Federal Register, Volume 75, Number 226, November 24, 2010, Pages 71519-72652 Page: 71,828
viii, 72651, iv p. ; 28 cm.View a full description of this periodical.
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No. 226/Wednesday, November 24, 2010/Rules and Regulations
the full spectrum of National Correct
Coding Initiative (NCCI) edits. To
ensure that we are using valid claims
that represent the cost of payable
services to set payment rates, we
removed line-items with an OPPS status
indicator for the claim year and a status
indicator of "S," "T," "V," or "X" when
separately paid under the prospective
year's payment system. This logic
preserves charges for services that
would not have been paid in the claim
year but for which some estimate of cost
is needed for the prospective year, such
as services newly proposed to come off
the inpatient list for CY 2010 that were
assigned status indicator "C" in the
claim year. It also preserves charges for
packaged services so that the costs can
be included in the cost of the services
with which they are reported, even if
the CPT codes for the packaged services
were not paid because the service is part
of another service that was reported on
the same claim or the code otherwise
violates claims processing edits.
For CY 2011, for this final rule with
comment period, we are expanding the
application of this trim to exclude line-
item data for pass-through drugs and
biologicals (status indicator "G" for CY
2009) and nonpass-through drugs and
biologicals (status indicator "K" for CY
2009) where the charges reported on the
claim for the line were either denied or
rejected during claims processing.
Removing lines that were eligible for
payment but were not paid ensures that
we are using appropriate data. The trim
avoids using cost data on lines that we
believe were defective or invalid
because those rejected or denied lines
did not meet the Medicare requirements
for payment. For example, edits may
reject a line for a separately paid drug
because the number of units billed
exceeded the number of units that
would be reasonable and, therefore, is
likely a billing error (for example, a line
reporting 55 units of a drug for which
5 units is known to be a fatal dose). For
approximately 90 percent of the codes
with status indicators "G" and "K" in
their claims year, to which the
expansion of the trim would apply,
between 0 and 10 percent of lines would
be removed due to receiving zero
payment. As with our trimming in the
CY 2010 OPPS/ASC final rule with
comment period (74 FR 60359) of line
items with a status indicator of "5," "T,"
"V"or "X", we believe that unpaid line-
items represent services that are
invalidly reported and, therefore,
should not be used for ratesetting. We
believe that removing lines with valid
status indicators that were edited andincreases the accuracy of the single bills
used to determine the mean unit costs
for use in the ASP+X calculation
described in section V.B.3. of this final
rule with comment period.
Comment: One commenter requested
that CMS conduct analysis of the overall
CCR error trim in 2010 and provide
APC-specific impacts for all radiation
oncology services. The commenter also
recommended that CMS consider
implementation of a lower-level
threshold for the CCR error trim in
future rulemaking.
Response: As we noted above, the
impact of moving the lower-level error
CCR threshold is minimal because of its
interaction with the standard trim of all
hospitals whose overall ancillary CCR is
three standard deviations beyond the
geometric mean. Established tolerances
of 0.0001 and 90 remove those hospitals
whose CCRs are highly aberrant relative
to the others in the data set, in
particular because they apply at the
hospital level and not at the
departmental level. While the
commenter has requested that we
conduct an analysis of the impact of the
overall CCR error trim on the APCs for
radiation oncology, we note that this
standard error CCR trim is intended to
remove all claims (not limited to a
particular category of care) from
hospitals with highly aberrant CCRs so
that the relativity of the APC payment
weights is accurate. Therefore, the
impact on selected APCs, such as
radiation oncology APCs, is not relevant
to a determination of whether a
hospital's overall CCR is so extreme that
all claims for the hospital should be
excluded from the data on which the
OPPS relative weights are based. We
will continue to monitor whether our
established error CCR thresholds are
appropriate. However, based on the
recent study we provided to the APC
Panel Data Subcommittee, we agree
with the Panel's assessment that the
current error CCR tolerances are
appropriate.
"Pseudo" Single Procedure Claimsno
(1) Splitting Claims
We then split the remaining claims
into five groups: single majors; multiple
majors; single minors; multiple minors;
and other claims. (Specific definitions
of these groups follow below.) For CY
2011, we proposed to continue our
current policy of defining major
procedures as any HCPCS code having
a status indicator of "5," "T," "V," or "X;"
defining minor procedures as any code
having a status indicator of "F," "G," "H,""K," "L," "R," "U," or "N," and classifying
"other" procedures as any code having a
status indicator other than one that we
have classified as major or minor. For
CY 2011, we proposed to continue
assigning status indicator "R" to blood
and blood products; status indicator "U"
to brachytherapy sources; status
indicator "Q1" to all "STVX-packaged
codes;" status indicator "Q2" to all "T-
packaged codes;" and status indicator
"Q3" to all codes that may be paid
through a composite APC based on
composite-specific criteria or paid
separately through single code APCs
when the criteria are not met. As
discussed in the CY 2009 OPPS/ASC
final rule with comment period (73 FR
68709), we established status indicators
"Q1," "Q2," and "Q3" to facilitate
identification of the different categories
of codes. We proposed to treat these
codes in the same manner for data
purposes for CY 2011 as we have treated
them since CY 2008. Specifically, we
proposed to continue to evaluate
whether the criteria for separate
payment of codes with status indicator
"Q1" or "Q2" are met in determining
whether they are treated as major or
minor codes. Codes with status
indicator "Q1" or "Q2" are carried
through the data either with status
indicator "N" as packaged or, if they
meet the criteria for separate payment,
they are given the status indicator of the
APC to which they are assigned and are
considered as "pseudo" single procedure
claims for major codes. Codes assigned
status indicator "Q3" are paid under
individual APCs unless they occur in
the combinations that qualify for
payment as composite APCs and,
therefore, they carry the status indicator
of the individual APC to which they are
assigned through the data process and
are treated as major codes during both
the split and "pseudo" single creation
process. The calculation of the median
costs for composite APCs from multiple
procedure major claims is discussed in
section II.A.2.e. of this final rule with
comment period.
Specifically, we divided the
remaining claims into the following five
groups:
1. Single Procedure Major Claims:
Claims with a single separately payable
procedure (that is, status indicator "5,"
"T," "VJ," or "X," which includes codes
with status indicator "Q3"); claims with
one unit of a status indicator "QI" code
("STVX-packaged") where there was no
cude with status indicator "5," "T," "V,"
or "X" on the same claim on the same
date; or claims with one unit of a status
indicator "Q2" code ("T-packaged")
where there was no code with a status
indicator "T" on the same claim on the71828 Federal Register/Vol. 75,
not paid during claims processing
same date.
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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/m1/317/: accessed April 25, 2024), University of North Texas Libraries, UNT Digital Library, https://digital.library.unt.edu; crediting UNT Libraries Government Documents Department.