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

74178 Federal Register / Vol. 76, No. 230 / Wednesday, November 30, 2011 / <strong>Rule</strong>s and Regulationsjlentini on DSK4TPTVN1PROD <strong>with</strong> RULES2together. While the other combinationsof CRT procedures listed in Table 10may also be performed together, we didnot propose to implement compositeAPCs for these services because of thelow frequency <strong>with</strong> which CPT code33225 was reported in the claims datain combination <strong>with</strong> other CPT codesthat describe the insertion of an ICD anda pacemaker. As we have statedpreviously (74 FR 60392), because of thecomplex claims processing andratesetting logic involved, in the past,we have explored composite APCs onlyfor combinations of services that arecommonly performed together. Becauseof the low frequency of the othercombinations of CRT procedures listedin Table 10 above, we did not considerthem to be commonly performedtogether.Under the authority of section1833(t)(2)(E) of the Act, we alsoproposed to cap the payment rate forcomposite APC 8009 at the mostcomparable Medicare-severitydiagnosis-related group (MS–DRG)payment rate established under the IPPSthat would be provided to acute carehospitals for providing CRT–D servicesto hospital inpatients. Specifically, weproposed a payment rate for APC 8009as the lesser of the APC 8009 mediancost or the IPPS payment rate for MS–DRG 227 (Cardiac Defibrillator Implant<strong>with</strong>out Cardiac Catheterization <strong>with</strong>outMajor Complication or Comorbidity), asadopted in the FY 2012 IPPS/LTCH PPSfinal rule. We stated that we wouldestablish the OPPS payment amount asthe FY 2012 IPPS standardized paymentamount for MS–DRG 227 under thisproposal. In the FY 2012 IPPS/LTCHproposed rule, this amount was$26,364.93. We calculated thestandardized payment rate for MS–DRG227 ($26,364.93) by multiplying thenormalized weight from Table 5 of theFY 2012 IPPS/LTCH proposed rule(5.1370) by the sum of the non-labor andlabor-related shares of the proposed FY2012 IPPS operating standardizedamount (nonwage-adjusted) ($5,132.36),which were obtained from Table 1B ofthe FY 2012 IPPS/LTCH proposed rule.For further detail on the calculation ofthe IPPS proposed FY 2012 paymentsrates, we refer readers to the FY 2012IPPS/LTCH PPS proposed rule (76 FR26028 through 26029).We stated that we consider thestandardized payment rate for MS–DRG227 to represent appropriate paymentfor a comparable package of servicesfurnished to outpatients. We also statedthat we believe that, because this MS–DRG includes defibrillator implantationfor those inpatients <strong>with</strong>out majorcomplications or comorbidities, itrepresents the payment made forhospital inpatients who are most similarto patients who would receive CRT–Dservices on an outpatient basis becausehospital outpatients are generally lesssick than hospital inpatients andbecause patients who havecomplications or comorbitities would bemost likely to be admitted to inpatientstatus to receive CRT–D services.Similar to the proposed payment rate forcomposite APC 8009, the proposedpayment rate for MS–DRG 227 includedthe device costs associated <strong>with</strong> CRT–Dservices, along <strong>with</strong> the service costsassociated <strong>with</strong> CPT codes 33225 and33249, which are the procedures thatare reported for implanting thosedevices. We stated that we believe thatwe should not pay more for theseservices under the proposed OPPScomposite APC payment than under theIPPS because the OPPS payment would,by definition, include fewer items andservices than the corresponding IPPSMS–DRG payment. For example, theIPPS MS–DRG payment includespayment for drugs and diagnostic teststhat would be separately payable underthe OPPS. We explained that a paymentcap is necessary, therefore, to ensurethat we do not create an inappropriatepayment incentive to provide CRT–Dservices in one setting of care asopposed to another by paying more forCRT–D services in the outpatient settingcompared to the inpatient setting. Wealso explained that we believe thatlimiting payment for CRT–D servicesunder the OPPS to the IPPS MS–DRGpayment will ensure appropriate andequitable payment to hospitals becausepatients who receive these services inthe hospital outpatient setting are not assick as patients who have been admittedto receive this same service in thehospital inpatient setting. Therefore, weexpect it would be less costly to providecare for these patients, who would alsospend less time in the facility.In the CY 2012 OPPS/ASC proposedrule (76 FR 42241 through 42242), wealso addressed cases when CPT codes33225 and 33249 are performed ondifferent dates of service. We proposedto retain CPT code 33249 in APC 0108,but to reassign CPT code 33225 to APC0108 on the basis that these codes aresimilar in clinical characteristics andmedian cost. We proposed to revise thetitle of APC 0108 to read ‘‘Insertion/Replacement/Repair of AICD Leads,Generator, and Pacing Electrodes’’ forCY 2012. We also proposed to reassignCPT code 33224 (Insertion of pacingelectrode, cardiac venous system, forleft ventricular pacing, <strong>with</strong> attachmentto previously placed pacemaker orVerDate Mar2010 17:08 Nov 29, 2011 Jkt 226001 PO 00000 Frm 00058 Fmt 4701 Sfmt 4700 E:\FR\FM\30NOR2.SGM 30NOR2pacing cardioverter-defibrillator pulsegenerator (including revision of pocket,removal, insertion, and/or replacementof generator)) from APC 0418 to APC0655, and to change the title of APC0655 from ‘‘Insertion/Replacement/Conversion of a Permanent DualChamber Pacemaker’’ to ‘‘Insertion/Replacement/Conversion of aPermanent Dual Chamber Pacemaker orPacing Electrode.’’ In the CY 2012OPPS/ASC proposed rule (76 FR 42205),we stated that we believe thatreassigning CPT code 33224 to APC0655 will promote stability in paymentfor CPT code 33224 because CPT code33224 would then be assigned to anAPC <strong>with</strong> similar median costs, but <strong>with</strong>a higher volume of services and,therefore, will benefit from the stabilityin APC median costs and payment ratesthat generally result as the volume ofservices <strong>with</strong>in an APC increases.Because these proposed actions wouldresult in APC 0418 containing no CPTcodes, we proposed to delete APC 0418.In addition, as <strong>with</strong> composite APC8009 and under the authority of section1833(t)(2)(E) of the Act, we proposed tolimit the payment for services assignedto APC 0108 to the IPPS standardizedpayment amount for MS–DRG 227. Inother words, we proposed a paymentrate for APC 0108 as the lesser of theAPC 0108 median cost or the IPPSstandardized payment rate for MS–DRG227. We stated that we believe that MS–DRG 227 is the most comparable DRG toAPC 0108 because, like APC 0108, MS–DRG 227 includes implantation of adefibrillator in patients who do not havemedical complications or comorbidities.If we were to base payment for APC0108 on our calculated median cost ofapproximately $27,361, it would resultin a payment under the CY 2012 OPPSthat would exceed our proposedstandardized payment under the IPPSfor MS–DRG 227 of $26,364.93. Westated that we do not believe that itwould be equitable to pay more for theimplantation of a cardioverterdefibrillator or implantation of a leftventricular pacing electrode for anoutpatient encounter, which, bydefinition, includes fewer items andservices than an inpatient stay duringwhich the patient has the sameprocedure.In order to ensure that hospitalscorrectly code for CRT services in thefuture, we proposed to create claimprocessing edits that would returnclaims to providers unless CPT code33225 is billed in conjunction <strong>with</strong> oneof the following CPT codes, as specifiedby the AMA in the CPT code book: