Highlights of the 2012 OPPS Final Rule

Introduction

CMS publishes updates to its outpatient prospective payment system (OPPS) that are effective each January 1. CMS published a display copy of the 2012 update on November 1, 2011 and the Federal Register version on November 30, 2011. In a change for this year, all of the Addenda files (CPT and APC listings, payment rates, etc.) were published separately and are available on the CMS website at: http://www.cms.gov/HospitalOutpatientPPS.

Click here to download or review the display copy of the CY 2012 OPPS final rule.

The final rule documents updates to the policies and payment rates for covered outpatient department services furnished by hospitals that are paid under the OPPS.  Several hospital types are excluded from OPPS including: Maryland hospitals covered under state cost containment waivers, Critical Access Hospitals, and hospitals outside the 50 states-- DC, Puerto Rico, and Indian Health Services Hospitals. 

This document contains a summary of issues discussed in this year’s Final Rule that are relevant to emergency department (ED) visits. The lengthy rule covers a lot of information that does not apply to emergency departments and will not be discussed here such as the Ambulatory Surgical Center rule and policies, partial hospitalization and specific details related to geographic wage adjustments, APC cost calculation strategies, and APC relative weight changes.  For information on these topics, please refer to the final rule link above; for more specific info related to the items summarized below refer to the Final Rule page numbers accompanying discussion points.

Financial Summary Points 

Each year CMS evaluates cost data and revises APC relative weights and thus payment rates.

Because of CMS’ two year lag in claims data analysis the 2012 relative weights are based on 2010 data.

In addition to the visit and procedure specific rate changes noted in this summary, a complete list of updates, including patient co-pays, can be found Addenda A and B on the CMS website:  https://www.cms.gov/apps/ama/license.asp?file=/HospitalOutpatientPPS/Downloads/CMS-1525-FC_Addenda.zip

Other important information:

• The 2012 conversion factor is $70.016. CMS will use a reduced conversion factor of $68.616 for calculating payments for hospitals that fail to comply with the Hospital Outpatient Quality Reporting requirements. The conversion factor for 2011 was $68.876.
• Patient copays are listed in the addenda files as above.
• CMS allocates 1.0% of total OPPS payments to make outlier payments.  For 2012 the total outlier threshold will be $1,900. This represents a 6.2% reduction from 2011. (CMS pays outlier payments under OPPS at “50% of the amount by which the cost of furnishing the service exceeds 1.75 times the APC payment amount when both the 1.75 threshold and the fixed-dollar threshold are met.”)
• In 2012 CMS will no longer pay Transitional Outpatient Payments (TOPs) to rural hospitals with 100 or fewer beds, rural sole community hospitals (SCHs) and essential access community hospitals (EACHs).

OPPS Visit Level Guidelines for CY 2012: Continue to Use Internal Hospital Guidelines (page 774) 

  • Hospitals are encouraged to continue to report visits during CY 2012 according to their own internal hospital guidelines.
  • CMS continues to believe that, generally, hospitals are billing in an appropriate and consistent manner that distinguishes among different leveles of visits based on their required hospital resources.
  • As originally noted in detail in the CY 2008 OPPS final rule with comment period (72 FR 66648), there is a continuation of the exprectation that hospitals will not purposely change their visit guidelines or otherwise upcode clinic and emergency department (ED) visits for purposes of extended assessment and management composite ambulatory payment classification (APC) payment.
  • Also noted are findings that, in aggregate, hospitals' charges for these higher level ED visits seem to be trending upward year over year.  Comments were welcomed on whether this is consistent with an individual hospital's experiences in developing, implementing, and refining its own guidelines over the last several years.

 

Type A and Type B ED Visits (page 749)

  • For CY 2012, CMS will continue to recognize two levels of ED visit codes:  Type A and Type B.
  • ED visit codes consist of five CPT codes that apply to Type A EDs - 99281-99285, and five Level II HCPCS G codes that apply to Type B EDs - G0380-G0384.
  • A Type A ED is available to provide services 24 hours a day, 7 days a week, and meets one or both of the following EMTALA requirements for dedicated EDs as specified at 42 CFR 489.24(b), specifically:
  • It is licensed by the state in which it is located under the applicable state law as an emergency room or ED

      Or

  • It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.
  • A Type B ED is a dedicated ED that still has EMTALA obligations but it does not meet the CPT definition of an ED.
  • For CY 2012, CMS continues to believe that this configuration pays hospital EDs appropriately based on analysis of resource data from 2010 claims.

