CMS issues manual revisions incorporating CY 2010 OPPS final rule changes

On Friday, CMS issued two transmittals containing manual provisions that incorporate key changes to the Outpatient Prospective Payment System (OPPS) for CY 2010.  In Medicare Claims Processing Manual Transmittal 1871, CMS noted the following key changes:

• CMS has added HCPCS code 92520 (Laryngeal function studies [i.e., aerodynamic testing and acoustic testing]) to the list of “sometimes therapy” services that may be paid under the OPPS when provided by a non-therapist as a non-therapy service, that is, without a certified therapy plan of care.  A list of all ”sometimes therapy” services is included in the transmittal.
• CMS has updated the list of those HCPCS codes that are included in the three imaging families that are subject to composite payment when two or more imaging services from the same family are performed on the same date of service.  The updated lists are also included in the transmittal.
• CMS has revised the coverage and coding requirements, including those relating to physician supervision, for cardiac rehabilitation, intensive cardiac rehabilitation and pulmonary rehabilitation.
• CMS will pay for brachytherapy seeds and sources on a prospective payment basis, rather than charges reduced to cost.  As a result, brachytherapy seeds and sources will be eligible for outlier payments and for the rural sole community hospital (SCH) adjustment.
• Although not requiring hospitals to do so, generally, CMS strongly encourages hospitals to report drugs and biologicals with the appropriate HCPCS codes when HCPCS codes are available.  In addition, for the first time, CMS encourages hospitals to use revenue code 0636 when reporting drugs and biologicals with HCPCS codes.  By doing so, CMS believes that it will be able to capture the most accurate cost information, which is used to determine whether drugs and biologicals will be separately payable or packaged two years from now.
• CMS generally will continue to reimburse separately payable drugs and biologicals (except for pass throughs) on the basis of ASP + 4%, which is updated on a quarterly basis.  This will include therapeutic radiopharmaceuticals that exceed the median per day cost threshold for CY 2010, if ASP data is available.  If not, payment for those therapeutic radiopharmaceuticals will be provided based on the most recent hospital mean unit cost data.
• CMS will continue to reimburse pass-through drugs and biologicals on the basis of ASP + 6%, which is also updated on a quarterly basis.  Payment for pass-through diagnostic radiopharmaceuticals and contrast agents may be subject to an offset for the portion of the APC payment for the related procedure that was designed to cover the cost of the predecessor drug.
• Effective January 1, 2009, blood and blood products, that have a status indicator of “R,” are eligible for the reduced update if the hospital fails to meet its quality indicator reporting requirements and for outlier payments, but are not subject to wage index adjustment.  They are also subject to the rural SCH/EACH adjustment, if applicable.

The above provides a brief summary of key claims processing related changes. Therefore, hospitals are encouraged to more carefully review Transmittal 1871 in its entirety, as well as Medicare Benefit Policy Manual Transmittal 116, to assure that they are prepared to implement all relevant OPPS changes by January 1.