On October 30, 2009, the Centers for Medicare & Medicaid Services (CMS) posted the 2010 Hospital Outpatient Prospective Payment System (HOPPS) final rule.  The rule affects hospital outpatient and ambulatory surgical center payments for services paid in 2010.  A market basket update of 2.1 percent was applied for most procedures. 

The 2010 HOPPS final rule is now posted on the CMS Web site.  The information from this final rule would be effective for services on or after January 1, 2010.

2010 HOPPS Policies Related to Nuclear Cardiology

Payment Rates

CMS finalized payment rates for nuclear cardiology procedures based on the established rate-setting methodology using claims that include a charge for a required diagnostic radiopharmaceutical or other radioactive product. A market basket increase of 2.1 percent was applied for 2010 (Table 1).

Table 1: 2010 HOPPS Final Rule - Nuclear Cardiology Procedures (PDF)

New CPT Codes

CMS implements new 2010 CPT codes that bundle wall motion and or ejection fraction with the base myocardial perfusion imaging new procedure CPT codes 78451-78454.

Diagnostic Radiopharmaceuticals

CMS continues packaging payment for all contrast agents and diagnostic radiopharmaceuticals, regardless of their per day costs for 2010.

Payment for Diagnostic and Therapeutic Radiopharmaceuticals

For 2010, CMS is finalizing payment policy for both diagnostic and therapeutic radiopharmaceuticals that are granted pass-through status based on the average sales price (ASP) methodology.  

• If ASP information is available, the payment rate would be equivalent to the payment rate that drugs receive:  ASP+6 percent.  
• If ASP data are not available for a radiopharmaceutical, CMS is finalizing a policy to provide pass-through payment at Wholesale Acquisition Cost (WAC) + 6 percent.  
• If WAC information is also not available, CMS will provide payment for the pass-through radiopharmaceutical at 95 percent of its most recent AWP.  
• In addition, CMS is finalizing a policy to update pass-through payment rates on a quarterly basis on the CMS Web site during 2010 if later quarter ASP submissions (or more recent WAC or AWP information, as applicable) indicate that adjustments to the payment rates for these pass-through drugs or biologicals are necessary.

Drug and Biological Pass-Through Payment

Consistent with current policy, CMS will continue to recognize the first date of OPPS pass-through payment of ASP plus 6 percent as the beginning of the two- to three-year pass-through payment eligibility period for a new drug or non-implantable biological.

Co-Payment for Pass-Through Diagnostic Pharmaceuticals

CMS finalized the policy to set the associated copayment amount for pass-through diagnostic radiopharmaceuticals and contrast agents to zero in 2010.  CMS states that the separate HOPPS payment to a hospital for the pass-through diagnostic radiopharmaceutical and contrast agent, after taking into account any applicable payment offset for the item due to the device or "policy-packaged" APC offset policy, is the item's pass-through payment, which is not subject to a copayment according to the statute.

Therapeutic Radiopharmaceutical Drugs

CMS finalized the policy to pay separately for drugs, biological, and therapeutic radiopharmaceuticals costing $65 or more per day.  Payments for other drugs will continue to be bundled into payments for the associated procedures.

Therapeutic Radiopharmaceuticals

Separately payable therapeutic radiopharmaceuticals are finalized to be paid by CMS utilizing voluntary manufacturer-submitted ASP information through the existing ASP process at ASP+4 percent as the best proxy for therapeutic radiopharmaceutical average acquisition and handling costs. 

• If ASP information is not available, CMS is finalizing a policy that payment would be based upon mean costs from hospital claims data. 
• CMS published detailed instructions for submission of OPPS ASP data for non-pass-through separately payable therapeutic radiopharmaceuticals and radiopharmaceuticals with pass-though status, located at http://www.cms.hhs.gov/HospitalOutpatientPPS/05_OPPSGuidance.asp.
• Manufacturers wishing to submit data should immediately contact CMS at outpatientpps@cms.hhs.gov so CMS can facilitate the submission process.

Drugs and Biological

Drugs and biological are finalized to be paid at 104 percent of the average sales price (ASP+4).

Supervision Requirements for Outpatient Services

In order to ensure that hospital outpatient services are appropriately supervised by qualified practitioners while not impeding beneficiary access to these services, and in response to concerns raised by the hospital community, CMS is revising or further defining several current policies for the supervision of outpatient services.  

• Non-Physician Practitioners: In 2010, CMS will allow certain nonphysician practitioners — specifically physician assistants, nurse practitioners, clinical nurse specialists, certified nurse-midwives, and licensed clinical social workers — to provide direct supervision for all hospital outpatient therapeutic services that they are authorized to personally perform according to their state scope of practice rules and hospital-granted privileges.  (Under current policy, only physicians may provide the direct supervision of these services.
• On-Campus Hospital Outpatient Therapeutic Services:  For purposes of on-campus hospital outpatient therapeutic services, CMS is defining “direct supervision” to mean that the physician or nonphysician practitioner must be present anywhere on the hospital campus and immediately available to furnish assistance and direction throughout the performance of the procedure. 
• Off-Campus Provider-Based Department Services:   For services furnished in an off-campus provider-based department, “direct supervision” would continue to mean that the physician or nonphysician practitioner must be present in the off-campus provider-based department and immediately available to furnish assistance and direction throughout the performance of the procedure. 

CMS also will require that all hospital outpatient diagnostic services furnished directly or under arrangement, whether provided in the hospital, in a provider-based department, or at a nonhospital location, follow the MPFS physician supervision requirements for individual tests. 

Quality Data Reporting

The final rule includes quality measures for reporting hospital outpatient (HOP) quality data for the annual payment update factor for 2012 and subsequent calendar years; sets forth the requirements for data collection and submission for the annual payment update; and finalizes a reduction in the HOPPS payment for hospitals that fail to meet the HOP Quality Data Reporting Program requirements for 2010.