjusted OPPS payment rate and the copayment amount.

As published in the original OPPS April 7, 2000 final rule with comment period (65 FR 18545), OPPS has consistently adopted the final IPPS wage indices as the wage indices for adjusting the OPPS standard payment amounts for labor market differences. Thus, the wage index that applies to a particular hospital under the IPPS will also apply to that hospital under the OPPS. As initially explained in the September 8, 1998 OPPS proposed rule, we believed and continue to believe that using the IPPS wage index as the source of an adjustment factor for OPPS is reasonable and logical, given the inseparable, subordinate status of the hospital outpatient within the hospital overall. In accordance with section 1886(d)(3)(E) of the Act, the IPPS wage index is updated annually. In accordance with our established policy, we are proposing to use the final FY 2008 final version of these wage indices to determine the wage adjustments for the OPPS payment rate and copayment standardized amount that would be published in our final rule with comment period for CY 2008.

We note that the proposed FY 2008 IPPS wage indices continue to reflect a number of changes implemented over the past few years as a result of the revised Office of Management and Budget (OMB) standards for defining geographic statistical areas, the implementation of an occupational mix adjustment as part of the wage index, wage adjustments provided for under Pub. L. 105-33 and Pub. L. 108-173, and clarification of our policy for multicampus hospitals. The following is a brief summary of the components of the proposed FY 2008 IPPS wage indices and any adjustments that we are proposing to apply to the OPPS for CY 2008. We refer the reader to the FY 2008 IPPS proposed rule (72 FR 24776 through 24802) for a detailed discussion of the changes to the wage indices and to the correction notice to the FY 2008 IPPS proposed rule published in the Federal Register on June 7, 2007 (72 FR 31507). In this proposed rule, we are not reprinting the proposed FY 2008 IPPS wage indices referenced in the discussion below, with the exception of the out-migration wage adjustment table (Addendum L to this proposed rule). We also refer readers to the CMS Web site for the OPPS at http://www.cms.hhs.gov/​providers/​hopps. At this Web site, the reader will find a link to the proposed FY 2008 IPPS wage indices tables and to those tables as corrected in the correction notice to the FY 2008 IPPS proposed rule published in the Federal Register on June 7, 2007.

1. The proposed continued use of the Core Based Statistical Areas (CBSAs) issued by the OMB as revised standards for designating geographical statistical areas based on the 2000 Census data, to define labor market areas for hospitals for purposes of the IPPS wage index. The OMB revised standards were published in the Federal Register on December 27, 2000 (65 FR 82235), and OMB announced the new CBSAs on June 6, 2003, through an OMB bulletin. In the FY 2005 IPPS final rule, CMS adopted the new OMB definitions for wage index purposes. In the FY 2008 IPPS proposed rule, we again stated that hospitals located in Metropolitan Statistical Areas (MSAs) will be urban and hospitals that are located in Micropolitan Areas or outside CBSAs will be rural. We also reiterated our policy that when an MSA is divided into one or more Metropolitan Divisions, we use the Metropolitan Division for purposes of defining the boundaries of a particular labor market area. To help alleviate the decreased payments for previously urban hospitals that became rural under the new geographical definitions, we allowed these hospitals to maintain for the 3-year period from FY 2005 through FY 2007, the wage index of the MSA where they previously had been located. This hold harmless provision expires after FY 2007. We adopted the same policy for OPPS, but because the OPPS operates on a calendar year, wage index policies are in effect through December 31, 2007. To be consistent with the IPPS, as proposed in the FY 2008 IPPS proposed rule, beginning in CY 2008 (January 1, 2008) under the OPPS, these hospitals will receive their statewide rural wage index. Hospitals paid under the IPPS are eligible to apply for reclassification in FY 2008.

As noted above, for purposes of estimating an adjustment for the OPPS payment rates to accommodate geographic differences in labor costs in this proposed rule, we have used the wage indices identified in the FY 2008 IPPS proposed rule and as corrected in the June 7, 2007 correction notice to the FY 2008 IPPS proposed rule, that are fully adjusted for differences in occupational mix using the entire 6-month survey data collected in 2006.

2. The reclassifications of hospitals to geographic areas for purposes of the wage index. For purposes of the OPPS wage index, we are proposing to adopt all of the IPPS reclassifications for FY 2008, including reclassifications that the Medicare Geographic Classification Review Board (MGCRB) approved. We note that reclassifications under section 508 of Pub. L. 108-173 were set to terminate March 31, 2007. However, section 106(a) of the MIEA-TRHCA extended any geographic reclassifications of hospitals that were made under section 508 and that would expire on March 31, 2007 until September 30, 2007. On March 23, 2007, we published a notice in the Federal Register (72 FR 13799) that indicated how we are implementing section 106 of the MIEA-TRHCA through September 30, 2007. Because the section 508 provision will expire on September 30, 2007, the OPPS wage index will not include any reclassifications under section 508 for CY 2008.

3. The out-migration wage adjustment to the wage index. In the FY 2008 IPPS proposed rule (72 FR 24798 through 24799), we discussed the out-migration adjustment under section 505 of Pub. L. 108-173 for counties under this adjustment. Hospitals paid under the IPPS located in the qualifying section 505 “out-migration” counties receive a wage index increase unless they have already been otherwise reclassified. We note that in the FY 2008 IPPS proposed rule, we propose using the post-reclassified, rather than the pre-reclassified wage indices, in calculating the out-migration adjustment. (See the FY 2008 IPPS proposed rule for further information on the out-migration adjustment.) For OPPS purposes, we are proposing to continue our policy in CY 2008 to allow non IPPS hospitals paid under the OPPS to qualify for the out-migration adjustment if they are located in a section 505 out-migration county. Because non-IPPS hospitals cannot reclassify, they are eligible for the out migration wage adjustment. Table 4J published in the addendum to the FY 2008 IPPS proposed rule and as corrected in the June 7, 2007 correction notice to the FY 2008 IPPS proposed rule identifies counties eligible for the out-migration adjustment. As stated earlier, we are reprinting the corrected Start Printed Page 42695version of Table 4J in this proposed rule as Addendum L.

4. Wage Index for Multicampus Hospitals. We also wish to clarify that the IPPS policy for multicampus wage index payments also applies to OPPS. As a result of the new labor market areas introduced in FY 2005, there are hospitals with multiple campuses previously located in a single MSA that are now in more than one CBSA. A multicampus hospital is an integrated institution. For this reason, the multicampus hospital has one provider number and submits a single cost report that combines the total wages and hours of each of its campuses in the manner described in the FY 2008 IPPS proposed rule (72 FR 24783).

In the FY 2008 IPPS proposed rule, we proposed to apportion wages and hours across multiple campuses using full-time equivalent (FTE) staff data in order to include wage data for the individual campuses of a multicampus hospital in its local wage index calculation. To the extent that a multicampus hospital system has associated outpatient facilities, we would expect the FTEs for those outpatient facilities to be included in the FTE estimate for the closest inpatient facility. As part of this policy, we would fully expect that an OPD that is part of a multicampus hospital system would receive a wage index based on the geographic location of the inpatient campus with which it is associated. This would include cases where one inpatient campus reclassified. Affiliated outpatient facilities would receive the reclassified wage index of the inpatient campus. For further discussion of the FY 2008 IPPS proposed multicampus hospital policy in its entirety, we refer readers to the FY 2008 IPPS proposed rule (72 FR 24783 through 24784).

5. Rural Floor Provision. Section 4410 of Pub. L. 105-33 provides that the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas of the State (“the rural floor”). Table 4A in the FY 2008 IPPS proposed rule (72 FR 24924), as corrected in the June 7, 2007 correction notice (72 FR 31507), identifies urban areas where hospitals located in those areas are assigned the rural floor (noted by a superscript “2”). For CY 2008 under the OPPS, we are proposing to continue our policy to allow non-IPPS hospitals paid under the OPPS to receive the rural floor wage index when applicable under the IPPS for FY 2008. For the first time, the proposed FY 2008 IPPS wage indices include a blanket budget neutrality adjustment for including the rural floor provision, which previously had been applied to the IPPS standardized amount. For further discussion of this proposed policy in its entirety, we refer readers to the FY 2008 IPPS proposed rule (72 FR 24787 through 24792).

We note that all changes to the wage index resulting from geographic labor market area reclassifications or other adjustments must be incorporated in a budget neutral manner. Accordingly, in calculating the OPPS budget neutrality estimates for CY 2008, in this proposed rule, we have included the wage index changes that would result from the MGCRB reclassifications, implementation of sections 4410 of Pub. L. 105-33 and 505 of Pub. L. 108-173, and other refinements proposed in the FY 2008 IPPS proposed rule. For the CY 2008 OPPS final rule, we are proposing to use the final FY 2008 IPPS wage indices, including the budget neutrality adjustment for the rural floor for calculating OPPS payment in CY 2008. We discuss how the proposed OPPS conversion factor compensates for the inclusion of this budget neutrality adjustment in the wage indices in the budget neutrality section (II.C.) of this proposed rule.

E. Proposed Statewide Average Default CCRs

(If you choose to comment on issues in this section, please include the caption “OPPS: Statewide Cost-to Charge Ratios” at the beginning of your comment.)

CMS uses CCRs to determine outlier payments, payments for pass-through devices, and monthly interim transitional corridor payments under the OPPS. Some hospitals do not have a valid CCR. These hospitals include, but are not limited to, hospitals that are new and have not yet submitted a cost report, hospitals that have a CCR that falls outside predetermined floor and ceiling thresholds for a valid CCR, or hospitals that have recently given up their all-inclusive rate status. Last year, we updated the default urban and rural CCRs for CY 2007 in our final rule with comment period (71 FR 68006 through 68009). In this proposed rule, we are proposing to update the default ratios for CY 2008 using the most recent cost report data.

