CMS’ Outpatient Prospective Payment System (OPPS) proposed rule for fiscal year (FY) 2009 includes changes for Type B emergency departments (ED) and imaging services as well as expansions to quality measures.

Payment reduction for failure to report quality measures

Hospitals reporting required outpatient quality measures in 2009 would receive a 2% inflation update. Hospitals that do not report these measures will not receive this update. CMS is also proposing to reduce the beneficiary copayment amount for services in hospitals that have not met their reporting requirements.

CMS requests comment on 18 other quality measures for potential inclusion at a future date. Among the measures are emergency department processes, screening for fall risk, and management of such clinical conditions as depression, osteoporosis, asthma, and community-acquired pneumonia.

Under the proposed rule, CMS will put a data validation program into service for hospital quality data, effective January 2009. The proposed approach selects 800 reporting hospitals and validates reported data using 50 records per selected hospital annually.

New APCs for some Type B ED visits 

Currently, CMS pays for emergency visits provided in Type B EDs, which offer emergency-level services but are not open 24 hours per day, 7 days per week, at the same rate as a nonemergency visit to an outpatient department.

CMS data now shows that most Type B emergency visits are more expensive than clinic visits, but are less expensive than Type A ED visits. The proposed rule creates four new APCs for Type B ED visits, paid based on claims data from these providers.

CMS has also proposed to pay for the most intensive emergency visits using a single APC on the premise that costs for these are similar in both Type A and B emergency departments.

Changes in imaging services payments The OPPS proposed rule proposes a single payment for certain multiple imaging services when provided in one session. These include:

• Ultrasound

• Computed tomography (CT) and computed tomographic angiography (CTA) without contrast

• CT and CTA with contrast

• Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) without contrast

• MRI and MRA with contrast

“This is not good,” says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, an independent consultant in Milton, WI. “You used to get paid for two modalities [in multiple imaging services] and you got discounted on one, but now you’re only going to get paid for one. [CMS] is telling us to be more efficient and think twice about ordering. What they’re doing is practicing medicine.”

CMS has proposed these changes in an effort to eliminate unnecessary tests, and while Krauss says that this problem exists, he asks “but what happens if it [a test] is necessary?” He also foresees the changes posing a lose-lose choice for radiology departments. To run efficiently under the new rule, radiology departments must change their ordering patterns—but doing so may catch CMS’ attention, Krauss says.

The 2009 OPPS proposed rule is scheduled to be published in the July 18 Federal Register.

Comments on the proposed rule will be accepted through September 2. CMS will respond to comments in a final rule that it expects to release on or before November 1. Should the changes become final, they will become effective as of January 1, 2009.

Editor’s note: To view the OPPS/ASC proposed rule for 2009, click here.