Information provided by AACVPR: UPDATED JULY 8, 2016
- CMS releases 2017 proposed Hospital Outpatient Prospective Payment System (HOPPS) Regulation
- New ICD-10 Codes
CMS Releases 2017 Proposed Hospital Outpatient Prospective Payment System (HOPPS) Regulation
On July 7, 2016, CMS (The Centers for Medicare & Medicaid Services) posted proposed rules and payment amounts for hospital outpatient services in CY 2017. These regulations are open for public comment until Sept. 6, 2016. AACVPR plans to submit concerns regarding cardiac and pulmonary rehabilitation programs located off-campus. The final 2017 HOPPS regulation is expected in early November, 2016. It can be found here and runs 764 pages.
Site of Service Issues: The proposed regulation includes language to implement provisions of last year's budget bill (PL 114-74) that directed CMS to address the broad issue of hospitals purchasing certain physician practices, in part, to game the system - often the hospital outpatient payment rate is notably higher than the payment for the identical service when provided in a physician office.
The payment methodologies in these two distinctly different settings are vastly different. The result is widely varying payment amounts for the same service, based solely on the site of the service.
This broad rule does impact both cardiac and pulmonary rehab, but one very specific statement in the proposed regulation works to our favor. That statement reads, "These proposals are made in accordance with our belief that section 603 of Pub. L. 114-74 is intended to curb the practice of hospital acquisition of physician practices that then result in receiving additional Medicare payment for similar services."
We do not believe that there is any indication of physician practices that provide pulmonary or cardiac rehab services are being purchased in order to receive the higher payment afforded by HOPPS in comparison to the same service under the physician fee schedule. In fact, we can argue that the very nature of both cardiac and pulmonary rehab, i.e. the need for economy of scale precludes a physician office from actually providing either of those services. Space allotment, capital investment, staffing, etc. all add up to extreme cost barriers, understandably so, that deter the provision of the services in a physician office.
It is also worthwhile to compare CR/PR with the other outpatient services (a total of 19 families identified in Table 21 on page 342 of the proposed regulation) to support our contention.
In order to document this premise, AACVPR leadership is considering an examination of the use of G0424, 93797 and 93798 billing as part of the physician fee schedule. While we do not know for sure, intuitively we believe that billing through the physician office for those codes will be minimal, particularly in light of the threshold of physician practice purchase being the litmus test CMS has specifically identified.
You should also be aware that CMS is drawing a very tight circle, grandfathering only programs that were in place, functioning and billing, prior to enactment of PL 114-74 (11-2-2015). All new off campus departments after that date would be subject to billing under the physician fee schedule rather than the hospital outpatient payment formula as of January 1, 2017. Furthermore, any existing CR and PR programs relocated to an off-campus site after 11-2-15 would also be impacted unless we are able to garner specific exemptions for cardiac and pulmonary rehab services.
Proposed payment rates: The following table shows proposed payment and copayment rates for pulmonary rehabilitation, respiratory care services, cardiac rehabilitation, and intensive cardiac rehabilitation. Medicare reimburses approximately 80% of the total amount listed under Payment Rate. APC is the acronym for Ambulatory Payment Classification. It is important to remember that these are proposed payment rates and are subject to change in the final 2017 regulation.
|Code||Brief Descriptor||Status Indicator||APC||Payment Rate||Minimum
|G0422||Intensive cardiac rehab w/ exercise||S||5771||$110.24||$22.05|
|G0423||Intensivecardiac rehab no exercise||S||5771||$110.24||$22.05|
|G0424||Pulmonary rehab w exercise||Q1||5791||$161.29||$32.26|
|G0237||Therapeutic procd strg endur||Q1||5735||$265.56||$53.12|
|G0238||Oth res proc, indiv||Q1||5791||$161.29||$32.26|
|G0239||Oth resp proc, group||Q1||5734||$95.66||$19.14|
New ICD-10 Codes: The 2017 ICD-10-Procedure Coding System (PCS) updates, including a complete list of code titles, addenda and a conversion table showing changes from 2016, are now available on the CMS webpage. The following ICD-10 PCS codes are effective beginning Oct. 1, 2016:
* NCD 20.4 -Implantable Automatic Defibrillators
* NCD 20.7 -Percutaneous Transluminal Angioplasty (PTA)
* NCD 20.9 - Artificial Hearts
* NCD 260.9 - Heart Transplants
* NCD 210.4 - Smoking/Tobacco-Use Cessation Counseling
* NCD 210.4.1 - Counseling to Prevent Tobacco Use
From: CMS MLN Matters Number MM9631; released June 3, 2016.