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IMRT Outpatient Payment Drop Should Be Halted – APC Advisory Panel

This article was originally published in The Gray Sheet

Executive Summary

Intensity modulated radiation therapy should be kept in a new technology APC for one year to allow more data to be gathered in order to set a more accurate payment than the 2004 amount, according to the Ambulatory Payment Classification Advisory Panel

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OPPS Proposed Rule In Brief

Outlier threshold tightened: CMS takes steps to "redirect outlier payments from lower-cost and relatively simple procedures to more complex, expensive procedures," according to the 2005 hospital outpatient prospective payment system proposed rule. The agency would require the cost of the service to be 1.5 times the APC payment rate and surpass the sum of the APC rate plus a $625 fixed-dollar threshold. CMS' action arises from a Medicare Payment Advisory Commission recommendation that the outlier policy be eliminated due to misuse of payments intended for high-cost cases (1"The Gray Sheet" Jan. 19, 2004, p. 14). AdvaMed and the American Hospital Association support the proposal...

OPPS Proposed Rule In Brief

Outlier threshold tightened: CMS takes steps to "redirect outlier payments from lower-cost and relatively simple procedures to more complex, expensive procedures," according to the 2005 hospital outpatient prospective payment system proposed rule. The agency would require the cost of the service to be 1.5 times the APC payment rate and surpass the sum of the APC rate plus a $625 fixed-dollar threshold. CMS' action arises from a Medicare Payment Advisory Commission recommendation that the outlier policy be eliminated due to misuse of payments intended for high-cost cases (1"The Gray Sheet" Jan. 19, 2004, p. 14). AdvaMed and the American Hospital Association support the proposal...

APC Floor Will Not Be Applied To Devices, But C-Codes Are Back – OPPS Rule

The payment rates for five device-related APCs will be raised from their 2004 proposed rates through the use of external data, but CMS will not apply a dampening mechanism for APCs falling in excess of 5%, according to the 12004 OPPS final rule

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