by Bonnie Kirschenbaum, MS, FASHP, FCSHP
This year, due to the federal government shutdown, the final Outpatient Prospective Payment System (OPPS) rule was released at the end of November—so cancer programs have less time than usual to prepare for changes that will go into effect on Jan. 1, 2014. Last week, ACCC held a conference call for members with analysis of the final 2014 OPPS and Physician Fee Schedule (PFS) rules. And it’s clear from the call that cancer programs have plenty of homework to do.
Here are 5 things to do for 2014, organized by OPPS payment category.
1. New drugs not yet assigned unique Healthcare Common Procedure Coding System (HCPCS) codes. When an injectable drug first comes to market and has pass-through status, it may not yet have a HCPCS code assigned to it. Instead, it will be paid for at 95% of average wholesale price (AWP) using code C9399, unclassified drugs or biologics, along with the National Drug Code (NDC) number of the drug. Homework: This coding procedure and payment rate remains for 2014, but you must report the NDC to identify the drug.
2. New pass-through drugs with HCPCS codes. If a new drug is assigned a HCPCS code at or after FDA approval, it must be used. No payment will be made if the miscellaneous unclassified code persists in your system. Homework: Scour your files to remove and replace miscellaneous codes.
3. Specified covered outpatient drugs (SCODs) costing more than $90 per day. This reimbursement “basket” is where the majority of drug payment lies and where most drugs land once their pass-through status expires. Accurate billing is critical for these drugs. Homework: Make sure HCPCS codes, billing unit assignments, and conversions from actual dose given to billing units submitted are faultless!
4. Lower-cost packaged products costing less than $90 per day. There is no separate reimbursement for these products; payment for them is included in the bundled payment for the specific procedure or visit for which they were used. However, they must be billed as separate line items to ensure adequate payment for the bundle and, if they were administered as infusions, to ensure payment for drug administration (which is available separately from the bundle). Homework: Keep on documenting and billing for these drugs!
5. Drugs with pass-through status. The usual annual reworking of pass-through drugs resulted in 14 drugs and biologicals losing their pass-through status effective Dec. 31, 2013. Interestingly, only 9 of these products will be separately paid for in 2014, and 5 no longer will be separately reimbursed (see Table 32 in the final OPPS rule). Drugs and biologicals keeping or newly assigned pass-through status (see the list of 26 in Table 33 in the final OPPS rule) will have their pass-through payment rates reviewed on a quarterly basis with payment adjustment as needed. Homework: Several 2014 HCPCS codes have changed, as well as the status indicators which will indicate whether or not there is separate payment in 2014. Ensure that these HCPCS code changes are part of your IT systems.
Of course payments will be reduced by approximately 2% for as long as sequestration remains in effect. Counteract this by ensuring accuracy in the areas discussed above!
ACCC members can access an archived conference call and analysis of the 2014 Medicare rules here. Look for an in-depth discussion of the rules in your January/February Oncology Issues.
Bonnie Kirschenbaum, MS, FASHP, FCSHP, is a healthcare consultant and columnist, and serves on the editorial board for ACCC’s Oncology Drug Reference Guide.
By Matt Farber, MA, Director Provider Economics and Public Policy, ACCC
On Friday, September 6, ACCC formally submitted comments to the Centers for Medicare & Medicaid Services (CMS) on the 2014 Physician Fee Schedule and the Hospital Outpatient Prospective Payment System proposed rules. ACCC has numerous concerns about proposals included in each of the rules, and the public comment period is an important opportunity to voice those concerns. If CMS does not hear from organizations such as ACCC, the agency may believe that its proposals will not adversely impact community oncology. Some of the key issues we focused on in our comments are outlined below.
Physician Fee Schedule. In its comments, ACCC asked that CMS:
- Work with Congress to develop a long-term fix to the Sustainable Growth Rate (SGR) formula and avert a 24.4 percent reduction to the conversion factor in 2014;
- Work with ACCC to study the issue of payment for services rendered in off-campus hospital-based departments;
- Apply adjustments to the work relative value units (RVUs) instead of the conversion factor to reflect changes in the Medicare Economic Index (MEI);
- Exercise caution when reviewing codes it identifies as potentially misvalued;
- Implement the proposal to create a new G-code for complex chronic care management services that meet certain standards; and
- Not implement the proposed cap on PFS non-facility payments using facility rates calculated under the Hospital Outpatient Prospective Payment System (OPPS) or Ambulatory Surgical Center (ASC) payment systems.
