ACR Issues Analysis of Final HOPPS Rule for 2016

Transcription

1 Issues Analysis of HOPPS Rule for 2016 The Centers for Medicare and Medicaid Services () released its final rule for calendar year (CY) 2016 changes to the Hospital Outpatient Prospective Payment System (HOPPS) on Oct. 30, Any comments the American College of Radiology () would like to consider must be submitted within the 60-day comment period ending on Dec. 29, Following is a detailed summary of the Rule (FR). HOPPS Conversion Factor Despite heavy opposition by numerous commenters, has elected to move forward with their proposal to adjust the CY 2016 conversion factor by -2.0 percent. The stated reasoning is to make a budget neutral adjustment to recoup funds resulting from overpayment of Outpatient Prospective Payment System (OPPS) services for laboratory tests in CY Therefore the HOPPS conversion factor for 2016 will be $ and the adjusted conversion factor (CF) for hospitals that do not report measures will be 2 percent lower at $ Expansion of Comprehensive s In the CY 2014 OPPS/ Ambulatory Surgical Center (ASC) final rule with comment period, finalized a comprehensive payment policy that packages payment for adjunctive and secondary items, services and procedures at the claim level. For these single encounter payments, the HOPPS version of episodes-of-care moved package planning and preparation services into the most costly primary procedure. Services excluded from the Comprehensive Ambulatory Payment Classifications (C-) policy include those that cannot by statute be paid for under the OPPS and services that are required by statute that must be separately paid including mammography and brachytherapy seeds. The CY 2014 OPPS/ASC final rule included a provision for 25 C- s and with the CY 2016 rule moved forward with the establishment of 10 new C- s. The has commented extensively on this issue and maintains that the C- methodology represents a continued insensitivity to clinical complexity. As such, in response to the proposed rule, the requested that consider the use of tertiary codes to assign complexity for the C-s that represent more complex care, such as endovascular revascularization. stated that it did not believe that adjusting for the complexity of a claim with more than two primary J1 codes served the purpose of the policy. believes that failed to comprehend the potential purpose and impact of utilizing tertiary codes for the capture of deeper levels of complexity and costs. Stereotactic Radiosurgery (SRS) C The American Taxpayer Relief Act (ATRA) requires equal payment for SRS delivered by Cobalt-60 based or LINAC-based technology. has elected to move forward with their proposal to change payment for SRS by identifying services billed differentially for Healthcare Common Procedure Coding System (HCPCS) codes and on the same claim and on claims one month prior to delivery of SRS services. Any codes removes from the C- bundle will receive separate payment even when appearing with a J1 procedure code (HCPCS code or 77372) on the same claim for both CY 2016 and CY is establishing a

2 HCPCS CP modifier to be reported with every code that is adjunctive to a comprehensive stereotactic radiosurgery service. The use of this modifier is effective Jan. 1, Once has gathered data on the ancillary services using the new modifier, they may consider these services part of the SRS C- and discontinue separate payment in future years. For now, will not adopt a policy requiring a modifier for the identification of separately reported adjunctive services with any other C-, but mentions that they may elect do so in the future. Payment of Drugs, Biologicals and Radiopharmaceuticals has elected to continue to pay for the acquisition and pharmacy overhead costs of separately payable drugs and biologicals that do not have pass-through status at the statutory default of average sales price (ASP) plus 6 percent. Pass-Through Payments For CY 2016 is moving forward with several novel payment offsets for products that may be approved for pass-through status throughout the year including those for contrast, stress agents and diagnostic radiopharmaceuticals. Currently, there is only one contrast agent with pass-through payment status under the OPPS. HCPCS code Q9950 (Injection, sulfur hexafluoride lipid microsphere, per ml) and it was granted pass-through payment status as recently as Oct. 1, The rationale for providing payment offsets for products that have yet to be approved stems from seeking to avoid inadvertently duplicate payments similar to those responsible for the proposed net downward adjustment to the CY 2016 HOPPS conversion factor. Packaging Threshold has elected to raise the packaging threshold for therapeutic radiopharmaceuticals from $95 to $100. In addition, is moving forward with their proposal to package those drugs with a per-day cost less than or equal to $100, and to identify those with a per day cost greater than $100 which will be paid separately. All non-pass-through, separately payable therapeutic radiopharmaceuticals will be paid at ASP plus 6 percent. Treatment of New and Revised CY 2016 Category I and III Current Procedural Terminology (CPT) Codes That Will Be Effective Jan. 1, 2016 As stated in the proposed rule, will be assigning s and Status Indicators for new and revised Category I and III CPT codes as long as they are made available to the public by the American Medical Association (AMA) in a timely manner. They have additionally finalized their proposal to make interim and status indicator assignments for CPT codes that are not available in time for the proposed rule and that describe wholly new services (such as new technologies or new surgical procedures), solicit public comments, and finalize the specific and status indicator assignments for those codes in the following year s final rule. OPPS Changes Variations within s

