2013 Final OPPS
Final HOPPS 2013
Summary
SIR
On November 1, 2012 The Centers for Medicare & Medicaid Services (CMS) issued a final rule
that would update payment policies and payment rates for services furnished to Medicare
beneficiaries in hospital outpatient departments (HOPDs) and ambulatory surgical centers
(ASCs) beginning Jan. 1, 2013.
The final rule affects hospital outpatient departments in more than 4,000 hospitals, including
general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities,
long-term acute care hospitals, children’s hospitals, and cancer hospitals, and approximately
5,000 Medicare-participating ASCs.
The final rule will be published on November 15, 2012. It will take effect January 1, 2013 with a
comment period that closes on December 31, 2012.
A display copy of the final rule can be found at:
http://www.ofr.gov/OFRUpload/OFRData/2012-26902_PI.pdf
The Addenda to the final rule for the HOPPS are available at:
http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS1589-FC.html
The Addenda to the final rule for the ASC payment system are available at:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/ASCRegulations-and-Notices-Items/CMS-1589-FC.html
Under the policies in this final rule payment rates for hospital outpatient departments will
increase by 1.8 percent. The increase is based on the projected hospital market basket—an
inflation rate for goods and services used by hospitals—of 2.6 percent, minus 0.8 percent in
statutory reductions, including a 0.7 percent adjustment for economy-wide productivity and a 0.1
percentage point adjustment required by statute.
CMS is using a final conversion factor of $71.313 for CY2013 in the calculation of the national
unadjusted payment rates for those items and services for which payment rates are calculated
using geometric mean costs. They also are using a reduced conversion factor of $69.887 in the
calculation of payments for hospitals that fail to comply with the Hospital OQR Program
requirements.
Total payments to hospitals under the OPPS in CY 2013 will be approximately $48.1 billion.
Table 57 (page 1169) of this final rule displays the distributional impact all the OPPS changes on
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2013 Final OPPS
various groups of hospitals and CMHCs for CY 2013 compared to all estimated OPPS payments
in CY 2012.
Geometric Mean-Based Relative Payment Weights (p. 172)
CY 2013 CMS is using the geometric mean costs of services within an APC to determine the
relative payment weights of services, rather than the median costs they have used since the
inception of the OPPS. CMS says that the final policy to base the APC relative payment weights
on the geometric mean costs rather than the median costs of services within an APC will not
significantly impact most providers.
Number of Claims
CMS used approximately 153 million final action claims for HOPD services furnished on or
after January 1, 2011, and before January 1, 2012. Of those approximately 153 million final
action claims, approximately 121 million claims )re the type of bill potentially appropriate for
use in setting rates for OPPS services. Of the approximately 121 million claims, approximately
5 million claims were not for services paid under the OPPS or were excluded as not appropriate
for use. From the remaining approximately 116 million claims, CMS created approximately 120
million single records, of which approximately 81 million were “pseudo” single or “single
session” claims (created from approximately 39 million multiple procedure claims).
Approximately 1 million claims were trimmed out on cost or units in excess of +/- 3 standard
deviations from the geometric mean, yielding approximately 120 million single bills for
ratesetting.
Bypass List (p. 69)
For CY2013 CMS will bypass 480 HCPCS codes, as displayed in Addendum N. Table 1
contains the list of codes that they are removing from the CY 2013 bypass list because these
codes were either deleted from the HCPCS before CY 2011 (and therefore were not covered
OPD services in CY 2011) or were not separately payable codes under the CY 2013 OPPS
because these codes are not used for ratesetting (and therefore would not need to be bypassed).
None of these deleted codes are “overlap bypass” codes.
Packaged Costs
CMS will continue to update the packaged cost threshold by the market basket increase. By
applying the final CY 2012 market basket increase of 1.9 percent to the prior non-rounded dollar
threshold of $52.76, CMS determined that the threshold remains for CY 2013 at $55 ($53.76
rounded to $55, the nearest $5 increment). Therefore, they will set the geometric mean packaged
cost threshold on the CY 2011 claims at $55 for a code to be considered for addition to the CY
2013 OPPS bypass list.
Two Times Rule (p. 357)
CMS is finalizing their two times rule proposals with some modifications. The final list of 19
APCs exempted from the 2 times rule for CY 2013 is displayed in Table 17.