We calculated the statewide default CCRs using the same overall CCRs that we use to adjust charges to costs on claims data. Table 25 lists the proposed CY 2008 default urban and rural CCRs by State and compares them to last year's default CCRs. These CCRs are the ratio of total costs to total charges from each provider's most recently submitted cost report, for those cost centers relevant to outpatient services weighted by Medicare Part B charges. We also adjusted these ratios to reflect final settled status by applying the differential between settled to submitted costs and charges from the most recent pair of settled to submitted cost reports.

For this proposed rule, 78.17 percent of the submitted cost reports represented data for CY 2005. We only used valid CCRs to calculate these default ratios. That is, we removed the CCRs for all-inclusive hospitals, CAHs, and hospitals in Guam, and the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands because these entities are not paid under the OPPS, or in the case of all-inclusive hospitals, because their CCRs are suspect. We further identified and removed any obvious error CCRs and trimmed any outliers. We limited the hospitals used in the calculation of the default CCRs to those hospitals that billed for services under the OPPS during CY 2006.

Finally, we calculated an overall average CCR, weighted by a measure of volume for CY 2006, for each state except Maryland. This measure of volume is the total lines on claims and is the same one that we use in our impact tables. For Maryland, we used an overall weighted average CCR for all hospitals in the nation as a substitute for Maryland CCRs. Few providers in Maryland are eligible to receive payment under the OPPS, which limits the data available to calculate an accurate and representative CCR. The observed differences between last year's and this year's default statewide CCRs largely reflect a general decline in the ratio between costs and charges widely observed in the cost report data. However, observed increases in some areas suggest that the decline in CCRs is moderating. Further, the addition of weighting by Part B charges to the overall CCR in CY 2007 slightly increases the variability of the overall CCR calculation.

As stated above, CMS uses default statewide CCRs for several groups of hospitals, including, but not limited to, hospitals that are new and have not yet submitted a cost report, hospitals that have a CCR that falls outside predetermined floor and ceiling thresholds for a valid CCR, and hospitals that have recently given up their all-inclusive rate status. Current OPPS policy also requires hospitals that experience a change of ownership, but that do not accept assignment of the previous hospital's provider agreement, to use the previous provider's CCR. Start Printed Page 42696

For CY 2008, we are proposing to continue to apply this treatment of using the default statewide CCR, to include an entity that has not accepted assignment of an existing hospital's provider agreement in accordance with § 489.18, and that has not yet submitted its first Medicare cost report. This policy is effective for hospitals experiencing a change of ownership on or after January 1, 2007. As stated in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68006), we believe that a hospital that has not accepted assignment of an existing hospital's provider agreement is similar to a new hospital that will establish its own costs and charges. We also believe that the hospital that has chosen not to accept assignment may have different costs and charges than the existing hospital. Furthermore, we believe that the hospital should be provided time to establish its own costs and charges. Therefore, we are proposing to use the default statewide CCR to determine cost-based payments until the hospital has submitted its first Medicare cost report.

Table 25.—Proposed CY 2008 Statewide Average CCRs

StateRural/urbanProposed CY 2008 default CCRPrevious default CCR (CY 2007 OPPS final rule)
ALASKARURAL0.53890.5337
ALASKAURBAN0.38510.3830
ALABAMARURAL0.23170.2321
ALABAMAURBAN0.21980.2228
ARKANSASRURAL0.26600.2645
ARKANSASURBAN0.27760.2749
ARIZONARURAL0.27700.2823
ARIZONAURBAN0.23600.2323
CALIFORNIARURAL0.23050.2463
CALIFORNIAURBAN0.22600.2324
COLORADORURAL0.36770.3704
COLORADOURBAN0.25780.2672
CONNECTICUTRURAL0.38880.3886
CONNECTICUTURBAN0.34810.3491
DISTRICT OF COLUMBIAURBAN0.33640.3392
DELAWARERURAL0.31920.3230
DELAWAREURBAN0.39520.3953
FLORIDARURAL0.21750.2191
FLORIDAURBAN0.19850.1990
GEORGIARURAL0.28420.2846
GEORGIAURBAN0.27860.2888
HAWAIIRURAL0.37810.3574
HAWAIIURBAN0.31710.3199
IOWARURAL0.34990.3489
IOWAURBAN0.33790.3428
IDAHORURAL0.43690.4360
IDAHOURBAN0.40970.4159
ILLINOISRURAL0.29100.3082
ILLINOISURBAN0.28120.2878
INDIANARURAL0.32070.3160
INDIANAURBAN0.31550.3204
KANSASRURAL0.32010.3200
KANSASURBAN0.24660.2523
KENTUCKYRURAL0.24800.2508
KENTUCKYURBAN0.26660.2698
LOUISIANARURAL0.27270.2808
LOUISIANAURBAN0.28420.2730
MARYLANDRURAL0.29240.3181
MARYLANDURBAN0.31400.2978
MASSACHUSETTSURBAN0.34660.3487
MAINERURAL0.45800.4568
MAINEURBAN0.42610.4294
MICHIGANRURAL0.33540.3461
MICHIGANURBAN0.32720.3286
MINNESOTARURAL0.50940.5085
MINNESOTAURBAN0.34520.3383
MISSOURIRURAL0.29160.2944
MISSOURIURBAN0.29770.3034
MISSISSIPPIRURAL0.28200.2841
MISSISSIPPIURBAN0.23000.2312
MONTANARURAL0.46640.4392
MONTANAURBAN0.46460.4628
NORTH CAROLINARURAL0.30070.3048
NORTH CAROLINAURBAN0.35800.3700
NORTH DAKOTARURAL0.38310.3668
NORTH DAKOTAURBAN0.38420.3945
NEBRASKARURAL0.35610.3756
Start Printed Page 42697
NEBRASKAURBAN0.28320.2899
NEW HAMPSHIRERURAL0.36460.3700
NEW HAMPSHIREURBAN0.32170.3249
NEW JERSEYURBAN0.29080.2972
NEW MEXICORURAL0.27590.2741
NEW MEXICOURBAN0.36910.3978
NEVADARURAL0.33700.3348
NEVADAURBAN0.19490.2141
NEW YORKRURAL0.42100.4446
NEW YORKURBAN0.41770.4275
OHIORURAL0.36290.3689
OHIOURBAN0.27600.2834
OKLAHOMARURAL0.28740.2949
OKLAHOMAURBAN0.25170.2608
OREGONRURAL0.33440.3438
OREGONURBAN0.38990.4054
PENNSYLVANIARURAL0.29800.3052
PENNSYLVANIAURBAN0.24480.2524
PUERTO RICOURBAN0.47180.4689
RHODE ISLANDURBAN0.30850.3087
SOUTH CAROLINARURAL0.25890.2546
SOUTH CAROLINAURBAN0.25630.2479
SOUTH DAKOTARURAL0.35170.3479
SOUTH DAKOTAURBAN0.29180.3035
TENNESSEERURAL0.26070.2648
TENNESSEEURBAN0.25140.2491
TEXASRURAL0.28230.2891
TEXASURBAN0.24950.2580
UTAHRURAL0.43200.4410
UTAHURBAN0.42180.4161
VIRGINIARURAL0.27880.2821
VIRGINIAURBAN0.27890.2805
VERMONTRURAL0.43290.4325
VERMONTURBAN0.34010.3376
WASHINGTONRURAL0.37960.3742
WASHINGTONURBAN0.35740.3717
WISCONSINRURAL0.36330.3670
WISCONSINURBAN0.36480.3638
WEST VIRGINIARURAL0.31340.3162
WEST VIRGINIAURBAN0.36770.3691
WYOMINGRURAL0.46550.4714
WYOMINGURBAN0.35920.3520

F. Proposed OPPS Payments to Certain Rural Hospitals

1. Hold Harmless Transitional Payment Changes Made by Pub. L. 109-171 (DRA)

(If you choose to comment on issues in this section, please include the caption “Rural Hospital Hold Harmless Transitional Payments” at the beginning of your comment.)

When the OPPS was implemented, every provider was eligible to receive an additional payment adjustment (transitional corridor payment) if the payments it received for covered OPD services under the OPPS were less than the payments it would have received for the same services under the prior reasonable cost-based system. Section 1833(t)(7) of the Act provides that the transitional corridor payments are temporary payments for most providers, with two exceptions, to ease their transition from the prior reasonable cost-based payment system to the OPPS system. Cancer hospitals and children's hospitals receive the transitional corridor payments on a permanent basis. Section 1833(t)(7)(D)(i) of the Act originally provided for transitional corridor payments to rural hospitals with 100 or fewer beds for covered OPD services furnished before January 1, 2004. However, section 411 of Pub. L. 108-173 amended section 1833(t)(7)(D)(i) of the Act to extend these payments through December 31, 2005, for rural hospitals with 100 or fewer beds. Section 411 also extended the transitional corridor payments to SCHs located in rural areas for services furnished during the period that begins with the provider's first cost reporting period beginning on or after January 1, 2004, and ends on December 31, 2005. Accordingly, the authority for making transitional corridor payments under section 1833(t)(7)(D)(i) of the Act, as amended by section 411 of Pub. L. 108-173, expired for rural hospitals having 100 or fewer beds and SCHs located in rural areas on December 31, 2005.

Section 5105 of Pub. L. 109-171 reinstituted the hold harmless transitional outpatient payments (TOPs) for covered OPD services furnished on or after January 1, 2006, and before January 1, 2009, for rural hospitals having 100 or fewer beds that are not SCHs. When the OPPS payment is less than the payment the provider would have received under the previous Start Printed Page 42698reasonable cost-based system, the amount of payment is increased by 95 percent of the amount of the difference between those two payment systems for CY 2006, by 90 percent of the amount of that difference for CY 2007, and by 85 percent of the amount of that difference for CY 2008.

