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Archive for November, 2013

CMS Publishes OPPS/ASC Final Rules for 2014

Wednesday, November 27th, 2013

On November 27, 2013, the Centers for Medicare & Medicaid Services (CMS) finalized the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) rules updating Medicare payment policies and rates for hospital outpatient and ASC services beginning January 1, 2014. Total CY 2014 OPPS payments are projected to increase by $4.4 billion or 9.5 percent, and CY 2014 Medicare payments to ASCs are projected to increase by approximately $143 million or 5.3 percent as compared to CY 2013.

The final rule updates the OPPS market basket by 1.7 percent for CY 2014; the ASC payments update is 1.2 percent. The annual update is reduced by two percent for ASCs that fail to meet ASC Quality Reporting Program requirements.

The final rule expands the categories of related items and services packaged into a single payment for a primary service under the OPPS. When the OPPS began in 2000, the payment system provided for the packaging of a limited number of items and services, such as anesthesia and surgical supplies. CMS expanded the categories of packaged items and services in 2008 and 2009 by adding a number of additional categories, including image processing services and implantable biologicals. CMS had proposed to package an additional seven categories of services for 2014. However, based on public comments, CMS decided not to finalize packaging of two of the seven proposed categories. This final rule with comment period expands the categories of packaged items and services by adding five additional categories of supporting services. In addition to packaging these five categories, CMS proposed to create 29 comprehensive APCs to replace 29 existing device-dependent APCs for 2014.  After considering public comment, CMS is finalizing this policy with a delayed implementation date of CY 2015.

In addition, the final rule streamlines the current five levels of outpatient clinic visit codes, replacing them with a single Healthcare Common Procedure Coding System (HCPCS) code describing all clinic visits. A single code and payment for clinic visits is more administratively simple for hospitals and better reflects hospital resources involved in supporting an outpatient visit. The current five levels of outpatient visit codes are designed to distinguish differences in physician work. However, the final rule does not finalize the proposal to replace the current five levels of codes for each type of emergency department visits. CMS intends to consider options to improve the codes for these services in future rulemaking.

The rule also finalizes the proposal to continue paying at ASP+6 percent for non-pass-through drugs and biologicals that are payable separately under the OPPS.

The rule finalizes the proposal to update the two payment rates for community mental health centers and the two payment rates for hospital-based PHPs (partial hospitalization programs). For community mental health centers, the final CY 2014 geometric mean per diem cost for Level I (three services) is $99 and for Level II (four or more services), $112. For hospital-based PHPs, the final CY 2014 geometric mean per diem cost is $191 for Level I and $214 for Level II.

The rule finalizes four new measures for the Outpatient Quality Reporting (OQR) program, affecting the payment determination for CY 2016 and subsequent years, with data collection beginning in CY 2014:

- Influenza Vaccination Coverage among Healthcare Personnel

- Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average-Risk Patients.

- Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use

- Cataracts: Improvement in Patient’s Visual Function Within 90 Days Following Cataract Surgery

The final rule also removes two measures for the CY 2015 payment determination and subsequent years:

- Transition Record with Specified Elements Received by Discharged ED Patients

- Cardiac Rehabilitation Measure: Patient Referral from an Outpatient Setting

These final rules were published in the December 10 Federal Register and may be accessed here:  https://federalregister.gov/a/2013-28737

2014 MPFS Final Rule Released

Wednesday, November 27th, 2013

On November 27, 2013, the Centers for Medicare & Medicaid Services (CMS) issued a final rule with comment period updating Medicare payment policies and rates for physicians. The Medicare Physician Fee Schedule (MPFS) final rule includes a statutorily required 20% reduction to Medicare payment rates under the Balanced Budget Act of 1997’s Sustainable Growth Rate (SGR) methodology. The conversion factor for 2013 will be $27.0006. CMS projects that total payments under the fee schedule in 2014 will be approximately $87 billion.

As part of CMS’ continuing effort to recognize the critical role primary care plays in providing care to beneficiaries with multiple chronic conditions, beginning in 2015 the agency is establishing separate payments for managing a patient’s care outside of a face-to-face visit for practices equipped to provide these services.

The 2014 payment rates increase payments for many medical specialties with some of the greatest increases going to providers of mental health services including psychiatry, clinical psychologists and clinical social workers.

CMS is finalizing a process to adjust payment rates for test codes on the Clinical Laboratory Fee Schedule (CLFS) based on technological changes. Currently, the payment rates for test codes on the CLFS do not change once they have been set (except for changes due to inflation and other statutory adjustments). This review process will enable CMS to pay more accurately for laboratory tests on the CLFS.

