The Centers for Medicare and Medicaid Services (CMS) has issued the calendar year (CY) 2020 Hospital Outpatient Prospective Payment System (OPPS) final rule. It addresses payment to hospital outpatient departments and ambulatory surgical centers (ASCs), including payment rates for blood components.
Laboratory date of service (DOS) exception policy. The rule finalized the categorical exemption of blood centers from the Medicare laboratory Date of Service (DOS) policy, clarifying that blood centers do not have to bill Medicare directly for molecular tests. This was required following a 2019 CMS exception to the DOS policy that would have required a laboratory, including a blood center, to bill Medicare directly for advanced diagnostic laboratory tests (ADLTs) and molecular pathology tests under some circumstances. Following extensive advocacy by America’s Blood Centers (ABC) and other blood industry stakeholders, CMS has been exercising enforcement discretion of the DOS policy for blood centers with an extension that lasts until January 2, 2020. The exclusion of blood centers from the laboratory DOS policy is a substantial victory for blood centers and was achieved following a year-long effort by ABC and other blood community stakeholders.
Payment Policies. CMS is continuing the cost-to-charge methodology in use since 2005 for blood and blood products.
The agency is using claims data instead of a crosswalk from another code to pay for pathogen reduced platelets despite receiving multiple comments highlighting accuracy concerns with the underlying claims data. The result is about a two percent reduction in payment from $624.93 in CY2019 to $611.94 for CY2020. The payment for pathogen reduced platelets had been paid based on a crosswalk from another code [Healthcare Common Procedure Coding System (HCPCS) code P9072 (Platelets, pheresis, pathogen reduced or rapid bacterial tested, each unit), the predecessor code to HCPCS code P9073 (Platelets, pheresis, pathogen-reduced, each unit) which was changed in CY2016 because P9072 could be either pathogen reduction technology or rapid bacterial tested, two very different products in terms of costs). As is customary, the new code was paid based on a crosswalk from P9037 (Platelets, pheresis, leukocytes reduced, irradiated, each unit)]. Last year’s proposed rule for CY2019 recommended payment based on the claims data for the new code instead of the crosswalk, but industry commenters expressed concern that the data was not reflecting the costs and the HCPCS code data still inappropriately included non-pathogen reduced products.
CMS finalized the proposed increase in payment for pathogen testing for platelets (HCPCS P9100), the two approved bacterial detection tests for seven-day platelets by assigning these tests to a higher level of 1D ($31-40) with a payment rate of $35.50 resulting from claims data reflecting a higher cost, an increase from the CY2019 rate of $25.50 which had been based on a new technology level 1C ($21-$30).
CMS created a new HCPCS code, P9099 Blood component/product noc. This new code is the result of advocacy efforts of ABC along with AABB and the American Red Cross (ARC) for the establishment of a level II P-code for use by hospitals to bill third party payers for anticipated new blood products. This code was discussed at a June 12th, 2019 meeting and was not included in the proposed rule as the CMS HCPCS Public Meeting Agenda for Durable Medical Equipment (DME) and Accessories; Orthotics and Prosthetics (O & P); Supplies and Other. Previously, a “not otherwise classified code” did not exist for blood products, a barrier to the timely adoption of new products that may have the potential to result in improved clinical outcomes. This code was created with a status indicator of E2, Items and Services for which pricing information and claims data are not available. ABC, along with AABB and ARC, is working to ensure this code facilitates the collection of claims data to inform future decisions to include specific new products and to ensure the correct status indicator is assigned. The full listing of payment rates can be found in Addendum B of the file rule. The blood codes are listed below in the CY2019 rate for comparison.
|HCPCS Code||Short Descriptor||CY2019 Final Payment Rate||CY2020 Final Payment Rate||Percentage Change|
|P9010||Whole blood for transfusion||$111.18||$127.19||14.40%|
|P9011||Blood split unit||$126.06||$134.46||6.66%|
|P9012||Cryoprecipitate each unit||$49.40||$50.43||2.09%|
|P9016||Rbc leukocytes reduced||$184.78||$188.33||1.92%|
|P9017||Plasma 1 donor frz w/in 8 hr||$71.53||$83.74||17.07%|
|P9019||Platelets, each unit||$107.96||$108.02||0.06%|
|P9020||Platelet rich plasma unit||$125.23||$141.22||12.77%|
|P9021||Red blood cells unit||$140.12||$139.75||-0.26%|
|P9022||Washed red blood cells unit||$355.93||$379.68||6.67%|
|P9023||Frozen plasma, pooled, sd||$75.96||$80.13||5.49%|
|P9031||Platelets leukocytes reduced||$136.61||$126.34||-7.52%|
|P9033||Platelets leukoreduced irrad||$167.14||$217.10||29.89%|
|P9035||Platelet pheres leukoreduced||$486.30||$499.55||2.72%|
|P9036||Platelet pheresis irradiated||$552.91||$692.30||25.21%|
|P9037||Plate pheres leukoredu irrad||$624.93||$634.62||1.55%|
|P9040||Rbc leukoreduced irradiated||$255.58||$262.73||2.80%|
|P9041||Albumin (human),5%, 50ml||$10.490||$10.490||0.00%|
|P9043||Plasma protein fract,5%,50ml||$26.95||$18.43||-31.61%|
|P9045||Albumin (human), 5%, 250 ml||$52.450||$52.450||0.00%|
|P9046||Albumin (human), 25%, 20 ml||$20.980||$20.980||0.00%|
|P9047||Albumin (human), 25%, 50ml||$52.450||$52.450||0.00%|
|P9050||Granulocytes, pheresis unit|
|P9051||Blood, l/r, cmv-neg||$175.94||$188.09||6.91%|
|P9052||Platelets, hla-m, l/r, unit||$844.83||$854.32||1.12%|
|P9053||Plt, pher, l/r cmv-neg, irr||$492.31||$502.19||2.01%|
|P9054||Blood, l/r, froz/degly/wash||$298.37||$281.07||-5.80%|
|P9055||Plt, aph/pher, l/r, cmv-neg||$445.06||$485.12||9.00%|
|P9056||Blood, l/r, irradiated||$225.47||$203.31||-9.83%|
|P9057||Rbc, frz/deg/wsh, l/r, irrad||$224.51||$241.62||7.62%|
|P9058||Rbc, l/r, cmv-neg, irrad||$229.29||$246.78||7.63%|
|P9059||Plasma, frz between 8-24hour||$76.66||$75.90||-0.99%|
|P9060||Fr frz plasma donor retested||$62.81||$49.98||-20.43%|
|P9070||Pathogen reduced plasma pool||$41.43||$32.30||-22.04%|
|P9071||Pathogen reduced plasma sing||$78.35||$80.10||2.23%|
|P9073||Platelets pheresis path redu||$624.93||$611.94||-2.08%|
|P9100||Pathogen test for platelets||$25.50||$35.50||39.33%|