 

Comparison of 2011 OPPS Payments vs. 2012 Payments and APCs - ED Type A and Type B Visits

 

Type A ED Visits, from Appendix B

 

Type A Emergency Department Visit HCPCS Code

2011

2012

Payment Difference

APC

Payment Rate

APC

Payment Rate

Level 1-- 99281

609

$51.77

609

 $50.61

($1.16)

Level 2-- 99282

613

$87.25

613

$86.25

($1.00)

Level 3-- 99283

614

$139.14

614

$137.24

($1.90)

Level 4-- 99284

615

$222.58

615

$220.86

($1.72)

Level 5-- 99285

616

$329.54

616

$328.24

($1.30)

Critical Care-- 99291

617

$464.75

617

$473.25

$8.50

Critical Care w/Trauma Team Activation--G0390

618

$924.48

618

$808.06

($116.42)

 

Type B ED Visits, from Appendix B

Type B Emergency  Department Visit HCPCS Code

2011

2012

Payment Difference

APC

Payment Rate

APC

Payment Rate

Level 1-- G0380

626

$41.36

626

$39.38

($1.98)

Level 2-- G0381

627

$59.23

627

$56.81

($2.42)

Level 3-- G0382

628

$101.52

628

$90.43

($11.09)

Level 4-- G0383

629

$165.48

629

$136.42

($29.06)

Level 5-- G0384

616

$273.24

630

$261.30

($11.94)

Critical Care-- 99291

617

$464.75

617

$473.25

$8.50

Critical Care w/Trauma Team Activation-- G0390

618

$924.48

618

$808.06

($116.42)

 

Critical Care Services 

  • The CPT codes 99291 and 99292, and the HCPCS G code describing critical care services provided with trauma team activation - G0390, will continue to be recognized (page 764).
  • Because the median cost data for critical care services are based upon CY 2010 claims data, which packages the designated CPT "bundled" procedures, for 2012 CMS will not pay for these critical care procedures separately; this will include procedures such as x-rays, pulse oximetry, and transcutaneous pacing.
  • Hospitals may still report these bundled CC procedures; CMS implemented a claims processing edit to avoid overpayments.

 

Observation

  • For CY 2012, Observation services will continue to be reported with the HCPCS G code, G0378, and paid by Medicare using composite APCs 8002 and 8003 (page 175).
  • CMS continues to believe that the composite APCs and related policies provide the most appropriate means of paying for Observation services.

 APC 8002 Level I Extended Assessment and Management Composite

APC 8002 requires a level 99205 or 99215 clinic visit on the day of or the day before observation or a direct referral to observation code - G0379, at least 8 units of G0378 and no procedure with a status indicator of T.  The payment rate for 2012 is $393.15.

APC 8003 Level II Extended Assessment and Management Composite

APC 8003 requires a level 99284 or 99285 ED visit, a level 5 Type B ED visit - G0384, or 99291 critical care to be reported on the day of or day before observation, at least 8 units of G0378 and no procedure with a status indicator of T.  The payment rate for 2012 is $720.64.

    

 

Procedures and Services

Supervision of Outpatient Services Furnished in Hospitals and CAHs (page 820)

Medicare defines supervision in the hospital outpatient setting for direct and general supervision.  General supervision has been defined only as it applies to the provision of nonsurgical extended duration therapeutic services, such as observation.  For these services CMS requires direct supervision during an initiation period, followed by a minimum standard of general supervision for the duration of the service (75 FR 72012).

Under the OPPS, general supervision means that the service is furnished under the overall direction and control of the physician or appropriate non-physician practitioner (NPP), but his or her physical presence is not required during the performance of the service. Direct supervision means that the physician or NPP is immediately available to furnish assistance and direction throughout the performance of a therapeutic service or procedure; however, he or she does not have to be present in the room where the service or procedure is being performed.

