HOP panel makes recommendations to CMS, requests response in OPPS final rule

Wednesday, August 21, 2019

CMS’ Hospital Outpatient Payment (HOP) panel made numerous recommendations at its annual meeting August 19 for the agency to consider ahead of the release of the 2020 OPPS final rule—with the panel and other stakeholders urging CMS to be more transparent with its responses and release of data.

While CMS has historically accepted many HOP panel recommendations—or at least acknowledged and responded to them—recent recommendations have been ignored in the OPPS final rules, resulting in some stakeholders repeating their requests from previous years.

The recommendation that could have the most impact on providers in 2020 related to CMS’ continued efforts at reducing payments for clinic visits at off-campus, provider-based departments originally grandfathered under section 603 of the Bipartisan Budget Act of 2015. Last year, CMS finalized a policy to effectively pay providers 70% of the OPPS rate in 2019 and 40% of the OPPS rate in 2020 and beyond.

In the 2020 OPPS proposed rule, CMS says it intends to continue with this reduction, despite a recommendation from the HOP panel last year that the agency continue to study the issue and pause the reimbursement change. Blair Burnett, representing the Association of Community Cancer Centers, asked the panel this year to recommend CMS again continue to study utilization and provide more data before making further changes. The panel unanimously supported this position, asking CMS to freeze rates at 2019 levels.

In 2018, representatives of the Provider Roundtable (PRT), a group that represents 13 hospitals and health systems across 35 states, had asked the HOP panel to recommend CMS publish more specific information about its packaging and rate setting for laboratory and ancillary services. Without that information in its APC offset file, which CMS currently publishes for drugs and devices, it’s more difficult for hospitals and other stakeholders to understand all of the services each APC is intended to pay.

The panel supported the request and asked CMS to publish that data in subsequent rules, but this information was not included in the 2020 OPPS proposed rule. The PRT submitted a similar request this year, and the HOP panel unanimously recommended that CMS explain and assess the appropriateness of excluding charges from rate setting, as described in its claims account document, simply because the revenue center charge is equal to the APC payment.

“We appreciate the panel’s support of our request,” says Terri Rinker, MT (ASCP), MHA, PRT chair and revenue cycle director for Community Hospital Anderson in Anderson, Indiana. “The more data providers have available to them, the more substantive and beneficial comments to CMS can be.”

The HOP panel unanimously (albeit with one abstention) recommended that CMS study the creation of a new comprehensive APC (C-APC) for autologous stem cell transplant. This follows a similar request and recommendation on the same topic last year last year. This service is currently reported with CPT code 38241 (hematopoietic progenitor cell; autologous transplantation) and assigned to APC 5242 (Level 2 Blood Product Exchange and Related Services).

In addition to recommending CMS study creating this C-APC, the panel specifically asked CMS to respond directly about why it would not create this C-APC if it declines to do so in the 2020 OPPS final rule.

In 2018, Jugna Shah, MPH, CHRI, president and founder of Nimitt Consulting, presenting on behalf of the American Society of Transplantation and Cellular Therapy, asked the panel to reassign the status indicators for a series of HCPCS codes related to chimeric antigen receptor T-cell (CAR-T) therapy. Despite the panel’s recommendations, the codes continued to be assigned status indicator B (not paid under OPPS).

She returned this year to ask the panel to recommend that CMS change the status indicators of the following codes from B to Q1 (packaged APC payment if billed on the same date of service as a HCPCS code assigned status indicator S, T, V, or X):

  • 0537T, CAR-T therapy; harvesting of blood-derived T lymphocytes for development of genetically modified autologous CAR-T cells, per day
  • 0538T, CAR-T therapy; preparation of blood-derived T lymphocytes for transportation (e.g., cryopreservation, storage)
  • 0539T, CAR-T; receipt and preparation of CAR-T cells for administration

The change in status indicators would allow hospital reimbursement for these services when they are provided on claims without other significant procedures. The panel unanimously, with one abstention, recommended CMS once again change the status indicator for these services from B.

Editor's note: Shah, a NAHRI Advisory Board member, will be presenting with fellow NAHRI Advisory Board member Valerie Rinkle, MPA, CHRI, on the OPPS proposed rule at the Revenue Integrity Symposium (RIS) to be held October 15–16 in Orlando. Join Shah and Rinkle on day one of RIS for their session "Round the Rule Merry-Go-Round: IPPS, OPPS, and MPFS."

Register for the 2019 Revenue Integrity Symposium before August 17 to get the $100 early bird discount. NAHRI members get an additional $100 discount. NAHRI members get free admission to a special members-only networking reception on October 14, the night before RIS officially kicks off. NAHRI members attending this reception should RSVP online as soon as possible to reserve their space.

Need help getting approval to attend? Click here to download a justification letter proposal that you can use to gain administrative support and approval for attending.

This article originally appeared on Revenue Cycle Advisor.

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