News Tagged as OP PPS

OPPS – April 2012 Update

From: CMS Transmittal 2418 (Medicare Claims Processing) – 3/2/12

Transmittal Summary of Changes

 This Recurring Update Notification describes changes to and billing instructions for various payment policies implemented in the April 2012 OPPS update. The April 2012 Integrated Outpatient Code Editor (I/OCE) and OPPS Pricer will reflect the Healthcare Common Procedure Coding System (HCPCS), Ambulatory Payment Classification (APC), HCPCS Modifier, and Revenue Code additions, changes, and deletions identified in this Change Request (CR).

MLN Matters Article MM7672 Revised – 12/29/11

MLN Summary:

This article is based on change request (CR) 7672 which describes changes to the OPPS to be implemented in the January 2012 OPPS update. CR7672, from which this article is taken:

1. Describes changes to, and billing instructions for, various payment policies implemented in the January 2012 OPPS update; and
2. Implements several changes and clarifications in the manual requirements for the provision of hospital outpatient therapeutic services, finalized in the Calendar Year (CY) 2012 OPPS/Ambulatory Surgical Center (ASC) Final Rule.

You should make sure your billing staffs are aware of these changes.

Final Rules – OPPS & ASC for CY 2012, Value-Based Purchasing, Physician Self-Referrals & Patient Notification Requirements

CMS-1525-FC Federal Register 11/30/11

The final rule federal register was released on November 30, 2011.  Click here to view our previous post about these final rules.

Final Rules – OPPS & ASC for CY2012, Value-Based Purchasing, Physician Self-Referral; & Patient Notification Requirements

CMS-1525-FC; Posted 11/01/11; FR 11/30/11

Excerpts from CMS E-mail:

…CMS projects that total payments to more than 4,000 hospitals – which includes general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children’s hospitals, and cancer hospitals – paid under the Outpatient Prospective Payment System (OPPS) in CY 2012 will be approximately $41.1 billion.  CMS also projects that payments to approximately 5,000 Medicare-participating ASCs paid under the ASC Payment System will be approximately $3.5 billion for CY 2012.

…The final rule also establishes an electronic reporting pilot that will allow additional hospitals, including critical access hospitals (CAHs), to report clinical quality measures in CY 2012 for purposes of participating in the Medicare Electronic Health Record Incentive Program.  

Provisions affecting payments to Hospital Outpatient Departments

The final rule will increase payment rates under the OPPS by 1.9 percent in CY 2012.  This increase is based on the projected hospital inpatient market basket percentage increase of 3.0 percent for inpatient services paid under the Hospital Inpatient Prospective Payment System (IPPS) minus the multifactor productivity adjustment of 1.0 percentage points and minus a 0.1 percentage point adjustment, both of which are required by the Affordable Care Act.

The final rule also provides a payment adjustment for designated cancer hospitals as required by the Affordable Care Act.  This payment adjustment is expected to increase payments to cancer hospitals by 11.3 percent (or approximately $71 million) over what they would have otherwise been paid…

Provisions affecting payments to Ambulatory Surgical Centers

The final rule increases payment rates to ASCs by 1.6 percent in CY 2012.  This reflects a consumer price index for all urban consumers estimated at 2.7 percent, minus a 1.1 percent productivity adjustment required by the Affordable Care Act.

 The final rule also establishes a quality reporting program for ASCs and adopts five quality measures, including four outcome measures and one surgical infection control measure beginning in CY 2012 for the CY 2014 payment determination… 

Provisions affecting the Hospital Value-Based Purchasing program

The Hospital VBP, which was required by section 3001(a) of the Affordable Care Act, was initially established in a final rule published in May 2011.  The final rule contained the measures, performance standards, and scoring methodology that would be used to determine the value-based incentive payments to hospitals in FY 2013.  The final rule announced today addresses the program requirements for the FY 2014 program. These changes include: adding one clinical process measure to guard against infections due to urinary catheters; and, establishing the weighting, performance periods, and performance standards for the clinical process, patient experience, and outcomes measures for FY 2014.

October 2011 Update of the Hospital OPPS

MLN Matters – 9/6/11

This article describes the changes to OPPS that will be implemented on October 1, 2011.

St. Mary & Elizabeth Med Ctr – FYE 12/31/09

PRRB 2011–D35

Valley Presbyterian Hospital – FFY 2008

PRRB 2011–D28

Both cases involved an appeal of the reduction the Providers received for Outpatient PPS services for the case of St. Mary & Elizabeth Medical Center and for Inpatient PPS rates for Valley Presbyterian Hospital due to the lack of filing the required quality reporting data to CMS.

Despite the best attempts to provide an explanation for the lack of reporting, both Providers were unsuccessful in obtaining relief through the PRRB.

Notice from NHIC MAC

It appears that the grace period for establishing an account to obtain PS&R data is over. For the past two years, FI/MACs have been fairly accommodating in sending providers the PS&R reports where the online account has not been properly established. Here is an announcement from NHIC stating that Providers are now responsible for obtaining the PS&R information. Please pass this information on to your clients that have not fully established the online accounts.

E-mail received from NHIC:

As instructed by the Centers for Medicare & Medicaid Services (CMS), NHIC, Corp. will no longer provide Provider Statistical and Reimbursement (PS&R) reports.  Over the last two years CMS has sent multiple letters and Listserv messages to facilities with the language below, instructing providers that obtaining the PS&R is the responsibility of the facility. (more…)