News You Can Use: Expect Payment Hike for OPPS 2006

Proposed OPPS rule offers coverage perks, payment increases
CMS wants to pay you more for most Part B drugs, biologicals and radiopharmaceuticals administered in your outpatient departments. Acute care hospitals could receive a 3.2 percent inflation adjustment to their payment rates under the outpatient prospective payment system (OPPS) in 2006, CMS announced July 18. CMS' proposed rule contains policy changes and updated payment rates, including:

  Coinsurance rates will decrease gradually to 20 percent of the hospital's total payment for 12 additional medical and surgical ambulatory payment classifications (APCs).

  Sole community hospitals in rural areas may see an additional 6.6 percent payment adjustment.

  Medicare could pay 106 percent of the drug manufacturer's average sales price (ASP) for Part B drugs administered in hospital outpatient departments.

  CMS proposes to pay an additional 2 percent over the Part B drug payment to cover pharmacy costs until 2008.
 
CMS also proposes to implement the Medicare Payment Advisory Commission's (MedPAC's) recommendations to Congress regarding payment changes for outpatient diagnostic imaging procedures. When you perform two or more procedures in the same CMS-identified imaging procedure "family," Medicare will pay for the first procedure in full and 50 percent of the second and subsequent procedures, CMS says.
You can read the proposed rule in the July 25 Federal Register and submit your comments until Sept. 16, 2005. To read CMS' press release, go to http://www.cms.hhs.gov/media/press/release.asp?Counter=1506.
You can get cochlear implantation payment for more patients - but check the tests  If your facility's performing cochlear implantation for certain patients, Medicare will help foot the bill if the physician performed the implantation after April 4, 2005. For you to receive reimbursement, your patients must fall into one of these two categories, according to a July 1 revision from CMS:

People with moderate-to-profound hearing loss who score at or less than 40 percent correct on a hearing test on the best aided listening condition. The test must be tape-recorded tests of open-set sentence recognition, and the patient must show benefit from amplification.

People whose scores on the same kind of test are greater than 40 percent and up to 60 percent, and who received the implantation during a clinical trial. The patient needs to have received the device at one of these trials, according to the CMS transmittal:  

an FDA-approved category-B investigational device exemption clinical trial

a trial under the CMS Clinical Trial Policy, or 

a prospective, controlled, comparative trial approved by CMS.

- Published on 2005-08-12