3 With a single exception, is moving forward with its proposal to restructure and renumber nine of the clinical families including those for Excision/Biopsy, Incision and Drainage, Radiology, and Nuclear Medicine Services. This restructure decreases the number of Imaging s from 54 to 26. In keeping with their insistence that previous groupings were too granular, has elected to combine the Excision/Biopsy s with those for Incision and Drainage and to place the nuclear medicine s under the diagnostic radiology category (including X-Ray, CT, MRI, and ultrasound). The single exception to the reduction of total groupings was the creation of a fourth Nuclear Medicine to separate out the PET studies which many have commented have much higher costs than other nuclear medicine studies (e.g. SPECT). Additionally, it was noted by the that some codes did not fit neatly in their respective modalities and the proposed alternate family placement. Below you will find those suggestions. The furthest right-hand column represents the placement finalized in the CY 2016 OPPS FR. Table 1 - HCPCS/CPT Codes that Change Family HCPC 2016P S/CPT Mri brain w/o & Ct colonography dx 5521 Descriptor MRI MRA w wo Contrast Level Level 1 X-Ray and Related Services F Descriptor Level 6 X-Ray and Related Services 5526 Computed Tomography without Contrast CT hrt w/3d image 5523 Cardiac mri w/stress img 5581 Cardiac mri for morph 5581 Level 3 X-Ray and Related Services 5571 Level 1 Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast 5592 Level 1 Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast 5593 Level 1 Computed Tomography with Contrast and Computed Tomography Angiography 5571 Level 2 Nuclear Medicine and Related Services 5592 Level 3 Nuclear Medicine and Related Services 5581 believes that the restructure simplifies and makes more understandable the OPPS structure and ostensibly reduces resource overlap by decreasing the total s. also states that the new structure will more readily accept future services under these broader groupings. is also proposing to renumber several families of s to provide consecutive numbers for consecutive levels within a clinical family for improved identification of s and ease of understanding the groupings. These new placements alter the pricing of many imaging studies, some significantly. Below you will find a series of tables detailing the proposed placement of HCPCS/CPT codes into families ( 2016 P ), the proposal for code placement and the furthest right-hand column represents the placement finalized in the CY 2016 OPPS FR.

4 X-Ray s The was disappointed to learn that code (Artery X-Rays spine) was left in 5526 Level 6 X-Ray and Related Services, and maintains that this code should be moved to a higher cost category in a different so that hospitals can be paid to cover their costs. Table 3 X-Ray and Related Services HCPCS/CPT that Decreased Levels HCPCS/C PT 2016 P X-ray exam of eye sockets Contrst x-ray exam of throat X-ray exam neck spine 203 vw Complex body section x-ray Vein thrombosis images bilat X-ray exam of kidney lesion Follow-up angiography Vein x-ray chest Vein x-ray skull epidural

5 Table 2 - X-Ray and Related Services HCPCS/CPT that Increased Levels HCPCS/CPT 2016 P Throat x-ray & fluoroscopy Chest x-ray 4/> views X-ray exam si joints Fluoroscopic procedure X-ray exam neck spine 4/5vws X-ray exam 1-2 neck spine 4/vws X-ray exam thorac spine 4/>vw X-rays bone survey limited X-ray upper gi delay w/o kub X-ray nose to rectum X-ray exam neck spine 6/>vws Contrst x-ray uppr gi tract Cine/videos x-rays Contrast x-ray exam of colon X-ray upper gi delay w/kub Speech evaluation complex X-rays bone survey complete Contrst x-ray uppr gi tract Fluoro exam of g/colon tube X-ray exam of arm infant Full Mouth x-ray of teeth X-ray exam of small bowel X-ray exam of teeth Contrast x-ray gallbladder Contrast x-ray bladder X-ray urethra/bladder X-ray urethra/bladder X-ray female genital tract C9733 Non-opthalmic fva G0120 Colon ca scrn; barium enema X-ray exam of penis Venous thrombosis imaging Acute venous thrombus imaging Lymph vessel x-ray trunk CT Family The had requested that when the s were reorganized that the CT family would be divided by CT with contrast (Level I), CT without contrast (Level II) and CT without followed

