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CMS Releases OPPS Final Rule

Michelle A. Leppert, CPC-A, for HCPro, November 3, 2011

The 2012 Outpatient Prospective Payment System final rule contains some significant wins, including changes to cancer center payments and separately payable drug payments, for facilities and one major loss involving intensity modulated radiation therapy. 

CMS finalized changes to cancer center payments for 11 hospitals, cardiac resynchronization therapy payment, and physician supervision in its final rule released November 1.

"This is one of the first rules in the last three or four years that I recall where I  can go down the list of big ticket items and see that CMS responded to commenters' suggestions and concerns very carefully," says Jugna Shah, MPH, president of Nimitt Consulting based in Washington, DC. "This doesn't necessarily mean increased APC payment rates for all services, but this rule definitely reflects a lot of thoughtful analyses and changes to initial proposals resulting in sound policy making for 2012, which adds up to a lot of nice wins for providers."

Payment for cancer centers

One of CMS' biggest proposed OPPS changes turned into a win for multiple stakeholders in the final rule despite what CMS had originally proposed. For calendar year (CY)2012, CMS finalized a revised version of its initial proposal of providing a payment adjustment to 11 cancer centers. After studying how the centers' costs and payments compared to the costs and payments for all other providers, which CMS was required to do by law, the agency found that a payment fix was warranted.

CMS' original proposal for 2012 would have resulted in a large financial impact on beneficiaries and on the payment that non-cancer hospitals would receive due to CMS' budget neutral implementation. In addition to these impacts, CMS' proposal for CY 2012 would not have solved the main problem at hand for cancer hospitals, Shah says.

CMS received numerous comments from industry stakeholders on its proposal, including the inappropriate financial impact that beneficiaries and other hospitals would have to bear and as a result, the agency revised its proposal, Shah says. "CMS should be commended for figuring out a different and better way to implement the payment adjustment for the cancer centers that does not come on the backs of beneficiaries or other hospitals in the manner it would have under CMS' original proposal," she says.

"CMS clearly listened to issues raised by commenters," she adds, "and significantly revised its proposal in terms of what has now been finalized for 2012 and the net result appears positive for everybody."

Cardiac resynchronization therapy payment

Also welcome news for providers: CMS decided not to implement a proposal to limit payment for cardiac resynchronization therapy defibrillator (CRT-D) procedures provided in the outpatient to the inpatient MS-DRG 0227 payment rate.

As part of the 2012 OPPS proposed rule, CMS announced plans to create a new composite APC for CRT-D procedures and cap payment for those services at the lesser of the newly established APC median cost or the inpatient standardized payment for MS-DRG 227, resulting in a proposal to decrease payments to hospitals for this service when provided in the outpatient setting.

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