For CY 2006, we implemented section 5105 of Pub. L. 109-171 through Transmittal 877, issued on February 24, 2006. We did not specifically address whether TOPs payments apply to essential access community hospitals (EACHs), which are considered to be SCHs under section 1886(d)(5)(D)(iii)(III) of the Act. Accordingly, under the statute, EACHs are treated as SCHs. Therefore, we believe that EACHs are not currently eligible for TOPs payment under Pub. L. 109-171. In the CY 2007 OPPS/ASC final rule with comment period, we updated § 419.70(d) to reflect the requirements of Pub. L. 109 171 (71 FR 68010 and 68228).

2. Proposed Adjustment for Rural SCHs Implemented in CY 2006 Related to Public Law 108-173 (MMA)

(If you choose to comment on issues in this section, please include the caption “OPPS: Rural SCH Payments” at the beginning of your comment.)

In the CY 2006 OPPS final rule with comment period (70 FR 68556), we finalized a payment increase for rural SCHs of 7.1 percent for all services and procedures paid under the OPPS, excluding drugs, biologicals, brachytherapy seeds, and services paid under pass-through payment policy in accordance with section 1833(t)(13)(B) of the Act, as added by section 411 of Pub. L. 108 173. Section 411 gave the Secretary the authority to make an adjustment to OPPS payments for rural hospitals, effective January 1, 2006, if justified by a study of the difference in costs by APC between hospitals in rural and urban areas. Our analysis showed a difference in costs only for rural SCHs and we implemented a payment adjustment for those hospitals beginning January 1, 2006.

Last year, we became aware that we did not specifically address whether the adjustment applies to EACHs, which are considered to be SCHs under section 1886(d)(5)(D)(iii)(III) of the Act. Thus, under the statute, EACHs are treated as SCHs. Currently, fewer than 10 hospitals are classified as EACHs. As of CY 1998, under section 4201(c) of Pub. L. 105-33, a hospital can no longer become newly classified as an EACH. Therefore, in the CY 2007 OPPS/ASC final rule with comment period for purposes of receiving this rural adjustment, we revised § 419.43(g) to clarify that EACHs are also eligible to receive the rural SCH adjustment, assuming these entities otherwise meet the rural adjustment criteria (71 FR 68010 and 68227).

This adjustment is budget neutral and applied before calculating outliers and coinsurance. As stated in the CY 2006 OPPS final rule with comment period (70 FR 68560), we would not reestablish the adjustment amount on an annual basis, but we might review the adjustment in the future and, if appropriate, would revise the adjustment.

For CY 2008, we are proposing to continue our current policy of a budget neutral 7.1 percent payment increase for rural SCHs, including EACHs, for all services and procedures paid under the OPPS, excluding drugs, biologicals, and services paid under the pass-through payment policy in accordance with section 1833(t)(13)(B) of the Act. For CY 2008, we are proposing to include brachytherapy sources in the group of services eligible for the 7.1 percent payment increase because we are proposing to pay them at prospective rates based on their median costs as calculated from historical claims data. Consequently, we are proposing to revise § 419.43 to reflect our proposal to make brachytherapy sources eligible for the 7.1 percent payment increase for rural SCHs. We plan to reassess the 7.1 percent adjustment in the near future by examining differences between urban and rural costs using updated claims, cost, and provider information. In that process, we will include brachytherapy sources in each hospital's mix of services.

G. Proposed Hospital Outpatient Outlier Payments

(If you choose to comment on issues in this section, please include the caption “OPPS: Outlier Payments” at the beginning of your comment.)

Currently, the OPPS pays outlier payments on a service-by-service basis. For CY 2007, the outlier threshold is met when the cost of furnishing a service or procedure by a hospital exceeds 1.75 times the APC payment amount and exceeds the APC payment rate plus a $1,825 fixed-dollar threshold. We introduced a fixed-dollar threshold in CY 2005 in addition to the traditional multiple threshold in order to better target outliers to those high cost and complex procedures where a very costly service could present a hospital with significant financial loss. If a provider meets both of these conditions, the multiple threshold and the fixed-dollar threshold, the outlier payment is calculated as 50 percent of the amount by which the cost of furnishing the service exceeds 1.75 times the APC payment rate.

As explained in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68011 through 68012), we set our projected target for aggregate outlier payments at 1.0 percent of aggregate total payments under the OPPS for CY 2007. The outlier thresholds were set so that estimated CY 2007 aggregate outlier payments would equal 1.0 percent of aggregate total payments under the OPPS. In that final rule with comment period (71 FR 68010), we also published total outlier payments as a percent of total expenditures for CY 2005. In the past, we have received comments asking us to publish estimated outlier payments to provide a context for the proposed outlier thresholds for the update year. Our current estimate, using available CY 2006 claims, is that outlier payments for CY 2006 would be approximately 1.1 percent of total CY 2006 OPPS payment. Using the same set of claims and CY 2007 payment rates, we currently estimate that outlier payments for CY 2007 would be approximately 1.0 percent of total CY 2007 OPPS payments. We note that we provide estimated CY 2008 outlier payments by hospital for hospitals with claims included in the claims data that we used to model impacts on the CMS Web site in the Hospital Specific Impacts—Provider-Specific Data file on the CMS Web site at: http://www.cms.hhs.gov/​HospitalOutpatientPPS/​.

For CY 2008, we are proposing to continue our policy of setting aside 1.0 percent of aggregate total payments under the OPPS for outlier payments. We are proposing that a portion of that 1.0 percent, 0.03 percent, would be allocated to CMHCs for partial hospitalization program service outliers. This amount is the amount of estimated outlier payments resulting from the proposed CMHC outlier threshold of 3.4 times the APC payment rate, as a proportion of all payments dedicated to outlier payments. For further discussion of CMHC outliers, we refer readers to section II.B.3. of this proposed rule.

In order to ensure that estimated CY 2008 aggregate outlier payments would equal 1.0 percent of estimated aggregate total payments under the OPPS, we are proposing that the outlier threshold be set so that outlier payments would be triggered when the cost of furnishing a service or procedure by a hospital exceeds 1.75 times the APC payment amount and exceeds the APC payment rate plus a $2,000 fixed-dollar threshold. This proposed threshold reflects minor changes to the Start Printed Page 42699methodology discussed below as well as APC recalibration, including changes due in part to the CY 2008 packaging proposal discussed in section II.A.4. of this proposed rule.

We calculated the fixed-dollar threshold for this CY 2008 proposed rule using largely the same methodology as we did in CY 2007, except that we are proposing to adjust the overall CCRs to reflect the anticipated annual decline in overall CCRs, discussed below, and to use CCRs from the most recent update to the Outpatient Provider-Specific File (OPSF), rather than CCRs we calculate internally for ratesetting. In November 2006, we issued Transmittal 1030, “Policy Changes to the Fiscal Intermediary (FI) Calculation of Hospital Outpatient Payment System (OPPS) and Community Mental Health Center (CMHC) Cost-to-Charge Ratios (CCRs),” instructing fiscal intermediaries (or, if applicable, the MAC) to update the overall CCR calculation for outlier and other cost-based payments using the CCR calculation methodology that we finalized for CY 2007. As discussed in the CY 2007 proposed and final rules, this methodology aligned the fiscal intermediary's CCR calculation and the CCR calculation we previously used to model outlier thresholds by removing allied and nursing health costs for those hospitals with paramedical education programs from the fiscal intermediary's CCR calculation and weighting our “traditional” CCR calculation by total Medicare Part B charges. We believe that the OPSF best estimates the CCRs that fiscal intermediaries (or, if applicable, MAC) would use to determine outlier payments in CY 2008. For this proposed rule, we used the April update to the OPSF. We supplemented a CCR calculated internally for the handful of providers with claims in our claims dataset that were not listed in the April update to the OPSF.

The claims that we use to model each OPPS update lag by 2 years. For this proposed rule, we used CY 2006 claims to model the CY 2008 OPPS. In order to estimate CY 2008 outlier payments for this proposed rule, we inflated the charges on the CY 2006 claims using the same inflation factor of 1.1504 that we used to estimate the IPPS fixed dollar outlier threshold for the FY 2008 IPPS proposed rule. For 1 year, the inflation factor is 1.0726. The methodology for determining this charge inflation factor was discussed in the FY 2008 IPPS proposed rule (72 FR 24837). As we stated in the CY 2005 OPPS final rule with comment period, we believe that the use of this charge inflation factor is appropriate for the OPPS because, with the exception of the routine service cost centers, hospitals use the same cost centers to capture costs and charges across inpatient and outpatient services (69 FR 65845).

In comments on the CY 2007 OPPS/ASC proposed rule, a commenter asked that CMS modify the charge methodology used to set the OPPS outlier threshold to account for the change in CCRs over time in a manner similar to that used for the FY 2007 IPPS. The commenter indicated that it would be appropriate to apply an inflation adjustment factor so that the CCRs that CMS uses to simulate OPPS outlier payments would more closely reflect the CCRs that would be used in CY 2007 to determine actual outlier payment. In the CY 2007 OPPS/ASC final rule with comment period, we expressed concern that cost increases between inpatient and outpatient departments could be different and indicated that we would study the issue and address any changes to the outlier methodology through future rulemaking (71 FR 68012).

In assessing the possibility of utilizing a cost inflation adjustment for the OPPS, we determined that we could not calculate an OPPS-specific reliable cost per unit, comparable to the cost per discharge component of the IPPS calculation, because of variability in definition of an OPPS unit of service across calendar years. However, we also believe that the costs and charges reported under the applicable cost centers largely are commingled inpatient and outpatient costs and charges. Notwithstanding fairly accurate estimates of outlier payments as a percent of total payments over the past few years, as discussed above, we do not want to systematically overestimate the OPPS outlier threshold as could occur if we did not apply a CCR inflation adjustment factor. Therefore, we are proposing to apply the CCR inflation adjustment factor that is proposed to be applied for IPPS outlier calculation to the CCRs used to simulate the CY 2008 OPPS outlier payments that determine the fixed dollar threshold. Specifically, for CY 2008, we are proposing to apply an adjustment of 0.9912 to the CCRs that are currently on the OPSF to trend them forward from CY 2007 to CY 2008. The methodology for calculating this adjustment is discussed in the FY 2008 IPPS proposed rule (72 FR 24837).