Items and services within an APC group shall not be treated as comparable with respect to the
use of resources if the highest median/mean cost for an item or service within the group is more
than 2 times greater than the lowest median/mean cost for an item or service within the same
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2013 Final OPPS
group (the 2 times rule).
For purposes of identifying significant HCPCS for examination in the 2 times rule, CMS
considers codes that have more than 1,000 single major claims or codes that have both greater
than 99 single major claims and contribute at least 2 percent of the single major claims used to
establish the APC geometric mean cost to be significant.
Packaging (p. 246)
CMS is finalizing their existing packaging policies. The HCPCS codes that CMS
unconditionally packaged (assigned status indicator “N”), or conditionally packaged (assigned
status indicators “Q1,” “Q2,” or “Q3”) are displayed in Addendum B.
Device Dependent APCs (p. 119)
CMS is finalizing their proposed policy to use the standard methodology for calculating costs for
device-dependent APCs for CY 2013 that was finalized in the CY 2012 OPPS/ASC final rule.
Hospital Outpatient Outlier Payments (p. 313)
CMS will continue to make an outlier payment that equals 50 percent of the amount by which
the cost of furnishing the service exceeds 1.75 times the APC payment amount when both the
1.75 multiple threshold and the final fixed-dollar threshold of $2,025 are met.
Rural Adjustment (p. 303)
CMS is continuing the adjustment of 7.1 percent to the OPPS payments to certain rural sole
community hospitals (SCHs), including essential access community hospitals (EACHs). This
adjustment will apply to all services paid under the OPPS, excluding separately payable drugs
and biologicals, devices paid under the pass-through payment policy, and items paid at charges
reduced to cost.
Cancer Hospital Payment Adjustment (p. 306)
For CY 2013, CMS is continuing their policy to provide additional payments to cancer hospitals
so that the hospital’s payment-to-cost ratio (PCR) with the payment adjustment is equal to the
weighted average PCR for the other OPPS hospitals using the most recent submitted or settled
cost report data. Based on those data, a target PCR of 0.91 will be used to determine the CY
2013 cancer hospital payment adjustment to be paid at cost report settlement. That is, the
payment amount associated with the cancer hospital payment adjustment will be the additional
payment needed to result in a PCR equal to 0.91 for each cancer hospital.
Table 9 indicates the estimated percentage increase in OPPS payments to each cancer hospital
for CY 2013 due to the cancer hospital payment adjustment policy.
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2013 Final OPPS
New Carotid Angiography Codes for CY2013
HCPCS
36221
36222
36223
36224
36225
36226
36227
36228
Short Descriptor
Place cath thoracic aorta
Place cath carotid/inom art
Place cath carotid/inom art
Place cath carotd art
Place cath subclavian art
Place cath vertebral art
Place cath xtrnl carotid
Place cath intracranial art
2013
APC
2013
Payment
Rate
2012
Payment
Rate
0279
0279
0279
0280
0279
0280
$2,219.82
$2,219.82
$2,219.82
$3,630.40
$2,219.82
$3,630.40
N/A
N/A
N/A
N/A
N/A
N/A
2013
APC
2013
Payment
Rate
2012
Payment
Rate
0621
$786.08
N/A
0621
0622
0622
$786.08
$1,754.10
$1,754.10
N/A
N/A
N/A
New Thrombolysis Codes for CY2013
HCPCS
Short Descriptor
37211
Thrombolytic art therapy
Thrombolytic venous
therapy
Thromblytic art/ven therapy
Cessj therapy cath removal
37212
37213
37214
Mechanical Thrombectomy (APC 0653) (p. 409)
CMS received comments expressing concern regarding the proposed 19.7 percent reduction in
the payment rate CPT code 36870. CMS continues to believe that APC 0653 is the most
appropriate APC assignment for CPT code 36870 based on its clinical homogeneity and resource
costs in relation to the other procedures assigned to the APC. CMS stated that their analysis of
the latest hospital outpatient data for claims submitted for services provided during CY 2011
shows a geometric mean cost for CPT code 36870 of approximately $2,662, based on 539 single
claims (out of 50,476 total claims), which is relatively similar to the proposed rule payment rate
of approximately $2,748 for APC 0653.
