• Insight
  • Medicare Coverage Gap Discount Program Guidance Beginning in 2011
  • CMS Proposed 2011 Policies and Payment Rates for Inpatient Services
  • CMS Issues Final 2011 Payment Policies for Medicare Advantage and Prescription Drug Plans
  • OPPS 2010 Rule Update
  • MPFS 2010 Rule Update
  • OIG releases CY 2010 Work Plan – Is your brand at risk?
  • Medicare Administrative Contractor Protest Update
  • Health Economics and Reimbursement
  • The Impact of ICD-10 on MS-DRGs

OPPS 2010 Rule Update

On Friday, October 30, 2009, the Centers for Medicare and Medicaid Services (CMS) released a display copy of its final calendar year (CY) 2010 policy for updating payment policies and rates for hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASC) that would take effect on January 1, 2010. This final rule affects more than 4,000 hospitals and 5,000 ASCs that receive payment for outpatient services under the Outpatient Prospective Payment System (OPPS).

Some major topics discussed in the rule include:

Most hospitals will receive a 2.1 percent increased inflation update to their payment rates for services to Medicare beneficiaries in the outpatient departments. Services furnished in ASC setting of care will receive a 1.2 percent increase.

Payment for Drugs and Biologicals

• The Bundling Threshold finalized for CY 2010 is $65, an increase of $5 from CY 2009.
• CMS finalized its proposal to make a single packaging determination for a product, rather than an individual HCPCS code, when a product has multiple HCPCS codes describing different dosages.
• In CY 2010, six drugs and biologicals will be removed from pass-through payment status, while 31 will continue to receive pass-through payment status.
• In CY 2010, drugs and biologicals with pass-through status will continue to be paid at a rate of ASP+6 percent.
• In CY 2010, CMS will pay for nonpass-through separately payable drugs and biologicals at a rate of ASP+4 percent. This payment rate accounts for both the acquisition cost and the pharmacy overhead costs applicable to these products. 
• In the event that the Part B drug competitive acquisition program (CAP) is reinstated in CY 2010, the Part B drug CAP rate will apply to drugs covered under this program.

Payment for 5-HT3 antiemetics

• In CY 2010, CMS will no longer pay separately for dolasetron mesylate, granisetron hydrochloride, or ondansetron hydrochloride when administered in the hospital outpatient setting. 

Payment of Implantable biologicals

• Beginning in CY 2010, implantable biologicals will no longer be eligible for biological pass-through payment at ASP+6 percent. Since implantable biologicals have been viewed as similar to devices due to their surgical nature, they will be eligible for device pass-through payment and would be paid under the cost-to-charge methodology used for all pass-through device categories.

Payment for Drug Administration Services

• For CY 2010, payment for drug administration services will continue to be based according to the five-level Ambulatory Payment Classification (APC) structure used in CY 2009

Proposed ASC Payment System

• Payment for items and services ancillary to a covered surgery which are paid separately under OPPS will continue mirror the payment available under OPPS.
• The 2010 ASC conversion factor will be updated for inflation by 1.2 percent. Payments for covered surgical procedures will follow the established rate setting methodology.
• CMS has added 26 procedures to the ASC list of covered surgical procedures and re-designated 6 procedures as permanently office based.

HAC (Hospital Acquired Conditions)

• Continuing with current policy, a list of HACs will not be implemented for CY 2010.  There is ongoing discussion of implementation of such policy in the future.

Quality Reporting initiative

• To receive the CY 2010 2.1 percent payment update, hospitals are required to submit data on certain quality measures. Failure to do so results in a reduction of the 2010 payment update by two percentage points, resulting in net increase of payment of only 0.1% for outpatient services performed in 2010.

The CY 2010 OPPS/ASC final rule will be published in the November 20, 2009 Federal Register. CMS is accepting comments on the final rule until December 29, 2009, and responses to these comments will appear in the CY 2011 OPPS/ASC final rule.  New payment rates and policies published in the final rule will apply to services furnished to Medicare beneficiaries beginning January 1, 2010.

For more information on any of these rule changes, or for an in-depth analysis of the impacts on your product, contact The Aequitas Group today.