Therefore, for this CY 2008 proposed rule, we applied the overall CCRs from the April 2007 OPSF file after adjustment to approximate CY 2008 CCRs (using the proposed CCR inflation adjustment factor of 0.9912) to charges on CY 2006 claims that were adjusted to approximate CY 2008 charges (using the proposed charge inflation factor of 1.1504). We simulated aggregated CY 2008 outlier payments using these costs for several different fixed-dollar thresholds, holding the 1.75 multiple constant and assuming that outlier payment would continue to be made at 50 percent of the amount by which the cost of furnishing the service would exceed 1.75 times the APC payment amount, until the total outlier payments equaled 1.0 percent of aggregated estimated total CY 2008 OPPS payments. We estimate that a proposed fixed dollar threshold of $2,000, combined with the proposed multiple threshold of 1.75 times the APC payment rate, would allocate 1.0 percent of aggregated total OPPS payments to outlier payments. We are proposing to continue to make an outlier payment that equals 50 percent of the amount by which the cost of furnishing the service exceeds 1.75 times the APC payment amount when both the 1.75 multiple threshold and the fixed dollar $2,000 threshold are met. For CMHCs, if a CMHC provider's cost for partial hospitalization exceeds 3.4 times the payment rate for APC 0033, the outlier payment is calculated as 50 percent of the amount by which the cost exceeds 3.4 times the APC payment rate.

H. Calculation of the Proposed National Unadjusted Medicare Payment

(If you choose to comment on issues in this section, please include the caption “OPPS: National Unadjusted Medicare Payment” at the beginning of your comment.)

The basic methodology for determining prospective payment rates for OPD services under the OPPS is set forth in existing regulations at § 419.31 and § 419.32. The payment rate for services and procedures for which payment is made under the OPPS is the product of the conversion factor calculated in accordance with section II.C. of this proposed rule and the relative weight determined under section II.A. of this proposed rule. Therefore, the national unadjusted payment rate for each APC contained in Addendum A to this proposed rule and for HCPCS codes to which payment under the OPPS has been assigned in Addendum B to this proposed rule (Addendum B is provided as a convenience for readers) was calculated by multiplying the proposed CY 2008 scaled weight for the APC by the proposed CY 2008 conversion factor.

However, to determine the payment that will be made in a calendar year under the OPPS to a specific hospital for Start Printed Page 42700an APC for a service that has a status indicator of “S,” “T,” “V,” or “X” in a circumstance in which the multiple procedure discount does not apply, we take the following steps:

Step 1. Calculate 60 percent (the labor-related portion) of the national unadjusted payment rate. Since the initial implementation of the OPPS, we have used 60 percent to represent our estimate of that portion of costs attributable, on average, to labor. (We refer readers to the April 7, 2000 final rule with comment period (65 FR 18496 through 18497) for a detailed discussion of how we derived this percentage.) We confirmed that this labor-related share for hospital outpatient services is still appropriate during our regression analysis for the payment adjustment for rural hospitals in the CY 2006 OPPS final rule with comment period (70 FR 68553).

Step 2. Determine the wage index area in which the hospital is located and identify the wage index level that applies to the specific hospital. The wage index values assigned to each area reflect the new geographic statistical areas as a result of revised OMB standards (urban and rural) to which hospitals are assigned for FY 2008 under the IPPS, reclassifications through the MCGRB, section 1886(d)(8)(B) “Lugar” hospitals, and section 401 of Pub. L. 108-173. We note that the reclassifications of hospitals under the one-time appeals process under section 508 of Pub. L. 108-173 expires on September 30, 2007, and is no longer applicable in this determination of appropriate wage values for CY 2008 OPPS. The wage index values include the occupational mix adjustment described in section II.D. of this proposed rule that was developed for the proposed FY 2008 IPPS payment rates published in the Federal Register on May 3, 2007 (72 FR 24777 through 27782).

Step 3. Adjust the wage index of hospitals located in certain qualifying counties that have a relatively high percentage of hospital employees who reside in the county, but who work in a different county with a higher wage index, in accordance with section 505 of Pub. L. 108-173. Addendum L to this proposed rule contains the qualifying counties and the proposed wage index increase developed for the FY 2008 IPPS as corrected in the June 7, 2007 correction notice to the FY 2008 IPPS proposed rule (72 FR 31507). This step is to be followed only if the hospital has chosen not to accept reclassification under Step 2 above.

Step 4. Multiply the applicable wage index determined under Steps 2 and 3 by the amount determined under Step 1 that represents the labor-related portion of the national unadjusted payment rate.

Step 5. Calculate 40 percent (the nonlabor-related portion) of the national unadjusted payment rate and add that amount to the resulting product of Step 4. The result is the wage index adjusted payment rate for the relevant wage index area.

Step 6. If a provider is a SCH, as defined in § 412.92, or an EACH, which is considered to be a SCH under section 1886(d)(5)(D)(iii)(III) of the Act, and located in a rural area, as defined in § 412.63(b), or is treated as being located in a rural area under § 412.103, multiply the wage index adjusted payment rate by 1.071 to calculate the total payment.

I. Proposed Beneficiary Copayments

(If you choose to comment on issues in this section, please include the caption “OPPS: Beneficiary Copayments” at the beginning of your comment.)

1. Background

Section 1833(t)(3)(B) of the Act requires the Secretary to set rules for determining copayment amounts to be paid by beneficiaries for covered OPD services. Section 1833(t)(8)(C)(ii) of the Act specifies that the Secretary must reduce the national unadjusted copayment amount for a covered OPD service (or group of such services) furnished in a year in a manner so that the effective copayment rate (determined on a national unadjusted basis) for that service in the year does not exceed specified percentages. For all services paid under the OPPS in CY 2008, and in calendar years thereafter, the specified percentage is 40 percent of the APC payment rate (section 1833(t)(8)(C)(ii)(V) of the Act). Section 1833(t)(3)(B)(ii) of the Act provides that, for a covered OPD service (or group of such services) furnished in a year, the national unadjusted coinsurance amount cannot be less than 20 percent of the OPD fee schedule amount. Sections 1834(d)(2)(C)(ii) and (d)(3)(C)(ii) of the Act further requires that the coinsurance for screening flexible sigmoidoscopies and screening colonoscopies be equal to 25 percent of the payment amount. We have applied the 25-percent coinsurance to screening flexible sigmoidoscopies and screening colonoscopies since the beginning of the OPPS.

2. Proposed Copayment

For CY 2008, we are proposing to determine copayment amounts for new and revised APCs using the same methodology that we implemented for CY 2004. (We refer readers to the November 7, 2003 OPPS final rule with comment period (68 FR 63458).) The proposed unadjusted copayment amounts for services payable under the OPPS that would be effective January 1, 2008, are shown in Addendum A and Addendum B to this proposed rule.

We note that we have historically used standard rounding principles to establish a 20 percent copayment for those few circumstances where the copayment rate was between 19.5 and 20 percent using our established copayment rules. For example, the CY 2008 proposed payment and copayment amounts for APC 9228 (Tigecycline injection) are $0.91 and $0.18, respectively. Twenty percent of $0.91 is $0.182. Because it would be impossible to set a copayment rate at exactly 20 percent in this case, that is, $0.182, we rounded the amount, using standard rounding principles, to $0.18. Also using standard rounding principles, 19.78 percent ($0.18 as a percentage of $0.91) rounds to 20 percent and meets the statutory requirement of a copayment amount of at least 20 percent. For CY 2008, APC 9046 (Iron Sucrose Injection) has a proposed payment amount and copayment amount of $0.37 and $0.08, respectively. Using our established copayment rules, 20 percent of $0.37 is $0.074. Normally, we would apply standard rounding principles to achieve an amount that is payable, here $0.07 rather than $0.074. However, if we were to set a copayment amount of $0.07, which is 18.9 percent of $0.37, we would not be setting a copayment rate that is at least 20 percent of the OPPS payment rate. We believe that section 1833(t)(3)(B) of the Act requires us to set a copayment amount that is at least 20 percent of the OPPS payment amount, not less than 20 percent. Therefore, we are proposing to set the copayment rate for APC 9046 at $0.08. Eight cents represents the lowest amount that we could set that would bring the copayment rate to 20 percent or, in this case, just above 20 percent. We are proposing to apply this same methodology in the future to instances where the application of our standard copayment methodology would result in a copayment amount that is under 20 percent and cannot be rounded, under standard rounding principles, to 20 percent.

3. Calculation of a Proposed Adjusted Copayment Amount for an APC Group

To calculate the OPPS adjusted copayment amount for an APC group, take the following steps:

Step 1. Calculate the beneficiary payment percentage for the APC by Start Printed Page 42701dividing the APC's national unadjusted copayment by its payment rate. For example, using APC 0001, $7.00 is 21 percent of $33.15.

Step 2. Calculate the wage adjusted payment rate for the APC, for the provider in question, as indicated in section II.H. of this proposed rule. Calculate the rural adjustment for eligible providers as indicated in section II.H. of this proposed rule.

Step 3. Multiply the percentage calculated in Step 1 by the payment rate calculated in Step 2. The result is the wage-adjusted copayment amount for the APC.

The proposed unadjusted copayments for services payable under the OPPS that would be effective January 1, 2008, are shown in Addendum A and Addendum B to this proposed rule.

III. Proposed OPPS Ambulatory Payment Classification (APC) Group Policies

A. Proposed Treatment of New HCPCS and CPT Codes

(If you choose to comment on issues in this section, please include the caption “OPPS: New HCPCS and CPT Codes” at the beginning of your comment.)

1. Proposed Treatment of New HCPCS Codes Included in the April and July Quarterly OPPS Updates for CY 2007

For the July quarter of CY 2007, we created a total of 16 new Level II HCPCS codes, specifically C2638, C2639, C2640, C2641, C2642, C2643, C2698, C2699, C9728, Q4087, Q4088, Q4089, Q4090, Q4091, Q4092, and Q4095 that were not addressed in the CY 2007 OPPS/ASC final rule with comment period that updated the CY 2007 OPPS. We designated the payment status of these codes and added them through the July 2007 update (Change Request 5623, Transmittal 1259, dated June 1, 2007). There were no new Level II HCPCS codes for the April 2007 update. In this CY 2008 OPPS/ASC proposed rule, we are soliciting public comment on the status indicators, APC assignments, and payment rates of these codes, which are listed in Table 26A and Table 26B of this proposed rule. Because of the timing of this proposed rule, the codes implemented through the July 2007 OPPS update are not included in Addendum B to this proposed rule. We are proposing to assign the new HCPCS codes for CY 2008 to the appropriate APCs with the proposed rates as displayed in the tables and incorporate them into our final rule with comment period for CY 2008, which is consistent with our annual APC updating policy.

Table 26A.—New Non-Drug HCPCS Codes Implemented in July 2007

HCPCS codeLong descriptorProposed CY 2008 status indicatorProposed CY 2008 APCProposed CY 2008 payment rateImplementation date
C2638Brachytherapy source, stranded, iodine-125, per sourceK2638$ 42.86July 1, 2007.
C2639Brachytherapy source, non-stranded, iodine-125, per sourceK263931.91July 1, 2007.
C2640Brachytherapy source, stranded, palladium-103, per sourceK264062.24July 1, 2007.
C2641Brachytherapy source, non-stranded, palladium-103, per sourceK264145.29July 1, 2007.
C2642Brachytherapy source, stranded, cesium-131, per sourceK264297.72July 1, 2007.
C2643Brachytherapy source, non stranded, cesium-131, per sourceK264351.35July 1, 2007.
C2698Brachytherapy source, stranded, not otherwise specified, per sourceK269842.86July 1, 2007.
C2699Brachytherapy source, non-stranded, not otherwise specified, per sourceK269929.93July 1, 2007.
C9728Placement of interstitial device(s) for radiation therapy/surgery guidance (eg, fiducial markers, dosimeter), other than prostate (any approach) single or multipleT0156194.91July 1, 2007.

Table 26B.—New Drug HCPCS Codes Implemented in July 2007

HCPCS codeLong descriptorProposed CY 2008 status indicatorProposed CY 2008 APCProposed CY 2008 payment rateImplementation date
Q4087Injection, immune globulin, (Octogam), intravenous, non-lyophilized, (e.g. liquid), 500 mgK0943$ 33.48July 1, 2007.
Q4088Injection, immune globulin, (Gammagard), intravenous, non-lyophilized, (e.g. liquid), 500 mgK094431.20July 1, 2007.
Q4089Injection, rho(d) immune globulin (human), (Rhophylac), intravenous, 100 iuK094580.00July 1, 2007.
Q4090Injection, hepatitis b immune globulin (Hepagam B), intramuscular, 0.5 mlK094664.74July 1, 2007.
Q4091Injection, immune globulin, (Flebogamma), intravenous, non-lyophilized, (e.g. liquid), 500 mgK094732.61July 1, 2007.
Q4092Injection, immune globulin, (Gamunex), intravenous, non-lyophilized, (e.g. liquid), 500 mgK094831.86July 1, 2007.
Q4095Injection, zoledronic acid (Reclast), 1 mgK0951220.81July 1, 2007.

2. Proposed Treatment of New Category I and III CPT Codes and Level II HCPCS Codes

As has been our practice in the past, we implement new Category I and III CPT codes and new Level II HCPCS codes, which are released in the summer through the fall of each year for annual updating, effective January 1, in the final rule updating the OPPS for the following calendar year. These codes are flagged with comment indicator “NI” in Addendum B to the OPPS/ASC final rule with comment period to indicate that we are assigning them an interim Start Printed Page 42702payment status which is subject to public comment following publication of the final rule that implements the annual OPPS update. (We refer readers to the discussion immediately below concerning our policy for implementing new Category I and III mid-year CPT codes.) We are proposing to continue this recognition and process for CY 2008. New Category I and III CPT codes and new Level II HCPCS codes, effective January 1, 2008, will be listed in Addendum B to the CY 2008 OPPS/ASC final rule with comment period and designated using comment indicator “NI.” The status indicator, the APC assignment, or both, for all such codes flagged with comment indicator “NI” will be open to public comment. We will respond to all comments received concerning these codes in a subsequent final rule.

In addition, we are proposing to continue our policy of the last 2 years of recognizing new mid-year CPT codes, generally Category III CPT codes, that the AMA releases in January for implementation the following July through the OPPS quarterly update process. Therefore, for CY 2008, we are proposing to include in Addendum B to the CY 2008 OPPS/ASC final rule with comment period the new Category III CPT codes released in January 2007 for implementation on July 1, 2007 (through the OPPS quarterly update process) and the new Category III codes released in July 2007 for implementation on January 1, 2008. However, only those new Category III CPT codes implemented effective January 1, 2008, will be flagged with comment indicator “NI” in Addendum B to the CY 2008 OPPS/ASC final rule with comment period, to indicate that we have assigned them an interim payment status which is subject to public comment. Category III CPT codes implemented in July 2007, which appear in Table 27 below, are subject to comment through this proposed rule, and their status will be finalized in the CY 2008 OPPS/ASC final rule with comment period.

Table 27.—Category III CPT Codes Implemented in July 2007

HCPCS codeLong descriptorProposed CY 2008 status indicatorProposed CY 2008 APC
0178TElectrocardiogram, 64 leads or greater, with graphic presentation and analysis; with interpretation and reportBNot applicable.
0179TElectrocardiogram, 64 leads or greater, with graphic presentation and analysis; tracing and graphics only, without interpretation and reportX0100.
0180TElectrocardiogram, 64 leads or greater, with graphic presentation and analysis; interpretation and report onlyBNot applicable.
0181TCorneal hysteresis determination, by air impulse stimulation, bilateral, with interpretation and reportS0230.
0182THigh dose rate electronic brachytherapy, per fractionS1519.

B. Proposed Changes—Variations Within APCs

(If you choose to comment on issues in this section, please include the caption “OPPS: 2 Times Rule” at the beginning of your comment.)

1. Background

Section 1833(t)(2)(A) of the Act requires the Secretary to develop a classification system for covered hospital outpatient services. Section 1833(t)(2)(B) of the Act provides that this classification system may be composed of groups of services, so that services within each group are comparable clinically and with respect to the use of resources. In accordance with these provisions, we developed a grouping classification system, referred to as APCs, as set forth in § 419.31 of the regulations. We use Level I and Level II HCPCS codes and descriptors to identify and group the services within each APC. The APCs are organized such that each group is homogeneous both clinically and in terms of resource use. Using this classification system, we have established distinct groups of similar services, as well as medical visits. We also have developed separate APC groups for certain medical devices, drugs, biologicals, radiopharmaceuticals, and brachytherapy devices.

We have packaged into payment for each procedure or service within an APC group the costs associated with those items or services that are directly related to and supportive of performing the main procedures or furnishing services. Therefore, we do not make separate payment for packaged items or services. For example, packaged items and services include: (1) Use of an operating, treatment, or procedure room; (2) use of a recovery room; (3) most observation services; (4) anesthesia; (5) medical/surgical supplies; (6) pharmaceuticals (other than those for which separate payment may be allowed under the provisions discussed in section V. of this proposed rule); and (7) incidental services such as venipuncture. Our proposed packaging approach for CY 2008 is discussed in section II.A.4. of this proposed rule.

Under the OPPS, we pay for hospital outpatient services on a rate-per-service or, as proposed for CY 2008, on a rate-per-encounter basis that varies according to the APC group to which the independent service or combination of services is assigned. Each APC weight represents the hospital median cost of the services included in that APC relative to the hospital median cost of the services included in APC 0606. The APC weights are scaled to APC 0606 because it is the middle level clinic visit APC (that is, where the Level 3 Clinic Visit HCPCS code of five levels of clinic visits is assigned), and because middle level clinic visits are among the most frequently furnished services in the hospital outpatient setting.

Section 1833(t)(9)(A) of the Act requires the Secretary to review the components of the OPPS not less than annually and to revise the groups and relative payment weights and make other adjustments to take into account changes in medical practice, changes in technology, and the addition of new services, new cost data, and other relevant information and factors. Section 1833(t)(9)(A) of the Act, as amended by section 201(h) of the BBRA of 1999, also requires the Secretary, beginning in CY 2001, to consult with an outside panel of experts to review the APC groups and the relative payment weights (the APC Panel recommendations for specific services for the CY 2008 OPPS and our responses to them are discussed in the relevant specific sections throughout this proposed rule). Start Printed Page 42703

Finally, as discussed earlier, section 1833(t)(2) of the Act provides that, subject to certain exceptions, the items and services within an APC group cannot be considered comparable with respect to the use of resources if the highest median (or mean cost, if elected by the Secretary) for an item or service in the group is more than 2 times greater than the lowest median cost for an item or service within the same group (referred to as the “2 times rule”). We use the median cost of the item or service in implementing this provision. The statute authorizes the Secretary to make exceptions to the 2 times rule in unusual cases, such as low-volume items and services.

2. Application of the 2 Times Rule

In accordance with section 1833(t)(2) of the Act and § 419.31 of the regulations, we annually review the items and services within an APC group to determine, with respect to comparability of the use of resources, if the median of the highest cost item or service within an APC group is more than 2 times greater than the median of the lowest cost item or service within that same group (“2 times rule”). We make exceptions to this limit on the variation of costs within each APC group in unusual cases such as low volume items and services.