CMS will establish an independent advisory body who will recommend the appropriate supervision levels for therapeutic services provided in a hospital outpatient department. Under the OPPS, general supervision means that the service is furnished under the overall direction and control of the physician or appropriate non-physician practitioner (NPP), but his or her physical presence is not required during the performance of the service. Direct supervision means that the physician or NPP is immediately available to furnish assistance and direction throughout the performance of a therapeutic service or procedure; however, he or she does not have to be present in the room where the service or procedure is being performed.CMS will establish an independent advisory body who will recommend the appropriate supervision levels for therapeutic services provided in a hospital outpatient department. 

 

 

 

  

Blood Transfusion Services

There were no changes to blood transfusion services for CY 2012.  

 

Frequently Performed ED Procedures and Services

 

CPT/HCPCS codes

Description

2011 National Payment Rate

2012 National Payment Rate

Difference

96365

Therapeutic /prophylactic/diagnostic  iv infusion, initial

$128.44

$132.71

$4.27

96366

Therapeutic /prophylactic/diagnostic  iv infusion, add on

$26.35

$26.24

($0.11)

96367

Therapeutic /prophylactic/diagnostic  additional sequential iv infusion

$36.88

$36.65

($0.23)

96368

Therapeutic / prophylactic/diagnostic concurrent infustion

$0.00

$0.00

__

96372

Therapeutic /prophylactic/diagnostic  injection, SC/IM

$26.35

$26.24

($0.11)

96374

Therapeutic /prophylactic/diagnostic  injection, iv push

$36.88

$36.65

($0.23)

96375

Therapeutic /prophylactic/diagnostic  injection new drug add on

$36.88

$36.65

($0.23)

96360

Hydration iv infusion, initial

$75.58

$73.22

($2.36)

96361

Hydration iv infusion, add-on

$26.35

$26.24

($0.11)

12001

Repair superficial wound(s)

    $91.81    

$84.27

($7.54)

12002

Repair superficial wound(s)

$91.81

$84.27

($7.54)

12011

Repair superficial wound(s)

$91.81

$84.27

($7.54)

29125

Apply forearm splint

$77.15

$78.99

$1.84

29515

Application lower leg splint

$77.15

$78.99

$1.84

31500

Insert emergency airway

$163.04

$158.09

($4.95)

51702

Insert temp bladder catheter

$46.23

$46.78

$0.55

71020

2-view CXR

$45.04

$44.55

($0.49)

93005

Electrocardiogram, tracing

$27.26

$27.04

($0.22)

 


 

Hospital Outpatient Quality Reporting

Quality Reporting Measures (page 1069)


The reporting program for hospital outpatient quality measures, known as the Hospital Outpatient Quality Reporting (Hospital OQR) Program has been generally modeled after the inpatient quality reporting program.  The proposed and final rules for 2012 contain a significant amount of information about this program and its requirements, which can be found in section XIV. E and also at the QualityNet website: http://www.QualityNet.org.  

There are revisions to measures previously adopted for the Hospital OQR Program beginning with CY 2012 and further changes are planned for both CY 2013 and CY 2014. Hospitals need to be aware that when CMS discusses measures as being relevant to a specific year’s payment update the measure must be reported in the preceding year: the measures affecting the 2013 payment update will need to be reported in 2012. 

The 2012 OPPS final rule contains information regarding the history of measures adopted for the Hospital OQR Program.  Plans for quality reporting in 2012 and moving forward include:

  • 11 total measures adopted for the CY 2011 payment determination
  • 15 total measures adopted for the CY 2012 payment determination
  • 23 total measures adopted for the CY 2013 payment determination
  • 25 total measures adopted for the CY 2014 payment determination

The table below outlines the quality measures for reporting in CY 2012 through 2014

CY 2014 Hospital OQR Program Measure Set Reflecting Measures Previously Adopted and the Additions in this Final Rule with Comment Period