Endovascular Revascularization of the Lower Extremity (APCs 0083, 0229, and 0319) (p.
416)
Despite objections, CMS is finalizing, without modification, their LE placements:
 CPT codes 37183 and 37210 to APC 0229;
 CPT code 37223 to APC 0083; and
 CPT codes 37234 and 37235 to APC 0083.
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2013 Final OPPS
HCPCS
Short Descriptor
2013
Payment
Rate
2013
APC
2012
Payment
Rate
% Change
in Payment
Rate
37220
Iliac revasc
0083
$4,023.05
$4,623.91
-12.99%
37221
Iliac revasc w/stent
0229
$8,656.82
$8,095.74
6.93%
37222
Iliac revasc add-on
0083
$4,023.05
$4,623.91
-12.99%
37223
Iliac revasc w/stent add-on
0083
$4,023.05
$4,623.91
-12.99%
37224
Fem/popl revas w/tla
0083
$4,023.05
$4,623.91
-12.99%
37225
Fem/popl revas w/ather
0229
$8,656.82
$8,095.74
6.93%
37226
Fem/popl revasc w/stent
0229
$8,656.82
$8,095.74
6.93%
37227
Fem/popl revasc stnt & ather
0319
$14,596.24
$14,210.32
2.72%
37228
Tib/per revasc w/tla
0083
$4,023.05
$4,623.91
-12.99%
37229
Tib/per revasc w/ather
0229
$8,656.82
$8,095.74
6.93%
37230
Tib/per revasc w/stent
0229
$8,656.82
$8,095.74
6.93%
37231
Tib/per revasc stent & ather
0319
$14,596.24
$14,210.32
2.72%
37232
Tib/per revasc add-on
0083
$4,023.05
$4,623.91
-12.99%
37233
Tibper revasc w/ather add-on
0229
$8,656.82
$8,095.74
6.93%
37234
Revsc opn/prq tib/pero stent
0083
$4,023.05
$4,623.91
-12.99%
37235
Tib/per revasc stnt & ather
0083
$4,023.05
$4,623.91
-12.99%
Non-Ophthalmic Fluorescent Vascular Angiography (APC 0397) (p. 485)
CMS is finalizing their proposal to assign HCPCS code C9733 to APC 0397 and to continue to
assign the code to status indicator “Q2.” APC 0397 has a CY 2013 final geometric mean cost of
approximately $340.
New/Revised Respiratory System: Lungs and Pleura Codes for CY2013
HCPCS
Short Descriptor
2013
APC
32551
32554
32555
32556
32557
Insertion of chest tube
Aspirate pleura w/o imaging
Aspirate pleura w/ imaging
Insert cath pleura w/o image
Insert cath pleura w/ image
0070
0070
0070
0070
0070
2013
Payment
Rate
2012
Payment
Rate
$412.39
$412.39
$412.39
$412.39
$412.39
$385.64
N/A
N/A
N/A
N/A
%
Change in
Payment
Rate
6.94%
Packaging Recommendation of the HOP Panel (p. 227)
For CY 2013, CMS is accepting the Panel’s recommendation and finalizing their proposal to
assign a status indicator of “Q1” to HCPCS code 19290, which is assigned to APC 0340 with a
CY 2013 final payment rate of approximately $51.
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2013 Final OPPS
Therapeutic Radiopharmaceuticals (p. 561)
CMS is finalizing their proposal to provide payment for drugs, biologicals, diagnostic and
therapeutic radiopharmaceuticals and contrast agents that are granted pass-through status based
on the ASP methodology. If a diagnostic or therapeutic radiopharmaceutical receives
passthrough status during CY 2013, they will follow the standard ASP methodology to determine
the pass-through payment rate that drugs receive which is ASP+6 percent. If ASP data are not
available for a radiopharmaceutical, CMS will provide pass-through payment at WAC+6
percent, the equivalent payment provided to pass-through drugs and biologicals without ASP
information. If WAC information is also not available, they will provide payment for the passthrough radiopharmaceutical at 95 percent of its most recent AWP.
