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From Health Law Daily, July 3, 2014

CY 2015 ESRD PPS proposal addresses quality measures and DMEPOS issues

By Harold M. Bishop, JD

CMS issued an advance release of its Proposed rule that would update payment policies and rates under the End-Stage Renal Disease Prospective Payment System (ESRD PPS) for renal dialysis services furnished on or after January 1, 2015. The Proposed rule also proposes requirements for the ESRD Quality Incentive Program (QIP), including for payment years (PYs) 2017 and 2018. Finally, the Proposed rule addresses numerous other issues related to the coverage and payment of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).

Statutory basis.Section 1881(b)(14) of the Social Security Act, as added by section 153(b) of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) (P.L. 110-275), and Soc. Sec. Act Sec. 1881(b)(14)(F), as added by section 153(b) of MIPPA and amended by section 3401(h) of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), established that beginning calendar year (CY) 2012, and each subsequent year, the Secretary of HHS must annually increase ESRD payment amounts by an ESRD market basket increase factor, reduced by the productivity adjustment described in Soc. Sec. Act Sec. 1886(b)(3)(B)(xi)(II).

Update to the ESRD PPS base rate. For CY 2015, CMS proposes an ESRD PPS base rate of $239.33. This reflects a 0.0 percent update to the payment rate as required by section 1881(b)(14)(F)(i) of the Soc. Sec. Act, as amended by section 217(b)(2) of the Protecting Access to Medicare Act of 2014 (PAMA) (P.L. 113-93), and the application of the proposed wage index budget-neutrality adjustment factor of 1.001306 to the CY 2014 ESRD PPS base rate of $239.02.

ESRD bundled (ESRDB) market basket. For CY 2015, CMS proposes to rebase and revise the ESRDB market basket so the cost weights and price proxies would reflect the mix of goods and services that underlie ESRDB operating and capital costs for CY 2012.

Labor-related share. For CY 2015, CMS is proposing a 2-year transition, in which the CY 2015 payment would be based on a 50/50 blended labor-related share that would apply to all ESRD facilities. ESRD facilities would receive 50 percent of their current labor-related share and 50 percent of their revised labor-related share. CMS would apply a labor-related share of 46.205 ((41.737+50.673)/2 = 46.205). Then, for CY 2016, the labor-related share would be based on 100 percent of the revised labor-related share.

Wage index and wage index floor. CMS adjusts wage indices on an annual basis using the most current hospital wage data to account for differing wage levels in areas in which ESRD facilities are located. In CY 2015, CMS is not proposing any changes to the application of the wage index budget-neutrality adjustment factor and will continue to apply the budget-neutrality adjustment to the base rate for the ESRD PPS. CMS will continue its policy for the gradual phase-out of the wage index floor and reduce the wage index floor values to 0.40.

Core-Based Statistical Areas (CBSA). For CY 2015, CMS is proposing to implement a 2-year transition, under which a 50/50 blended wage index would apply to all ESRD facilities. Specifically, facilities would receive 50 percent of their CY 2015 wage index based on the CBSA delineations for CY 2014 and 50 percent of their CY 2015 wage index based on the proposed new CBSA delineations. In CY 2016, facilities’ wage index values would be based 100 percent on the new CBSA delineations.

Outlier policy. For CY 2015, CMS would update the outlier services fixed dollar loss amounts for adult and pediatric patients and Medicare Allowable Payments (MAPs) for adult patients using 2013 claims data. The fixed dollar loss amount for pediatric beneficiaries would increase from $54.01 to $56.30 and the MAP amount would increase from $37.29 to $40.05, as compared to CY 2014 values. For adult beneficiaries, the fixed-dollar loss amount would decrease from $98.67 to $85.24 and the MAP amount would increase from $51.97 to $52.61.

Low-volume payment adjustment (LVPA). CMS is clarifying that Medicare Administrative Contractors (MACs) can consider supporting data from hospital-based ESRD facilities to verify the facility’s total treatment count. CMS also clarifies that MACs can add or prorate treatment counts from non-standard cost reporting periods where there is a change in ownership that does not result in a new Provider Transaction Access Number.

