On July 8, the Centers for Medicare and Medicaid Services (CMS) issued its proposed CY 2014 payment rate regulation for hospital outpatient departments (HOPD) and ambulatory surgery centers (ASC).  The proposal regulation will soon be published in the Federal Register, after which time OOSS and other interested parties will have an opportunity to submit public comments.

Below please find a brief summary of key components of the proposed rule. A more detailed summary with proposed payment rates of representative ophthalmic surgical procedures will be provided shortly.

CY 2014 Payment Rates

As you may recall, under the ASC payment system, facilities receive a percentage of the relative weight assigned to a code for procedures furnished in HOPDs.  The relative weights are recalibrated each year based under a complex formula that takes into account a number of factors, including changes in hospitals’ costs in providing such services and the mandate that the ASC payment system remain budget-neutral.

Again this year, the 2014 proposal contemplates an inflation update for ASCs; CMS is providing an update based upon the Consumer Price Update –Urban (CPI-U), which the agency estimates to be 1.4 percent. However, as you may recall, most health care providers will incur a “productivity adjustment” against their cost of living updates; CMS estimates that this adjustment will be 0.5 percent, which would result in a 2014 ASC payment rate update of positive update of 0.9 percent.  (For 2014, HOPDs would receive an update of 1.8 percent.) Although the government has once again rejected the ASC community’s recommendation that facilities be paid on the basis of the same update factor provided hospital outpatient departments, the agency has acknowledged that the CPI-U may not be the best inflator for ASCs.

Proposed 2014 payment rates for an illustrative selection of high-volume ophthalmic services are as follows:

ASC Quality Reporting

As OOSS members are well aware, effective October 1, 2012, facilities commenced reporting data with respect to the following measures: patient burns; patient fall in the ASC; wrong site, wrong side, wrong patient, wrong procedure, wrong implant; hospital transfer/admission; and, prophylactic IV antibiotic timing.  As discussed in prior Updates Online, facilities are also required to report through CMS’ QualityNet website data respecting procedure volume and use of a safe surgery checklist.

In this rule, CMS is proposing that, commencing in 2014 for purposes of 2016 payment determinations, ASCs report on four new measures, two of which are ophthalmology-specific:

  • Complications Within 30 days Following Cataract Surgery Requiring Additional Surgical Procedures (NQF#0564); and,
  • Improvement in Patient’s Visual Function Within 90 days Following Cataract Surgery (NQF#1536).

Facilities would provide aggregate data on these chart-abstracted measures via an online web-based tool on a CMS web page.  OOSS has submitted comments in the past objecting to the application of these two measures to the ASC setting and we will reiterate our concerns in our formal comments to the agency.

New Technology Intraocular Lens (NTIOL) Payment

ASCs that implant lenses that have secured NTIOL status receive an additional $50 in facility reimbursement. Last year, CMS adopted changes in the standards through which it reviews NTIOL applications, requiring that as a condition to a lens being eligible for NTIOL status that the FDA approved labeling for the product contain a claim of a specific clinical benefit imparted by a new lens characteristic.  CMS reports that there were no applications submitted by ophthalmics manufacturers requesting NTIOL status for lenses for the 2014 ASC payment rate rulemaking.

OOSS Action on this Rule and ASC Industry-Supported Legislation

We are disappointed, but not surprised, by CMS’ effort to update payment rates.  OOSS’ position is very simple:  ASC payment rates should be updated annually by the same factor used to update hospital rates: the Hospital Market Basket.  We will ask you, the OOSS member, to submit comments this summer to CMS and will provide you with all the tools to do so. With your assistance at the grassroots, OOSS will also seek enactment of The ASC Quality and Access Act of 2013, legislation that will mandate that the ASC update factor be identical to that afforded hospitals and make other important systemic reforms in our payment system.

The proposed regulation (CMS-1589-P) can be reviewed at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2013-16555.pdf.

The proposed payment rates can be reviewed by clicking here.

OOSS will keep you abreast of further developments as well as instructions for OOSS members to submit public comments on the proposed regulation.  Should you have any questions regarding the rule, please contact Mike Romansky at mromansky@OOSS.org.

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