Alliance Update: Comments Submitted to CMS About Hospital Outpatient Prospective Payment System, Ambulatory Surgical Center Payment System and Physician Fee Schedule Protection Status
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by The Alliance of Wound Care Stakeholders

The Alliance of Wound Care Stakeholders submitted two sets of formal written comments to the Centers for Medicare and Medicaid Services (CMS) during September 2015 in response to the proposed updates to CMS' outpatient payment rates and to the physician payment schedule. The Alliance's comments focused on provisions that have potential impact to wound care. These proposed rules have important implications to health care providers and health care administrators as CMS sets future reimbursement for services and procedures.

In June, CMS released its 2016 plan for its Hospital Outpatient Prospective Payment and Ambulatory Surgical Center reimbursement for outpatient services provided; and in July, issued its proposed revisions to payment policies under the Physician Fee Schedule.

The Alliance submitted detailed comments addressing the provisions of these proposed rules that have potential impact to wound care services and procedures.

Comments on the Hospital Outpatient Prospective Payment & Ambulatory Surgical Center Reimbursement

  • Restructuring of all the skin-related procedure APC assignments: "For CY 2016, CMS has proposed to restructure many Ambulatory Payment Classifications (APCs) leading to significant changes in payment for many outpatient services...One area in particular that we are concerned with is in the restructuring of all the skin-related procedure APC assignments by combining the debridement and skin procedure APCs. While CMS believes this will more appropriately reflect the costs and clinical characteristics of the procedures within each APC there are some areas in which the Alliance disagrees including, but not limited to, total contact casting and disposable negative pressure wound therapy."
  • Total contact casting: "CMS has inappropriately proposed to assign CPT 29445 – Application of a rigid leg contact cast (total contact casting) in the same APC as the application of an Unna Boot (paste boot CPT 29580) and the Application of a multi-layer compression system (CPT 29581). Total contact casting is not clinically similar nor is it similar in terms of resource use to those procedures' codes...Having them bundled together in this proposal is inconsistent with the resources required and the clinical benefit derived by a total contact cast."
  • Disposable products for negative pressure wound therapy (NPWT): "The Alliance does not believe that the payment rates cover the cost of the disposable device used in these services and therefore the rates are not adequate within this APC."
  • Low-frequency ultrasound therapy: The newly-proposed APC for low-frequency ultrasound therapy (LFU Therapy) "inappropriately characterized this independent service as an 'ancillary service.' The American Medical Association (AMA) states that debridement services and LFU Therapy 'represent different interventions using different medical equipment with distinctly different clinical outcomes,' suggesting that one service is not ancillary to another...CMS must ensure that CPT [Current Procedural Terminology] code 97610 – an independent clinical procedure that exceeds the cost thresholds for ancillary services – does not receive a Q1 status [ancillary service] indicator."

Comments on the Physician Fee Schedule

  • Lack of Transparency and Predictability Regarding Negative Pressure Wound Therapy Payment Rates: "We ask CMS to urge the Medicare Administrative Contractors (MACs) to publicly post payment rates for CPT codes that are contractor priced under the Physician Fee Schedule, specifically the new codes for single-use NPWT. This will restore the previous transparency and predictability with respect to claims adjudications for these therapies."
  • Global surgical periods – pilot program: "The Alliance did not support CMS's proposals to eliminate the 10 and 90 day global surgical periods...If CMS has remaining concerns with the post-operative visits in specific codes, it should nominate those particular codes and have specialty societies work them through the Relative-Value Update Committee process. We support CMS gathering information needed to value surgical services from a sample of physicians...The Alliance strongly recommends that CMS begins this process with a small pilot program using the input of surgical societies to determine how best to collect data."
  • Global surgical periods – beyond claims data: "CMS will need to go beyond claims data to determine all the services provided in the post-operative period. Many post-operative services performed in a global surgical period in the days immediately following surgery do not have CPT codes to bill separately, such as a change of dressings."
  • Physician Compare Website: "The Affordable Care Act requires that CMS develop a Physician Compare Internet website with information on physicians enrolled in the Medicare program... Our biggest concern is there is too much data on the website that patients do not understand... Most consumers are not familiar with Physician Quality Reporting System (PQRS), registry and EHR measures so using these measures with just a check mark continues to be problematic."
  • Qualified Clinical Data Registry (QCDR): "The creation of QCDRs has been important to wound care. Since wound care is not a recognized specialty of the American Board of Medical Specialties... the Alliance appreciates CMS' proposal to have materials for QCDR nomination... However, we're concerned that after the entity submits its validation plan and measure specifications for non-PQRS measures, there would be no opportunity to change any of this information post-submission for the purposes of qualification. CMS hasn't indicated what information would be considered supplemental."
  • CY2016 reporting and potential penalties: "The requirement of reporting 9 measures across 3 National Quality Strategy (NQS) domains and one cross-cutting measure is going to be challenging for CY2016 reporting. Once CMS analyzes the 2015 reported data, there will likely be many more providers receiving a penalty due to this complex and burdensome reporting requirement for providers." Also, "the Alliance has concerns about the lack of transparency provided in regard to the Measures Application Validity process for eligible professionals who do not meet the 9 measure/3 domain threshold. A more transparent process offered at the beginning of the reporting period for physicians to pre-verify the lack of 9 measures would be more appropriate. The Alliance recommends that CMS allow physicians to apply to the Measure Application Validity process at any time during the reporting period to verify that the measures they are reporting will meet the PQRS reporting requirements. This is an important step to assure providers that they can meet the requirements of the PQRS program and not incur unnecessary penalties."

Read the Alliance's full comments here.

About the Author
The Alliance of Wound Care Stakeholders: The Alliance is a nonprofit multidisciplinary trade association of health care professional and patient organizations whose mission is to promote quality care and access to products and services for people with wounds through effective advocacy and educational outreach in the regulatory, legislative, and public arenas.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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