ACCC has great concern about the proposal to cap the PFS payments using rates from the hospital outpatient department or ambulatory surgical center settings. Our concern is that, for some codes, CMS is reducing payments based on procedures that are rarely given in certain sites of service. CMS also proposes to apply the cap when as little as five percent of the total volume of services are furnished in the hospital outpatient setting. Analysis of the proposed rates indicates that CMS often set the cap using ASC rates, even though the volume of services in that setting was far below five percent. This extremely low threshold does not help ensure that the capped rates accurately reflect typical costs for providing the service in either the physician office or facility setting. Further, when the Medicare Payment Advisory Commission (MedPAC) recommended that CMS cap certain hospital outpatient payments at the rates applicable in physician offices or ASCs, it recommended a threshold of 50 percent of claims in the setting used to establish the cap to ensure that payment rates are sufficient to protect access to care. ACCC believes that CMS’s proposal is unnecessary, and we are asking the agency to provide justification for its choice of site of service for setting payments.
OPPS Proposed Rule. ACCC asks that CMS:
- Implement the proposal to reimburse hospitals for the acquisition cost of separately payable drugs at ASP+ 6%;
- Make separate payment for all drugs with HCPCS codes, or, at a minimum, not increase the packaging threshold for drugs;
- Not implement the proposal to change the calculation for payment rates of computed tomography (CT) scans and magnetic resonance imaging (MRI);
- Not implement the proposal to consolidate clinic and emergency department evaluation and management (E&M) codes from five levels to one level; and
- Not implement the proposal to expand packaging for additional items and services until the agency corrects the significant errors and inconsistencies in the proposed rates, provides opportunity to comment on the corrections and clarifications, and reviews those comments.
In the 2014 proposed OPPS rule, CMS made some drastic moves to increase the amount of bundling in the hospital outpatient department. ACCC believes that the proposals will adversely impact cancer care. Of particular concern are proposals for the consolidation of E&M codes, changes to the calculation for payment rates of CT and MRI, and additional packaging of drug administration services. Added to these concerns is the fact that ACCC and other organizations believe there are significant errors in the proposed rates. We fear that these errors would further decrease reimbursement to critical areas of oncology care. Included with ACCC’s comments are memos from numerous experts that echo the same concerns about the validity of the data. The Hospital Payment Advisory Panel (HOP) agreed with ACCC and other stakeholders at its meeting last month, and recommended that CMS delay its proposals until the agency could verify these data. At a minimum, ACCC asks that CMS delay these proposals. Ultimately, however, it is our hope that CMS will listen to the stakeholders’ concerns and opt not to implement many of the packaging proposals.
We are reminded, once again, of the importance of public comments to these proposed rules. Unless ACCC and other organizations submit comments to CMS, these issues might never have come to light. If you are interested in learning more, or possibly submitting comments in the future, please contact me at email@example.com
On July 8, the Centers for Medicare & Medicaid Services (CMS) released the 2014 Physician Fee Schedule (PFS) and the Outpatient Prospective Payment System (OPPS) proposed rules. ACCC is currently reviewing the rules and preparing detailed summaries for its membership. On Wednesday, July 24, from 2:00 – 3:00 pm ET, ACCC will host a conference call for members to review the rules and their potential impact on community oncology. ACCC members should be on the lookout next week for an email with the call-in details for the conference call.
At first glance, what’s on the horizon for 2014? Not surprisingly, there are some positives and some negatives.
On the positive side, under the 2014 OPPS proposed rule, drug reimbursement will remain at the current level of ASP+ 6%. Under the 2014 PFS proposed rule, medical oncology will see about a 1% reduction in Medicare payments.
The news is less positive for radiation oncology, which faces a 5% cut in Medicare payments under the proposed 2014 Physician Fee Schedule. These cuts are due to several factors, including a change in the utilization rate for equipment—from 75 percent to 90 percent—that was mandated by the American Taxpayer Relief Act of 2012. CMS is also reviewing potentially misvalued codes, and the agency is seeking comments on how best to analyze the effects that consolidation has had on the Medicare system. As in both the proposed 2014 Inpatient Prospective Payment System (IPPS) rule and the proposed 2014 PFS, under the 2014 OPPS proposed rule radiation oncology will also see cuts. Most, if not all, of the APCs associated with MRI and CT testing will see double digit decreases in 2014. (Read ACCC’s comment letter to CMS on the IPPS 2014 Proposed Rule and Use of Separate Cost Centers for CT Scans and MRI Imaging here.)
Stay tuned for summaries and analysis from ACCC of the 2014 proposed PFS and OPPS rules. ACCC members, please join us on July 24 for our conference call on the rules.