ICD-9-CM codes. HHS intends to issue an Interim final rule that will require use of ICD-10 beginning October 1, 2015. Therefore, CMS proposes that ESRD PPS will continue to use ICD-9 through September 30, 2015, and will require use of ICD-10 beginning October 1, 2015, for purposes of the comorbidity payment adjustment.

ESRD QIP.CMS proposes to implement requirements for the ESRD QIP, including measure sets for PYs 2017 and 2018.

  • PY 2017 measure set. For PY 2017, CMS is proposing to remove the Hemoglobin Greater than 12 g/dL clinical measure, on the grounds that it is “topped out.” It is also proposing to adopt the Standardized Readmission Ratio (SRR) clinical measure, which evaluates care coordination.

  • PY 2018 measure set. For PY 2018, CMS is proposing to adopt the Standardized Transfusion Ratio (STrR) and Pediatric Peritoneal Dialysis Adequacy as clinical measures and (1) Pain Assessment and Follow-Up; (2) Clinical Depression Screening and Follow-Up; and (3) National Healthcare Safety Network (NHSN) Healthcare Personnel Influenza Vaccination as reporting measures. It is also proposing to transition the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey reporting measure to a clinical measure.

  • ICH CAHPS reporting measure. Beginning with the PY 2017 program year, CMS is proposing to revise the ICH CAHPS reporting measure to determine facility eligibility for the measure based on the number of survey-eligible patients treated during the “eligibility period,” which it proposes to define as the CY that immediately precedes the performance period.

  • NHSN Bloodstream Infection in Hemodialysis Outpatients clinical measure. Beginning with the PY 2016 program year, CMS is proposing to revise the NHSN Bloodstream Infection in Hemodialysis Outpatients clinical measure to calculate facility performance using the Adjusted Ranking Metric (ARM).

  • Mineral Metabolism reporting measure. Beginning with the PY 2018 program year, CMS is proposing to revise the Mineral Metabolism reporting measure to allow facilities to submit both serum phosphorus and plasma phosphorus measurements.

  • Extraordinary circumstances exemption. Beginning with the PY 2017 ESRD QIP, CMS is proposing to exempt dialysis facilities from all requirements of the ESRD QIP clinical and reporting measures during the months in which they are forced to close due to a natural disaster or other extraordinary circumstances.

  • New soring methodology. For PY 2018, CMS is proposing to use a new scoring methodology for the ESRD QIP. This proposed scoring methodology would assign facility Total Performance Scores (TPS) on the basis of two domains, the Clinical Measure Domain and the Reporting Measure Domain.

DMEPOS.The rule proposes methodologies for using information from the DMEPOS competitive bidding programs (CBPs) to adjust the fee schedule amounts for DME in areas where CBPs are not implemented. The rule also proposes to use the same methodologies to adjust the fee schedule amounts for enteral nutrition and off-the shelf (OTS) orthotics in areas where CBPs are not implemented. The rule further proposes to:

  • phase-in special payment rules for certain DME and enteral nutrition under the DMEPOS CBP in a limited number of competitive bidding areas (CBAs);

  • modify the regulation at 42 C.F.R. Sec. 411.15(d) to address the scope of the statutory hearing aid exclusion and note the types of devices that are not subject to the hearing aid exclusion;

  • update the regulation at 42 C.F.R. Sec. 414.402 to indicate what specialized training is needed to provide custom fitting services if suppliers are not certified orthotists;

  • establish an exception under the Change of Ownership (CHOW) rules to allow CMS to sever a product category from a contract, incorporate the product category into a new contract, and transfer the new contract to a qualified new owner under certain specific circumstances; and

  • clarify the effective date for terminations of competitive bidding contracts, which impacts the deadline for which contract suppliers must notify its beneficiaries of the termination.

CMS will accept comments on the Proposed rule until September 2, 2014. The Proposed rule will appear in the Federal Register on July 11, 2014.

MainStory: TopStory NewsStory ReimbursementNews CMSNews CoverageNews DMENews ESRDNews HealthReformNews MedicaidPaymentNews PaymentNews QualityNews

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