During the APC Panel's March 2007 meeting, we presented median cost and utilization data for services furnished during the period of January 1, 2006, through September 30, 2006, about which we had concerns or about which the public had raised concerns regarding their APC assignments, status indicator assignments, or payment rates. The discussions of most service-specific issues, the APC Panel recommendations if any, and our proposals for CY 2008 are contained principally in sections III.C. and III.D. of this proposed rule.

In addition to the assignment of specific services to APCs that we discussed with the APC Panel, we also identified APCs with 2 times violations that were not specifically discussed with the APC Panel but for which we are proposing changes to their HCPCS codes' APC assignments in Addendum B to this proposed rule. In these cases, to eliminate a 2 times violation or to improve clinical and resource homogeneity, we are proposing to reassign the codes to APCs that contained services that were similar with regard to both their clinical and resource characteristics. We also are proposing to rename existing APCs, discontinue existing APCs, or create new clinical APCs to complement proposed HCPCS code reassignments. In many cases, the proposed HCPCS code reassignments and associated APC reconfigurations for CY 2008 included in this proposed rule are related to changes in median costs of services and APCs resulting from our proposed packaging approach for CY 2008, as discussed in section II.A.4. of this proposed rule. We also are proposing changes to the status indicators for some codes that are not specifically and separately discussed in this proposed rule. In these cases, we are proposing to change the status indicators for some codes because we believe that another status indicator more accurately describes their payment status from an OPPS perspective based on the policies that we are proposing for CY 2008.

Addendum B to this proposed rule identifies with a comment indicator “CH” those HCPCS codes for which we are proposing a change to the APC assignment or status indicator as assigned in the April 2007 Addendum B update.

3. Proposed Exceptions to the 2 Times Rule

As discussed earlier, we may make exceptions to the 2 times limit on the variation of costs within each APC group in unusual cases such as low volume items and services. Taking into account the APC changes that we are proposing for CY 2008 based on the APC Panel recommendations discussed mainly in sections III.C. and III.D. of this proposed rule, the proposed changes to status indicators and APC assignments as identified in Addendum B to this proposed rule, and the use of CY 2006 claims data to calculate the median costs of procedures classified in the APCs, we reviewed all the APCs to determine which APCs would not satisfy the 2 times rule. We used the following criteria to decide whether to propose exceptions to the 2 times rule for affected APCs:

  • Resource homogeneity.
  • Clinical homogeneity.
  • Hospital concentration.
  • Frequency of service (volume).
  • Opportunity for upcoding and code fragments.

For a detailed discussion of these criteria, we refer readers to the April 7, 2000 OPPS final rule with comment period (65 FR 18457).

Table 28 lists the APCs that we are proposing to exempt from the 2 times rule for CY 2008 based on the criteria cited above. For cases in which a recommendation by the APC Panel appeared to result in or allow a violation of the 2 times rule, we generally accepted the APC Panel's recommendation because those recommendations were based on explicit consideration of resource use, clinical homogeneity, hospital specialization, and the quality of the data used to determine the APC payment rates that we are proposing for CY 2008. The median costs for hospital outpatient services for these and all other APCs that were used in the development of this proposed rule can be found on the CMS Web site at: http://www.cms.hhs.gov.

Table 28.—Proposed APC Exceptions to the 2 Times Rule for CY 2008

APCAPC title
0033Partial Hospitalization.
0043Closed Treatment Fracture Finger/Toe/Trunk.
0060Manipulation Therapy.
0080Diagnostic Cardiac Catheterization.
0093Vascular Reconstruction/Fistula Repair without Device.
0105Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices.
0106Insertion/Replacement of Pacemaker Leads and/or Electrodes.
0109Removal/Repair of Implanted Devices.
0235Level I Posterior Segment Eye Procedures.
0251Level I ENT Procedures.
0260Level I Plain Film Except Teeth.
0278Diagnostic Urography.
0282Miscellaneous Computed Axial Tomography.
0303Treatment Device Construction.
0323Extended Individual Psychotherapy.
0330Dental Procedures.
0340Minor Ancillary Procedures.
0368Level II Pulmonary Tests.
0381Single Allergy Tests.
0409Red Blood Cell Tests.
0432Health and Behavior Services.
0438Level III Drug Administration.
0604Level 1 Hospital Clinic Visits.
0664Level I Proton Beam Radiation Therapy.
0688Revision/Removal of Neurostimulator Pulse Generator Receiver.

C. New Technology APCs

(If you choose to comment on issues in this section, please include the caption “New Technology APCs” at the beginning of your comment.)

1. Introduction

In the November 30, 2001 final rule (66 FR 59903), we finalized changes to the time period a service was eligible for payment under a New Technology APC. Beginning in CY 2002, we retain services within New Technology APC groups until we gather sufficient claims data to enable us to assign the service Start Printed Page 42704to a clinically appropriate APC. This policy allows us to move a service from a New Technology APC in less than 2 years if sufficient data are available. It also allows us to retain a service in a New Technology APC for more than 3 years if sufficient data upon which to base a decision for reassignment have not been collected.

We note that the cost bands for New Technology APCs range from $0 to $50 in increments of $10, from $50 to $100 in increments of $50, from $100 through $2,000 in increments of $100, and from $2,000 through $10,000 in increments of $500. These increments, which are in two parallel sets of New Technology APCs, one with status indicator “S” and the other with status indicator “T,” allow us to price new technology services more appropriately and consistently.

2. Proposed Movement of Procedures From New Technology APCs to Clinical APCs

As we explained in the November 30, 2001 final rule (66 FR 59897), we generally keep a procedure in the New Technology APC to which it is initially assigned until we have collected data sufficient to enable us to move the procedure to a clinically appropriate APC. However, in cases where we find that our original New Technology APC assignment was based on inaccurate or inadequate information, or where the New Technology APCs are restructured, we may, based on more recent resource utilization information (including claims data) or the availability of refined New Technology APC cost bands, reassign the procedure or service to a different New Technology APC that most appropriately reflects its cost.

At its March 2007 meeting, the APC Panel recommended that CMS keep services in New Technology APCs until sufficient data are available to assign them to clinical APCs, but for no longer than 2 years. We note that because of the potential for quarterly assignment of new services to New Technology APCs and the 2 year time lag in claims data for an OPPS update (that is, CY 2006 data are utilized for this CY 2008 OPPS rulemaking cycle), if we were to accept the APC Panel's recommendation, we would always reassign services from New Technology to clinical APCs based on 1 year or less of claims data. For example, if a new service was first assigned to a New Technology APC in July 2006, we would have 6 months of data for purposes of CY 2008 rulemaking but, in order to ensure that the service was in a New Technology APC for no longer than 2 years, we would need to move the service to a clinical APC for CY 2008. While we might have sufficient claims data from 6 months of CY 2006 to support a proposal for such a reassignment for CY 2008, we are not confident that this would always be the case for all new services, given our understanding of the dissemination of new technology procedures into medical practice and the diverse characteristics of new technology services that treat different clinical conditions. Therefore, we are not accepting the APC Panel's recommendation because we believe that accepting the recommendation would limit our ability to individually assess the OPPS treatment of each new technology service in the context of available hospital claims data. We are particularly concerned about continuing to provide appropriate payment for low volume new technology services that may be expected to continue to be low volume under the OPPS due to the prevalence of the target conditions in the Medicare population. We appreciate the APC Panel's thoughtful discussion of new technology services, and we agree with the APC Panel that it should be our priority to regularly reassign services from New Technology APCs to clinical APCs under the OPPS, so that they are treated like most other OPPS services for purposes of ratesetting once hospitals have had sufficient experience with providing and reporting the new services. Rather, consistent with our current policy, for CY 2008 we are proposing to retain services within New Technology APC groups until we gather sufficient claims data to enable us to assign the service to a clinically appropriate APC. The flexibility associated with this policy allows us to move a service from a New Technology APC in less than 2 years if sufficient data are available. It also allows us to retain a service in a New Technology APC for more than 2 years if sufficient hospital claims data upon which to base a decision for reassignment have not been collected.

The procedures presented below represent services assigned to New Technology APCs for CY 2007 for which we believe we have sufficient data to reassign them to clinically appropriate APCs for CY 2008. Therefore, we are proposing to reassign them to clinically appropriate APCs as indicated specifically in our discussion and in Table 29 of this proposed rule.

a. Positron Emission Tomography (PET)/Computed Tomography (CT) Scans (New Technology APC 1511)

(If you choose to comment on issues in this section, please include the caption “PET/CT Scans” at the beginning of your comment.)

From August 2000 through April 2005, we paid separately for PET and CT scans. In CY 2004, the payment rate for nonmyocardial PET scans was $1,450, while it was $193 for typical diagnostic CT scans. Prior to CY 2005, nonmyocardial PET and the PET portion of PET/CT scans were described by G-codes for billing to Medicare. Several commenters to the November 15, 2004 final rule with comment period (69 FR 65682) urged that we replace the G-codes for nonmyocardial PET and PET/CT scan procedures with the established CPT codes. These commenters stated that movement to the established CPT codes would greatly reduce the burden on hospitals of tracking and billing the G-codes which are not recognized by other payers and would allow for more uniform hospital billing of these scans. We agreed with the commenters that movement from the G-codes to the established CPT codes for nonmyocardial PET and PET/CT scans would allow for more uniform billing of these scans. As a result of a Medicare national coverage determination (Publication 100-3, Medicare Claims Processing Manual section 220.6) that was made effective January 28, 2005, we discontinued numerous G-codes that described myocardial PET and nonmyocardial PET procedures and replaced them with the established CPT codes. The CY 2005 payment rate for concurrent PET/CT scans using the CPT codes 78814 (Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; limited area (eg, chest, head/neck); 78815 (Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; skull base to mid-thigh); and 78816 Tumor imaging, positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization; whole body) was $1,250, which was $100 higher than the payment rate for PET scans alone. These PET/CT CPT codes were placed in New Technology APC 1514 (New Technology—Level XIV, $1,200-$1,300) for CY 2005.

