Federal Register: November 1, 2002 (Volume 67, Number 212)
DOCID: FR Doc 02-27548
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Veterans Affairs Department
CFR Citation: 42 CFR Parts 405 and 419
RIN ID: RIN 0938-AL19 and 0938-AK59
CMS ID: [CMS-1206-FC and CMS-1179-F]
NOTICE: Part II
DOCUMENT ACTION: Final rule with comment period.
SUBJECT CATEGORY:
Medicare Program; Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2003 Payment Rates; and Changes to Payment Suspension for Unfiled Cost Reports
DATES: Effective date: This final rule is effective January 1, 2003.
Comment date: We will consider comments on the ambulatory payment classification assignments of Healthcare Common Procedure Coding System codes identified in Addendum B with condition code NI, and on Sec. 419.23(d)(3), if we receive them at the appropriate address, as provided below, no later than 5 pm on December 31, 2002.
DOCUMENT SUMMARY:
This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In addition, it describes changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2003. This rule also allows the Secretary to suspend Medicare payments ``in whole or in part'' if a provider fails to file a timely and acceptable cost report.
In addition, this rule responds to public comments received on the November 2, 2001 interim final rule with comment period (66 FR 55850) that set forth the criteria the Secretary will use to establish new categories of medical devices eligible for transitional passthrough payment under the Medicare's hospital outpatient prospective payment system. Finally, this rule responds to public comments received on the August 9, 2002 proposed rule for revisions to the hospital outpatient prospective payment system and payment rates (67 FR 52092). CMS finds good cause to waive proposed rulemaking for the assignment of new codes to Ambulatory Payment Classifications and for the payment of influenza and pneuomococcal vaccines under reasonable cost; justification for the waiver will follow in a subsequent Federal Register notice.
SUMMARY:
Health and Human Services Department, Centers for Medicare & Medicaid Services,
SUPPLEMENTAL INFORMATION
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www.access.gpo.gov/nara/index.html. To assist readers in referencing
sections contained in this document, we are providing the following table of contents.
Outline of Contents
I. Background
A. Authority for the Outpatient Prospective Payment System (OPPS)
B. Summary of Rulemaking for the Outpatient Prospective Payment System
C. Authority for Payment Suspensions for Unfiled Cost Reports
D. Summary of Changes in the August 9, 2002 Proposed Rule
1. Changes Relating to the OPPS
a. Changes Required by Statute
b. Additional Changes to OPPS
c. Changes to the Regulations Text
2. Changes Relating to Payment Suspension for Unfiled Cost Reports
E. Summary of the November 2, 2001 Interim Final Rule with Comment Period
F. Public Comments and Responses to the August 9, 2002 Proposed Rule
1. OPPS
2. Payment Suspension for Unfiled Cost Reports
II. Changes to the Ambulatory Payment Classification (APC) Groups and Relative Weights
A. Recommendations of the Advisory Panel on APC Groups
1. Establishment of the Advisory Panel
2. General Issues Considered by the Advisory Panel
3. Recommendations of the Advisory Panel and Our Responses
B. Other Changes Affecting Ambulatory Payment Classification (APC) Assignments
1. Limit on Variation of Costs of Services Classified Within a Group
2. Procedures Moved from New Technology APCs to Clinically Appropriate APCs
3. APC Assignment for New Codes Created During Calenday Year (CY) 2002 and Selected Codes and APC Assignments for 2003
4. Other Public Comments on APC Assignments and Payment Rates
5. Procedures That Will Be Paid Only As Inpatient Procedures
C. Partial Hospitalization
III. Recalibration of APC Weights for 2003
A. Data Issues
1. Treatment of ``Multiple Procedure'' Claims
2. Calendar Year 2002 Charge Data for PassThrough Device Categories
B. Description of How Weights Were Calculated for 2003 IV. Transitional PassThrough and Related Payment Issues
A. Background
B. Discussion of Pro Rata Reduction
C. Expiration of Transitional PassThrough Payments in Calendar Year 2003 for Devices
D. Expiration of Transitional PassThrough Payments in Calendar Year 2003 for Drugs and Biologicals (Including Radiopharmaceuticals, Blood, and Blood Products)
E. Expiration of Transitional PassThrough Payments in Calendar Year 2003 for Brachytherapy
F. Payment for Transitional PassThrough Drugs and Biologicals for Calendar Year 2003
V. Criteria for New Device Categories As Implemented in the November 2, 2001 Interim Final Rule with Comment
A. Criteria for Eligibility for PassThrough Payment of a Medical Device
B. Criteria for Establishing Additional Device Categories
1. Application Process for Creation of a New Device Category
2. Announcing a New Device Category
VI. Wage Index Changes for Calendar Year 2003
VII. Copayment for Calendar Year 2003
VIII. Conversion Factor Update for Calendar Year 2003
IX. Outlier Policy for Calendar Year 2003
X. Other Policy Decisions and Changes
A. Hospital Coding for Evaluation and Management (E/M) Services
B. Observation Services
[[Page 66719]]
C. Payment Policy When A Surgical Procedure on the Inpatient List Is Performed on an Emergency Basis
1. Current Policy
2. Hospital Concerns
3. Clarification of Payment Policy
4. Orders to Admit
D. Status Indicators
E. Other Policy Issues Relating to PassThrough Device Categories
1. Reducing Transitional PassThrough Payments To Offset Costs Packaged Into APC Groups
2. Devices Paid With Multiple Procedures
F. Outpatient Billing for Dialysis
XI. Summary and Responses of Public Comments to CMS's Response to MedPAC Recommendations
XII. Provisions of the Final Rule With Comment for 2003
A. OPPS
1. Statutory and Discretionary Changes
2. Changes to the Regulations Text
B. Payment Suspension for Unfiled Cost Reports
C. Partial Hospitalization Services
D. Pneumococcal and Influenza Vaccines
XIII. Response to Public Comments
XIV. Collection of Information Requirements
XV. Regulatory Impact Analysis
A. OPPS
1. General
2. Changes in this Final Rule
3. Limitations of Our Analysis
4. Estimated Impacts of this Final Rule on Hospitals
5. Estimated Impacts of this Final Rule on Beneficiaries
B. Payment Suspension for Unfiled Cost Reports Regulations Text
1. Effects on Provider that File Cost Reports
2. Effects on Other Providers
3. Effects on the Medicare Program
4. Effects on Beneficiaries
Addenda
Addendum AList of Ambulatory Payment Classifications (APCs) with Status Indicators, Relative Weights, Payment Rates, and Copayment Amounts
Addendum BPayment Status by HCPCS Code, and Related Information
Addendum CHospital Outpatient Payment for Procedures by APC: Displayed on Web site Only
Addendum DPayment Status Indicators for the Hospital Outpatient Prospective Payment System
Addendum D1Code Conditions
Addendum ECPT Codes That Would Be Paid Only As Inpatient Procedures
Addendum GService Mix Indices by Hospital: Displayed on Web site Only
Addendum HWage Index for Urban Areas
Addendum IWage Index for Rural Areas
Addendum JWage Index for Hospitals That Are Reclassified Alphabetical List of Acronyms Appearing in the Final Rule
ACEPAmerican College of Emergency Physicians
AMAAmerican Medical Association
