October 7, 2002
Thomas A. Scully
Centers for Medicare and Medicaid Services
Department of Health and Human Services
P.O. Box 8018
Baltimore, MD 21244-8018
Re: CMS-1206-P—Medicare Program; Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2003 Payment Rates; and Changes to Payment Suspension for Unified Cost Reports
Dear Mr. Scully:
On behalf of the American Urological Association (AUA), which represents 10,000 practicing urologists, I am pleased to submit comments on the proposed changes to the hospital outpatient prospective payment system (OPPS) for calendar year 2003. We appreciate that CMS has encountered many challenges in implementing the OPPS, including legislative constraints and a limited data set. Nevertheless, we are concerned about proposed changes in the August 9, 2002 rule that could negatively affect Medicare beneficiaries who are in need of certain types of urological care.
For many urologic procedures, CMS has proposed substantial payment reductions. As a physician organization charged with seeking adequate physician payment, the AUA does not have the means to verify whether these payments are accurate or to assess how hospitals will react to these payment cuts. However, we are worried that many of these cuts are based on a data collection and analysis process that may not be accurately capturing hospital costs due to the learning curve for hospital billing as well as to the fact that many multiple-procedure claims are thrown out of the data set used for developing OPPS payments.
Also, the elimination of many pass-through payments-coupled with CMS's seemingly-strict interpretation of the criteria for new pass through categories-compounds the problem. Because of this, we urge CMS to be open to making changes (as discussed on page 52093 of the proposed rule) based on the comments it receives regarding urological services provided in an outpatient setting. This is particularly true for procedures within the following APC groups, which are proposed to receive offsets in 2003 for device costs that are losing their pass-through status:
New G Code for Prostate Brachytherapy
CMS proposes to eliminate the separate seed pass-through payment for prostate brachytherapy and to establish a G code for hospital use only that will specifically identify prostate brachytherapy: G0KKK, Prostate brachytherapy, including transperineal placement of needles or catheters into the prostate, cystoscopy, and interstitial radiation source application. APC 0684 would be created for prostate brachytherapy, with a proposed payment rate of $5,381.37.
We are confused by the discussion about this on page 52128 of the rule, which says "This G code would be used by hospitals instead of HCPCS codes 55859 and 77778 to bill for prostate brachytherapy. Hospitals would continue to use HCPCS codes 55859 and 77778 when reporting services other than prostate brachytherapy." CPT® code 55859, Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy, is specifically for prostate brachytherapy. Therefore, hospitals could not use this code to report services other than prostate brachytherapy. Furthermore, if there were 12,000 claims that contained CPT® codes 77778 and 55859, we do not understand the need to develop a G code to facilitate tracking of brachytherapy used to treat prostate cancer.
The AUA also believes that the creation of a G code in this instance goes against the purposes of such codes which were meant to be temporary codes for procedures and services which are being reviewed prior to inclusion in the AMA CPT® coding system. In fact, CMS has stated at CPT® meetings that it is their goal to review and translate the existing G codes over to their appropriate or new CPT® counterparts as quickly as possible and we have worked with them on several issues to do just that. We would be opposed to and are very concerned about this reverse trend of changing an existing CPT® code to a G code.
For the reasons discussed above, we urge CMS to withdraw this G code for prostate brachytherapy.
Multiple Procedure Reductions for APCs with Device Costs
In the rule, CMS solicits comments on the status indicators assigned to each APC and on the proposal to continue its current policy of multiple procedure discounting. We agree that some efficiencies are realized when multiple procedures are performed. However, CMS should not apply the multiple procedure reduction if multiple procedures requiring expensive devices are performed at the same time. Or, at the very least, CMS should offset the multiple procedure reduction in some way for such procedures if they are performed at the same time. For urological services, examples include APC groups 179, Urinary incontinence procedures, 182, Insertion of penile prosthesis and 225, Implantation of neurostimulator electrodes.
For example, in the proposed rule, CMS says that procedures with "high device costs" would not be "performed during the same operative procedure." However, in some instances, prostate cancer survivors who have incontinence and impotence as a result of a radical prostatectomy have both an artificial urinary sphincter and a penile prosthesis implanted during the same surgical procedure. The cost of these devices is not reduced 50 percent when a hospital purchases two or more of them. The multiple procedure reduction could force hospitals to make purely economic decisions and limit patients' access to certain devices. Alternately, hospitals may force surgeons to schedule a single "device" implanting procedure, which means patients would be subjected to another subsequent procedure.
Therefore, for APC groups 225, 179 and 182, we recommend changing the status indicator to "S" or in some way applying a multiple procedure reduction only to the cost portion of the procedure that is not for the device. Once again, we would urge CMS to seriously consider the comments it receives about these procedures, the devices used to perform them and recommendations on how to handle questions about multiple service procedures and status indicators.
Thank you for considering our comments. If you have any questions, please contact Robin Hudson, AUA Manager of Regulatory Affairs, at 410-689-3762 or govaffairs@AUAnet.org.
Winston K. Mebust, MD
American Urological Association
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