We continued with these coding and payment methodologies in CY 2006. For CY 2007, while we proposed to reassign both PET and PET/CT Scans to the same new clinical APC, we finalized a policy that reassigned conventional PET procedures to APC 0308 (Non-Start Printed Page 42705Myocardial Positron Emission Tomography (PET) Imaging) with a final median cost of about $850. We also reassigned PET/CT services to a different New Technology APC for CY 2007, specifically New Technology APC 1511 (New Technology—Level XI, $900-$1000), thereby maintaining the historical payment differential of about $100 between PET and PET/CT procedures. Furthermore, we stated in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68022) that we would wait for a full year of CPT coded claims data prior to assigning the PET/CT services to a clinical APC and that maintaining a modest payment differential between PET and PET/CT procedures was warranted for CY 2007.

For CY 2008, we are proposing the reassignment of concurrent PET/CT scans, specifically CPT codes 78814, 78815, and 78816, to a clinical APC because we believe we have adequate claims data from CY 2006 upon which to determine the median cost of performing these procedures. Based on our analysis of approximately 117,000 CY 2006 single claims, the median cost of PET/CT scans is $1,093.52. In comparison, the median cost of the nonmyocardial PET scans, as described by CPT codes 78608, 78811, 78812, and 78813, is $1,093.51 based on our analysis of approximately 34,000 single claims from CY 2006. We note that a comparison of the median cost of PET/CT scans with the median cost of nonmyocardial PET scans, as derived from CY 2006 claims data, demonstrates that these costs are almost the same, thereby reflecting significant hospital resource equivalency between the two types of services. This result is not unexpected because many newer PET scanners also have the capability of rapidly acquiring CT images for attenuation correction and anatomical localization, sometimes with simultaneous image acquisition. The median costs for both PET and PET/CT scans are significantly higher for CY 2008 than for CY 2007 due to our CY 2008 proposal to package payment for all diagnostic radiopharmaceuticals as described in section II.A.4. of this proposed rule that would package payment for the costs of the radiopharmaceuticals utilized similarly into the payment for both PET and PET/CT scans. We believe that our claims data accurately reflect the comparable hospital resources required to provide nonmyocardial PET and PET/CT procedures, and the scans have obvious clinical similarity as well. Therefore, for CY 2008 we are proposing to reassign the CPT codes for PET/CT scans to the clinical APC where nonmyocardial PET scans are also assigned, specifically APC 0308, with a proposed median cost of $1,093.52.

We note that we have been paying separately for fluorodeoxyglucose (FDG), the radiopharmaceutical described by HCPCS code A9552 (F18 fdg), that is commonly administered during nonmyocardial PET and PET/CT procedures. For CY 2008, consistent with our proposed packaging approach as discussed in section II.A.4. of this proposed rule, we are proposing to package payment for the diagnostic radiopharmaceutical FDG into payment for the associated PET and PET/CT procedures. Because FDG is the most commonly used radiopharmaceutical for both PET and PET/CT scans and our single claims for these procedures include FDG more than 80 percent of the time, the packaging of this radiopharmaceutical fully maintains the clinical and resource homogeneity of the reconfigured APC 0308 that we are proposing.

b. IVIG Preadministration-Related Services (New Technology APC 1502)

(If you choose to comment on issues in this section, please include the caption “IVIG Preadministration-Related Services” at the beginning of your comment.)

In CY 2006, we created the temporary HCPCS G-code G0332 (Services for intravenous infusion of immunoglobulin prior to administration (this service is to be billed in conjunction with administration of immunoglobulin)). Based on our estimate of the costs of this service in comparison with other services, HCPCS code G0332 was assigned to New Technology APC 1502 (New Technology—Level II, $50-$100), with a payment rate of $75 effective January 1, 2006. In the CY 2007 OPPS/APC final rule with comment period, we indicated our belief that it was appropriate to continue the temporary IVIG preadministration-related services payment through HCPCS code G0332 and its continued assignment to New Technology APC 1502 for CY 2007, in order to help ensure continued patient access to IVIG (71 FR 68092).

For CY 2008, we are proposing to continue to provide separate payment for IVIG preadministration-related services through the assignment of HCPCS code G0332 to a clinical APC. This service has been assigned to a New Technology APC under the OPPS for 2 full years. As noted previously, under the OPPS, we retain services within New Technology APC groups where they are assigned according to our estimates of their costs until we gather sufficient claims data to enable us to assign the services to clinically appropriate APCs based on hospital resource costs as calculated from claims. According to our analysis of the hospital outpatient claims data, we believe we have adequate claims data from CY 2006 upon which to determine the median cost of performing IVIG preadministration related services and to reassign HCPCS code G0332 to an appropriate clinical APC for CY 2008. Our claims data for this high volume service show a total of over 49,000 services performed, with about 48,000 single claims available for ratesetting. The median cost of this service according to our claims data is $38.52. Therefore, we are proposing to reassign HCPCS code G0332 to new clinical APC 0430 (Drug Preadministration-Related Services) with a median cost of $38.52 for CY 2008, where it would be the only service assigned to the APC at this time.

We note that IVIG preadministration-related services are always provided in conjunction with other separately payable services such as drug administration services, and thus are well suited for packaging into the payment for the separately payable services. While at this time we have not made a determination about the appropriateness of continuing separate OPPS payment for HCPCS code G0332 after CY 2008, we would consider packaging payment for HCPCS code G0332 in future years if we determine separate payment is no longer warranted. We intend to reevaluate the appropriateness of separate payment for preadministration-related services for the CY 2009 OPPS rulemaking cycle, especially as we explore the potential for greater packaging and possible encounter-based or episode-based OPPS payment approaches.

c. Other Services in New Technology APCs

(If you choose to comment on issues in this section, please include the caption “Other Services in New Technology APCs” at the beginning of your comment.)

Other than the concurrent PET/CT and IVIG preadministration-related new technology services discussed in sections III.C.2.a. and III.C.2.b. of this proposed rule, there are five procedures currently assigned to New Technology APCs for CY 2007 for which we believe we also have data that are adequate to support their reassignment to clinical APCs. For CY 2008, we are proposing to reassign these procedures to clinically appropriate APCs, applying their CY 2006 claims data to develop their Start Printed Page 42706clinical APC median costs upon which payments would be based. These procedures and their proposed APC assignments are displayed in Table 29 below.

Table 29.—Proposed CY 2008 APC Reassignments of Other New Technology Procedures to Clinical APCs

HCPCS codeShort descriptorCY 2007 SICY 2007 APCCY 2007 APC payment rateProposed CY 2008 SIProposed CY 2008 APCProposed CY 2008 APC median cost
19298Place breast rad tube/cathsS1524$3,250T0648$3,416.66
G0302Pre-op service LVRS completeS1509750S0209727.48
G0303Pre-op service LVRS 10-15dosS1507550S0209727.48
G0304Pre-op service LVRS 1-9 dosS1504250S0213147.68
G0305Post op service LVRS min 6S1504250S0213147.68

D. Proposed APC-Specific Policies

1. Hyperbaric Oxygen Therapy (APC 0659)

(If you choose to comment on issues in this section, please include the caption “Hyperbaric Oxygen Therapy” at the beginning of your comment.)

When hyperbaric oxygen therapy (HBOT) is prescribed for promoting the healing of chronic wounds, it typically is prescribed for 90 minutes and billed using multiple units of HBOT on a single line or multiple occurrences of HBOT on a claim. In addition to the therapeutic time spent at full hyperbaric oxygen pressure, treatment involves additional time for achieving full pressure (descent), providing air breaks to prevent neurological and other complications from occurring during the course of treatment, and returning the patient to atmospheric pressure (ascent). The OPPS recognizes HCPCS code C1300 (Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval) for HBOT provided in the hospital outpatient setting.

In the CY 2005 final rule with comment period (69 FR 65758 through 65759), we finalized a “per unit” median cost calculation for APC 0659 (Hyperbaric Oxygen) using only claims with multiple units or multiple occurrences of HCPCS code C1300 because delivery of a typical HBOT service requires more than 30 minutes. We observed that claims with only a single occurrence of the code were anomalies, either because they reflected terminated sessions or because they were incorrectly coded with a single unit. In the same rule, we also established that HBOT would not generally be furnished with additional services that might be packaged under the standard OPPS APC median cost methodology. This enabled us to use claims with multiple units or multiple occurrences. Finally, we also used each hospital's overall CCR to estimate costs for HCPCS code C1300 from billed charges rather than the CCR for the respiratory therapy cost center. Comments on the CY 2005 proposed rule effectively demonstrated that hospitals report the costs and charges for HBOT in a wide variety of cost centers. We used this methodology to estimate payment for HBOT in CYs 2005, 2006, and 2007. For CY 2008, we are proposing to continue using the same methodology to estimate a “per unit” median cost for HCPCS code C1300 of $98.63 using 60,774 claims with multiple units or multiple occurrences.

CY 2008 is the fourth year in which we would have a special methodology to develop the median cost for HBOT services that removed obviously erroneous claims and deviated from our standard methodology of using departmental CCRs, when available, to convert hospitals' charges to costs. Prior to CY 2005, our inclusion of significant numbers of miscoded claims in the median calculation for HBOT and our exclusion of the claims for multiple units of treatment, the typical scenario, resulted in payment rates that were artificially elevated. As explained earlier, beginning in CY 2005 and continuing through the present, we have adjusted the CCR used in the conversion of charges to costs for these services so that claims data would more accurately reflect the relative costs of the services. The median costs of HBOT calculated using this methodology have been reasonably stable for the last 4 years. We believe that this adjustment through use of the hospitals' overall CCRs is all that is necessary to yield a valid median cost for establishing a scaled weight for HBOT services. Therefore, for CY 2008, we are proposing to continue to use the same methodology that we have used since CY 2005 to estimate payment for HBOT.