APCAmbulatory payment classification
AWPAverage wholesale price
BBABalanced Budget Act of 1997
BIPAMedicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000
BBRABalanced Budget Refinement Act of 1999
CCRCost center specific costtocharge ratio
CMHCCommunity mental health center
CMSCenters for Medicare & Medicaid Services (Formerly known as the Health Care Financing Administration)
CPT (Physician's) Current Procedural Terminology, Fourth Edition, 2002, copyrighted by the American Medical Association
CSW Clinical social worker
CY Calendar year
DRG Diagnosisrelated group
DSH Disproportionate Share Hospital
EACH Essential Access Community Hospital
E/M Evaluation and management
ERCP Endoscopic retrograde cholangiopancreatography
ESRD Endstage renal disease
FACA Federal Advisory Committee Act
FY Federal fiscal year
HCPCS Healthcare Common Procedure Coding System
HIPAA Health Insurance Portability and Accountability Act of 1996 ICU Intensive care unit
ICD9CM International Classification of Diseases, Ninth Edition, Clinical Modification
IME Indirect Medical Education
IPPS (Hospital) inpatient prospective payment system
LTC Long Term Care
MedPAC Medicare Payment Advisory Commission
MDH Medicare Dependent Hospital
MSA Metropolitan statistical area
NECMA New England County Metropolitan Area
OCE Outpatient code editor
OMB Office of Management and Budget
OPD (Hospital) outpatient department
OPPS (Hospital) outpatient prospective payment system
OT Occupational therapist
PHP Partial hospitalization program
PPS Prospective payment system
PPV Pneumococcal pneumonia (virus)
PRA Paperwork Reduction Act
RFA Regulatory Flexibility Act
RRC Rural Referral Center
RVUs Relative value units
SCH Sole Community Hospital
TEFRA Tax Equity and Fiscal Responsibility Act
USPDI United States Pharmacopoeia Drug Information
I. Background
A. Authority for the Outpatient Prospective Payment System (OPPS)
When the Medicare statute was originally enacted, Medicare payment
for hospital outpatient services was based on hospitalspecific costs.
In an effort to ensure that Medicare and its beneficiaries pay
appropriately for services and to encourage more efficient delivery of
care, the Congress mandated replacement of the costbased payment
methodology with a prospective payment system (PPS). The Balanced
Budget Act of 1997 (BBA) (Pub. L. 10533), enacted on August 5, 1997,
added section 1833(t) to the Social Security Act (the Act) authorizing
implementation of a PPS for hospital outpatient services. The Balanced
Budget Refinement Act of 1999 (BBRA) (Pub. L. 106113), enacted on
November 29, 1999, made major changes that affected the hospital
outpatient PPS (OPPS). The Medicare, Medicaid, and SCHIP Benefits
Improvement and Protection Act of 2000 (BIPA) (Pub. L. 106554),
enacted on December 21, 2000, made further changes in the OPPS. The
OPPS was first implemented for services furnished on or after August 1, 2000.
B. Summary of Rulemaking for the Outpatient Prospective Payment System
[sbull] On September 8, 1998, we published a proposed rule (63 FR
47552) to establish in regulations a PPS for hospital outpatient
services, to eliminate the formuladriven overpayment for certain
hospital outpatient services, and to extend reductions in payment for
costs of hospital outpatient services. On June 30, 1999, we published a
correction notice (64 FR 35258) to correct a number of technical and
typographic errors in the September 1998 proposed rule including the
proposed amounts and factors used to determine the payment rates.
[sbull] On April 7, 2000, we published a final rule with comment
period (65 FR 18434) that addressed the provisions of the PPS for
hospital outpatient services scheduled to be effective for services
furnished on or after July 1, 2000. Under this system, Medicare payment
for hospital outpatient services included in the PPS is made at a
predetermined, specific rate. These outpatient services are classified
according to a list of ambulatory payment classifications (APCs). The
April 7, 2000 final rule with comment period also established
requirements for provider departments and providerbased entities and
prohibited Medicare payment for nonphysician services furnished to a
hospital outpatient by a provider or supplier other than a hospital
unless the services are furnished under arrangement. In addition, this
rule extended reductions in payment for costs of hospital outpatient
services as required by the BBA and amended by the BBRA. Medicare
regulations governing the hospital OPPS are set forth at 42 CFR part 419.
[[Page 66720]]
[sbull] On June 30, 2000, we published a notice (65 FR 40535)
announcing a delay in implementation of the OPPS from July 1, 2000 to August 1, 2000. We implemented the OPPS on August 1, 2000.
[sbull] On August 3, 2000, we published an interim final rule with
comment period (65 FR 47670) that modified criteria that we use to
determine which medical devices are eligible for transitional pass
through payments. The August 3, 2000 rule also corrected and clarified
certain providerbased provisions included in the April 7, 2000 rule.
[sbull] On November 13, 2000, we published an interim final rule
with comment period (65 FR 67798). This rule provided for the annual
update to the amounts and factors for OPPS payment rates effective for
services furnished on or after January 1, 2001. We implemented the 2001
OPPS on January 1, 2001. We also responded to public comments on those
portions of the April 7, 2000 final rule that implemented related
provisions of the BBRA and public comments on the August 3, 2000 rule.
[sbull] On August 24, 2001, we published a proposed rule (66 FR
44672) that would revise the OPPS to implement applicable statutory
requirements, including relevant provisions of the Medicare, Medicaid,
and SCHIP Benefits Improvement and Protection Act of 2002 (BIPA) and
changes arising from our continuing experience with this system. It
also described proposed changes to the amounts and factors used to
determine the payment rates for Medicare hospital outpatient services
paid under the PPS. The changes applied to services furnished on or after January 1, 2002.
[sbull] On November 2, 2001, we published a final rule (66 FR
55857) that announced the Medicare OPPS conversion factor for calendar
year 2002. In addition, it described the Secretary's estimate of the
total amount of the transitional passthrough payments for CY 2002 and
the implementation of a uniform reduction in each of the passthrough payments for that year.
[sbull] On November 2, 2001, we also published an interim final
rule with comment period (66 FR 55850) that set forth the criteria the
Secretary will use to establish new categories of medical devices
eligible for transitional passthrough payments under Medicare's OPPS.
[sbull] On November 30, 2001, we published a final rule (66 FR
59856) that revised the Medicare OPPS to implement applicable statutory
requirements, including relevant provisions of BIPA, and changes
resulting from continuing experience with this system. It addition, it
described the CY 2002 payment rates for Medicare hospital outpatient
services paid under the PPS. This final rule also announced a uniform
reduction of 68.9 percent to be applied to each of the transitional
passthrough payments for certain categories of medical devices and drugs and biologicals.
