AABB is committed to seeking enhanced and fair reimbursement for blood products, and transfusion services and cellular therapies through both education regarding the complexities of blood coding and billing, and advocacy to reimbursement policy makers.
CMS Finalizes Rule Updating Medicare Hospital Outpatient Payment Rates and Policies for 2019, Adopts Several AABB Recommendations
The Centers for Medicare & Medicaid Services released a rule Nov. 2 that finalizes the Medicare payment rates and policies under the hospital outpatient prospective payment system (OPPS) for 2019. The final rule includes updates to several payment policies that may have an effect on AABB members, including payment policies and rates for blood and blood products, transfusion, apheresis and stem cell procedures covered by the OPPS, as well as transfusion laboratory services. AABB successfully advocated for CMS to reconsider the payment rate for pathogen-reduced platelets (P9073), which resulted in a final payment rate that is approximately $180 higher than the proposed payment rate. In addition, CMS added revenue code 0815 (Allogeneic Stem Cell Acquisition Services) to the packaged revenue code list after agreeing with AABB and other stakeholders that the agency had inadvertently excluded the code from the list. This resulted in CMS finalizing a payment rate for allogeneic transplantation of hematopoietic progenitor cells that is approximately $12,000 higher than the proposed rate. CMS did not adopt the recommendations made by AABB and others to make separate payments under the OPPS for several of the steps required to collect and prepare genetically modified T-cells or to remove leukapheresis and dose preparation procedures from the HCPCS codes approved for CAR T-cell therapy drugs. CMS reasoned that Medicare does not typically pay separately for each step used to manufacture a drug or biological, and since CAR T-cell therapies were approved as biologicals, the Medicare statute governing biologicals applies. CMS did adopt AABB’s recommendation to make a separate payment for the administration of CAR-T cells. AABB prepared a summary of the final rule, which goes into effect on January 1.
AABB, America’s Blood Centers and the American Red Cross Submit Joint Comments on Proposed Medicare Hospital Outpatient Payment Rates and Policies for 2019
AABB, America’s Blood Centers and the American Red Cross submitted
joint comments to the Centers for Medicare & Medicaid Services (CMS) in response to the proposed rule updating Medicare payment policies and rates for hospital outpatient services for 2019. The organizations highlighted that the proposed reimbursement rate for pathogen reduced platelets is erroneous, and requested that CMS clarify the applicability of recent changes to a billing requirement (i.e., the “14-day rule”) to certain services and tests performed by blood centers. In addition, the organizations provided comments on proposed payment policies related to stem cell transplants, chimeric antigen receptor T-cell therapy and certain services furnished in off-campus provider-based hospital departments.
CMS Proposes Medicare Hospital Outpatient Payment Rates and Policies for CY 2019
On July 31, 2018, the Centers for Medicare & Medicaid Services (CMS) published a
proposed rule in the Federal Register that would update Medicare payment rates and policies under the hospital outpatient prospective payment system (OPPS) and the ambulatory surgical center (ASC) payment system for 2019. CMS proposes substantial changes to Medicare payment policies for hospital outpatient services, including expanding the site-neutral payment policy to certain outpatient services furnished in off-campus provider-based hospital departments, changing the payment policy applicable to clinic visit services, and changing the payment policy for certain outpatient drugs. In addition, CMS proposes reduced payment rates for several blood products, including pathogen-reduced platelets, pathogen-reduced pooled plasma, deglycerolized red blood cells, whole blood and apheresis platelets. In contrast, CMS proposes increases in payments for certain blood products, including blood split units; pooled, solvent/detergent treated, frozen plasma; plasma protein fraction, 5%, 250 ml; leukoreduced, CMV-negative, apheresis platelets; leukoreduced, irradiated blood; and fresh-frozen plasma, donor retested. CMS also proposes increases in payment rates for most transfusion, apheresis and stem cell procedure codes, as well as transfusion laboratory services codes. AABB prepared a
summary of key provisions of the proposed rule. Comments are due to CMS on Sept. 24.
Centers for Medicare & Medicaid Services Finalizes Medicare Hospital Outpatient Payment Policies for 2018
On November 13, 2017, the Centers for Medicare & Medicaid Services (CMS) published in the Federal Register the
final rule updating Medicare payment rates and policies under the hospital outpatient prospective payment system for calendar year 2018. AABB prepared a
summary of key provisions impacting transfusion medicine and cellular therapies. CMS finalized payment rates for 2018 for blood and blood products that are 1 percent lower than the payment rates finalized for 2017. This reflects decreases in payment for certain products as well as increases in payment for other products. In general, CMS finalized increased payment rates for transfusion services, apheresis and stem cell procedures as well as transfusion laboratory services. The new payment rates will go into effect on January 1, 2018.
AABB Submits Comments Responding to the 2018 Preliminary Payment Rates Established Under the Medicare Clinical Laboratory Fee Schedule (CLFS) Private Payor Rate-Based Payment System
comments to the Centers for Medicare & Medicaid Services (CMS) opposing the preliminary payment rates for 2018 established under the Medicare clinical laboratory fee schedule (CLFS) private payor rate-based payment system, as well as the data collection methodology and process used to establish the proposed rates. The Protecting Access to Medicare Act of 2014 drastically revises the methodology that CMS uses to determine payment rates under the CLFS, and requires the Agency to establish payment amounts based on private payor rates beginning in 2018. The preliminary payment rates for 2018 include significant payment reductions for codes related to blood banking, transfusion medicine and cellular therapies.