The final rule also includes several provisions regarding physician quality programs and the Physician Value-Based Payment Modifier (Value Modifier). As CMS continues to phase in the Physician Value-Based Payment Modifier for 2016, CMS is finalizing its proposals to apply the Physician Value Modifier to groups of physicians with 10 or more eligible professionals, and to apply upward and downward payment adjustments based on performance to groups of physicians with 100 or more eligible professionals. However, only upward adjustments based on performance (not downward adjustments) will be applied to groups of physicians with between 10 and 99 eligible professionals.

CMS is also finalizing several related proposals to the Physician Quality Reporting System (PQRS) for 2014, including a new option for individual eligible professionals to report quality measures through qualified clinical data registries. In 2014, quality measures will be aligned across quality reporting programs so that physicians and other eligible professionals may report a measure once to receive credit in all quality reporting programs in which that measure is used. Additionally, CMS is better aligning PQRS measures with the National Quality Strategy and meaningful use requirements, and transitioning away from process measures in favor of performance and outcome measures. Finally, certain data collected in 2012 for groups reporting certain PQRS measures under the Group Practice Reporting Option (GPRO) will be publicly reported on the CMS Physician Compare website in 2014.

The final rule was published in the Federal Register on December 10 and may be accessed here: https://federalregister.gov/a/2013-28696


ESRD Rule Finalized

Friday, November 22nd, 2013

The Centers for Medicare & Medicaid Services (CMS) issued a final rule that updates Medicare policies and payment rates for 2014 for dialysis facilities paid under the End Stage Renal Disease (ESRD) Prospective Payment System (PPS). CMS received extensive public comment on the proposed rule issued in July. CMS carefully reviewed the comments and has decided to implement a three- to four-year transition for the drug utilization adjustment to the base rate mandated by Congress as part of the American Taxpayer Relief Act. Overall payments for 2014 will see a zero percent change.

The rule also finalized a 50 percent increase to the home dialysis training add-on payment adjustment that is made for both peritoneal dialysis and home hemodialysis training treatments.

The final rule will also strengthen the ESRD Quality Incentive Program (QIP), which creates incentives for dialysis facilities to improve the quality of care and patient outcomes for beneficiaries diagnosed with ESRD. For the ESRD QIP Payment Year (PY) 2016 program (which will rely on measures of dialysis facility performance during 2014), CMS is finalizing 11 measures addressing infections, anemia management, dialysis adequacy, vascular access, mineral metabolism management, and patient experience of care. CMS is also finalizing the method by which performance scores will be calculated by weighting clinical measures at 75 percent of the total performance score and weighting the reporting measures at 25 percent. The ESRD QIP will reduce payments to ESRD facilities that do not meet or exceed certain performance standards.

Additionally, the final rule includes several provisions related to Medicare policies on durable medical equipment (DME). CMS is a finalizing clarification of the 3-year minimum lifetime requirement for DME and the distinction between routinely purchased and capped rental DME. The rule also finalizes the implementation of budget-neutral fee schedules for splints and casts, and intraocular lenses inserted in a physician’s office as well as a few technical amendments and corrections to existing regulations related to payment for durable medical equipment, prosthetics, and orthotics items and services.

This final rule was published in the Federal Register on December 2 and may be accessed here: https://federalregister.gov/a/2013-28451

Final 2014 Home Health Rule Published

Friday, November 22nd, 2013

On November 22, the Centers for Medicare & Medicaid Services (CMS) issued the final calendar year (CY) 2014 home health care payment final rule. The CY 2014 final rule reduces Medicare payments under the Home Health Prospective Payment System (HH PPS) by 1.05 percent. This amount reflects the combined effects of an increase in the home health payment update percentage of 2.3 percent, offset by a decrease of 2.7 percent and a 0.6 percent decrease due to a refinement of the HH PPS Grouper.

As required by the Affordable Care Act (ACA), CMS must begin phasing in rebasing adjustments to the national standardized 60-day episode payment rate, the national per-visit payment rates, and the NRS conversion factor to reflect changes since the inception of the HH PPS, such as change in the number of visits in an episode, the mix of services in an episode, the level of intensity of services in an episode, the average cost of providing care per episode, and other relevant factors.

The final rule adds two new quality measures, which will require HHAs to report unnecessary hospital readmission rates and preventable trips to the emergency room. These measures support critical reforms laid out in the Affordable Care Act. The final rule reduces the number of home-health quality measures reported by home health agencies.

