The National Association for Medical Direction of Respiratory Care (NAMDRC)

November 9, 2011

NAMDRC HEALTH POLICY UPDATE

CMS Posts 2012 Rules for Hospital Outpatient Prospective Payment

CMS has posted the 2012 rules for Hospital Outpatient Prospective Payment, effective 1/1/12, with a payment rate of $37/session for pulmonary rehabilitation services (HCPCS code G0424), a reduction of about 40% from the $63 rate for the current year. CMS rejected the multi society argument that CMS data, while accurate, is basically artifact data. CMS uses hospital charges that are included in claims data to determine hospital outpatient payment rates, and when hospitals do not accurately compute their charges for new, bundled services such as pulmonary rehab, the effect is a notable reduction in payment rates.

New CMS links for Pulmonary Rehabilitation and the Physician Fee Schedule are as follows:

• Hospital Outpatient Rule, as posted on CMS website for publication later this month in the Federal Register
• Physician Fee Schedule Rule, as posted on CMS website for publication later this month in the Federal Register

ADDITIONAL DETAILS ON THE NEW PHYSICIAN FEE SCHEDULE WILL BE PUBLISHED IN THE DECEMBER WASHINGTON WATCHLINE AND WATCH FOR MORE E-MAIL UPDATES AS WELL.

If NAMDRC can be of further assistance, please do not hesitate to contact the NAMDRC Executive Office at 703-752-4359.

Your Advocate

The complexity of our nation’s health care system in general, and Medicare in particular, create a true challenge for physicians and their office staffs. One of NAMDRC’s key strengths is to offer assistance on a myriad of coding, coverage and payment issues.

Regulations of Interest

NAMDRC has won praise with its track record with government agencies, most notably the Centers for Medicare and Medicaid Services (CMS). The majority of NAMDRC members agree that NAMDRC’s voice before regulatory agencies and legislators has been the #1 reason for belonging to and continuing membership.

That effective voice is translated into providing members with timely information, identifying important Federal Register announcements, pertinent statements and notices by the Centers for Medicare and Medicaid Services, the Durable Medical Equipment Regional Carriers, and local medical review policies.

NAMDRC has been a successful advocate on these issues:

• Obtaining a change in the Medicare physician update, resulting in an increase, rather than a decrease, in the conversion factor used to determine payments to physicians
• Securing new CPT codes for placement of tracheal and bronchial stents, placement of additional stents in another main bronchus, endobroncial ultrasound, and high altitude simulation testing (HAST) and HAST with oxygen titration
• Increasing the work valve for Transbronchial Needle Aspiration biopsies
• Working to secure Medicare coverage of smoking cessation counseling
• Collaborating to assist CMS in better defining critical care services and teaching physicians’ documentation of these services.

NAMDRC’s advocacy focuses on issues of immediate importance to you and your patients. NAMDRC continues to:

• Monitor changes in the Medicare Physician Fee Schedule and the current five (5) year review of selected pulmonary related codes
• Monitor development of pay-for-performance models
• Advocate the adoption of a national coverage policy for pulmonary rehabilitation
• Advocate a change in Medicare policy to ensure that home oxygen patients receive the delivery system most appropriate for the patient’s needs

In response to NAMDRC pressure, the FAA has published a final ruling that will make airline travel easier for oxygen patients.