6 by with (Level III). elected to finalize those categories but did not adhere to the suggested Geometric Mean calculations. Table 4 - CT with and without Contrast Calculation of Geo-mean Post Restructuring Title Geometric Mean Geometric Mean Payment Rate also recommended the following changes to the placement of HCPCS/CPT codes in the CT Family of s. The furthest right-hand column represents the placement finalized in the CY 2016 OPPS FR. Table 5 - CT with Contrast and CT Angiography HCPCS/CPT that Increased Levels ized Payment Rate 5570 Computed Tomography without Contrast $ $ $ $ Level 1 Computed Tomography with Contrast and Computed Tomography Angiography $ $ $ $ Leve 2 Computed Tomography with Contrast and Computed Tomography Angiography $ $ $ $ HCPCS/ CPT 2016 P Ct head/brain w/o & Ct orbit/ear/fossa w/o & Ct maxillofacial w/o & Ct sft tsue nck w/o & Ct angiography head Ct angiography neck Ct angiography chest Ct neck spine w/o & Ct chest spine w/o & Ct lumbar spine w/o & Ct angiograph pelv w/o & Ct pelvis w/o & Ct uppr extremity w/o & Ct angio uppr extrm w/o & Ct lwr extremity w/o & Ct angio lwr extr w/o & Ct abdomen w/o & Ct angio abdom w/o & Ct angio hrt w/3d image Ct angio abdominal arteries

7 Table 6 - CT with Contrast and CT Angiography HCPCS/CPT that Lowered Levels HCPCS/ CPT MR Family recommended the following changes to the placement of HCPCS/CPT codes in the MR Family of s. The furthest right-hand column represents the placement finalized in the CY 2016 OPPS FR. Table 7 - MRI and MR Angiography HCPCS/CPT that Increased Levels Ultrasound Family 2016 P Ct neck spine CT upper extremity Ct abd & pelv w/contrast HCPCS/ CPT 2016 P Mr angiography head w/o dye Mr angiography neck w/o dye Mr angiography head w/ dye Mr angiography head w/o and w/ dye Mr angiography neck w/ dye Mr angiography neck w/o and w/ dye C8902 Mra w/o fol w/cont, abd C8911 Mra w/o fol w/cont, chest C8914 Mra w/o fol w/cont, lwr ext C8920 Mra w/o fol w/cont, pelvis C8933 Mra w/o&, spinal canal C8936 Mra w/o&, upper extr The recommended the following changes to the placement of HCPCS/CPT codes in the Ultrasound Family of s which we believed fit better clinically and with respect to resources. The furthest right-hand column represents the placement finalized in the CY 2016 OPPS FR.

8 Table 8 - Ultrasound HCPCS/CPT that Increased Levels HCPCS/CPT 2016 P Vascular Study Echo exam of eye water bath Us exam of head and neck Ob us limited fetus(s) Us exam abdo back wall lim Us exam scrotum Transvaginal us obstetric Tcd vasoreactivity study Liver elastography Table 9 - Ultrasound HCPCS/CPT that Decreased Levels HCPCS/ CPT Nuclear Medicine 2016 P In response to comments, elected to add a fourth level to the nuclear medicine and related services group ( 5594 (Level 4 Nuclear Medicine and Related Services), and are reassigning the PET procedures that were proposed to be assigned to 5593 (Level 3 Nuclear Medicine and Related Services) to While they state that this is not necessarily limited to only PET procedures, currently all those codes residing in 5594 describe PET procedures. Excision/Biopsy and Incision and Drainage Procedures Echo exam of abdomen Ob us < 14 wks single fetus Transvaginal us non-ob Us transrectal Us xtr non-vasc complete Intracranial limited study Upper extremity study The recommended the following changes to the placement of HCPCS/CPT codes in the Excision/Biopsy and Incision and Drainage Family of s which we believed fit better