[sbull] On December 31, 2001, we published a final rule (66 FR
67494) that delayed, until no later than April 1, 2002, the effective
date of CY 2002 payment rates and the uniform reduction of transitional
passthrough payments that were announced in the November 30, 2001
final rule. In addition, this final rule indefinitely delayed certain related regulatory provisions.
[sbull] On March 1, 2002, we published a final rule (67 FR 9556)
that corrected technical errors that affected the amounts and factors
used to determine the payment rates for services paid under the
Medicare OPPS and corrected the uniform reduction to be applied to
transitional passthrough payments for CY 2002 as published in the
November 30, 2001 final rule. These corrections and the regulatory
provisions that had been delayed became effective on April 1, 2002.
[sbull] On August 9, 2002, we published a proposed rule (67 FR
52092) that would revise the OPPS to implement applicable statutory
requirements and changes arising from our continuing experience with
this system. The changes would be applicable to services furnished on
or afterJanuary 1, 2003. This rule also proposed to allow the Secretary
to suspend Medicare payments ``in whole or in part'' if a provider fails to file a timely and acceptable cost report.
C. Authority for Payment Suspensions for Unfiled Cost Reports
Authority for the provision regarding payment suspensions for
unfiled cost reports is contained within the authority for subpart C of
42 CFR part 405, that is, sections 1102, 1815, 1833, 1842, 1866, 1870,
1871, 1879, and 1892 of the Social Security Act (42 U.S.C. 1302, 1395g,
1395l, 1395u, 1395cc, 1395gg, 1395hh, 1395pp, and 1395ccc) and 31 U.S.C. 3711.
D. Summary of Changes in the August 9, 2002 Proposed Rule
1. Changes Relating to the OPPS
On August 9, 2002, we published a proposed rule (67 FR 52092) that set forth proposed changes to the Medicare hospital OPPS and CY 2003 payment rates including changes used to determine these payment rates. The following is a summary of the major changes that we proposed and the issues we addressed in the August 9, 2002 proposed rule.
a. Changes Required By Statute
We proposed the following changes to implement statutory requirements:
[sbull] Add APCs, delete APCs, and modify the composition of some existing APCs.
[sbull] Recalibrate the relative payment weights of the APCs.
[sbull] Update the conversion factor and the wage index.
[sbull] Revise the APC payment amounts to reflect the APC
reclassifications, the recalibration of payment weights, and the other required updates and adjustments.
[sbull] Cease transitional passthrough payments for drugs and
biologicals (including blood and blood products) and devices (including
brachytherapy), that will, on January 1, 2003, have been paid under transitional passthrough methodology for at least 2 years.
b. Additional Changes to OPPS
We proposed the following additional changes to the OPPS and Payment Suspension Provisions:
[sbull] Creation of new evaluation and management service codes for outpatient clinic and emergency department encounters for
implementation no earlier than January 1, 2004.
[sbull] Changes to the list of services that we do not pay in
outpatient departments because we define them as inpatient only procedures.
[sbull] Changes to our policy of nonpayment for procedures on the
inpatient only list in special cases involving death or transfer before inpatient admission.
[sbull] Changes to our policy governing observation in cases of direct admission to observation.
[sbull] Changes to status indicators for Healthcare Common Procedure Coding System (HCPCS) codes.
[sbull] Changes to our policies governing dialysis for endstage
renal disease (ESRD) patients and regarding partial hospitalization.
C. Changes to the Regulations Text
A. We proposed to make the following changes to our regulations:
Amend Sec. 419.66(c)(1) to specify that we must establish a new category for a medical device if it is not described by any category previously in effect as well as an existing category.
2. Changes Relating to Payment Suspension for Unfiled Cost Reports [[Page 66721]]
We proposed to revise Sec. 405.371(c) to specify that we may suspend Medicare payments ``in whole or in part'' if a provider has failed to timely file an acceptable cost report. This provision is consistent with the existing provisions in Sec. 405.371(a) governing the suspension of Medicare payments ``in whole or in part'' under certain conditions. We believe the Medicare program would benefit because immediate complete payment suspension can be disruptive to providers and may negatively affect the care of Medicare patients. E. Summary of the November 2, 2001 Interim Final Rule with Comment Period
On November 2, 2001, we published an interim final rule with comment period in the Federal Register (66 FR 55850) that set forth the criteria for establishing new categories of medical devices eligible for transitional passthrough payments under Medicare's hospital OPPS as required by section 1833(t)(6)(B)(ii) of the Act, as amended by BIPA.
In the April 7, 2000 final rule with comment period (65 FR 18480), we defined new or innovative devices using eight criteria, three of which were revised in our August 3, 2000 interim final rule with comment period (65 FR 4767374). These criteria remained applicable when defining a new category for devices, (that is, devices to be included in a category must meet all previously established applicable criteria for a device eligible for transitional passthrough payments) but we revised the definition of an eligible device to conform the requirements of amended section 1833(t)(6)(B)(ii) of the Act.
We also clarified our criterion that states that a device must be approved or cleared by the Food and Drug Administration (FDA).
In establishing the criteria for establishing additional
categories, the Act mandates that new categories be established for
devices that were not being paid for as an outpatient hospital service
as of December 31, 1996 and for which no categories in effect (or
previously in effect) are appropriate, in such a way that no device is
described by more than one category and the average cost of devices to
be included in the category is not insignificant in relation to the APC
payment amount for the associated service. Based on these requirements,
we used the following criteria to establish a category of devices:
[sbull] Substantial clinical improvement. The category describes
devices that demonstrate a substantial improvement in medical benefits
for Medicare beneficiaries compared to the benefits obtained by devices
in previously established categories or other available treatments, as described in regulations at new Sec. 419.66(c)(1).
[sbull] Cost. We determine that the estimated cost to hospitals of
the devices in a new category (including any candidate devices and the
other devices that we believe will be included in the category) is
``not insignificant'' relative to the payment rate for the applicable procedures.
We received five timely items of correspondence on the November 2, 2001 interim final rule with comment period. Summaries of the public comments and our responses to those comments are set forth below under the appropriate section heading of this final rule with comment period. F. Public Comments and Responses to the August 9, 2002 Proposed Rule
We received approximately 1,000 timely items of correspondence containing multiple comments on the August 9, 2002 proposed rule. Of that total, we received eight comments relating to the payment suspension provision described in section I.D.2. Summaries of the public comments received on other provisions and our responses to those comments are provided below in section I.F.2 of this preamble. 1. OPPS
We received comments from various sources including but not limited
to health care facilities, physicians, drug and device manufacturers,
and beneficiaries. Hospital associations and the Medicare Payment
Advisory Commission (MedPAC) generally supported our proposed approach
to revising the relative weights and incorporating the drugs and
devices into payment for APCs. Pharmaceutial and medical device
manufacturers and some individual hospitals that furnish particular
devices or drugs were concerned with the proposed reductions in payment
for medical devices and drugs. We received many thoughtful comments
from a wide range of commenters with regard to methodological issues in
OPPS. In addition, several comments provided data to support their
assertions. The following are the major OPPS related issues addressed by the commenters:
[sbull] Expiration of passthrough payment for most devices and drugs/biologicals.
[sbull] Extent of reduction in payments for devices compared to payments in 2002.
[sbull] Potential impact on access to care of proposed payments.
[sbull] The proposal to package drugs with a per line cost less than $150 and to pay separately for others.
[sbull] Assignment and reassignment of codes to APCs (including assignments to procedural APCs from new tech APCs).
[sbull] Quality, quantity and content of claims data used to set payment weights.
[sbull] Continuation of a list of procedures that are not paid
under OPPS because we believe that they should be performed as inpatient services.
[sbull] Policy on payment for outpatient observation care.
[sbull] Creation of evaluation and management codes for OPPS use.
Summaries of the public comments received and our responses to
those comments are set forth below under the appropriate headings of this final rule with comment period.
2. Payment Suspension for Unfiled Cost Reports
Comments and Responses
Comment: All of the commenters stated that the rule provides for increased flexibility and a reduction in the financial impact of payment suspensions on providers. They indicated the increased flexibility would allow providers to receive partial payments from Medicare, which would lessen the financial impact of payment suspensions.
Response: We appreciate the hospital associations supporting this change.
Comment: One commenter suggested that payment suspension be limited to those payments directly determined by the cost report.
Response: We believe that immediate suspension of all payments when
a cost report is not filed timely may not always be the appropriate
response. However, if we require a provider to file a cost report, it
is important for the cost report to be filed in a timely manner
regardless of the amount of payment that is determined based on the
cost report. We need flexibility in determining the amount of a
provider's payments to suspend if its cost report is not filed timely.
This could include the potential suspension of payments that are not
determined by the cost report. Thus, we will retain Sec. 405.371 of the regulation as set forth in the proposed rule.
II. Changes to the Ambulatory Payment Classification (APC) Groups and Relative Weights
Under the OPPS, we pay for hospital outpatient services on a rate
perservice basis that varies according to the APC group to which the service is assigned. Each APC weight represents the median
[[Page 66722]]
hospital cost of the services included in that APC relative to the
median hospital cost of the services included in APC 601, MidLevel
Clinic Visits. The APC weights are scaled to APC 601 because a mid
level clinic visit is one of the most frequently performed services in the outpatient setting.
Section 1833(t)(9)(A) of the Act requires the Secretary to review the components of the OPPS not less often than annually and to revise the groups and related payment adjustment factors to take into account changes in medical practice, changes in technology, and the addition of new services, new cost data, and other relevant information. Section 1833(t)(9)(A) of the Act requires the Secretary, beginning in 2001, to consult with an outside panel of experts when annually reviewing and updating the APC groups and the relative payment weights.
Finally, section 1833(t)(2) of the Act provides that, subject to certain exceptions, the items and services within an APC group cannot be considered comparable with respect to the use of resources if the highest median or mean cost item or service in the group is more than 2 times greater than the lowest median cost item or service within the same group (referred to as the ``2 times rule'').
We use the median cost of the item or service in implementing this provision. The statute authorizes the Secretary to make exceptions to the 2 times rule ``in unusual cases, such as low volume items and services.''
For purposes of the proposed rule and for this final rule with
comment period, we analyzed the APC groups within this statutory framework.
A. Recommendations of the Advisory Panel on APC Groups
1. Establishment of the Advisory Panel
Section 1833(t)(9)(A) of the Act, requires that we consult with an outside panel of experts when annually reviewing and updating the APC groups and the relative weights. The Act specifies that the panel will act in an advisory capacity. The expert panel, which is to be composed of representatives of providers, is to review and advise us about the clinical integrity of the APC groups and their weights. The panel is not restricted to using our data and may use data collected or developed by organizations outside the Department in conducting its review.
On November 21, 2000, the Secretary signed the charter establishing an ``Advisory Panel on APC Groups'' (the Panel). The Panel is technical in nature and is governed by the provisions of the Federal Advisory Committee Act (FACA) as amended (Pub. L. 92463). To establish the Panel, we solicited members in a notice published in the Federal Register on December 5, 2000 (65 FR 75943). We received applications from more than 115 individuals nominating either themselves or a colleague. After carefully reviewing the applications, we chose 15 highly qualified individuals to serve on the Panel. The first APC Panel meeting was held on February 27, February 28, and March 1, 2001, to discuss the 2001 APCs in anticipation of the 2002 OPPS.
We published a notice in the Federal Register on December 14, 2001, to announce the location and time of the second Panel meeting, a list of agenda items, and that the meeting was open to the public. We also provided additional information through a press release and on our Web site. We convened the second meeting of the Panel on January 22 through January 24, 2002.
2. General Issues Considered by the Advisory Panel
In the proposed rule, we summarized the Panel's discussion of a recommendation by the Panel's Research Subcommittee concerning the format of written submissions and oral presentations to the Panel and of several general OPPS payment issues.
Content for Future Presentations to the Panel
During the 2001 meeting, the Panel members felt that requiring consistency for all presentations with regard to format, data submission, and general information would assist them in analyzing the submissions and presentations and making recommendations. Therefore, upon the Panel's recommendation, the Research Subcommittee was established during the 2001 meeting.
The Panel began its 2002 meeting by considering the Research
Subcommittee's recommendation to the Panel on requirements for written
submissions and oral presentations. The Research Subcommittee
recommended that all future oral presentations and written submissions contain the following:
[sbull] Name, address, and telephone number of the proposed presenter.
[sbull] Financial relationship(s), if any, with any company whose products, services, or procedures are under consideration.
[sbull] CPT codes involved.
[sbull] APC(s) affected.
[sbull] Description of the issue.
[sbull] Clinical description of the service under discussion, with comparison to other services within the APC.
[sbull] Description of the resource inputs associated with the
service under discussion, with a comparison to resource inputs for other services within the APC.
[sbull] Recommendations and rationale for change.
[sbull] Expected outcome of change and potential consequences of no change.
The Panel adopted the Subcommittee s recommendation. Presentations for the 2003 meeting must contain, at a minimum, this information. Inpatient Only List
At its February 2001 meeting, the Panel discussed the existence of the inpatient list. The Panel favored its elimination. At the January 2002 meeting, Panel members noted that hospitals receive no payment for a service performed in an outpatient department that appears on the inpatient list, even though the physician performing that service will receive payment for his or her services. The Panel believes the physician should determine what procedure to perform and that both the hospital and the physician should receive payment for the procedure. We continue to disagree with the position taken by the Panel regarding the inpatient list for reasons that we discuss in detail in the April 7, 2000 final rule (65 FR 18456).
Prior to the 2002 Panel meeting, we received requests from hospital and surgical associations and societies to remove certain procedures from the inpatient list. We reviewed those requests and presented to the Panel the requests for which we were unable to make a determination based on the information submitted with the request.
The Panel considered removing the following procedures from the inpatient list:
CPT Description
21390..................................... Treat eye socket fracture
27216..................................... Treat pelvic ring fracture
27235..................................... Treat thigh fracture [[Page 66723]]
32201..................................... Drain, precut, lung lesion
33967..................................... Insert a precut device
47490..................................... Incision of gallbladder
62351..................................... Implant spinal canal cath
64820..................................... Remove sympathetic nerves
92986..................................... Revision of aortic valve
92987..................................... Revision of mitral valve
92990..................................... Revision of pulmonary valve
92997..................................... Pul art balloon repr, precut
92998..................................... Pul art balloon repr, precut
As the Panel recommended, we solicited comments and additional information from hospitals and medical specialty societies that have an interest in these procedures. At their 2003 meeting, the Panel also recommended that we present to them any such comments that we receive to assist in their evaluation of whether to recommend removing the codes from the inpatient list.
The Panel did recommend that we remove from the inpatient list CPT
code 47001, Biopsy of liver, needle; when done for indicated purpose at time of other major procedure. We agreed with the Panel's
recommendation and we proposed to remove 47001 from the inpatient list.
We further proposed to assign it status indicator ``N'' so that costs
associated withCPT code 47001 would be packaged into the APC payment
for the primary procedure performed during the same operative session.
In section II.B.5 of the proposed rule, we discussed additional procedures, which were not considered by the Panel, that we proposed to remove from the inpatient list. We discussed in detail our reasons for proposing these additional changes, and we proposed two new criteria that we would adopt in the future when evaluating whether to make a procedure on the inpatient list payable under the OPPS. Table 6 in section II.B.5 of the proposed rule lists all the procedures we proposed to remove from the inpatient list, including those discussed by the Panel. We considered the removal of CPT code 33967, Insertion of intraaortic balloon assist device, percutaneous from the inpatient list, but did not include it in Table 6. The Panel considered this code for removal from the inpatient list and had concerns about whether performing this procedure in an outpatient setting is appropriate. Further, we were not able to confirm that this procedure is being performed on Medicare beneficiaries in an outpatient setting. We solicited comments, including clinical data and specific case reports, which would support payment for CPT 33967 under the OPPS.
Our discussion of the comments we received on this issue, our response and the statement of final action regarding what services to remove from the inpatient list is contained in section II.B.5. Multiple Bills
During its February 2001 meeting, the Panel received oral testimony identifying CMS exclusive use of single procedure claims to set relative weights for APCs as a potential problem in setting appropriate payment rates for APCs. Therefore, the panel asked its Research Subcommittee to work with CMS staff, using the Endoscopic Retrograde Cholangiopancreatography (ERCP) code family as a case study, to explore the use of multiple procedure claims data for setting relative weights.
The Subcommittee made the following recommendations to the Panel, which the Panel approved:
[sbull] We should continue to explore the use of multiple procedure
claims data for setting payment rates but should continue to use only
single procedure claims data to determine relative payment weights for CY 2003.
[sbull] We should work with the APC Panel to explore the use of
multiple claims data drawn from OPPS claims for services such as radiation oncology in time for the next APC Panel meeting.
[sbull] We should educate hospitals on appropriate coding and
billing practices to ensure that claims with multiple procedures are
properly coded and that costs are properly allocated to each procedure.
One presenter to the panel suggested a method to increase the number of claims that could be considered as single claims. Currently, we consider any claim submitted with two or more primary codes (that is, a code assigned to an APC for separate payment) to be a multiple procedure claim. When these claims contain line items for revenue centers without an accompanying Healthcare Common Procedure Coding System (HCPCS) code there is no way to determine the appropriate primary code with which to package the revenue center. The presenter suggested that we consider all claims where every line contains a separately payable HCPCS code as a single procedure claim, reasoning that on such claims we do not have to determine how and where to ``package'' line items not identified by a separately payable HCPCS code. Where every line item contains a separately payable HCPCS code, every cost can easily be allocated to a separately payable HCPCS code on the line item and all costs for each HCPCS code can then be accurately and completely determined.
We agreed with that suggestion. In section II.B.4 of the proposed rule, we described how we determined the number of single claims used to set the APC relative weights proposed for 2003 using this methodology. We requested comments on our methodology.
Discussion of the comments we received on this issue, our responses, and the statement of final action are contained in section III.A.
Packaging
We sought the Panel's guidance on whether we should package the costs of HCPCS codes for radiologic guidance and radiologic supervision and interpretation services whose descriptors require that they only be performed in conjunction with a surgical procedure.
In the proposed rule, we discussed why we package the costs of
certain procedures. We specified for example, that ``addon''
procedures and radiologic guidance procedures should never be billed on
a claim without the code for an associated procedure. A facility should
not submit a claim for ultrasound guidance for a biopsy unless the
claim also includes the biopsy procedure, because the guidance is
necessary only when a biopsy is performed. A claim for a packaged
guidance procedure (or a supervision and interpretation procedure whose
descriptor requires it be performed in association with a surgical procedure)
[[Page 66724]]
would be returned to the provider for correction and resubmission.
Also, we explained that we use packaging because billing conventions allow hospitals to report costs for certain services using only revenue center codes (that is, hospitals are not required to specify HCPCS codes for certain services). Packaging allows these costs to be captured in the data used to calculate median costs for services with an APC.
After hearing the requests of several presenters, (details discussed at 66 FR 52098 of the proposed rule) the Panel concluded that, even though we could be setting relative weights based on error claims, we should not package additional radiologic guidance and supervision and interpretation procedures and should continue to explore methodologies that would allow these procedures to be recognized for separate payment. The Panel also recommended that radiology guidance codes that were in APC 268 for CY 2001 but that were designated with status indicator ``N'' as packaged services in 2002, be restored as separately payable services for CY 2003. The Panel requested that this topic be placed on the agenda for the next Panel meeting.
Our discussion of the comments we received on this issue, our responses and a statement of final action is contained in section III.B.
AddOn Codes
As discussed in the proposed rule (66 FR 52098), we presented for the Panel's consideration several options for payment of addon codes, including assignment of status indicator ``N'' to package them into the payment for the base procedure. After thorough review, the Panel concluded that we should continue to pay for addon codes separately, setting relative weights with the use of single procedure claims in spite of the fact that these were error claims. The Panel asked us to continue exploring ways to most appropriately pay for these services. They requested that this item also be placed on the agenda for the next Panel meeting.
