FACT SHEET
FOR IMMEDIATE RELEASE Contact: CMS Media Relations
July 8, 2013
CMS PROPOSES HOSPITAL OUTPATIENT AND AMBULATORY SURGICAL CENTERS POLICY AND PAYMENT CHANGES FOR 2014
The Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2014 Hospital
Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical
Center (ASC) Payment System Policy Changes and Payment Rates proposed rule [CMS-1601-P] on July 8, 2013.
The
proposed rule with comment period would update Medicare payment
policies and rates for hospital outpatient department and ASC services,
and update and streamline programs that encourage high-quality
care in these outpatient settings consistent with policies included in
the Affordable Care Act. Total CY 2014 OPPS payments are projected to
increase by $4.37 billion or 9.5 percent, and CY 2014 Medicare payments
to ASCs are projected to increase by approximately $133 million or 3.51
percent as compared to CY 2013.
Overview
More
than 4,000 hospitals, including general acute care hospitals, inpatient
rehabilitation facilities, inpatient psychiatric facilities, long-term
acute care hospitals, children’s hospitals, and cancer hospitals are
paid under the OPPS. There are approximately 5,000
Medicare-participating ASCs paid under the ASC payment system.
The
OPPS is currently a hybrid of a prospective payment system and a
fee‑for‑service system, with some payments representing costs packaged
into a primary service and other payments representing the cost of a
particular item, service, or procedure. Payment amounts vary according
to the Ambulatory Payment Classification (APC) group to which a service
is assigned. The OPPS includes payment for most hospital outpatient
department services, and covers partial hospitalization services
furnished by hospital outpatient departments and community mental health
centers.
The CY 2014 OPPS/ASC rule proposes to expand the categories of related
items and services packaged into a single payment for a primary service
under the OPPS, in order to make the OPPS more of a prospective payment
system. 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
included items and services in 2008 and 2009, by adding eight additional
categories, including image processing services, and implantable
biologicals. This proposed rule would further expand the categories of
packaged items and services by adding seven additional categories of
supporting services, thereby moving the OPPS closer to a prospective
payment system that is more analogous to Medicare payment for hospital
inpatient services and less like a rate-for-service payment model. In
addition to packaging these seven categories, CMS is proposing to create
29 comprehensive APCs to replace 29 existing device-dependent APCs.
Proposed Changes to Hospital OPPS Payments and Policies
Proposed Payment Update.
CMS proposes to update the OPPS market basket by 1.8 percent for CY
2014. The proposed hospital market basket increase published in the
Fiscal Year (FY) 2014 Inpatient Prospective Payment System
(IPPS)/Long-Term Care Hospital Prospective Payment System (LTCH PPS)
proposed rule is 2.5 percent. The Medicare statute requires a
productivity adjustment reduction of 0.4 percentage points and a 0.3
percentage point reduction to the CY 2014 OPPS market basket, so the
proposed CY 2014 OPPS market basket update would be 1.8 percent.
Proposed Items and Services to be “Packaged” or Included in Payment for a Primary Service.
For 2014, CMS proposes to package seven new categories of supporting
items and services. For many of these services, the OPPS will continue
to make a separate payment if they are reported alone on a claim. The
seven proposed categories are:
(1) Drugs, biologicals, and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure;
(2) Drugs and biologicals that function as supplies or devices when used in a surgical procedure;
(3) Certain clinical diagnostic laboratory tests;
(4) Procedures described by add-on codes;
(5) Ancillary services, such as a chest x-ray, that are assigned status indicator “X”;
(6) Diagnostic tests on the bypass list, and
(7) Device removal procedures.
In
addition to packaging these seven categories, CMS is proposing to
create 29 comprehensive APCs to replace 29 existing device-dependent
APCs.
Collapsing Five Levels of Visits to One.
In an effort to further our goals of using larger payment bundles to
maximize hospitals’ incentives to provide care in the most efficient
manner, discouraging upcoding, and to continue to set accurate payments,
CMS is proposing to streamline the current five levels of outpatient
visit codes. The proposal would replace them with a single Healthcare
Common Procedure Coding System (HCPCS) code for each unique type of
outpatient hospital visit; one for clinic and one for each type of
emergency department visit (24 hour and non-24 hour). By collapsing the
current five levels of codes to one level, CMS believes this proposal
will remove incentives hospitals may have to provide medically
unnecessary services or expend additional, unnecessary resources to
achieve a higher level of visit payment under the OPPS, will reduce
administrative burden and be easily adopted by hospitals, and will allow
a large universe of claims to be utilized for rate setting.
