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CMS Releases OPPS Final Rule

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

To make a long mathematical story short, CMS analysts realized that they should be redistributing a proportion of packaged drug costs to the pool of separately payable drugs prior to computing the ASP plus percentage rather than redistributing a fixed dollar amount. That way, when additional claims and cost data are used to generate the final rule, the mathematical relationship of the amount of costs to move from packaged drugs is preserved since a proportion is relied upon rather than raw dollars.

"It's great that CMS looked into this and uncovered a mathematical issue that resulted in the ASP plus percentage fluctuating between the proposed and final rule. It's also good that CMS finalized a change in its computation methods for CY 2012, which results in separately payable drug APC payments remaining at ASP+4% for CY 2012," Shah says.

APCs for abdominal and pelvic CTs

CMS finalized its proposal to create two new APCs for computed tomography (CT) of abdominal and pelvis. The American Medical Association (AMA) introduced new CPT® codes for combined CT of the abdomen and pelvis in 2011. CMS assigned those new CPT codes to existing APCs with payment rates that many felt were far too low to cover the costs of providing the combined (two) service. CMS did not use historical data in the form of the predecessor codes that it could have used in setting payment rates for 2011 and if it had, hospitals would have received better reimbursement this year for the combined service. This has been a very hot point of contention all year long, Shah says.

CMS proposed and finalized the use of historical predecessor code information for these services for CY 2012 and the result is hospitals will see greatly improved APC payment rates for the combined services next year. 

Shah sees this as another victory for hospitals, especially because this is another example of CMS listening to hospital comments and making a change. "It also sets a good precedent for how CMS will approach the APC rate-setting process in the future when we are likely to see even more combination codes."

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