OP-1

Median Time to Fibrimolysis

OP-2

Fibrinolytic Therapy Received Within 30 Minutes

OP-3

Median Time to Transfer to Another Facility for Acute Coronary Intervention

OP-4

Aspirin at Arrival

OP-5

Median Time to ECG

OP-6

Timing of Antibiotic Prophylaxis

OP-7

Prophylactic Antibiotic Selection for Surgical Patients

OP-8

MRSI Lumbar Spine for Low Back Pain

OP-9 Mammography Follow-up Rates
OP-10 Abdomen CT-Use of Contrast Material
OP-11 Thoraz CT-Use of Contrast Material
OP-12 The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into their Qualified Certified EHR System as Discrete Searchable Data*
OP-13 Cardiac Imaging for Preoperative Risk Assessment for Non-Cardiac Low-Risk Surgery*
OP-14 Simultaneous Use of Brain Computed Tomography (CT) and Sinus Computed Tomography (CT)*
OP-15 Use of Brain Computed Tomography (CT) in the Emergency Department for Atraumatic Headache*
OP-16      Troponin Results for Emergency Department acute myocardial infarction (AMT) patients or chest pain patients (with Probable Cardiac Chest Pain) Received Within 60 minutes of Arrival**
OP-17 Tracking Clinical Results between Visits**
OP-18   Median Time from ED Arrival to ED Departue for Discharged ED Patients**
OP-19    Transition Record with Specified Elements Received by Discharged Patients**
OP-20     Door to Diagnostic Evaluation by a Qualified Medical Professional**
OP-21      ED-Median Time to Pain Management for Long Bone Fracture**
OP-22   ED-Patient Left Before Being Seen**
OP-23     ED-Head CT Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke who Received Head CT Scan Interpretation Within 45 minutes 
OP-24 Cardiac Rehabilitation Patient Referral From an Outpatient Setting***
OP-25 Safety Surgery Checklist***

*Measures #12 through #15 are new measures being adopted with the 2012 payment determination.

**Measures #16 through #23 will be reported in 2012 for 2013 payment determination.

*** Measures #24 and #25 will be added for reporting in 2013 and 2014 for the following year's payment determination.

 

Other Important Points About OP Hospital Quality Reporting

1. As with the physician quality reporting program, PQRS, CPT and ICD-9 codes are used to identify the patient population included in the quality measures.
2. The reporting specifications and requirements are complex and vary by measure. These can be found on the CMS or QualityNet websites and in the Hospital OQR Specifications Manual: http://www.QualityNet.org.
3. There are three types of quality measures: Process, Outcome and Structural and three categories of measures:
• Chart abstraction measures (measures 1, 2, 3, 4, 5, 6, 7, 16, 18, 19, 20, 21, 22 and 23)—data is submitted quarterly; applies to all patients, irrespective of payer.  Hospitals can choose to include the entire population of applicable patients (per CPT and ICD-9s) or use a statistically valid random sample. The required sample size for measures varies by the size of the total population of applicable patients—the hospital’s sample size must meet or exceed the CMS specified quarterly sample size.  Many hospitals use electronic medical records to make this process more efficient.
• Claims-based measures (measures 8, 9, 10, 11, 13, 14 and 15) apply only to Medicare fee-for-service claims and patients.
• Structural measures (measures 12, and 17) are usually reported thorough QualityNet. These measures assess operational conditions or processes in the hospital outpatient department.
4. CMS provides a financial incentive for hospitals to participate in the quality reporting program.  Failure to accurately or sufficiently report measures will result in a 2% reduction in the following year’s Medicare payments (conversion factor).  CMS has made provision for an extraordinary circumstances waiver for hospitals that are unable to report quality measures due to circumstances beyond their control.
5. CMS reports quality data on the Hospital Compare website site:    http://www.hospitalcompare.hhs.gov, where it is available for providers, employers and the general public.   Claims-based and structural measures are updated annually; abstracted measures are updated quarterly.

Electronic Health Record Incentive Program (page 1205)

CMS confirmed that eligible hospitals and Critical Access Hospitals (CAHs) may continue to report clinical quality measures and results as calculated by certified EHR technology.
Eligible hospitals and CAHs participating in the Electronic Reporting Pilot will report data based on a pilot measurement period of one full Federal fiscal year (October 1, 2011 through September 30, 2012), regardless of whether the eligible hospital or CAH is in its first year of participation in the Medicare and Medicaid EHR Incentive Programs.
The period for submission of data and or information under the Electronic Reporting Pilot will be October 1, 2012 through November 30, 2012 (60 days following the close of the measurement period).

Additional details including educational materials about participation in the proposed Electronic Reporting Pilot are provided for review on the Quality Net Web site at http://www.qualitynet.org.

 

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