Federal Register, Volume 75, Number 226, November 24, 2010, Pages 71519-72652 Page: 71,854
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No. 226/Wednesday, November 24, 2010/Rules and Regulations
"T" that is reported with a date of
service on the same day as or one day
prior to the date of the service
associated with HCPCS code G0378. We
agree that payment for such services is
included in the payment for the surgical
procedure. It is unclear to us exactly
how the commenter defines minor
procedures; however, we do allow
payment of APCs 8002 and 8003 when
ancillary services with status indicator
"X" or packaged services with status
indicator "N" appear on the same claim
as HCPCS code G0378.
Comment: One commenter
recommended that CMS consider
adopting the National Universal Billing
Committee (NUBC) guidelines, utilized
by private insurance carriers, which
permit payment for observation care
furnished during the time of an
inpatient hospital stay that is
subsequently overturned by a hospital's
utilization review committee.
Response: This comment is outside of
the scope of the proposals in the CY
2011 OPPS/ASC proposed rule.
However, we will consider the
possibility of addressing this concern
through other available mechanisms, as
appropriate. We note that we have
continued to emphasize that observation
care is a hospital outpatient service,
ordered by a physician and reported
with a HCPCS code, like any other
outpatient service. It is not a patient
status for Medicare payment purposes.
After consideration of the public
comments we received, we are adopting
as final, without modification, our CY
2011 proposal to continue to include
composite APCs 8002 and 8003 in the
OPPS and to continue the extended
assessment and management composite
APC payment methodology and criteria
that we finalized for CYs 2009 and 2010.
We also are calculating the median costs
for APCs 8002 and 8003 using all single
and "pseudo" single procedure claims
from CY 2009 that meet the criteria for
payment of each composite APC. The
final CY 2011 median cost resulting
from this methodology for APC 8002 is
approximately $390, which was
calculated from 19,156 single and
"pseudo" single bills that met the
required criteria. The final CY 2011
median cost for composite APC 8003 is
approximately $707, which was
calculated from 221,246 single and
"pseudo" single bills that met the
required criteria.
(2) Low Dose Rate (LDR) Prostate
Brachytherapy Composite APC (APC
8001)
LDR prostate brachytherapy is a
treatment for prostate cancer in whichhollow needles or catheters are inserted
into the prostate, followed by
permanent implantation of radioactive
sources into the prostate through the
needles/catheters. At least two CPT
codes are used to report the composite
treatment service because there are
separate codes that describe placement
of the needles/catheters and the
application of the brachytherapy
sources: CPT code 55875 (Transperineal
placement of needles or catheters into
prostate for interstitial radioelement
application, with or without cystoscopy)
and CPT code 77778 (Interstitial
radiation source application; complex).
Generally, the component services
represented by both codes are provided
in the same operative session in the
same hospital on the same date of
service to the Medicare beneficiary
being treated with LDR brachytherapy
for prostate cancer. As discussed in the
CY 2008 OPPS/ASC final rule with
comment period (72 FR 66653), OPPS
payment rates for CPT code 77778, in
particular, had fluctuated over the years.
We were frequently informed by the
public that reliance on single procedure
claims to set the median costs for these
services resulted in use of mainly
incorrectly coded claims for LDR
prostate brachytherapy because a
correctly coded claim should include,
for the same date of service, CPT codes
for both needle/catheter placement and
application of radiation sources, as well
as separately coded imaging and
radiation therapy planning services (that
is, a multiple procedure claim).
In order to base payment on claims for
the most common clinical scenario, and
to further our goal of providing payment
under the OPPS for a larger bundle of
component services provided in a single
hospital encounter, beginning in CY
2008, we provide a single payment for
LDR prostate brachytherapy when the
composite service, reported as CPT
codes 55875 and 77778, is furnished in
a single hospital encounter. We base the
payment for composite APC 8001 (LDR
Prostate Brachytherapy Composite) on
the median cost derived from claims for
the same date of service that contain
both CPT codes 55875 and 77778 and
that do not contain other separately paid
codes that are not on the bypass list. In
uncommon occurrences in which the
services are billed individually,
hospitals continue to receive separate
payments for the individual services.
We refer readers to the CY 2008 OPPS/
ASC final rule with comment period (72
FR 66652 through 66655) for a full
history of OPPS payment for LDR
prostate brachytherapy and a detaileddescription of how we developed the
LDR prostate brachytherapy composite
APC.
In the CY 2011 OPPS/ASC proposed
rule (75 FR 46210), for CY 2011, we
proposed to continue paying for LDR
prostate brachytherapy services using
the composite APC methodology
proposed and implemented for CYs
2008, 2009, and 2010. That is, we
proposed to use CY 2009 claims on
which both CPT codes 55875 and 77778
were billed on the same date of service
with no other separately paid procedure
codes (other than those on the bypass
list) to calculate the payment rate for
composite APC 8001. Consistent with
our CY 2008 through CY 2010 practice,
we proposed not to use the claims that
meet these criteria in the calculation of
the median costs for APCs 0163 (Level
IV Cystourethroscopy and Other
Genitourinary Procedures) and 0651
(Complex Interstitial Radiation Source
Application), the APCs to which CPT
codes 55875 and 77778 are assigned,
respectively. The median costs for APCs
0163 and 0651 would continue to be
calculated using single and "pseudo"
single procedure claims. We indicated
in the proposed rule that we continue to
believe that this composite APC
contributes to our goal of creating
hospital incentives for efficiency and
cost containment, while providing
hospitals with the most flexibility to
manage their resources. We also
continue to believe that data from
claims reporting both services required
for LDR prostate brachytherapy provide
the most accurate median cost upon
which to base the composite APC
payment rate.
Using partial year CY 2009 claims
data available for the CY 2011 proposed
rule, we were able to use 788 claims that
contained both CPT codes and 55875
and 77778 to calculate the median cost
upon which the proposed CY 2011
payment for composite APC 8001 was
based. The proposed median cost for
composite APC 8001 for CY 2011 was
approximately $3,265. This is an
increase compared to the CY 2010
OPPS/ASC final rule with comment
period in which we calculated a final
median cost for this composite APC of
approximately $3,084 based on a full
year of CY 2008 claims data. The
proposed CY 2011 median cost for this
composite APC was slightly less than
$3,604, the sum of the proposed median
costs for APCs 0163 and 0651 ($2,606 +
$998), the APCs to which CPT codes
55875 and 77778 map if one service is
billed on a claim without the other. We
indicated in the proposed rule that we
believe the proposed CY 2011 median
cost for composite APC 8001 ofapproximately $3,265, calculated from
71854 Federal Register/Vol. 75,
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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/m1/343/: accessed April 25, 2024), University of North Texas Libraries, UNT Digital Library, https://digital.library.unt.edu; crediting UNT Libraries Government Documents Department.