HCPCS
Short Descriptor
2013
APC
2013
Payment
Rate
A9543
A9545
Y90 ibritumomab, rx
I131 tositumomab, rx
1643
1645
$38,058.06
$30,188.56
% Change
in
Payment
Rate
$35,830.70
6.22%
$29,618.96
1.92%
2012
Payment
Rate
Computed Tomography of Abdomen/Pelvis (APCs 0331 and 0334) (p. 491)
CMS is finalizing their proposal, without modification to continue to assign CPT code 74176 to
APC 0331 and CPT codes 74177 and 74178 to APC 0334. In addition, they are continuing to
assign these CPT codes to their existing composite APCs for CY 2013. Specifically, they are
continuing to assign CPT code 74176 to composite APC 8005, and to assign CPT codes 74177
and 74178 to composite APC 8006.
Level II Nervous System Imaging (APC 0402) (p. 489)
CMS is finalizing their proposal, without modification, to continue to assign CPT code 78607 to
APC 0402. The final CY 2013 geometric mean cost for APC 0402 is approximately $472.
Multiple Imaging Composite (p. 156)
CMS is finalizing their proposed policy, without modification, to calculate multiple imaging
composite APC costs for CY 2013 pursuant to their established methodology. CMS used
approximately 1.0 million “single session” claims out of an estimated 1.6 million potential
composite cases from our ratesetting claims data, to calculate the final CY 2013 costs for the
multiple imaging composite APCs.
APC
Group Title
2013
Payment
Rate
2012
Payment
Rate
% Change
in Payment
Rate
8004
Ultrasound Composite
$196.61
$191.69
3%
8005
CT and CTA without Contrast Composite
$400.28
$431.98
-7%
8006
CT and CTA with Contrast Composite
$682.10
$721.75
-5%
8007
MRI and MRA without Contrast Composite
$706.85
$699.94
1%
8008
MRI and MRA with Contrast Composite
$1,038.94
$1,000.68
4%
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2013 Final OPPS
Table 6 lists the HCPCS codes that will be subject to the multiple imaging composite policy and
their respective families and approximate composite APC costs for CY 2013. Table 7 lists the
OPPS imaging family services that overlap with HCPCS codes on the CY 2013 bypass list.
Payment Adjustment Policy for Radio-Isotopes Derived from Non-Highly Enriched
Uranium Sources (p. 372)
CMS is finalizing their proposed non-highly enriched uranium sources policy with some
modifications. Specifically, they are modifying the policy to provide that a product identified as
non-HEU sourced must be at least 95 percent derived from non-HEU sources. They also are
finalizing their proposal to establish a HCPCS code for Tc-99m from non-HEU sources with a
revised code definition. The number and title of the new HCPCS code is HCPCS code Q9969
(Tc-99m from non- highly enriched uranium source, full cost recovery add-on, per study dose)
for CY 2013. HCPCS code Q9969 is assigned to APC 1442 (Non-HEU TC-99M Add-On/Dose)
with a status indicator of “K” and a CY 2013 payment rate of $10.
Supervision of Hospital Outpatient Therapeutic Services (p. 736)
CMS clarified the application of the supervision regulations to physical therapy, speech-language
pathology, and occupational therapy services that are furnished in OPPS hospitals and critical
access hospitals (CAHs). In addition, CMS noted that they are extending the enforcement
instruction one final year through CY 2013.
Outpatient Status (p. 744)
CMS stated that they were concerned about recent increases in the length of time that Medicare
beneficiaries spend as outpatients receiving observation services. Hospitals continue to express
concern about Medicare Part A to Part B rebilling policies when a hospital inpatient claim is
denied because the inpatient admission was not medically necessary. In the CY 2013 OPPS/ASC
proposed rule, CMS provided an update on the Part A to Part B Rebilling Demonstration that is
in effect for CY 2012 through CY 2014, which was designed to assist CMS in evaluating these
issues. They also solicited public comments on potential clarifications or changes to their
policies regarding patient status that may be appropriate. CMS did not provide responses to the
public comments they received because in the proposed rule they solicited public comments, and
did not propose any changes in policy. They will consider the feedback they received from the
public as they move forward.