We proposed to accept the recommendations of the APC Panel both for packaging radiology guidance and supervision and interpretation codes and for payment of addon codes. We proposed to pay separately in 2003 for radiology guidance codes that were paid in APC 268 in CY 2001 but that were packaged in 2002.
3. Recommendations of the Advisory Panel and Our Responses
In the proposed rule, we summarized the issues considered by the Panel, the Panel's APC recommendations and our subsequent action with regard to the Panel's recommendations. The most recent data available for the Panel to review in considering specific APC groupings were the 19992000 preOPPS claims data that were the basis of the CY 2002 relative payment weights. In the proposed rule, we provided a detailed summary of the Panel discussion and recommendations (67 FR 52098 52102). See the proposed rule for more details regarding these discussions. The APC titles are shown in this discussion of the APC Panel recommendations as they existed when the APC Panel met in January 2002. In a few cases the APC titles were changed for the proposed 2003 OPPS and therefore some APCs do not have the same title in Addendum A as they have in this section.
As discussed below, the Panel sometimes declined to recommend a
change in an APC even though the APC violated the 2 times rule. In
section II.B.1 of this preamble, we discuss our proposals regarding the
2 times rule based on the CY 2001 data we are using to recalibrate the
2003 APC relative weights. Section II.B.1 also details the criteria we
use in deciding to make an exception to the 2 times rule. We asked the
Panel to review many of the exceptions we implemented in 2001 and 2002.
We refer to the exceptions as ``violations of the 2 times'' rule in the following discussion.
APC 215: Level I Nerve and Muscle Tests
APC 216: Level III Nerve and Muscle Tests
APC 218: Level II Nerve and Muscle Tests
We presented this agenda item because APC 215 appeared to violate
the 2 times rule. In order to remedy this violation, we asked the Panel to consider the following changes:
[sbull] Move CPT codes 95858, 95921, and 95922 from APC 215 to APC 218.
[sbull] Move CPT code 95930 from APC 216 to APC 218.
[sbull] Move CPT code 92275 from APC 216 to APC 231.
[sbull] Move CPT code 95920 from APC 218 to APC 216.
The Panel recommended that the changes we asked them to consider be
made, that is, to move CPT codes 95921 and 95922 to APC 218. However,
if the calendar year 2001 data support a move of 95921 to APC 216, the Panel recommended that we consider that move.
APC 600: Low Level Clinic Visits
APC 601: Mid Level Clinic Visits
APC 602: High Level Clinic Visits
APC 610: Low Level Emergency Visits
APC 611: Mid Level Emergency Visits
APC 612: High Level Emergency Visits
We discussed the Panel's recommendations related to facility coding
for clinic and emergency department visits are discussed below, in (section X.A of this rule).
APC 296: Level I Therapeutic Radiologic Procedures
APC 297: Level II Therapeutic Radiologic Procedures
APC 263: Level I Miscellaneous Radiology Procedures
APC 264: Level II Miscellaneous Radiology Procedures
APCs 296, 263, and 264 appear to violate the 2 times rule. We asked the Panel to consider three options for reconfiguring these APCs so that they would conform with the 2 times rule.
Option 1: Create a new APC, Level III Therapeutic Radiology Procedures, by moving CPT code 75984 from APC 296 and 74475 from APC 297. Also, move CPT codes 76101, 70390, and 71060 from APC 263 to APC 264 and move CPT code 75980 from APC 297 to APC 296.
Option 2: Move CPT codes 76101, 703690, and 71060 from APC 263 to APC 264 and move CPT code 75984 from APC 296 to APC 264. Move CPT code 75980 from APC 297 to APC 296.
Option 3: Create a new APC, Level III Miscellaneous Radiology
Procedures, by moving CPT codes 76080, 7036736, 76101, 70390, 74190, and 71060 from APC 263. Move CPT code 74327 from APC 296 to APC 263 and move CPT code 75980 from APC 297 to APC 296. APC 264 remains unchanged.
The Panel noted that none of the options that we presented resolve all of the 2 times violations. However, the Panel agreed that Option 2 would create more clinically coherent APCs without creating a new APC based on anticipated device costs that would be billed in 2002. In addition, the Panel invited the American College of Radiology and other interested parties to proposed further changes for the Panel's consideration next year.
We proposed to accept the Panel's recommendations that option 2 be implemented.
APC 230: Level I Eye Tests and Treatments
APC 231: Level III Eye Tests and Treatments
APC 232: Level I Anterior Segment Eye Procedures
APC 233: Level II Anterior Segment Eye Procedures
APC 234: Level III Anterior Segment Eye Procedures
[[Page 66725]]
APC 235: Level I Posterior Segment Eye Procedures
APC 236: Level II Posterior Segment Eye Procedures
APC 237: Level III Posterior Segment Eye Procedures
APC 238: Level I Repair and Plastic Eye Procedures
APC 239: Level II Repair and Plastic Eye Procedures
APC 240: Level III Repair and Plastic Eye Procedures
APC 241: Level IV Repair and Plastic Eye Procedures
APC 242: Level V Repair and Plastic Eye Procedures
APC 247: Laser Eye Procedures Except Retinal
APC 248: Laser Retinal Procedures
APC 698: Level II Eye Tests and Treatments
APC 699: Level IV Eye Tests and Treatments
We asked the Panel to review these APCs to address clinical
inconsistencies and violations of the 2 times rule. We suggested
creating a new level for posterior segment eye procedures and other
changes in order to make the groups more clinically coherent, as follows:
[sbull] Move CPT codes 65260 and 67218 from APC 237 to 236.
[sbull] Create a new APC (Level IV Posterior Segment Eye
Procedures) by moving CPT codes 67107, 67112, 67040, and 67108 from APC 237.
[sbull] Move CPT codes 67145, 67105, and 67210 from APC 247 to APC 248.
[sbull] Move CPT code 66999 from APC 247 to APC 232.
[sbull] Move CPT code 67299 from APC 248 to APC 235.
[sbull] Move CPT codes 65855, 66761, and 66821 from APC 248 to APC 247.
[sbull] Move CPT code 67820 from APC 698 to APC 230.
[sbull] Move CPT code 67208 from APC 231 to APC 235.
[sbull] Move CPT codes 92226, 92284, 65205, 92140 from APC 231 to APC 698.
[sbull] Move CPT code 92235 from APC 231 to APC 699.
[sbull] Move CPT code 68100 from APC 233 to APC 232.
[sbull] Move CPT code 65180 from APC 233 to APC 234.
[sbull] Create a new APC (Level IV Anterior Segment Eye Procedures)
by moving CPT codes 66172, 66185, 66180, 66225 from APC 234. [sbull] Move CPT code 92275 from APC 216 to APC 231.
