Final Rule with Comment Period on Medicare OPPS - Ropes & Gray

Federal Register / Vol. 76, No. 230 / Wednesday, November 30, 2011 / <strong>Rule</strong>s and Regulations74149this final rule <strong>with</strong> comment period formore information on these paymentmethodologies. For all OPPS services,we continue our efforts to use the datafrom as many claims as possible,through approaches such as use of thebypass list and date splitting of claimsas described further in section II.A. ofthis final rule <strong>with</strong> comment period,and through methodologies such asincreased packaging and compositeAPCs.As we have stated in the past (73 FR68535 through 68536 and 74 FR 60367),we agree that accurate reporting ofdevice, supply, and technology chargeswill help to ensure that these items areappropriately accounted for in futureyears’ OPPS payment rates. Weencourage stakeholders to carefullyreview HCPCS code descriptors, as wellas any guidance CMS may haveprovided for specific HCPCS codes. Inaddition, we have provided furtherinstructions on the billing of medicaland surgical supplies in the October2008 OPPS update (Transmittal 1599,Change Request 6196, dated September19, 2008) and the April 2009 OPPSupdate (Transmittal 1702, ChangeRequest 6416, dated March 13, 2009).For HCPCS codes that are paid underthe OPPS, providers may also submitinquiries to the AHA Central Office onHCPCS, which serves as a clearinghouseon the proper use of Level I HCPCScodes for hospitals and certain Level IIHCPCS codes for hospitals, physicians,and other health professionals. Inquiriesmust be submitted using the approvedform, which may be downloaded fromthe AHA Web site (http://www.ahacentraloffice.org) and eitherfaxed to (312) 422–4583 or maileddirectly to the AHA Central Office:Central Office on HCPCS, AmericanHospital Association, One NorthFranklin, Floor 29, Chicago, IL 60606.<strong>Comment</strong>: Some commentersconcurred <strong>with</strong> CMS’ proposeddetermination that APC 0385 (Level IProsthetic Urological Procedures) andAPC 0386 (Level II Prosthetic UrologicalProcedures) should be categorized asdevice-dependent APCs. Othercommenters expressed appreciation forthe proposed increase in payment forAPC 0425 (Level II Arthroplasty orImplantation <strong>with</strong> Prosthesis).Response: We appreciate thecommenters’ support of the designationof APC 0385 and APC 0386 as devicedependentAPCs and the proposedpayment increase for APC 0425.<strong>Comment</strong>: Several commentersexpressed concern that the proposed CY2012 payment rate for the implantationof cochlear implants, described by CPTcode 69930 (cochlear deviceimplantation, <strong>with</strong> or <strong>with</strong>outmastoidectomy) which is assigned toAPC 0259 (Level VII ENT Procedures),decreased by approximately 12 percentfrom that in the CY 2011 OPPS/ASCfinal rule <strong>with</strong> comment period.According to commenters, this paymentrate is inconsistent <strong>with</strong> the averagedecrease in proposed payment of allOPPS APCs relative to CY 2011 ofapproximately 6 percent and isinsufficient to cover hospitals’ costs forproviding this service and ensure thatbeneficiaries will continue to haveaccess to cochlear implants. Thecommenters observed, based on theiranalysis of Medicare claims data, thatwhile the overall median cost of APC0259 decreased, the component parts ofthe APC (that is, the device, theprocedure, and the other bundledsupplies and services) either remainedthe same or increased. The commentersrequested that CMS evaluate the dataupon which the proposed CY 2012payment rate for APC 0259 is based inorder to ensure its validity.Response: We appreciate thecommenters’ concerns regarding theproposed payment rate for proceduresinvolving cochlear implants. Under thestandard device-dependent APCratesetting methodology, the mediancost for APC 0259 is calculated usingonly those single bills that reflect thefull cost of the cochlear implant device.While we will monitor the changes inAPC 0259 over time, we believe that thepayment rate for this service, calculatedaccording to the standard devicedependentAPC ratesetting methodologyfor the proposed rule and this final rule<strong>with</strong> comment period, appropriatelyreflects hospitals’ relative costs forproviding this procedure as reported tous in the claims and cost report data.We note that the median cost for CPTcode 69930 calculated from the CY 2010hospital claims and cost report dataavailable for this final rule <strong>with</strong>comment is $28,892, approximately 6percent less than the median cost of$30,730 calculated from the CY 2009hospital claims and cost report dataupon which the final CY 2011 paymentrate was calculated.After consideration of the publiccomments we received, we arefinalizing our proposed CY 2012payment policies for device-dependentAPCs <strong>with</strong> modification. The CY 2012OPPS payment rates for devicedependentAPCs are based on theirmedian costs calculated from CY 2010claims and the most recent cost reportdata, using only single procedure claimsthat pass the procedure-to-device anddevice-to-procedure edits, do notcontain token charges for devices (lessthan $1.01), do not have an ‘‘FB’’modifier signifying that the device wasfurnished <strong>with</strong>out cost or <strong>with</strong> fullcredit, and do not contain an ‘‘FC’’modifier signifying that the hospitalreceived partial credit for the device.We continue to believe that the mediancosts calculated from the single claimsthat meet these criteria represent themost valid estimated relative costs ofthese services to hospitals when theyincur the full cost of the devicesrequired to perform the procedures.Table 3 below lists the APCs forwhich we used our standard devicedependentAPC ratesetting methodologyfor CY 2012. We note that we are notfinalizing our proposal to limit thepayment for services that are assigned toAPC 0108 to the IPPS standardizedpayment amount for MS–DRG 227, andthat we are continuing to apply thedevice edits and other standard featuresof the device-dependent APCs to thisAPC for CY 2012. We also are deletingAPC 0418 and changing the titles ofAPC 0108 and 0655 as we proposed. Werefer readers to section II.A.2.e.(6) ofthis final rule <strong>with</strong> comment period fora detailed discussion of these finalpolicies. We also note that we arerevising the APC titles for APC 0083,0229, and 0319 for CY 2012, as wediscuss in section II.A.2.d.(6) of thisfinal rule <strong>with</strong> comment period and thatwe are changing the APC titles for APC0040 and APC 0061 as discussed insection III.D.4.a. of this final rule <strong>with</strong>comment period. We refer readers toAddendum A to this final rule <strong>with</strong>comment period (which is available viathe Internet on the CMS Web site) forthe final payment rates for these APCsfor CY 2012.BILLING CODE 4120–01–Pjlentini on DSK4TPTVN1PROD <strong>with</strong> RULES2VerDate Mar2010 17:08 Nov 29, 2011 Jkt 226001 PO 00000 Frm 00029 Fmt 4701 Sfmt 4700 E:\FR\FM\30NOR2.SGM 30NOR2