OPPS Payment for Hospital Outpatient Visits (p. 665)
CMS is finalizing their proposals related hospital outpatient visits, with one modification. They
are reassigning HCPCS code G0379 to APC 0608 for CY 2013. CMS will:
 continue to recognize the definitions of a new patient and an established patient, which are
based on whether the patient has been registered as an inpatient or outpatient of the
hospital within the 3 years prior to a visit;
 apply their policy of calculating costs for clinic visits under the OPPS using historical
hospital claims data through five levels of clinic visit APCs (APCs 0604 through 0608);
and
 continue to recognize Type A emergency departments and Type B emergency departments
for payment purposes under the OPPS, and to pay for Type A emergency department
visits based on their costs through the five levels of Type A emergency department APCs
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2013 Final OPPS
(APCs 0609 and 0613 through 0616) and to pay for Type B emergency department visits
based on their costs through the five levels of Type B emergency department APCs
(APCs 0626 through 0630).
CMS will continue their policy to recognize the existing CPT codes for critical care services and
establish a payment rate based on historical claims data. They will continue to implement claims
processing edits that conditionally package payment for the ancillary services that are reported
on the same date of service as critical care services in order to avoid overpayment. CMS will
continue to monitor the hospital claims data for CPT code 99291 in order to determine whether
revisions to this policy are warranted based on changes in hospitals’ billing practices.
Inpatient Only Procedures (p. 722)
CMS reevaluated data on the 39 additional CPT codes requested by the commenters. The codes
are listed in Table 44. As a result of the reevaluation, CMS remains convinced that these
procedures can be safely performed only in the inpatient setting. (Codes of interest below)


0075T Transcatheter placement of extracranial vertebral or intrathoracic carotid artery
stent(s), including radiologic supervision and interpretation, percutaneous; initial vessel
37182 TIPS
The complete list of codes to be paid by Medicare in CY 2013 only as inpatient procedures is
included as Addendum E.
Hospital Outpatient Quality Reporting (OQR) Program (p. 875)
The rule made several changes to the quality-reporting program for outpatient departments.
While CMS did not add any new measures to the 22 measures finalized for the CY 2014
payment determination, CMS did confirm the removal of one measure; deferred data collection
for another measure, and confirmed the suspension of data collection for a third measure. In
addition, CMS finalized proposed revisions to several procedural requirements that apply to the
reporting of quality data and finalized the automatic retention of Hospital OQR Program
measures adopted in previous payment determinations for subsequent year payment
determinations, until the measures are actively removed, payment determinations for subsequent
year payment determinations, until the measures are actively removed, suspended, or replaced.
Electronic Health Record (EHR) Incentive Program (p. 968)
CMS is extending the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot for
Eligible Hospitals and CAHs through 2013, exactly as finalized for 2012. CMS recently issued a
final rule (77 FR 53968) for Stage 2 of the Medicare and Medicaid EHR Incentive Programs.
Revisions to the Quality Improvement Organization (QIO) Regulations (p. 1044)
CMS is revising the QIO program regulations to: (1) give QIOs the authority to send and receive
secure transmissions of electronic versions of medical information; (2) provide more detailed and
improved procedures for QIOs when completing Medicare beneficiary complaint reviews and
general quality of care reviews, including procedures related to a new alternative dispute
resolution process called “immediate advocacy”; (3) increase the information beneficiaries
receive in response to QIO review activities; (4) convey to Medicare beneficiaries the right to
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2013 Final OPPS
authorize the release of confidential information by QIOs; and (5) make other technical changes
that are designed to improve the regulations.
Other Provisions Included in this Final Rule
 Drugs and Pharmacy Overhead
 Payment for Partial Hospitalization Services
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2013 Final OPPS
AMBULATORY SURGICAL CENTER (ASC) PAYMENT SYSTEM
For CY 2013, CMS is increasing payment rates under the ASC payment system by 0.6 percent.
This increase is based on a projected CPI-U update of 1.4 percent minus a multifactor
productivity adjustment required by the Affordable Care Act that is projected to be 0.8 percent.
