Federal Register, Volume 75, Number 226, November 24, 2010, Pages 71519-72652 Page: 71,947

                                
Federal Register/Vol. 75, No. 226/Wednesday, November 24, 2010/Rules and Regulations  71947

believe it is appropriate to continue to
treat diagnostic radiopharmaceuticals
and contrast agents differently from
other SCODs for CY 2011. Therefore, in
the CY 2011 OPPS/ASC proposed rule
(75 FR 46271), we proposed to continue
packaging payment for all contrast
agents and diagnostic
radiopharmaceuticals, collectively
referred to as "policy-packaged" drugs,
regardless of their per day costs, for CY
2011. We also proposed to continue to
package the payment for diagnostic
radiopharmaceuticals into the payment
for the associated nuclear medicine
procedure and to package the payment
for contrast agents into the payment of
the associated echocardiography
imaging procedure, regardless of
whether the contrast agent met the
OPPS drug packaging threshold. We
refer readers to the CY 2010 OPPS/ASC
final rule with comment period for a
detailed discussion of nuclear medicine
and echocardiography services (74 FR
35269 through 35277).
Comment: Several commenters
expressed concerns about the
fluctuation in data for echocardiography
APCs used with contrast codes,
particularly the reductions in median
cost from CY 2010. The commenters
believed this fluctuation in the data is
due to the lack of familiarity among
hospital coders on contrast codes and C-
codes used for contrast enhanced
echocardiography. They pointed out
that CY 2009 is only the second year of
claims data for the new
echocardiography CPT codes and
associated C-codes. The commenters
also cited a smaller number of "days" for
contrast agents used with
echocardiography, HCPCS codes Q9956
(Injection, octafluoropropane
microspheres, per ml) and Q9957
(Injection, perflutren lipid
microspheres, per ml), in the published
"brachy-blood-drug" median cost file
that CMS published with the proposed
rule than total frequency of services for
contrast enhanced echocardiography. In
addition, the commenters stated that the
average cost of HCPCS codes Q9957 and
Q9956 for any given contrast enhanced
echocardiography is approximately
$120, and that the observed difference
in median cost between APC 0128
(Echocardiogram with Contrast) and
APC 0269 (Level II Echocardiogram
without Contrast) is approximately
$100, suggesting that the difference in
cost for with and without contrast is not
sufficient to cover the cost of the
contrast agent. Therefore, these
commenters concluded that the
reduction in the median cost for APC

0128 in the CY 2011 proposed rule is

due to the fact that the median cost for
these codes do not contain the cost of
contrast agents. A few commenters
suggested that CMS institute a claims
edit that would require a code for
contrast on claims that contain a
procedure code specified as "with"
contrast. Another commenter suggested
that CMS limit fluctuations that occur
from year to year on APC payment rates
to no more than 10 percent for any
unexplained and substantial changes in
cost data.
Response: We find no evidence that
would suggest that the fluctuations in
cost data for echocardiography APCs are
due to incorrect hospital billing
practices. Because some of the
echocardiography codes were new for
CY 2009, we believe the observed
reduction in median cost for CY 2011 is
due to the difference between CMS' best
estimate of a median cost for these
echocardiography codes based on
simulated CY 2008 claims data for CY
2010 payment, and median cost based
on actual hospital billing for these
echocardiography codes in CY 2009 for
CY 2011 payment. Specifically, while
most echocardiography codes and
associated C-codes for contrast
enhanced echocardiography were
implemented in CY 2008, the CPT code
93306 (Initial nursing facility care, per
day, for the evaluation and management
of a patient, which requires these 3 key
components) was not implemented until
CY 2009 and incorporated services
previously described in CY 2008 by
three CPT codes: 93307
(Echocardiography, transthoracic, real-
time with image documentation (2D)
with or without M-mode recording;
complete); 93320 (Doppler
echocardiography, pulsed wave and/or
continuous wave with spectral display;
complete); and 93325 (Doppler
echocardiography color flow velocity
mapping). As we discussed in our CY
2010 OPPS/ASC final rule with
comment period (74 FR 60374), we
simulated a median cost for both CPT
code 93306 and associated HCPCS code
C8929, which describe services billed
with CPT code 93306 but enhanced
with contrast. For CY 2009 (73 FR
68542) and CY 2010 (74 FR 60374), we
simulated a median cost for CPT code
93306 and HCPCS code C8929 based on
the long descriptor for the new code,
indentifying claims with CPT codes
93307, 93220, and 93225 as representing
the costs of CPT code 93306. We
simulated the CY 2010 medians for
93306 and C8929 to provide the most
accurate payment possible based on
available cost information in the CY

2008 claims without having actual

charge data for 93306 and C8929 from
hospitals.
CPT code 93306 and HCPCS code
C8929 are the highest volume
echocardiography codes, and their
median costs largely drive the median
cost of their respective APCs for CY
2011: APC 0269 (Level II
Echocardiogram without Contrast) and
APC 0128 (Echocardiogram with
Contrast). Therefore, changes in the
median cost of 93306 and C8929 will
significantly impact the median cost for
those APCs. Because CY 2011 OPPS
ratesetting is based on CY 2009 claims
data, as discussed in section II.A. of this
final rule with comment period, the CY
2011 median cost data for CPT code
93306 and HCPCS code C8929 represent
the first year of actual claims data for
these services. For this reason, we
believe that our CY 2011 estimated cost
for CPT code 93306 and HCPCS code
C8929 based on CY 2009 claim charges
and the most recent cost report data
available is more accurate than CY 2010
and CY 2009 simulated median costs.
We note that almost all of the median
cost estimates for all of the other
contrast enhanced echocardiography
services in APC 0128, which did not
rely on a simulated median cost in CY
2010, increase between CY 2010 and CY
2011.
Commenters suggested that the
discrepancy between observed
frequency of days for the two HCPCS for
contrast agents used with
echocardiography, HCPCS codes Q9956
and Q9957, indicates that the median
costs for APC 0128 do not reflect the
cost of contrast. We do not observe a
sizable discrepancy between observed
frequency of days, instead, we observe
fairly comparable numbers of
procedures for contrast enhanced
echocardiography and the number of
days associated with these contrast
agents. Specifically, we observe
approximately 53,000 procedures for
contrast enhanced echocardiography
and approximately 48,000 days of
administration for HCPCS codes Q9956
and Q9957 in our final rule claims data.
Finally, we believe that an observed
differential in payment of
approximately $100 between the APC
median cost for APC 0128 of
approximately $494 and APC 0269 of
approximately $398 in the final rule
with comment period both demonstrates
that hospitals are including the cost of
contrast in their charges for HCPCS code
C8929 and that this amount is sufficient
to capture the cost of contrast in a
prospective payment system that
includes packaging and averaging. In
summary, we have no reason to believe

that these first years of actual costs for