Hospital Outpatient Prospective Payment System (HOPPS) Impact on Hematology

On November 15, CMS will be publishing the final HOPPS rule for 2005. Linked below are a series of charts comparing the 2004 and 2005 payments for APC's and codes of interest to hematology.

Highlights of the final rule:

• There is an overall inflationary increase of 3.3 percent in total Medicare payments for hospital outpatient department services. However, the actual payments for individual procedures may be substantially more or less than this increase. This is because the APC rates are based on median hospital costs derived from hospital charges which will fluctuate greatly year to year.
• There were a number of payment improvements in the cancer screening service including mammograms, barium enemas, sigmoidoscopy and colonoscopy procedures.
• The rule incorporates a $78 facility payment for the new “Welcome to Medicare Physical” that provided coverage for a comprehensive preventative examination for new Medicare beneficiaries.
• CMS is increasing the number of APC’s for blood and blood products. In addition, for any low volume blood product APC’s which would have sustained a reduction in 2005, CMS is basing payment on a blend of 2004 and 2005 median cost data.
• CMS is discontinuing use of the “Q’ codes for reporting chemotherapy and other infusion services. Instead, CMS is going to use the existing CPT codes in the 90780ff and 96400ff series to determine payment. The payment will be based on the calculated cost for the Q codes. Thus, hospitals will report, for example, the initial first hour chemotherapy infusion code 96410 and code 96412 for each additional hour but payment will be derived from Q0084, Chemotherapy by infusion per visit. Even though no additional payment will be made for “each additional hour” (96412) in 2005, it is important to use code 96412 for reporting charges, so that CMS can establish a payment rate for these services sometime in the future.
• The payment for APC 0123, Bone Marrow Harvesting and Bone Marrow/Stem Cell Transplant will be increased from $335 to $608. This includes codes 38230-38241.
• CMS is continuing its policy of packaging drugs which cost less than $50. However, an exception is being made for anti-emetics whereby separate payment will be made for all injectible and oral forms of anti-emetic drugs even if the costs are less than $50.
• In the proposed rule, CMS announced its intention to move Code 36515, Therapeutic apheresis with extracorporeal immunoadsorption and plasma reinfusion from APC 0112, Aperhesis, Photopheresis and Plasmapheresis (paying $2,127) to APC 0111, Blood Product Exchange ($725). This change was being made because the charge data that CMS had for this code supported this lower payment level. ASH had commented that this payment would be grossly inadequate since the procedure is much more costly particularly considering the very high cost of the Prosoba Column. We noted that this rate would be less than 1/3 of the rate established in the physician fee schedule. We urged CMS to leave this procedure in APC 0112. Unfortunately, CMS rejected this comment and stated that “[W]e believe that the resources required for CPT code 36515 are more similar to the other CPT codes in APC 0111”. Due to this unsatisfactory response, ASH will consider bringing this issue before the APC Advisory Committee next year.
• APC payments for some blood products will not cover actual costs. ASH may want to work with AABB and the American Red Cross to see what can be done to remedy these problems.

HOPPS Final Rule Comparison