Based on this update, CMS estimates that total payments to ASCs (including beneficiary costsharing and estimated changes in enrollment, utilization, and case-mix), for CY 2013 will be
approximately $4.074 billion, an increase of approximately $310 million compared to estimated
CY 2012 payments.
Impacts of the ASC Payment Update
For impact purposes, the surgical procedures on the ASC list of covered procedures are
aggregated into surgical specialty groups using CPT and HCPCS code range definitions. The
percentage change in estimated total payments by specialty groups under the CY 2013 payment
rates compared to estimated CY 2012 payment rates ranges between -3 percent for respiratory
system procedures, integumentary system procedures, and cardiovascular system procedures and
3 percent for nervous system procedures.
ASC Conversion Factor (p. 872)
The final ASC conversion factor of $42.917 is the product of the CY 2012 conversion factor of
$42.627 multiplied by the wage index budget neutrality adjustment of 1.0008 and the MFPadjusted CPI-U payment update of 0.6 percent.
Changes for CY 2013 to Covered Surgical Procedures Designated as Office-Based (p. 804)
CMS is adding 25 procedures to the list of ASC covered surgical procedures for CY 2013. The
procedures, their descriptors, and payment indicators are displayed in Table 51.
Codes of Interest from Table 51—New ASC Covered Surgical Procedures For CY 2013
CY 2013 Descriptor
CY2013
ASC
Payment
Indicator**
Transcatheter placement of an intravascular stent(s) (except
coronary, carotid, vertebral, iliac, and lower extremity arteries),
percutaneous; initial vessel
G2
CY 2013
HCPCS
Codes
37205
37206
37224
37225
Transcatheter placement of an intravascular stent(s) (except
coronary, carotid, vertebral, iliac, and lower extremity arteries),
percutaneous; each additional vessel (list separately in addition
to code for primary procedure)
Revascularization, endovascular, open or percutaneous, femoral,
popliteal artery(s), unilateral; with transluminal angioplasty
Revascularization, endovascular, open or percutaneous, femoral,
popliteal artery(s), unilateral; with atherectomy, includes
angioplasty within the same vessel, when performed
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G2
G2
G2
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2013 Final OPPS
37226
Revascularization, endovascular, open or percutaneous, femoral,
popliteal artery(s), unilateral; with transluminal stent
placement(s), includes angioplasty within the same vessel, when
performed
G2
37227
Revascularization, endovascular, open or percutaneous, femoral,
popliteal artery(s), unilateral; with transluminal stent
placement(s) and atherectomy, includes angioplasty within the
same vessel, when performed
J8
37228
Revascularization, endovascular, open or percutaneous, tibial,
peroneal artery, unilateral, initial vessel; with transluminal
angioplasty
G2
37229
Revascularization, endovascular, open or percutaneous, tibial,
peroneal artery, unilateral, initial vessel; with atherectomy,
includes angioplasty within the same vessel, when performed
G2
37230
Revascularization, endovascular, open or percutaneous, tibial,
peroneal artery, unilateral, initial vessel; with transluminal stent
placement(s), includes angioplasty within the same vessel, when
performed
G2
37231
Revascularization, endovascular, open or percutaneous, tibial,
peroneal artery, unilateral, initial vessel; with transluminal stent
placement(s) and atherectomy, includes angioplasty within the
same vessel, when performed
J8
37232
Revascularization, endovascular, open or percutaneous, tibial/
peroneal artery, unilateral, each additional vessel; with
transluminal angioplasty (list separately in addition to code for
primary procedure)
G2
37233
Revascularization, endovascular, open or percutaneous, tibial/
peroneal artery, unilateral, each additional vessel; with
atherectomy, includes angioplasty within the same vessel, when
performed (list separately in addition to code for primary
procedure)
G2
37234
Revascularization, endovascular, open or percutaneous, tibial/
peroneal artery, unilateral, each additional vessel; with
transluminal stent placement(s), includes angioplasty within the
same vessel, when performed (list separately in addition to code
for primary procedure)
G2
37235
Revascularization, endovascular, open or percutaneous, tibial/
peroneal artery, unilateral, each additional vessel; with
transluminal stent placement(s) and atherectomy, includes
angioplasty within the same vessel, when performed (list
separately in addition to code for primary procedure)
G2
**Final payment indicators are based on a comparison of the final rates according to the ASC standard ratesetting methodology
and the MPFS final rates. At the time this final rule with comment period was being developed for publication, current law
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2013 Final OPPS
authorizes a negative update to the MPFS payment rates for CY 2013. For a discussion of those rates, we refer readers to the CY
