July 09, 2009 | Kimberly Hoy | Comments 0
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More on the OPPS proposed rule

Earlier this week, I discussed the physician supervision provisions of the CY2010 OPPS proposed rule.

Another section of interest to many providers will be the sections on the new cardiac rehab, intensive cardiac rehab and pulmonary rehab benefits.  CMS discusses their implementation of these new benefits added to the Social Security Act by the MIPPA, effective January 1, 2010.  Of particular interest is CMS implementation of the MIPPA provision that states that physician supervision for these programs is assumed when provided in a hospital.

Other significant proposals in the rule include a large proposed increase in the OPPS outlier threshold from $1800 to $2,225, the highest the fixed dollar threshold has been since its introduction.

Additionally, a significant portion of the rule was also devoted to payment methodologies for drugs, however, the end resultant proposal for most drugs remains at ASP + 4%.  This includes ASP based payment for therapeutic radiopharmaceutical when the statutory cost based payment methodology expires in 2009.  CMS did make the submission of ASP data for therapeutic radiopharmaceutical voluntary, and will base rates on CY2008 hospital mean cost data if ASP is not available.

Similarly, brachytherapy sources, which also were under a statutory cost based payment methodology for 2009, will be transitioned to CY2008 hospital mean cost data (the usual method for setting APC rates for other services).  CMS is soliciting comments on several of their proposals and I would encourage pharmacy, radiology and chargemaster coordinators to review these proposals carefully and submit comments if they disagree with any of the proposals.

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Kimberly Hoy About the Author:

Kimberly Anderwood Hoy is director of Medicare and compliance for HCPro, Inc.

As a hospital compliance officer, Kimberly regularly provided research and guidance on coding, billing, and reimbursement issues for a wide range of hospital services. She has a particular expertise in charge description master operation, development, and maintenance. She has experience conducting billing compliance audits and internal investigations. Kimberly also has had primary responsibility for HIPAA privacy regulation compliance, including risk assessment, program development, implementation of policies and procedures, and ongoing operations.

As In-House Legal Counsel, Kimberly had oversight of expense contracting and regulatory compliance, including federal and state laws and regulations. Kimberly regularly provided legal advice on such complex topics as consents, EMTALA, Stark, anti-kickback and anti-inducement laws, physician recruiting, and tax exemption regulations.

Kimberly has served as a speaker at compliance-related conferences in the areas of compliance program effectiveness and physician education. Kimberly is an active member of the American and California Bar Associations, the American Health Lawyers Association and the Health Care Compliance Association.

Kimberly earned her Juris Doctor degree from the University of Montana School of Law, where she received the Corpus Juris Secundum Award for Excellence in Contracts. She also holds a Bachelor of Arts degree in Philosophy from Yale University.

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