2. Skin Repair Procedures (APCs 0024, 0025, 0027, and 0686)

For CY 2006, the AMA made comprehensive changes, including code additions, deletions, and revisions, accompanied by new and revised introductory language, parenthetical notes, subheadings and cross-references, to the Integumentary, Repair (Closure) subsection of surgery in the CPT book to facilitate more accurate reporting of skin grafts, skin replacements, skin substitutes, and local wound care. In particular, the section of the CPT book previously titled “Free Skin Grafts” and containing codes for skin replacement and skin substitute procedures was renamed, reorganized, and expanded. New and existing CPT codes related to skin replacement surgery and skin substitutes were organized into five subsections: Surgical Preparation, Autograft/Tissue Cultured Autograft, Acellular Dermal Replacement, Allograft/Tissue Cultured Allogeneic Skin Substitute, and Xenograft.

As part of the CY 2006 CPT code update in the newly named “Skin Replacement Surgery and Skin Substitutes” section, certain codes were deleted that previously described skin allograft and tissue cultured and acellular skin substitute procedures, including CPT code 15342 (Application of bilaminate skin substitute/neodermis; 25 sq cm), CPT code 15343 (Application of bilaminate skin substitute/neodermis; each additional 25 sq cm), CPT code 15350 (Application of allograft, skin; 100 sq cm or less), and CPT code 15351 (Application of allograft, skin; each additional 100 sq cm). Thirty-seven new CPT codes were created in the “Skin Replacement Surgery and Skin Substitutes” section, and these codes received interim final status indicators and APC assignments in the CY 2006 OPPS final rule with comment period and were subject to comment.

In considering the final CY 2007 APC assignments of these 37 “Skin Start Printed Page 42707Replacement Surgery and Skin Repair” codes, we reviewed the recommendations made by the APC Panel at its March 2006 meeting; presentations made to the APC Panel; comments received on the CY 2007 proposed rule; the CPT code descriptors, introductory explanations, cross-references, and parenthetical notes; the clinical characteristics of the procedures; and the code-specific median costs for all related CPT codes available from our CY 2005 claims data. A discussion of the final CY 2007 APC assignments of these procedures can be found in the CY 2007 OPPS/ASC final rule with comment period (71 FR 68054 through 68057).

We now have CY 2006 data for the surgical procedures assigned to the 4 CY 2007 skin repair APCs, including the 37 codes considered last year that were new for CY 2006. These APCs are: APC 0024 (Level I Skin Repair); APC 0025 (Level II Skin Repair); APC 0686 (Level III Skin Repair); and APC 0027 (Level IV Skin Repair). Based on CY 2006 data available for this proposed rule, the median costs for the APCs as configured for CY 2007 are approximately: $93 for APC 0024; $251 for APC 0025; $1,027 for APC 0686; and $1,340 for APC 0027. Both APCs 0024 and 0025 have 2 times violations based on CY 2006 claims data. The HCPCS median costs of significant procedures in APC 0024 range from approximately $83 to $255. We note that a number of the procedures currently assigned to APC 0024 are very low volume, with few single claims available for ratesetting. Similarly, the median costs of the significant procedures in APC 0025 range from a low of $119 to a high of about $399. This APC also contains a number of low volume procedures, as well as some new CY 2007 CPT codes without CY 2006 claims data. There is also some variation in the median costs of the HCPCS codes assigned to APCs 0686 and 0027, but no 2 times violations in these two APCs.

At the March 2007 APC Panel meeting, we discussed with the APC Panel one possible reconfiguration of the skin repair APCs in order to address the 2 times violations in APCs 0024 and 0025 for CY 2008 by improving the resource homogeneity of the APCs, as well as ensuring their clinical homogeneity. We reviewed with the APC Panel the potential results associated with adding an additional level in this APC series and reallocating all of the procedures in the original four APCs among five new APCs, taking into account the frequency, resource utilization, and clinical characteristics of each procedure. We also gave particular attention to CPT code families in considering the clinical and resource homogeneity of each APC in the reconfigured series. The new configuration of APCs eliminates the 2 times violations that would otherwise exist in APCs 0024 and 0025. It also more accurately attributes higher cost procedures to the Levels IV and V APCs, which contain the surgical procedures of the greatest intensity and resource requirements, leading to a more balanced distribution of APC median costs across the five new APC levels.

The APC Panel made a recommendation at its March 2007 meeting supporting CMS' reorganization of the skin repair APCs into five levels. This recommendation also asked CMS to give special consideration to the APC assignments of “add-on” codes; in the context of skin procedures, these are generally those CPT codes that report treatment of an additional body area and that are reported along with a primary procedure for treatment of the first body area. We are accepting the APC Panel's recommendation through this CY 2008 proposal to reconfigure the skin APCs into five levels, and we have reexamined the placement of each of the add-on codes within the framework of the five APCs. We agree with the APC Panel that, because these skin repair APCs are assigned to status indicator “T” so that add-on codes would typically be paid at 50 percent of their APC payment rate, these add-on codes bear special examination with respect to their median costs and their appropriate APC assignments. As a result, several CPT code placements from the draft configuration discussed with the Panel were changed for this proposal.

In summary, for CY 2008 we are proposing to eliminate the four current skin repair APCs and replace them with five new APCs titled: APC 0133 (Level I Skin Repair); APC 0134 (Level II Skin Repair); APC 0135 (Level III Skin Repair); APC 0136 (Level IV Skin Repair); and APC 0137 (Level V Skin Repair). We are proposing to redistribute each of the procedures assigned to the current four levels of skin repair APCs into the five proposed APCs, with one exception. Specifically, we are proposing to reassign CPT code 15835 (Excision, excessive skin and subcutaneous tissue (including lipectomy); buttock) to APC 0022 (Level IV, Excision/Biopsy), where other CPT codes in its code family reside. The median costs of the five proposed APCs are $83.91 (APC 0133), $132.82 (APC 0134), $294.50 (APC 0135), $971.25 (APC 0136), and $1,316.85 (APC 0137). The proposed configurations of these new APCs are listed in Table 30 below.

Table 30—Proposed CY 2008 Skin Repair APC Configurations

HCPCS codeShort descriptorProposed CY 2008 APCProposed CY 2008 APC median cost
11950Therapy for contour defects0133$83.91
11951Therapy for contour defects.
11952Therapy for contour defects.
11954Therapy for contour defects.
12001Repair superficial wound(s).
12002Repair superficial wound(s).
12004Repair superficial wound(s).
12005Repair superficial wound(s).
12006Repair superficial wound(s).
12007Repair superficial wound(s).
12011Repair superficial wound(s).
12013Repair superficial wound(s).
12014Repair superficial wound(s).
12015Repair superficial wound(s).
12016Repair superficial wound(s).
12017Repair superficial wound(s).
12018Repair superficial wound(s).
Start Printed Page 42708
12031Layer closure of wound(s).
12041Layer closure of wound(s).
12051Layer closure of wound(s).
12052Layer closure of wound(s).
12053Layer closure of wound(s).
15775Hair transplant punch grafts.
15776Hair transplant punch grafts.
11760Repair of nail bed0134$132.82
11920Correct skin color defects.
11921Correct skin color defects.
11922Correct skin color defects.
12032Layer closure of wound(s).
12034Layer closure of wound(s).
12035Layer closure of wound(s).
12036Layer closure of wound(s).
12037Layer closure of wound(s).
12042Layer closure of wound(s).
12044Layer closure of wound(s).
12045Layer closure of wound(s).
12046Layer closure of wound(s).
12047Layer closure of wound(s).
12054Layer closure of wound(s).
12055Layer closure of wound(s).
12056Layer closure of wound(s).
12057Layer closure of wound(s).
13120Repair of wound or lesion.
13122Repair wound/lesion add-on.
13153Repair wound/lesion add-on.
15040Harvest cultured skin graft.
15170Acell graft trunk/arms/legs.
15171Acell graft t/arm/leg add-on.
15340Apply cult skin substitute.
15341Apply cult skin sub add-on.
15360Apply cult derm sub, t/a/l.
15361Aply cult derm sub t/a/l add.
15365Apply cult derm sub f/n/hf/g.
15366Apply cult derm f/hf/g add.
15819Plastic surgery, neck.
12020Closure of split wound0135$294.50
12021Closure of split wound.
13100Repair of wound or lesion.
13101Repair of wound or lesion.
13102Repair wound/lesion add-on.
13121Repair of wound or lesion.
13131Repair of wound or lesion.
13132Repair of wound or lesion.
13133Repair wound/lesion add-on.
13150Repair of wound or lesion.
13151Repair of wound or lesion.
13152Repair of wound or lesion.
15000Wound prep, 1st 100 sq cm.
15001Wound prep, addl 100 sq cm.
15002Wnd prep, ch/inf, trk/arm/lg.
15003Wnd prep, ch/inf addl 100 cm.
15004Wnd prep ch/inf, f/n/hf/g.
15005Wnd prep, f/n/hf/g, addl cm.
15050Skin pinch graft.
15110Epidrm autogrft trnk/arm/leg.
15111Epidrm autogrft t/a/l add-on.
15115Epidrm a-grft face/nck/hf/g.
15116Epidrm a-grft f/n/hf/g addl.
15150Cult epiderm grft t/arm/leg.
15151Cult epiderm grft t/a/l addl.
15152Cult epiderm graft t/a/l +%.
15155Cult epiderm graft, f/n/hf/g.
15156Cult epidrm grft f/n/hfg add.
15157Cult epiderm grft f/n/hfg +%.
15175Acellular graft, f/n/hf/g.
15176Acell graft, f/n/hf/g add-on.