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AUA Outpatient Comments

October 3, 2001

Thomas A. Scully
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1159-P
P.O. Box 8017
Baltimore, MD 21244-8017

Re: CMS-1159-P—Medicare Program; Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2002 Payment Rates.

Dear Administrator Scully:

On behalf of the American Urological Association (AUA), representing 10,000 urologists in the United States, I am pleased to submit comments on the proposed changes to the hospital outpatient prospective payment system (OPPS) for 2002, published in the August 21, 2001 Federal Register. The switch to a PPS for Medicare outpatient services has been a huge undertaking, with each unforeseen problem creating a more and more intricate payment system that is becoming more complex and difficult to understand. However, our basic concern with the OPPS is the extent to which inaccuracies in its implementation have the potential to create negative consequences for Medicare beneficiaries or lead to an increase in overall public health care expenditures.

For example, if, under the OPPS, an outpatient department cannot recover its costs on certain services, it may choose to admit the patient into the hospital or choose not to provide the service. More inpatient treatments could drive up the cost of health care services for Medicare and for patients, which is contrary to the original objective of the OPPS "to ensure that Medicare and its beneficiaries pay appropriately for services and to encourage more efficient delivery of care." (p. 44673).

Also, if patients want to receive a certain service in the outpatient setting, but their hospital does not provide that service, the beneficiary is inconvenienced by having to be admitted or by having to find another hospital that will provide the service in the desired outpatient setting. And, in these situations, physicians are put in the middle, forced to advise their patients in the absence of the best treatment options.

In addition to these general macro-level concerns the AUA also has more specific concerns or questions about the following issues:

  1. Transitional Pass-through Payments

    We applaud CMS for changing the classification system for categorizing devices eligible for pass-through payments under the OPPS. The new classification system based on categories of devices is superior to the original system based on particular brand names of products, which we disagreed with on the grounds that it arbitrarily favored some device companies and disadvantages others.

    However, we are concerned about the potential reductions in pass-through payments due to the statutory limit on the amount of transitional pass-through payments to 2.5 percent (in 2002) of projected total payments under the hospital OPPS. Cuts to the pass-through payments would defeat the purpose for which they were established, which was to provide incentive for hospitals to use newer technologies that were hopefully more efficient and effective than older technologies that treat the same medical condition. It is vital that improper payments do not jeopardize beneficiary access to care. Therefore, we urge CMS to find alternative solutions and not to cut pass-through payments.

  2. Cystourethroscopy with Lithotripsy

    Last year, the AUA wrote to CMS regarding CPT® code 52353 (previously 52337), Cystourethroscopy, with ureteroscopy and/or pyeloscopy; with lithotripsy (ureteral catheterization is included), saying that in the April 7, 2000 OPPS final rule, CMS had reassigned this code from its original APC group of 163 into APC 162. We believed this was an inadvertent error that would have had serious consequences on the availability of this procedure to Medicare beneficiaries. Therefore, we requested a meeting with CMS to discuss this issue and explain why the procedure did not belong in APC 162.

    Although we never had a meeting with CMS on this issue, at its first annual meeting February 27 - March 1, 2001, the APC Advisory Panel discussed whether or not CPT® code 52353 should be reclassified from APC 162 to APC 163, as requested. The panel ultimately voted to place the code in APC 169. In the rule, however, CMS proposes to place CPT® code 52353 into APC 163. We applaud CMS for making this correction and appreciate that the APC Advisory Panel played an important rule in correcting this mistake.

  3. BPH Heat Therapy Treatments

    Currently, there are four different thermotherapy treatments for BPH, all of which have received CPT® codes since 1997 (see Table I below). In past comments, the AUA has requested-based on cost data-that CPT® codes 52647, 53850 and 53852 be placed in the same APC, and also explained why these procedures should not be grouped with TURP (the gold-standard surgical treatment for BPH) in APC 163.

    Table I. Heat Therapy Procedures that Treat BPH



    APC Group

    Proposed 2002 OPPS Payment


    Non-contact laser coagulation of prostate, including control of postoperative bleeding, complete (vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included)




    Transurethral destruction of prostate tissue; by microwave thermotherapy




    Transurethral destruction of prostate tissue; by radiofrequency thermotherapy




    Water induced thermotherapy



    Last year, after Indigo applied for and received a HCPCS code (C1088) for reimbursement as a new technology under the OPPS for its LaserOptic Treatment System, these three procedures were placed in the same APC group of 980.

    However, in this proposed rule, 53850 and 53852 are in APC 982, while C1088 is still in APC 980. Indigo has contacted the AUA regarding this issue, saying that the payment rate for APC 980 is inadequate for this service. While we assume that the decision to keep C1088 in APC 980 was data driven and not arbitrary, we find no explanation of this in the rule. The data file shows that the median cost for CPT® code 52647 was $1,684.83 based on 705 single claims while the median cost for 53850 was $2,895.04 based on 3,634 single claims and the median cost for 53852 was $2,538.09 based on 573 single claims. However, there is no listing for C1088 in the data file, which leaves a question as to how the decision was made. We assume that CMS will work with Indigo and the hospitals to gather appropriate cost data and hope that this issue will be clarified.

    The manufacturer of water-induced thermotherapy, Argomed, has also contacted the AUA regarding the proposed OPPS payment for WIT, which will receive a CPT® code in January, 2002, but has already been assigned a code for OPPS reimbursement, C9700. Argomed believes that WIT should also be assigned to APC 982. The AUA currently has no way to substantiate these claims, but assumes that CMS will make its decisions based on the available data or will move the code into a higher paying APC if future data shows that the costs are greater than the payment.

Thank you for considering our comments. If you have any questions or need additional information, please contact Cherie McNett, AUA Government Affairs Director, at 410-689-3710.


E. Darracott Vaughan, MD
American Urological Association

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