This final rule was published in the Federal Register on December 2 and may be accessed here: https://federalregister.gov/a/2013-28457 


President Announces Surgeon General Nominee

Friday, November 15th, 2013

On November 14, President Obama announced his intent to nominate Dr. Vivek Hallegere Murthy to the post of Surgeon General. Dr. Murthy is the Co-Founder and President of Doctors for America, a position he has held since 2009.  Dr. Murthy is also a Hospitalist Attending Physician and Instructor in Medicine at Brigham and Women’s Hospital at Harvard Medical School, a position he has held since 2006.  In 2011, Dr. Murthy was appointed to serve as a Member of the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health.  Dr. Murthy has been the Co-Founder and Chairman of the Board of TrialNetworks, formerly known as Epernicus, since 2007.  Dr. Murthy co-founded VISIONS Worldwide in 1995, a non-profit organization focused on HIV/AIDS education in India and the United States, where he served as President from 1995 to 2000 and Chairman of the Board from 2000 to 2003.  Dr. Murthy received a B.A. from Harvard University, an M.B.A. from Yale School of Management, and an M.D. from Yale School of Medicine.

The press release can be found by going to http://www.whitehouse.gov/the-press-office/2013/11/14/president-obama-announces-more-key-administration-posts

Initial Report on Health Insurance Marketplace Enrollment Issued

Thursday, November 14th, 2013

According to a report released by the Department of Health and Human Services (HHS), an estimated 106,185 people selected a health plan through the new Health Insurance Marketplaces from October 1 through November 2. About three-quarters of them selected a plan through a state-based marketplace and the rest through a federally-facilitated marketplace. HHS anticipates that more comprehensive data will be available in future monthly reports as information system issues are resolved.

The report can be viewed at http://aspe.hhs.gov/health/reports/2013/MarketPlaceEnrollment/rpt_enrollment.pdf.

Virtual Research Data Center Launched

Tuesday, November 12th, 2013

The Centers for Medicare & Medicaid Service (CMS) has announced the launch of the CMS Virtual Research Data Center (VRDC), which will allow researchers to virtually access and analyze CMS health care data. Until now, researchers’ data requests were prepared and shipped via encrypted data files. However, because of the demand for more timely Medicare and Medicaid data, CMS needs a less resource-intensive means of responding to data requests from researchers. The VRDC will assist in meeting these demands while ensuring data privacy, security, and reducing the cost of data access.

Details bout the VRDC can be found in the “CMS Virtual Research Data Center FAQs” at www.resdac.org

CMS Updates ICD-10 Resources

Thursday, November 7th, 2013

The Centers for Medicare & Medicaid Services (CMS) has posted a draft ICD-10 definitions manual and code editor for the fiscal year 2014 Medicare Severity-Diagnosis-Related Groups (MS-DRG, Version 31). Health care providers can use the manual and editor, available under “downloads,” to better understand the impact of the ICD-10 coding system for medical diagnoses and inpatient procedures on the MS-DRG system. Hospitals and other entities covered by the Health Insurance Portability and Accountability Act (HIPAA) must convert to the ICD-10 coding system by October 1, 2014.

For more information, visit http://cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html

Ordering and Referring Denial Edits to be Implemented

Thursday, November 7th, 2013

Beginning January 6, the Centers for Medicare & Medicaid Services (CMS) will automatically deny certain Medicare claims for clinical laboratory tests, imaging procedures, and durable medical equipment and supplies if they do not contain a valid National Provider Identifier (NPI) for the ordering or certifying physician or eligible professional.  The requirement was included in an April 2012 final rule implementing several program integrity provisions of the Patient Protection and Affordable Care Act (ACA), but delayed to give physicians and EPs more time to enroll in the Medicare program or to revalidate their Medicare enrollment. The provision generally only impacts hospitals with home health agencies or enrolled as durable medical equipment suppliers.

For more information, see the Medicare Learning Network article at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf.

FAQ Document on Two-midnight Policy Published

Wednesday, November 6th, 2013

The Centers for Medicare & Medicaid Services (CMS) has published a frequently asked questions (FAQ) document about its two-midnight policy for hospital inpatient medical review and admissions criteria. These questions were received from hospitals and verbally reviewed by CMS at its September 26 Open Door Forum.

The document can be viewed at http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/QAsforWebsitePosting_110413-v2-CLEAN.pdf