Part B Drugs in the Outpatient Department.
We propose to continue paying at ASP+6 percent for non-pass-through
drugs and biologicals that are payable separately under the OPPS.
Other Proposed Payment Updates
ASC Payment Update.
ASC payments are annually updated for inflation by the percentage
increase in the consumer price index for all urban consumers (CPI-U).
The Medicare statute specifies a multifactor productivity (MFP)
adjustment to the ASC annual update. For CY 2014, the CPI-U update is
projected to be 1.4 percent. The MFP adjustment is projected to be 0.5
percent, resulting in an MFP-adjusted CPI-U update of 0.9 percent for CY
2014. In addition, CMS is proposing that certain ancillary or
adjunctive services that would be packaged under the OPPS for CY 2014
also would be packaged under the ASC payment system for CY 2014.
Payments to ASCs that fail to meet ASC Quality Reporting Program
requirements would be reduced by two percent.
Partial Hospitalization Program (PHP) Rates. CMS proposes to update the two
payment rates for community mental health centers and the two payment
rates for hospital-based PHPs. For community mental health centers, the
proposed CY 2014 APC geometric mean per diem cost
for Level I (three services) would be $94 and for Level II (four or
more services), $106. For hospital-based PHPs, the proposed update to
the APC geometric mean per diem cost would be $213 for Level I and $215
for Level II.
Proposed Quality Program Changes
Hospital Outpatient Quality Reporting (OQR) Program.
CMS is proposing five new measures for the OQR program, affecting
payment in CY 2016, with data collection beginning in CY 2014:
- Influenza Vaccination Coverage among Healthcare Personnel
- Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures (NQF #0564).
- Endoscopy/Poly Surveillance: Appropriate follow-up interval for normal colonoscopy in average-risk patients (NQF #0658).
- Endoscopy/Poly Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps -- Avoidance of Inappropriate Use (NQF #0659).
- Cataracts -- Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (NQF #1536).
CMS proposes to remove two measures:
- Transition Record with Specified Elements Received by Discharged ED Patients (OP-19), because this measure cannot be implemented with the degree of specificity that would be needed to fully address safety concerns related to confidentiality without being overly burdensome.
- Cardiac Rehabilitation Measure: Patient Referral from an Outpatient Setting (OP-24),
ASC Quality Reporting Program. CMS proposes to adopt four new measures for
the ASC Quality Reporting Program for the CY 2016 payment determination
and subsequent years. CMS proposes to collect the data on these
measures via an online Web-based tool. CMS asks for public comment on
alternative data collection strategies, such as through registries or
other third party data aggregators, and via certified EHR technology.
Hospital Value-Based Purchasing (VBP) Program.
The rule proposes to set performance and baseline periods for the
catheter-associated urinary tract infections (CAUTI), central
line-associated bloodstream infection (CLABSI), and surgical site
infection (SSI) measures for the FY 2016 Hospital VBP Program. The
proposed performance period would be January 1, 2014 through December
31, 2014, and the proposed baseline period would be January 1, 2012
through December 31, 2012. CMS proposed to adopt these measures for the FY 2016 Hospital VBP program in the FY 2014 IPPS/LTCH proposed rule.
The
rule also proposes to create a second level independent CMS review
process for hospitals that are dissatisfied with the result of an
existing administrative appeal.
QIO changes. The
rule seeks comment on proposed changes to the regulations governing
eligibility for organizations to be Quality Improvement Organizations
(QIOs) and the contracting process for QIOs. The proposed changes aim
to improve QIOs’ quality improvement initiatives and case review
activities and improve the QIOs’ ability to meet the needs of Medicare
beneficiaries by incorporating changes to the QIO statute made by the
Trade Adjustment Assistance Extension Act of 2011 (TAAEA).
Other changes. The
proposed rule also addresses the Provider Reimbursement Determinations
and Appeals policy, and would make changes to the Medicare EHR Incentive
Program that would affect eligible professionals who reassign their
benefits to Method II Critical Access Hospitals.