2013 MPFS final rule with comment period.
G2 - Non-office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight
J8 - Device-intensive procedure added to ASC list in CY 2008 or later; paid at adjusted rate
No Cost/Full Credit and Partial Credit Devices (p. 815)
CMS will reduce the payment for the device implantation procedures listed in Table 54 that are
subject to the adjustment by the full device offset amount for no cost/full credit cases. ASCs
must append the modifier “FB” to the HCPCS procedure code when the device furnished without
cost or with full credit is listed in Table 55, and the associated implantation procedure code is
listed in Table 54. In addition, for CY 2013, CMS will reduce the payment for implantation
procedures listed in Table 54 that are subject to the adjustment by one half of the device offset
amount if a device is provided with partial credit, if the credit to the ASC is 50 percent or more
of the device cost. If the ASC receives a partial credit of 50 percent or more of the cost of a
device listed in Table 55, the ASC must append the modifier “FC” to the associated implantation
procedure code if the procedure is listed in Table 54.
Table 54 includes the following codes of interest: 19296 (Place po breast cath for rad), 19297
(Place breast cath for rad), 19298 (Place breast rad tube/caths), 37227 (Fem/popl revasc stnt &
ather) and 37231 (Tib/per revasc stent & ather).
Table 55 includes the following codes of interest: C1777 (Stent, non-coat/cov w/o del)
Payment for Covered Ancillary Services for CY 2013 (p. 837)
CMS will provide payment for covered ancillary services in accordance with the policies in this
final rule. Covered ancillary services and their final CY 2013 payment indicators are listed in
Addendum BB. CMS will update the ASC payment rates and make changes to ASC payment
indicators as necessary to maintain consistency between the OPPS and ASC payment system
regarding the packaged or separately payable status of services and the proposed CY 2013 OPPS
and ASC payment rates.
Radiology Services
CY 2013 payment rates for separately payable covered radiology services are based on a
comparison of the MPFS nonfacility PE RVU-based amounts and the ASC payment rates
calculated according to the ASC standard ratesetting methodology and then set at the lower of
the two amounts.
Alternatively, payment for a radiology service may be packaged into the payment for the ASC
covered surgical procedure if the radiology service is packaged or conditionally packaged under
the OPPS.
Radiology services paid based on the ASC standard ratesetting methodology are assigned
payment indicator “Z2” (Radiology service paid separately when provided integral to a surgical
procedure on ASC list; payment based on OPPS relative payment weight) and those for which
the proposed payment is based on the MPFS nonfacility PE RVU-based amount are assigned
payment indicator “Z3” (Radiology service paid separately when provided integral to a surgical
procedure on ASC list; payment based on MPFS nonfacility PE RVUs).
Staff Summary
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2013 Final OPPS
Nuclear Medicine
Payment indicators for all nuclear medicine procedures (defined as CPT codes in the range of
78000 through 78999) that are designated as radiology services that are paid separately when
provided integral to a surgical procedure on the ASC list are set to “Z2” so that payment is made
based on the OPPS relative payment weights rather than the MPFS nonfacility PE RVU-based
amount, regardless of which is lower.
Contrast
Payment indicators for radiology services that use contrast agents are set to “Z2” so that payment
for these procedures will be based on the OPPS relative payment weight and, therefore, will
include the cost for the contrast agent.
Ambulatory Surgical Center Quality Reporting (ASCQR) Program
CMS finalized proposed revisions to the ASC Quality Reporting (ASCQR) program, including
requirements for claims-based measures regarding the dates for submission, payment of claims
and data completeness, and a methodology for reducing payment to ASCs that do not meet the
program’s reporting requirements. CMS also adopted principles to be applied in future measure
selection and development. CMS previously finalized the measure sets that apply to the CYs
2014 through 2016 payment determinations.
Staff Summary
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