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Regulation No.
CMS-1404-FC
Title
Final Changes to the ASC Payment System and CY 2009 Payment Rates
Year
11/18/2008

Medicare Program:  Changes to the Hospital Outpatient Prospective Payment System and CY 2009 Payment Rates; Changes to the Ambulatory Surgical Center Payment System and CY 2009 Payment Rates; Hospital Conditions of Participation: Requirements for Approval and Re-Approval of Transplant Centers to Perform Organ Transplants--Clarification of Provider and Supplier Termination Policy

Medicare and Medicaid Programs:  Changes to the Ambulatory Surgical Center Conditions for Coverage

SUMMARY:  This final rule with comment period, in part, revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system, and to implement a number of changes made by the Medicare Improvement for Patients and Providers Act of 2008.  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 prospective payment system.  These changes are applicable to services furnished on or after January 1, 2009. 

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 applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other pertinent ratesetting information for the CY 2009 ASC payment system.  These changes are applicable to services furnished on or after January 1, 2009.

The final rule (CMS-1404-FC) is available in the "Related Links Outside CMS" below.These 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 name, payment status indicator, relative weight, payment rate, and copayment amount(s) for the 2009 APC groups.

Median Costs for Hospital Outpatient Services, by ambulatory payment classification (APC) group - This Excel file displays median costs, by APC group, for services payable under the OPPS in calendar year 2009. The data are based on claims for hospital outpatient services provided January 1, 2007 through December 31, 2007.

TABLE 40. - NEW CATEGORY III CPT CODES IMPLEMENTED IN JULY 2008 FOR ASC PAYMENT

TABLE 41. - LEVEL II HCPCS CODES IMPLEMENTED ON APRIL 1, 2008

TABLE 42. - LEVEL II HCPCS CODES IMPLEMENTED ON JULY 1, 2008

TABLE 43. - ASC COVERED SURGICAL PROCEDURES ADDED FOR CY 2009

TABLE 44. - CY 2009 FINAL DESIGNATIONS OF ASC COVERED SURGICAL PROCEDURES NEWLY DESIGNATED AS OFFICE-BASED

TABLE 45. - FINAL CY 2009 PAYMENT INDICATORS FOR CY 2008 OFFFICE-BASED PROCEDURES FOR WHICH THEIR PROPOSED CY 2009 DESIGNATION WAS TEMPORARILY OFFICE-BASED*

TABLE 46. - CY 2009 PAYMENT INDICATORS FOR NEW CY 2009 HCPCS CODES FOR ASC COVERED SURGICAL PROCEDURES ASSIGNED TEMPORARY OFFICE‑BASED PAYMENT INDICATORS ON AN INTERIM BASIS

TABLE 47. - ASC COVERED SURGICAL PROCEDURES DESIGNATED AS DEVICE-INTENSIVE FOR CY 2009

TABLE 49. - DEVICES FOR WHICH THE "FB" OR "FC" MODIFIER MUST BE REPORTED WITH THE PROCEDURE CODE WHEN FURNISHED AT NO COST OR WITH FULL OR PARTIAL CREDIT

TABLE 50. - INSERTION OF IOL PROCEDURES AND THEIR CY 2009 ASC PAYMENT RATES

TABLE 53. - ESTIMATED CY 2009 IMPACT OF THE UPDATE TO THE ASC PAYMENT SYSTEM ON ESTIMATED AGGREGATE CY 2009 MEDICARE PROGRAM PAYMENTS UNDER THE 50/50 TRANSITION BLEND AND WITHOUT A TRANSITION, BY SURGICAL SPECIALTY GROUP

TABLE 54. - ESTIMATED IMPACT OF Update to CY 2009 ASC PAYMENT SYSTEM ON AGGREGATE PAYMENTS FOR SELECTED PROCEDURES

TABLE 55. - ACCOUNTING STATEMENT: CLASSIFICATION OF ESTIMATED EXPENDITURES FROM CY 2008 TO CY 2009 AS A RESULT OF THE CY 2009 UPDATE TO THE REVISED ASC PAYMENT SYSTEM

TABLE 56. - YEAR 2008 DATA USED THROUGH THIS IMPACT ANALYSIS
TABLE 57. - SUMMARY OF QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT BURDEN

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