No presenters commented on these APCs, and, after brief discussion,
the Panel recommended concurrence with our suggested changes. We
proposed to accept the Panel's recommendations. We noted in the
proposed rule that when we were able to use 2001 claims data to re
evaluate the changes recommended by the Panel for these APCs, we found
violations of the 2 times rule in the reconfigured APCs. Nonetheless,
we proposed to accept the Panel's recommendations because they result
in more clinically coherent APCs. We solicited comments on further
changes that would address the violations of the 2 times rule. APC 110: Transfusion
APC 111: Blood Product Exchange
APC 112: Apheresis, Photopheresis, and Plasmapheresis
We presented these APCs to the Panel in 2001 because of their low payment rates and concern that our cost data were inaccurate. These APCs were on the 2002 agenda in order to obtain further comment on our cost data. We suggested no changes in the structure of these APCs.
The Panel recommended that plasma derivatives be placed in their own APCs and classified in the same manner as whole blood products. In addition, the Panel observed that hospitals incur additional costs with each unit of blood product transfused and, therefore, recommended that APC 110 be revised to allow for the costs of additional units of blood product and clinical services.
In section IV.D of this rule, we discussed our payment proposals
for drugs and biologicals for which passthrough payments are scheduled
to expire in 2003. Those proposals would affect payment for blood and
blood products. We proposed not to accept the Panel's recommendation to change current OPPS payment policy for transfusions.
Panel Recommendations to Defer Changes Pending Availability of 2001 Claims Data
Regarding the remaining APC groups that are addressed below, the
Panel recommended that we make no changes until data from claims billed
in 2001 under the OPPS become available for analysis. The Panel further
requested that we place the APC groups in this section on the agenda
for consideration at its meeting in 2003. The changes that we proposed
for the APCs in this section are based upon our review of the 2001
claims data, which did not become available until March 2002. APC 203: Level V Nerve Injections
APC 204: Level VI Nerve Injections
APC 206: Level III Nerve Injections
APC 207: Level IV Nerve Injections
Several presenters to the Panel suggested changes in the configuration of these APCs because of concerns that the current classifications result in payment rates that are too low relative to the resource costs associated with certain procedures in the APCs. Several of these APCs include procedures associated with drugs or with device categories for which passthrough payments are scheduled to expire in 2003. The Panel recommended that we not change the structure of these APCs at this time. Because the structure of these APCs was substantially changed for 2002, and 2002 cost data was not yet available, the Panel felt it would be appropriate to review 2002 cost data prior to making further structural changes to these APCs. We proposed to accept the Panel's recommendation.
We will place these APCs on the Panel's agenda when 2002 cost data becomes available.
APC 43: Closed Treatment Fracture Finger/Toe/Trunk
APC 44: Closed Treatment Fracture/Dislocation, Except Finger/Toe/Trunk
On the basis of 19992000 claims data, these APCs violate the 2 times rule. The Panel reviewed these APCs and recommended no changes.
Our subsequent review of 2001 OPPS cost data shows continuing
violations of the 2 times rule and that costs within these APCs are
virtually identical. Therefore, we proposed to combine APCs 43 and 44
into APC 43. The procedures in the consolidated APC are clinically homogeneous.
APC 58: Level I Strapping and Cast Application
APC 59: Level II Strapping and Cast Application
The Panel reviewed these APCs and recommended that no changes be made pending analysis of 2001 claims data. The Panel did recommend that billing instructions be developed on the appropriate use of the codes in these APCs. We agreed with the Panel's recommendation regarding the need for billing instructions, and we expect to develop such instructions for hospitals to use in 2003.
Our subsequent review of 2001 claims data reveals that, in some
cases, costs for short casts and splints are greater than costs for
long casts and splints. Moreover, the proposed payments for these two
APCs, based on 2001 OPPS data, would not differ significantly from each
other. Therefore, we proposed to combine the codes in APC 58 and APC 59
into a single APC, APC 58. Combining these APCs does not compromise
clinical homogeneity. The relative weight of the proposed single APC is
virtually identical to the relative weight of each of the two current
APCs. We proposed to continue to work with hospitals to develop appropriate coding
[[Page 66726]]
for these services and will review the appropriate APC structure for these services next year.
APC 279: Level I Angiography and Venography Except Extremity
APC 280: Level II Angiography and Venography Except Extremity
Without the benefit of 2001 OPPS claims data, it was difficult for the Panel to determine whether the apparent violation of the 2 times rule in APCs 279 and 280 was attributable to underreporting of procedures or inaccurate coding. Therefore, the Panel recommended no changes pending the availability of the more recent claims data. After subsequently reviewing the 2001 claims data, we proposed to move CPT codes 75978, Transluminal balloon angioplasty, venous, radiological supervision and interpretation, and 75774, Angiography, selective, each additional vessel studied after basic examination, radiological supervision and interpretation, to new APC 0668. This would resolve violations of the 2 times rule and result in clinically coherent APCs. APC 115: Cannula/Access Device Procedures
We proposed to move CPT code 36860, External Cannula Declotting;
without balloon catheter, to APC 103, Miscellaneous Vascular
Procedures. We believe this makes both APC 115 and APC 103 more
clinically homogeneous and it resolves a violation of the 2 times rule
in APC 115 that was caused by the presence of CPT code 36860. APC 93: Vascular Repair/Fistula Construction
APC 140: Esophageal Dilation without Endoscopy
APC 141: Upper GI Procedures
APC 142: Small Intestine Endoscopy
APC 143: Lower GI Endoscopy
APC 144: Diagnostic Anoscopy
APC 145: Therapeutic Anoscopy
APC 146: Level I Sigmoidoscopy
APC 147: Level II Sigmoidoscopy
APC 148: Level I Anal/Rectal Procedure
APC 149: Level II Anal/Rectal Procedure
Our subsequent review of 2001 claims data suggests that the cost data for APCs 144 and 145 are aberrant. The cost data for these APCs yield relative weights and payments that are significantly higher than the relative weights for APCs 146 and 147, which consist of similar procedures performed through a sigmoidoscope rather than an anoscope. As currently arranged, the APC configuration for these services could provide a financial incentive for hospitals to perform unnecessary anoscopic procedures, either alone or with a sigmoidoscopy. To rectify this problem, we proposed to move the procedures in APCs 144 and 145 to APC 147 with the exception of CPT code 46600, Anoscopy; diagnostic, which we proposed to assign to APC 340, Minor Ancillary procedures. We believe these changes would result in clinically coherent APCs with appropriate relative weights and payment rates.
APC 363: Otorhinolaryngologic Function Tests
Based on 2001 claims data, we proposed to move CPT codes 92543,
92588, 92520, 92546, 92516, 92548, and 92584 to new APC 0660 (Level III
Otorhinolaryngolgic Function Tests). This change would resolve a 2 times rule violation and create clinically coherent APCs.
