Health Information Management

Healthcare News: CMS releases OPPS proposed rule for 2011

JustCoding News: Outpatient, July 14, 2010

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Editor’s note: The following article was adapted from HCPro’s e-mail alert about this breaking news.

by Michelle A. Leppert, CPC-A

CMS continues to refine the physician supervision requirements for diagnostic and therapeutic services in the 2011 outpatient prospective payment system (OPPS) proposed rule, released July 2. The rule would also put in place changes mandated by the recently enacted Patient Protection and Affordable Care Act of 2010.

CMS proposed no changes to two areas that have traditionally been challenging to providers: drug administration or evaluation and management (E/M) visit criteria. “The two places where there are changes are from the new law and physician supervision,” says Jugna Shah, MPH, president of Nimmit Consulting in Washington, DC.

The rulemaking includes proposals to implement provisions of the Patient Protection and Affordable Care Act relating to payments to hospitals for direct graduate medical education and indirect medical education costs. CMS also proposes new limitations on certain physician referrals to hospitals in which they have an ownership or investment interest.

Physician supervision

According to the proposed rule, CMS would identify a limited set of services as “nonsurgical extended duration therapeutic services,” requiring direct supervision for initiation of the service followed by general supervision for the remainder of the service. “General supervision” means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.

“This is clearly directed at observation services and in particular the difficulty critical access hospitals (CAH) had with covering these services at night, but the proposal would apply to all hospitals,” says Kimberly Anderwood Hoy, Esq., CPC, director of Medicare and compliance at HCPro, Inc., in Marblehead, MA.

The physician supervision changes proposed really show CMS listened to the concerns and issues raised late last year and earlier this year, says Shah.

CMS selected 16 services it proposes to include in the new category, including observation, intravenous infusion, subcutaneous infusion, and therapeutic, prophylactic, or diagnostic injections. To be considered for the new category, a service must:

  • Be of extended duration, frequently extending beyond normal business hours
  • Largely consist of a significant monitoring component typically conducted by nursing or other auxiliary staff
  • Be of sufficiently low risk, such that the service typically would not require direct supervision often during the service
  • Not be a surgical service that includes recovery time

CMS excluded all surgical services—including recovery time—from potential inclusion because, although monitoring of any patient in recovery is a key component of surgery, it is not the focus or a substantial component of the service. In addition, CMS states it believes the surgeon should personally evaluate the patient’s medical status during the recovery period.

CMS defines “initiation of the service” as the beginning portion of a service, ending when the patient is stable and the supervising physician or appropriate non-physician practitioner believes the remainder of the service can be delivered safely under his or her general direction and control without the physician’s physical presence on the hospital campus or in the provider-based department of the hospital.

This is an interesting change in how the supervising physician is viewed, says Hoy. “In the past, the supervising physician has been someone immediately available to step in and provide direction and assistance, but it didn’t require that they had seen the patient, only that they were available and qualified to step in if necessary,” she explains “The new guideline seems to presuppose at least some face-to-face service between the supervising physician and the patient because the supervising physician is the one to determine that the patient is ‘sufficiently stable’ to ‘transfer to general supervision.’”

Inpatient-only list

CMS proposes removing the following three procedures from the inpatient-only list:

  • 21193, reconstruction of mandibular rami; horizontal, vertical, C, or L osteotomy; without bone graft
  • 21395, open treatment of orbital floor blowout fracture; periorbital approach with bone graft (includes obtaining graft)
  • 25909, amputation, forearm, through radius and ulna; reamputation

All three would have a T status indicator (significant procedure subject to multiple procedure discounting that is paid by APC).

Drug reimbursement

In 2009, CMS finalized a new method for calculating payment for separately payable drugs and redistributing approximately $150 million of the costs associated with HCPCS-coded packaged drugs with average sales prices (ASP) to separately payable drugs. In 2010, CMS is reimbursing hospitals for separately payable drugs at ASP plus 4%.

While CMS is using the same calculation method for 2011, it proposes reimbursing hospitals at ASP plus 6% for 2011.

Hospital quality data reporting

CMS implemented quality measure reporting programs for multiple settings of care to promote higher quality, more efficient health care for Medicare beneficiaries.

For the CY 2009 annual payment update, CMS required Hospital Outpatient Quality Data Reporting Program (HOP QDRP) reporting using seven quality measures: five ED acute myocardial infarction cardiac care measures and two surgical care measures. CMS added four additional measures for 2010—MRI lumbar spine for low back pain, mammography follow-up rates, abdomen CT - use of contrast material, and thorax CT - use of contrast material.

For 2011, CMS proposes requiring hospitals to continue reporting quality data for the 11 HOP QDRP measures. CMS proposes additional changes for reporting HOP QDRP for 2012 and beyond.

CMS will accept comments on the proposed rule through August 31, and will issue the final rule by November 1. You may submit electronic comments on this regulation online. Click on the “Submit a comment” tab, and type in 2011 OPPS proposed rule in the search field. 



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