9 clinically and with respect to resources. The furthest right-hand column represents the placement finalized in the CY 2016 OPPS FR. Table 10 Excision/Biopsy/Incision and Drainage HCPCS/CPT that Increased Level HCPCS/CPT 2016 P Removal of nail bed Drainage lymph node lesion Needle biopsy spinal cord Drain external ear lesion Removal of pressure sore Drainage of arm bursa Liver surgery procedure Pancreas surgery procedure I & d vaginal hematoma pp Exc tr-ext mal+mrg cm Exc f/e/e/n/l mal+mrg Exc f/e/e/n/l mal+mrg Dermabrasion other than face Exc back les sc < 3 cm Vascular Procedures The recommended that make the following revisions to the vascular s as we believed they provided a better fit clinically and with respect to resources. The furthest righthand column represents the placement finalized in the CY 2016 OPPS FR. Table 11 - Vascular Procedures HCPCS/CPT that Increased Levels HCPCS/ CPT 2016 P Vascular surgery procedure Biopsy of heart lining Vascular edoscopy procedure Insert tunneled cv cath Cannula declotting Cardiac MR

10 The was glad to see that heeded the request by the Society for Cardiovascular Magnetic Resonance s (SCMR) to move CPT code (Cardiac MR) from the proposed 5592 to the Level III nuclear medicine Cardiac MR is clinically similar to the nuclear cardiology stress perfusion codes that has placed in Assignment of Lung Cancer Screening Codes On Feb. 5, 2015, issued a National Coverage Determination (NCD) for the coverage of lung cancer screening with low-dose computed tomography (LDCT) under Medicare. Under the HOPPS CY 2016 Rule has defined the placement of the HCPCS codes that describe these services. HCPCS code G0297 (LDCT scan) for lung cancer screening has been assigned to 5570 at a payment rate of $ HCPCS code G0296 (Counseling visit to discuss need for lung cancer screening (LDCT) using low dose CT scan has been assigned to 5822 at a payment rate of $ The agrees with placement of G0297. It fits clinically and with respect to resource use with its diagnostic counterpart code (CT thorax without contrast). The placements and payment rates of these new codes are effective from the Feb. 5, 2015 NCD effective date and may be billed under OPPS Jan. 1, Table 12: Placement and Payment Rates of Lung Cancer Screening Codes HCPCS Code Group Name Payment Rate G0296 Visit to determ ldct elig 5822 Level 2 Health and Behavior Services $69.65 G0297 Ldct for lung ca screen 5570 Computed Tomography without Contrast $ Changes for Payment for Computed Tomography (CT) When Not in Compliance with XR Section 218(a)(1) of the Protecting Access to Medicare Act of 2014 (PAMA) mandates that for the technical component of applicable computed tomography services paid under the physician fee schedule and HOPPS that a five percent reduction in 2016 and a 15 percent reduction in 2017 and subsequent years be made for services furnished using equipment that does not meet the requirements of the National Electrical Manufacturers Association (NEMA) Standard XR , entitled Standard Attributes on CT Equipment Related to Dose Optimization and Management. Below you will find a table of applicable CT services and the estimated payment rates for 2016 and beyond. Table 13 - Applicable CT Services and Estimated Payment Rates HCPCS Code Payment Rate Estimated 5% 2016 Adjustment Estimated 15% 2017 Adjustment Ct abd & pelvis w/o 5523 $ $ $ contrast Ct head/brain w/o dye 5570 $ $ $95.62

11 70480 Ct orbit/ear/fossa w/o 5570 $ $ $95.62 dye Ct maxillofacial w/o 5570 $ $ $95.62 dye Ct soft tissue neck 5570 $ $ $95.62 w/o dye Ct thorax w/o dye 5570 $ $ $ Ct neck spine w/o dye 5570 $ $ $ Ct chest spine w/o 5570 $ $ $95.62 dye Ct lumbar spine w/o 5570 $ $ $95.62 dye Ct pelvis w/o dye 5570 $ $ $ Ct upper extremity 5570 $ $ $95.62 w/o dye Ct lower extremity 5570 $ $ $95.62 w/o dye Ct abdomen w/o dye 5570 $ $ $ Ct colonography dx 5570 $ $ $ Ct head/brain 5571 $ $ $ Ct head/brain w/o & 5571 $ $ $ Ct orbit/ear/fossa 5571 $ $ $ Ct orbit/ear/fossa 5571 $ $ $ w/o& Ct maxillofacial 5571 $ $ $ Ct maxillofacial w/o 5571 $ $ $ & Ct soft tissue neck 5571 $ $ $ Ct sft tsue nck w/o & 5571 $ $ $ Ct angiography head 5571 $ $ $ Ct angiography neck 5571 $ $ $ Ct thorax 5571 $ $ $ Ct angiography chest 5571 $ $ $ Ct neck spine w/o & 5571 $ $ $ Ct chest spine 5571 $ $ $ Ct chest spine w/o & 5571 $ $ $ Ct lumbar spine w/o 5571 $ $ $201.33

