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ISSUE BRIEF | CMS Releases Final Rule For FY 2015 IPPS, LTCH PPS 1

4712 Country Club DriveJefferson City, MO 65109

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Issue Brief FEDERAL ISSUE BRIEF • AUGUST 6, 2014

CMS Releases Final Rule For FY 2015 IPPS, LTCH PPSThe Centers for Medicare & Medicaid Services (CMS) has released a final rule to update both the hospital inpatient prospective payment system (IPPS) and the long-term care hospital (LTCH) PPS for fiscal year (FY) 2015. The rule is an unbelievable 2,442 pages, and this doesn’t include any addendum tables.

The rule is currently on public display at the Federal Register office and avail-able online at www.ofr.gov/OFRUpload/OFRData/2014-18545_PI.pdf. This link will change once the rule is published in the Federal Register, which is scheduled for Friday, Aug. 22.

The IPPS tables are only available on CMS’ website at www.cms.hhs.gov/Medicare/medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html. The LTCH PPS tables are avail-able at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/LongTermCareHospitalPPS/index.html under the list item for Regulation Number CMS-1606-P.

COMMENT Unfortunately, this rule is not as concise or easy to follow as other recent CMS PPS FY 2015 updates. There is way too much history, redundancy and a lack of defined final outcomes/decisions. All contribute to a document that is way too long.

KEY POINTS

z The final updates for IPPS include a marketbasket update of 2.9 percent, which is slightly higher than the proposed increase of 2.7 percent.

z After applying the multifactor productivity mandate and additional adjustments in accordance with the ACA, CMS is estimating that net increase in payments will be an average of 1.4 percent.

Based on the extreme length of the rule, this analysis is long, as well. The introductory material presented below is adopted from CMS’ fact sheet. Detail material is from the rule, itself.

There are subjects that have not been covered.

This is no longer a simple PPS payment update. There is extensive material on quality, value-based purchasing, readmission policies, hospital-acquired conditions and other items. These items include requirements about time frames, forms and manner of reporting. They are as critical as the actual payments themselves. To help direct those with a particular subject interest, page numbers corresponding to the display copy of the final rule are provided. Please note these numbers will change when the rule is published in the Federal Register. It is highly recommended to download the display version before it is removed.

For many payment issues, the rule’s ad-dendum (beginning on Page 2,097) has concise and helpful information.

CMS said the operating payment rates paid under the IPPS for hospitals that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record users will increase by 1.4 percent. (The marketbasket update

continued

http://www.ofr.gov/OFRUpload/OFRData/2014-18545_PI.pdf

http://www.ofr.gov/OFRUpload/OFRData/2014-18545_PI.pdf

http://www.cms.hhs.gov/Medicare/medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html




http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/LongTermCareHospitalPPS/index.html





is 2.9 percent (up from the proposed 2.7 percent) for FY 2015, but the update is further reduced by additional factors described in the sections that follow.)

Beginning with FY 2015, hospitals that do not successfully participate in the Hospital IQR Program and do not submit the required quality data will be subject to a one-fourth reduction of the marketbasket update (these hospitals previously received a 2 percentage point reduction). Also, the law requires that the update for any hospital that is not a meaningful EHR user will be reduced by one-quarter of the marketbasket update in FY 2015, one-half of the marketbasket update in FY 2016 and three-fourths of the marketbasket update in FY 2017 and later years.

Total IPPS payments are projected to de-crease by $756 million. This is primarily due to a major reduction in estimated Medicare disproportionate share hospi-tal (DSH) payments. Medicare payments to LTCHs in FY 2015 are projected to increase by approximately 1.1 percent.

CHANGES IN POLICIES AFFECTING ACUTE-CARE HOSPITALS

Changes to Payment Rates Under IPPS

CMS said the final rule will increase IPPS operating payment rates by 1.4 per-cent. This reflects the projected hospital marketbasket update of 2.9 percent ad-justed by a -0.5 percentage point for the multifactor productivity (MFP) mandate and an additional adjustment of -0.2 percentage points in accordance with the Affordable Care Act (ACA); the rate is further decreased by 0.8 percent for a documentation and coding recoupment adjustment required by the American Taxpayer Relief Act of 2012.

continued

Documentation and Coding Adjustment (Refer Page 104 and following)

Section 631 of the American Taxpayer Relief Act of 2012 requires CMS to recover $11 billion by 2017 to fully recoup documentation and coding overpayments related to the transition to the MS-DRGs that began in FY 2008. For FY 2015, CMS will continue the approach begun in FY 2014 by mak-ing another -0.8 percent adjustment to continue the recovery process.

