CMS Releases 2012 OPPS Proposed Rule

“CMS has listened based on its proposal for 2012 and this is a huge win for the provider community given that we’ll see more appropriate payment, and significantly higher payment rates for these services if CMS’ proposal for 2012 is finalized. Moreover, since we expect to see more and more combination codes being released by the AMA, this change on CMS’ part is critical to ensure adequate future payments.”

CMS proposes to create two new APCs to assign the CPT codes for combined abdominal and pelvis CT services:

• APC 0331 (combined abdominal and pelvis CT without contrast) for CPT code 74176
• APC 0334 (combined abdominal and pelvis CT with contrast) for CPT codes 74177 and 74178

CMS proposed no changes to E/M visit coding guidelines nor did it discuss drug administration at all. This doesn’t mean that hospitals won’t see payment rates changes for these important and high volume services, says Shah. “That is the one thing we can count on every year – individual APC payment rate fluctuations so take a few minutes now to review the proposed payment rates compared to current rates for your most frequently billed services either by volume or percent of charges.”

Conversion factor update/ increase

Under the 2012 OPPS proposed rule, CMS is projecting a market basket update of 1.5%. However, that amount will likely decrease to 1.1% after CMS factors in all adjustments.

One such adjustment is related to a special payment provision proposed for 11 cancer hospitals. CMS proposed changes on how these cancer hospitals would be reimbursed due to the fact that its internal studies have shown that these hospitals have a much lower payment-to-cost ratio (PCR) compared to all other hospitals. CMS’ proposal is intended to create some payment parity between the hospitals.

CMS proposes that if the PCR for these cancer hospitals is below the weighted average PCR for all other OPPS hospitals, then it will increase the payment to these cancer hospitals on a hospital-specific basis.