APC 96: NonInvasive Vascular Studies
APC 265: Level I Diagnostic Ultrasound Except Vascular
APC 266: Level II Diagnostic Ultrasound Except Vascular
APC 267: Vascular Ultrasound
APC 269: Level I Echocardiogram Except Transesophageal
APC 270: Transesophageal Echocardiogram
The APC Panel recommended making no changes in the configuration of
these APCs. Based on 2001 claims data, we proposed to make several
changes in order to resolve 2 times rule violations and to make these
APCs more clinically coherent. Specifically, we proposed to move CPT
code 43499 from APC 0140 to APC 141; CPT code 93721 from APC 0096 to
APC 368; CPT code 93740 from APC 0096 to APC 367; CPT code 93888 from
APC 0267 to APC 266; and CPT code 93931 from APC 0267 to APC 266. We
also proposed to move CPT codes 78627, 76825, and 93320 from APC 0269
to new APC 0671 to achieve more clinical coherence. We also proposed to
create new APC 0670 for intravascular ultrasound and intracardiac
echocardiography consisting of CPT codes 37250, 37251, 92978, 92979, and 93662.
APC 291: Level I Diagnostic Nuclear Medicine Excluding Myocardial Scans
APC 292: Level II Diagnostic Nuclear Medicine Excluding Myocardial Scans
Subsequent to the APC Panel meeting, we received comments on these
APCs from the Nuclear Medicine Task Force. After a thorough review of
that proposal within the context of the 2001 claims data, we proposed
to accept the recommendations of the Nuclear Medicine Task Force, which
would result in a complete reconfiguration of APCs 290, 291, and 292.
Although the reconfiguration would create violations of the 2 times
rule, we agree with the Task Force that the reconfigured APCs are more
clinically coherent. We note that APCs 290, 291, and 292 as currently
configured would also violate the 2 times rule. Therefore, we solicited
comments on the proposed reconfiguration of APCs 290, 291, and 292 and
on alternative groupings that would achieve clinical coherence without violating the 2 times rule.
APC 274: Myleography
APC 179: Urinary Incontinence Procedures
APC 182: Insertion of Penile Prosthesis
APC 19: Level I Excision/Biopsy
APC 20: Level II Excision/Biopsy
APC 21: Level IV Excision/Biopsy
APC 22: Level V Excision/Biopsy
PC 694: Level III Excision/Biopsy
Based on 2001 claims data, we proposed to move several codes from
APC 19 to APC 20 and several codes from ACP 20 to APC 21. Additionally,
we proposed to move CPT codes 11770, 54105, and 60512 to APC 22. We
also proposed to move CPT code 58999 to APC 191 and CPT code 37799 to
APC 35. These changes would result in clinically coherent APCs that do not violate the 2 times rule.
APC 24: Level I Skin Repair
APC 25: Level II Skin Repair
APC 26: Level III Skin Repair
APC 27: Level IV Skin Repair
APC 686: Level V Skin Repair
Based on 2001 claims data, we proposed to move CPT code 43870 from
APC 0025 to APC 141; and CPT codes with high costs from APC 26 to APC
27. We also proposed to move the codes remaining in APC 26 to APC 25.
APC 26 would then be deleted. These changes would result in a more
compact APC structure without compromising the clinical homogeneity of
the reconfigured APCs and without violating the 2 times rule. See Table
1 for the final list of codes to be moved from APC 26 to APC 25 or APC 27.
Table 1.HCPCS Codes to be Moved From APC 26 Into APC 25 or APC 27
2003 2003
2002 APC 26 APC 25 APC 27
11960................................................... ...... 11960
11970................................................... ...... 11970
12037................................................... 12037 ......
12047................................................... 12047 ......
12057................................................... 12057 ......
13150................................................... 13150 ......
13160................................................... ...... 13160
14000................................................... ...... 14000
14001................................................... ...... 14001 [[Page 66727]]
14020................................................... ...... 14020
14021................................................... ...... 14021
14040................................................... ...... 14040
14041................................................... ...... 14041
14060................................................... ...... 14060
14061................................................... ...... 14061
14300................................................... ...... 14300
14350................................................... ...... 14350
15000................................................... 15000 ......
15001................................................... 15001 ......
15050................................................... 15050 ......
15101................................................... ...... 15101
15120................................................... ...... 15120
15121................................................... ...... 15121
15200................................................... ...... 15200
15201................................................... 15201 ......
15220................................................... ...... 15220
15221................................................... 15221 ......
15240................................................... ...... 15240
15241................................................... 15241 ......
15260................................................... ...... 15260
15261................................................... 15261 ......
15351................................................... ...... 15351
15400................................................... 15400 ......
15401................................................... 15401 ......
15570................................................... ...... 15570
15572................................................... ...... 15572
15574................................................... ...... 15574
15576................................................... ...... 15576
15600................................................... ...... 15600
15610................................................... ...... 15610
15620................................................... ...... 15620
15630................................................... ...... 15630
15650................................................... ...... 15650
15775................................................... 15775 ......
15776................................................... 15776 ......
15819................................................... 15819 ......
15820................................................... ...... 15820
15821................................................... ...... 15821
15822................................................... ...... 15822
15823................................................... ...... 15823
15825................................................... ...... 15825
15826................................................... ...... 15826
15829................................................... ...... 15829
15835................................................... 15835 ......
20101................................................... ...... 20101
20102................................................... ...... 20102
20910................................................... ...... 20910
20912................................................... ...... 20912
20920................................................... ...... 20920
20922................................................... ...... 20922
20926................................................... ...... 20926
23921................................................... 23921 ......
25929................................................... ...... 25929
33222................................................... ...... 33222
33223................................................... ...... 33223
44312................................................... ...... 44312
44340................................................... ...... 44340
15580Code Deleted ...... ......
15625Code Deleted ...... ...... APC 77: Level I Pulmonary Treatment
APC 78: Level II Pulmonary Treatment
APC 251: Level I ENT Procedures
APC 252: Level II ENT Procedures
APC 253: Level III ENT Procedures
APC 254: Level IV ENT Procedures
APC 256: Level V ENT Procedures
Based on 2001 claims data, we proposed to address violations of the 2 times rule by moving CPT codes 40812, 42330, and 21015 from APC 0252 to APC 253 and by moving CPT codes 41120 and 30520 to APC 254.
We are adopting the changes discussed in the proposed rule as final
except as noted in our discussion of specific APC changes in section II.B, below.
B. Other Changes Affecting Ambulatory Payment Classification (APC) Assignments
1. Limit on Variation of Costs of Services Classified Within a Group
Section 1833(t)(2) of the Act provides that the items and services within an APC group cannot be considered comparable with respect to the use of resources if the highest cost item or service within a group is more than 2 times greater than the lowest cost item or service within the same group. Howe
FOR FURTHER INFORMATION CONTACT
Anita Heygster, (410) 786-0378-- outpatient prospective payment issues; Lana Price, (410) 7864533 partial hospitalization and endstage renal disease issues; Gerald Walters, (410) 7862070payment suspension issues.