12 & Ct angiograph pelv 5571 $ $ $ w/o& Ct pelvis 5571 $ $ $ Ct pelvis w/o & 5571 $ $ $ Ct uppr extremity 5571 $ $ $ w/o& Ct angio upr extrm 5571 $ $ $ w/o& Ct lower extremity 5571 $ $ $ Ct lwr extremity 5571 $ $ $ w/o& Ct angio lwr extr 5571 $ $ $ w/o& Ct abdomen 5571 $ $ $ Ct abdomen w/o & 5571 $ $ $ Ct angio abdom w/o 5571 $ $ $ & Ct colonography dx 5571 $ $ $ Ct hrt w/3d image 5571 $ $ $ Ct hrt w/3d image 5571 $ $ $ congen Ct angio hrt w/3d 5571 $ $ $ image Ct thorax w/o & 5572 $ $ $ Ct neck spine 5572 $ $ $ Ct lumbar spine 5572 $ $ $ Ct upper extremity 5572 $ $ $ Ct angio abd&pelv 5572 $ $ $ w/o& Ct abd & pelv 5572 $ $ $ w/contrast Ct abd & pelv 1/> 5572 $ $ $ regns Ct hrt w/o dye w/ca 5731 $12.70 $12.07 $10.80 test Ct colonography Not paid by Medicare when submitted on

13 screening outpatient claims (any outpatient bill type). Hospital Outpatient Quality Reporting (OQR) Program Regarding the Hospital Outpatient Quality Reporting (OQR) Program, is moving forward with a number, but not all, of its proposals for the CY 2017, 2018 and 2019 payment determinations and those that carry over to subsequent years. has elected to move forward with the removal of the OP-15: Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache measure, effective Jan. 1, 2016 stating that the measure does not align with current clinical guidelines or practices. has additionally elected to change the deadline for withdrawing from the Hospital OQR Program from Nov. 1 to Aug. 31. In order to increase the total time for review, has elected to shift the quarters on which payment determinations are based. also proposed a new data submission period for measures submitted via the QualityNet Website, shifting the timeframe from July 1 through Nov. 1 to Jan. 1 through May 15. One of the reasons for this change was to bring the data submission period in line with those proposed by the ASCQR Program which would streamline hospital submissions, earlier public reporting and a reduced administrative burden associated with tracking multiple submission deadlines for measures. Similarly, in order to be consistent with the proposed ASCQR Program, has elected to move forward with a proposal to change the deadline for submitting a reconsideration request from the first business day of the month of February of the affected payment year to the first business day on or after March 17 of the affected payment year. Two minor clerical clarifications were also finalized for CY 2016: the renaming of the extension and exception policy to extension and exemption and the amendment of 42 CFR (f)(1) and 42 CFR (e)(2) to replace the term fiscal year with the term calendar year. The reasoning behind both of these was the remedy of inadvertent error, rather than the proscription of specific policy. In the CY 2016 OPPS Rule, proposed two new measures, OP-33: External Beam Radiotherapy (EBRT) for Bone Metastases (NQF # 1822) (for CY 2018 and subsequent years) and OP-34: Emergency Department Transfer Communication (EDTC) (NQF # 0291). The first of these, OP-33, which is designed to assesses the percentage of patients with painful bone metastases and no history of previous radiation who receive EBRT with an acceptable dosing schedule, has been finalized beginning for services furnished on January 1, The second proposal for this measure, which would allow hospitals to submit an aggregate data file for this measure through a vendor, was not finalized. Also not finalized was the proposed OP-34: Emergency Department Transfer Communication (EDTC) (NQF # 0291) measure. It was meant to address concerns associated with care transitions when patients are transferred from Emergency Departments to other facilities. The reasoning for this was the anticipation of a significant overlap with the Meaningful Use Stage 2 requirements that would divert attention and resources away from another priority. also took comments regarding electronic clinical quality measures (ecqms) and whether or not, in future rulemaking, would propose that hospitals have the option to voluntarily submit data for OP-18: Median Time from ED Arrival to ED Departure for Discharged ED Patients electronically beginning with the CY 2019 payment determination. Many of the comments came out in support of this optional measure while others worried about the management of data elements and the potential for

14 duplicative penalties. noted that a validation pilot is currently under way in the Hospital IQR Program and the results of that pilot are pending but that they will take into consideration lessons learned in the Hospital IQR Program before developing Hospital OQR Program policies. The s HOPPS Committee and staff will be reviewing these changes and drafting comments during the 60-day comment period.