CMS
will accept comments on the proposed rule until September 6, 2013 and
will respond to comments in a final rule to be issued by November 1,
2013. The proposed rule will appear in the July 19, 2013 Federal
Register and can be downloaded from the Federal Register at: http://www.ofr.gov/inspection.
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Proposed Policy and Payment Changes to the Medicare Physician Fee Schedule for Calendar Year 2014
OVERVIEW
On
July 8, 2013, the Centers for Medicare & Medicaid Services (CMS)
issued a proposed rule that would update payment policies and payment
rates for services furnished under the Medicare Physician Fee Schedule
(PFS) on or after Jan. 1, 2014. Currently, Medicare only pays for
primary care management services as part of a face-to-face visit. In the
proposed rule, in order to support primary care, CMS proposes to make a
separate payment to physicians for managing select Medicare patients’
care needs beginning in 2015. The proposed rule also proposes changes to
several of the quality reporting initiatives that are associated with
PFS payments – the Physician Quality Reporting System (PQRS), the
Medicare Electronic Health Record (EHR) Incentive program, as well as
changes to the Physician Compare tool on the Medicare.gov website.
Finally, the rule continues the phased-in implementation of the
physician value-based payment modifier (Value Modifier), created by the
Affordable Care Act, that would affect payments to physician groups
based on the quality and cost of care they furnish to beneficiaries
enrolled in the traditional Medicare fee-for-service program.
This
fact sheet discusses the proposed changes to payment policies and
payment rates for services furnished under the PFS. A separate fact
sheet, also issued today, discusses the proposed changes to the quality
reporting programs, the Medicare EHR Incentive program, and the
proposals for implementing the Value Modifier. That fact sheet is
available at: http://www.cms.gov/Newsroom/
BACKGROUND
Since
1992, Medicare has paid for the services of physicians, nonphysician
practitioners (NPPs), and certain other suppliers under the PFS, a
system that pays for covered physicians’ services furnished to a person
with Medicare Part B. Under the PFS, relative values are assigned to
each of more than 7,000 services to reflect the amount of work, the
direct and indirect (overhead) practice expenses, and the malpractice
expenses typically involved in furnishing that service. Each of these
three relative value components is multiplied by a geographic adjustment
factor to adjust the payment for variations in the costs of furnishing
services in different localities. The resulting RVUs are summed for each
service and then are multiplied by a fixed-dollar conversion factor to
establish the payment amount for each service. The higher the number of
relative value units (RVUs) assigned to a service, the higher the
payment.
Sustainable Growth Rate (SGR):
The proposed rule does not include any provisions on the physician fee
schedule update or SGR as these calculations are determined under a
prescriptive statutory formula that cannot be changed by CMS. The final
figures are announced in the final rule in November. In March, CMS
estimated the physician fee schedule update would be -24.4 percent. In
prior years, Congress has taken action to avert a large reduction in
physician fee schedule rates before they went into effect. The
Administration supports legislation to permanent address the flaws in
the SGR that would provide more stability for Medicare beneficiaries and
providers while promoting efficient, high quality care. The percent
change to the physician fee schedule conversion factor may be different
than the update because of various required budget neutrality
adjustments described in the rule.
Provisions INCLUDED IN THE CY 2014 PFS PROPOSED RULE
Primary Care and Complex Chronic Care Management:
Medicare continues to emphasize primary care management services with a
proposal for separate payment for complex chronic care management
services beginning in 2015. In last year’s final rule, we established
separate payment for transitional care management services for a
beneficiary making the transition from a facility stay back to the
community. We also solicited comment on establishing separate payment
for advanced primary care—ongoing care management and continuous
assessment that occurs outside of a face-to-face visit with a patient.
In
this proposed rule, we emphasize advanced primary care through our
proposal to pay separately for complex chronic care management services,
beginning in CY 2015. Specifically, we propose to pay for
non-face-to-face complex chronic care management services for Medicare
beneficiaries who have multiple, significant chronic conditions (two or
more). Complex chronic care management services include regular
physician development and revision of a plan of care, communication with
other treating health professionals, and medication management.
Medicare will make separate payment to physicians through two G-codes
for establishing of a plan of care and furnishing care management over
90-day periods. To be eligible for these services, we propose that
beneficiaries also must have had an Annual Wellness Visit (or an Initial
Preventive Physical Examination (IPPE), if applicable) -- as the Annual
Wellness Visit can serve as an important foundation for establishing a
plan of care. We also propose that a single practitioner furnish these
services and that they must have the beneficiary’s consent to receiving
these services over a one-year period.
