TITLE: Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment; Ambulatory Surgical Center Payment; Hospital Value-Based Purchasing Program; Physician Self-Referral; and Provider Agreement Regulations on Patient Notification Requirements
PUBLICATION DATE: November 1, 2011
SUMMARY: This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS. These changes are applicable to services furnished on or after January 1, 2012.
In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we set forth the relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other ratesetting information for the CY 2012 ASC payment system. These changes are applicable to services furnished on or after January 1, 2012.
We are revising the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, adding new requirements for ASC Quality Reporting System, and making additional changes to provisions of the Hospital Inpatient Value-Based Purchasing (VBP) Program.
We also are allowing eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot.
Finally, we are making changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreement regulations on patient notification requirements.
The final rule (CMS-1525-FC) is available in the "Related Links Outside CMS" below. The supporting files are located in the "Downloads" section below:
Addendum AA - a list of covered surgical procedures under the revised ASC payment system, including Category I and Category III CPT and Level II HCPCS codes. Included are surgical procedures that receive packaged payment through the payment for covered surgical procedures, as well as those that are paid separately. Payment indicators (defined in Addendum DD1) designate each procedure's payment status.
Addendum BB - a list of radiology services and other covered ancillary services eligible for ASC payment under the revised ASC payment system when provided integral to an ASC covered surgical procedure. Included are ancillary services that receive packaged payment through the payment for covered surgical procedures, as well as those that are paid separately. Payment indicators (defined in Addendum DD1) designate each service's payment status.
Addendum DD1 - a list of ASC payment indicators used in Addenda AA and BB to provide payment information regarding covered surgical procedures and covered ancillary services, respectively, under the revised ASC payment system. The payment indicators represent policy-relevant characteristics of HCPCS codes related to their payment status in ASCs; for example, whether a code is designated as packaged, office-based, or device-intensive.
Addendum DD2 - a list of ASC comment indicators.
Addendum EE - a list of surgical procedures excluded from Medicare payment in ASCs. The surgical procedures on that exclusionary list are those that are on the OPPS inpatient list, CPT unlisted codes, surgical procedures that are not recognized for payment under Medicare, and those that CMS medical advisors determined pose a significant risk to beneficiary safety or would be expected to require an overnight stay when provided in ASCs.
Addendum A - This Excel file lists, in APC order, the final name, payment status indicator, relative weight, payment rate, and copayment amount(s) for the final 2012 APC groups.
Median Costs for Hospital Outpatient Services, by ambulatory payment classification (APC) group - This Excel file displays final median costs, by APC group, for services payable under the OPPS in calendar year 2012. The data are based on claims for hospital outpatient services provided January 1, 2010 through December 31, 2010.
TABLE 46. "PROCEDURES REMOVED FROM THE INPATIENT ONLY LIST AND THEIR APC ASSIGNMENTS FOR CY 2012
TABLE 47. "ADDITIONAL PROCEDURES REQUESTED BY COMMENTERS TO BE REMOVED FROM THE INPATIENT ONLY LIST FOR CY 2012
TABLE 48. "NEW LEVEL II HCPCS CODES FOR COVERED ANCILLARY SERVICES IMPLEMENTED IN APRIL 2011
TABLE 49. "NEW LEVEL II HCPCS CODES FOR COVERED ANCILLARY SERVICES IMPLEMENTED IN JULY 2011
TABLE 50. "NEW CATEGORY III CPT CODES IMPLEMENTED IN JULY 2011 AS ASC COVERED SURGICAL PROCEDURES
TABLE 51. "SURGICAL PROCEDURES REQUESTED FOR ADDITION TO THE CY 2012 ASC LIST OF COVERED SURGICAL PROCEDURES
TABLE 52. "NEW ASC COVERED SURGICAL PROCEDURES FOR CY 2012
TABLE 53. "ASC COVERED SURGICAL PROCEDURES NEWLY DESIGNATED AS PERMANENTLY OFFICE-BASED FOR CY 2012
TABLE 54. "CY 2012 PAYMENT INDICATORS FOR ASC COVERED SURGICAL PROCEDURES DESIGNATED AS TEMPORARILY OFFICE-BASED IN THE CY 2011 OPPS/ASC FINAL RULE WITH COMMENT PERIOD
TABLE 55. "ASC COVERED SURGICAL PROCEDURES DESIGNATED AS DEVICE-INTENSIVE FOR CY 2012
TABLE 56. "PROCEDURES EXCLUDED FROM THE ASC LIST OF COVERED PROCEDURES FOR CY 2012 THAT WERE REMOVED FROM THE CY 2012 OPPS INPATIENT LIST
TABLE 57. "CY 2012 PROCEDURES TO WHICH THE NO COST/FULL CREDIT AND PARTIAL CREDIT DEVICE ADJUSTMENT POLICY APPLIES
TABLE 58. "DEVICES FOR WHICH THE "FB" OR "FC" MODIFIER MUST BE REPORTED WITH THE PROCEDURE CODE IN CY 2012 WHEN FURNISHED AT NO COST OR WITH FULL OR PARTIAL CREDIT
TABLE 61. "ESTIMATED IMPACT OF THE FINAL CY 2012 UPDATE TO THE ASC PAYMENT SYSTEM ON AGGREGATE CY 2012 MEDICARE PROGRAM PAYMENTS BY SURGICAL SPECIALTY OR ANCILLARY ITEMS AND SERVICES GROUP
TABLE 62. ESTIMATED IMPACT OF THE FINAL CY 2012 UPDATE TO THE ASC PAYMENT SYSTEM ON AGGREGATE PAYMENTS FOR SELECTED PROCEDURES
TABLE 64. ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED TRANSFERS FROM CY 2011 TO CY 2012 AS A RESULT OF THE FINAL CY 2012 UPDATE TO THE REVISED ASC PAYMENT SYSTEM