Federal Register, Volume 75, Number 226, November 24, 2010, Pages 71519-72652 Page: 71,814
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71814 Federal Register/Vol. 75, No. 226/Wednesday, November 24, 2010/Rules and Regulations
influencing the respective APC payment
rates.
Response: We note that, in the CY
2011 OPPS/ASC proposed rule (75 FR
46180), we described our process for
identifying additions to the bypass code
list by determining codes that, "using
both CY 2010 final rule data (CY 2008
claims) and February 2010 APC Panel
data (first 9 months of CY 2009 claims),
met the same previously established
empirical criteria for the bypass list."
However, we wish to clarify that
proposed additions to the bypass list
were identified by applying the
empirical criteria to both sets of data
individually. Thus, a code that met the
empirical criteria in either of the two
sets of claims data would be eligible for
addition to the proposed bypass list.
In proposing to add CPT code 93307
to the CY 2011 bypass list, we had
examined the single major claims using
CY 2010 final rule data, after performing
the process described in the CY 2010
OPPS/ASC final rule with comment
period to simulate billing for CPT code
93306 (74 FR 60374 through 60376).
That is, after we removed the claims
that we used to simulate the code
configuration for CPT code 93306, we
assessed only the remaining claims for
CPT code 93307 for the bypass list.
When we applied the bypass criteria to
these residual final rule claims for CPT
code 93307, CPT code 93307 met the
empirical criteria and we added it to the
proposed rule bypass list. However,
when we assessed CPT code 93307
against the CY 2009 claims in the APC
Panel data, it did not meet the criteria
and, similarly, it does not meet the
criteria when assessed against the
proposed rule data. Therefore we are
accepting the comment, and for the CY
2011 OPPS final rule, we are removing
CPT code 93307 from the CY 2011
bypass list. However, we are not
creating simulated claims for CPT code
93306 from the claims that report these
services using CPT codes 93307, 93320,
and 93325 in place of reporting CPT
code 93306. We have approximately
765,000 single bills for CPT code 93306,
and we see no reason to create
simulated median costs for services for
which we have adequate cost data from
correctly coded claims. We note that,
although miscoded claims for CPT code
93306 (that is, CPT code 93307 plus
CPT code 93320 plus CPT code 93325)
appeared in the data, only CPT code
93307 was paid on these claims because
we implemented NCCI edits on January
1, 2009, that stopped CPT codes 93320
and 93325 from being paid if reported
with CPT code 93307. Hospitals that
reported the service using the threecodes instead of reporting CPT code
93306 received payments based on the
CY 2009 national unadjusted payment
rate of $255.05 for CPT code 93307
rather than a payment based on a
national unadjusted payment rate of
$431.37 that they would have received
if they had reported the correct code for
the service.
Regarding the issue of reassignment of
CPT code 93307 from APC 0697 (Level
I Echocardiogram Without Contrast) to
APC 0269, after removing CPT code
93306 from the bypass list, the
calculated median cost for CPT code
93306 based on final rule data was
approximately $399. The calculated
median cost of approximately $399 for
CPT code 93306 suggests that the costs
of these two procedures are similar. CPT
codes 93306 and 93307 would thus
meet the APC recalibration standards of
clinical and resource homogeneity.
Thus, we are finalizing our proposal to
assign CPT code 93307 to APC 0269.
As we discussed in the CY 2010
OPPS/ASC final rule with comment
period (74 FR 60436), in the
determination of APCs that violate the
2 times rule, we apply the 2 times rule
to HCPCS codes that are determined to
be significant, either based on having a
frequency of more than 1,000 single
major claims or having both more than
99 single major claims and contributing
more than 2 percent of the claims used
to determine the APC median cost.
Codes that do not meet these criteria as
"significant procedures" are not used to
determine if there is a 2 times rule
violation in an APC. The 2 times rule is
discussed in section III.B. of this final
rule with comment period.
Comment: One commenter requested
that the proposed application of market
basket update to the median cost of
packaging threshold for the bypass
criteria be applied retroactively
beginning from CY 2005, when the $50
median packaged cost threshold
criterion was first applied.
Response: In the CY 2011 OPPS/ASC
proposed rule, we proposed to apply the
final market basket update for CY 2009,
since it is the most appropriate
representation of changes for hospital
input prices for CY 2009 and, therefore,
most applicable to CY 2009 claims data
used to set the CY 2011 OPPS payment
rates, to the median packaged cost
threshold of $50 established in the CY
2010 OPPS/ASC final rule with
comment period (75 FR 46181). We
believe that this would ensure that the
packaged cost threshold would
accurately reflect changes in costs from
the prior year. However, we proposed
that this market basket adjustment to the
packaged cost criterion would applyprospectively. The $50 threshold has
historically been an appropriate
measure for limiting the impact of
redistributing the packaged costs on the
multiple procedure claims. We
established a criterion of a maximum
median amount of packaging of $50 as
a means of ensuring that the typical
packaging for the service being placed
on the bypass list is minimal in amount.
With respect to the comment that we
apply a market basket update to the
median cost of the packaging threshold
for the bypass criteria retroactively to
CY 2005, we note that, in general, we
update our payment rates on a
prospective basis and, as explained
above, we believe that our proposed and
final policy adequately and
appropriately accounts for the effects of
inflation over time.
Therefore, for the CY 2011 OPPS, we
are applying the final CY 2009 market
basket update (which is 3.6 percent) to
the $50 median packaged cost criterion
and rounding the result ($51.80) to the
neared $5 increment. Thus, for this CY
2011 OPPS/ASC final rule with
comment period, the median cost of
packaging criterion for the CY 2011
OPPS bypass list remains at $50.
Comment: One commenter requested
that CPT codes 77310 (Teletherapy,
isodose plan (whether hand or computer
calculated); intermediate (3 or more
treatment ports directed to a single area
of interest)) and 77789 (Surface
application of radiation source) be
added to the bypass list because they
believed that these codes meet the
bypass criteria. The commenter also
suggested that there was a lack of
transparency in how the criteria were
applied, and that when codes were not
added that met the empirical criteria the
reasons for doing so should be
explained.
Response: Both CPT codes 77310 and
77789 failed to meet the empirical
criterion for addition to the bypass list
of having 100 or more "natural" single
procedure claims in both the APC Panel
data and the proposed rule data.
Specifically, CPT code 77310 had 0
natural single bills in the CY 2010 final
rule data and 2 natural single bills in the
CY 2011 APC Panel data; CPT code
77789 had 30 natural single bills in the
CY 2010 final rule data and 13 natural
single bills in the CY 2011 APC Panel
data. As described above, this criterion
ensures that we have an adequate base
of claims billed for each code so that we
can bypass lines with the bypass code
from the multiple procedure claims. In
addition to failing the number of
"natural" single procedure claims
criterion, CPT code 77789 failed to meet
the percentage of single claims withpackaged costs criterion (no more than
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United States. Office of the Federal Register. Federal Register, Volume 75, Number 226, November 24, 2010, Pages 71519-72652, periodical, November 24, 2010; Washington D.C.. (https://digital.library.unt.edu/ark:/67531/metadc52807/m1/303/: accessed April 26, 2024), University of North Texas Libraries, UNT Digital Library, https://digital.library.unt.edu; crediting UNT Libraries Government Documents Department.