The
proposed rule indicates that CMS intends to establish practice
standards necessary to support payment for furnishing complex care
coordination management services. Potential standards include access at
the time of service to Electronic Health Records (EHR) that meet the HHS
certification criteria and written protocols for many aspects of care
management implementation, such as specific steps for monitoring medical
and functional patient needs. The rule solicits comment on the
potential for CMS to recognize a patient-centered medical home (PCMH)
designation by private organizations as one means for a practice to
demonstrate that it has met the requisite practice standards. We plan to
address policy regarding the practice standards, including PCMH
recognition, through separate notice-and-comment rulemaking.
Telehealth Services: We
are proposing to modify our regulations describing eligible telehealth
originating sites to include health professional shortage areas (HPSAs)
located in rural census tracts of urban areas as determined by the
Office of Rural Health Policy. We believe this change will more
appropriately identify sites within urban HPSAs that have rural
characteristics and improve access to telehealth services in shortage
areas. In addition, we are proposing to add transitional care management services to the list of eligible Medicare telehealth services.
Revisions To The Practice Expense Geographic Adjustment:
As required by the Medicare law, CMS adjusts payments under the PFS to
reflect local differences in practice costs. CMS assigns separate
geographic practice cost indices (GPCIs) to the work, practice expenses
(PE), and malpractice cost components of each of more than 7,000
physicians’ services. Also, the law requires that we assess the GPCIs
every three years and adjust them as appropriate with a two-year
phase-in of the new GPCIs. We are proposing new GPCIs using updated
data. In addition, we are changing the weights assigned to each GPCI
(work, PE and malpractice) consistent with the recommendations of the
Medicare Economic Index (MEI) Technical Advisor Panel (see below) that
increases the weight of work and reduces the weight of practice expense.
These new GPCIs would be phased in over CY 2014 and CY 2015. These
changes are budget neutral. The statutory work GPCI “floor” of 1.0 is
scheduled to expire under current law on December 31, 2013. The
proposed GPCIs reflect the elimination of the work “floor” and as a
result 51 localities will have a work GPCI below 1.
Medicare Economic Index: CMS
is proposing revisions to the calculation of the MEI, which is the
price index used to update physician payments for inflation. The changes
are in response to recommendations by a Technical Advisory Panel that
met during CY 2012. Application of the MEI along with sustainable growth
rate determines the total amount of payment made each year under the
physician fee schedule. The proposed rule includes proposed changes in
the RVU and GPCI weights assigned to work and practice expense so that
the weights in the payment calculation would continue to mirror those in
the MEI if the proposed revisions are adopted. As a result, the
proposal is to re-distribute some payment to work from practice
expense.
Misvalued Codes:
Consistent with amendments to the Affordable Care Act, CMS has been
engaged in a vigorous effort over the past several years to identify and
review potentially misvalued codes, and make adjustments where
appropriate. In the proposed rule, CMS is proposing to adjust payment
rates for more than 200 codes where Medicare pays more for services furnished in an office than in an outpatient hospital department or ASC.
We generally expect the resource costs required to furnish a service to
be higher in a hospital or ASC, which have to meet conditions of
participation and conditions for coverage, respectively. Hospitals also
must have stand-by capacity. We are proposing to limit the PFS payment
in the situation described above to the total payment that Medicare
would make to the practitioner and the facility when the service is
furnished in a hospital outpatient department or ASC. In addition, for
CY 2014, we are proposing potentially misvalued codes that we identified
with the assistance of the Contractor Medical Directors based on their
personal experience in paying for Medicare services.
Application of Therapy Caps to Critical Access Hospitals:
The law applies two per beneficiary limits to outpatient therapy
services—one for physical therapy and speech-language pathology services
and another for occupational therapy services. Before the American
Taxpayers Relief Act passed earlier this year, the caps did not
previously apply in Critical Access Hospitals (CAH). We propose to
apply the therapy cap limitations and related policies to outpatient
therapy services furnished in a CAH beginning on January 1, 2014 to
conform Medicare’s regulations to current law.
The
proposed rule will appear in the July 19, 2013, Federal Register. CMS
will accept comments on the proposed rule until Sept. 6, 2013, and will
respond to them in a final rule with comment period to be issued on or
about Nov. 1, 2013.
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