AABB Comments on Medicare Proposed Rule Related to 2018 Hospital Outpatient Payment Rates and Policies
On September 8, 2017, AABB submitted
comments to the Centers for Medicare & Medicaid Services (CMS) in response to the 2018 hospital outpatient prospective payment system (OPPS) proposed rule. AABB commended CMS for continuing to provide separate payments for blood products in the hospital outpatient setting, encouraged CMS to ensure that the proposed payment rates for blood products are adequate and urged CMS to reduce unnecessary burdens for clinicians and providers by revising the HCPCS p-code descriptors for blood products. In addition, AABB urged CMS to ensure that payment rates are adequate for allogeneic transplantation of hematopoietic progenitor cells per donor (CPT code 38240) and to retain the status indicator “B” for CPT code 38205.
Centers for Medicare & Medicaid Services Proposes Medicare Hospital Outpatient Payment Rates and Policies for CY 2018
On July 20, the Centers for Medicare & Medicaid Services (CMS) published in the
Federal Register a
proposed rule that would update Medicare payment rates and policies under the hospital outpatient prospective payment system (OPPS) and the ambulatory surgical center (ASC) payment system for calendar year (CY) 2018. In general, CMS proposes to update payment rates under the OPPS by 1.75 percent. Overall, CMS proposes to reduce payments for blood and blood products by an unadjusted average of 1.6 percent, when compared with the payment rates for 2017. CMS proposes significant payment reductions for several blood product codes, but proposes substantial increases in payment rates for other blood product codes. CMS also proposes increases in payment rates for most transfusion, apheresis and stem cell procedure codes as well as transfusion laboratory services codes. AABB prepared a
summary of key provisions of the proposed rule. Comments are due to CMS on September 11.
AABB Billing Guide
Billing Guide is intended to assist hospitals, clinicians, billing and coding professionals involved with the utilization and subsequent billing of the services and procedures associated with the use of blood and transfusion and cellular therapies. AABB produced this guide with the generous support and cooperation of the blood sector member companies of the Advanced Medical Technology Association (AdvaMed).
Many U.S. hospitals do not bill accurately, or at all, for blood transfused in the inpatient setting. Failure to bill appropriately for blood can hinder patient access to new technologies and potentially can affect the hospital's bottom line. The
Billing Guide is intended to help hospitals bill accurately and completely for blood products and services. Though AABB does not provide any guarantees of reimbursement, the intent of this publication is to assist hospitals in understanding the billing rules and procedures that apply for Medicare and other payers.
Billing Guide is available below in PDF format for viewing and printing:
AABB Billing Guide – Version 4.0 (PDF)
AABB serves as a leading advocate before the Centers for Medicare and Medicaid Services (CMS) and Congress regarding the need for fair and timely Medicare reimbursement for blood products and services and cellular therapies. In the
inpatient arena, AABB, along with others in the blood community, has supported efforts to allow Medicare to better account for the increasing cost of blood. In particular, AABB asked Congress and CMS to create a new blood-related producer price index (PPI) to be used in calculating the change in prices for goods and services hospitals use to provide inpatient care (the so-called "market basket"). In past years, the cost of blood had been inappropriately bundled in unrelated indices for "chemicals" or "miscellaneous goods." In response, in FY 2010 CMS agreed to use a new PPI that specifically tracks changes in the cost of blood products to hospitals. The Bureau of Labor Statistics now collects data from blood centers for this separate PPI for blood and organ banks. AABB and its fellow blood organizations will continue to work to ensure that the new index does, in fact, reflect changes in blood costs as accurately as possible.
In the realm of
outpatient reimbursement, AABB was a staunch advocate for separate ambulatory payment classifications (APCs) for individual blood products and services when CMS first established the APC outpatient prospective payment system in 1998. AABB continues to support improvements in the APC system to ensure it accurately accounts for the costs of blood and reflects the increasingly complex array of blood products and services. Specifically, AABB has urged CMS to use outside cost data provided by hospitals and blood centers to establish its outpatient payment rates for blood products, rather than continuing to rely on faulty CMS data.
In response to AABB's requests, CMS issued revised guidance regarding billing for blood under the hospital outpatient prospective payment system, which took effect July 2005. This guidance can be found at
http://new.cms.hhs.gov/transmittals/downloads/R496CP.PDF. AABB, along with others in the blood banking community, continue to urge CMS to further update and improve its guidance regarding blood-related reimbursement.
AABB also is a strong advocate for improved Medicare reimbursement for bone marrow, hematopoietic progenitor cells and apheresis-related procedures. AABB, along with other interested organizations, have urged CMS to adjust its payments to hospitals for laboratory processing services associated with bone marrow and peripheral blood progenitor cell transplants to reflect their actual costs.
Finally, AABB has championed new or improved Current Procedural Terminology (CPT) codes for transfusion medicine and cellular therapy-related procedures. For example, in response to requests from AABB, the American Medical Association in 2005 issued new CPT codes for a pretransfusion electronic crossmatch test (86923) and for volume reduction of blood products (86960).
If you have questions relating to billing and reimbursement for blood products and services, please contact