Hospital-Acquired Condition Reduction Program (Refer Page 976 and following)

Section 3008 of the ACA established the Hospital Acquired Condition (HAC) Reduction Program. Beginning in FY 2015, the applicable hospitals in the top quartile for the rate of HACs (i.e., those with the poorest performance) will have their Medicare IPPS payments reduced by 1 percent.

Other ACA Quality-Related Provisions (Refer Pages 1,438 and following)

The final rule updates the measures and financial incentives in the Hospital Value-Based Purchasing (VBP) and Readmissions Reduction programs. It also revises measures for the Hospital Inpatient Quality Reporting, LTCH Quality Reporting and PPS-Exempt Cancer Hospital Quality Reporting Programs.

1. Changes to the Hospital IQR Program and the Medicare EHR Incentive Program (Refer Pages 1,438 and following)Measures reported under the Hospital IQR Program are available at http://www.medicare.gov/hospitalcompare/search.html).

http://www.medicare.gov/hospitalcompare/search.html




CMS is finalizing a total of 63 mea-sures (47 required and 16 voluntary electronic clinical quality measures) in the Hospital IQR Program measure set for the FY 2017 payment determination and subsequent years. The number of required measures, 47, is down from 57 measures in FY 2016. CMS added 11 new measures (one chart-abstracted, four claims-based and six voluntary electronic clinical quality measures). CMS will remove 19 measures but will retain the SCIP-INF-4 measure that was scheduled for removal.

Providers participating in the Hospital IQR Program have the option to volun-tarily report a minimum of 16 electroni-cally specified clinical quality measures over three domains from 28 available measures. The finalized proposals increase the number of electronic clini-cal quality measures in the Hospital IQR Program.

CMS is finalizing a modification of its proposal to align the Medicare Electronic Health Record (EHR) Incentive Program with the reporting and submission timelines of the Hospital IQR Program for measures reported electronically. CMS is not finalizing its proposal to require quarterly submission of clinical quality measure (CQM) data. Hospitals can voluntarily submit one calendar year (CY) quarter’s data for first quarter, second quarter or third quarter 2015 by Nov. 30, 2015, to partially fulfill requirements for both programs.

2. Hospital Readmissions Reduction Program (Refer Pages 722-822)The maximum reduction under this pro-gram will increase to 3 percent of pay-ment amounts in FY 2015. For FY 2015, CMS will assess hospitals’ readmission penalties using five readmissions mea-sures endorsed by the National Qualify Forum (NQF) — heart attack, heart failure, pneumonia, chronic obstructive

continued

pulmonary disease and hip/knee ar-throplasty. CMS has finalized an up-dated methodology to take into account planned readmissions for these five ex-isting readmissions measures, as well as refinement in the hip/knee arthroplasty readmission measure methodology. CMS will add a new readmission measure beginning in FY 2017 — readmissions for coronary artery bypass graft (CABG) surgical procedures.

3. Changes to the Hospital VBP Program (Refer Page 822 and following)The applicable percent reduction in-creases for FY 2015 to 1.5 percent of base operating DRG payment amounts to all participating hospitals. The total estimated amount available for value-based incentive payments in FY 2015 is approximately $1.4 billion.

CMS will remove PN-6, SCIP-Card-2, SCIP-Inf-2, SCIP-Inf-3, SCIP-Inf-9 and SCIP-VTE-2 from the FY 2017 measure set because they are “topped-out.”

CMS will adopt two new outcome measures for the new safety domain — hospital-onset methicillin-resistant Staphylococcus aureas (MRSA) bactere-mia and Clostridium difficile infection — and a clinical care process measure — early elective deliveries.

4. PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program (Refer Page 1745)CMS is adopting a new measure begin-ning with the FY 2017 PCHQR Program. The addition of this measure, external beam radiotherapy for bone metastases, will increase the number of measures beginning with the FY 2017 program to a total of 19.


Updated Labor Market Areas (Refer Pages 427-586)

The law requires that Medicare adjust its inpatient hospital payment for area differences in the cost of labor — an adjustment known as the wage index. CMS is revising the labor market areas used for the wage index based on the most recent core-based statistical area (CBSA) delineations issued by the Office of Management and Budget (OMB) based on 2010 census data.

To mitigate potential negative payment impacts caused by the adoption of the new OMB delineations, CMS is adopting a one-year transition during FY 2015 that will be based on a 50/50 blend of the former wage index and the new wage index. The new wage index will take effect in full in FY 2016. This will be for all hospitals that would have ex-perienced a decrease in their wage index exclusively due to the implementation of the new OMB delineations and a three-year transition for the relatively few hospitals currently located in an urban county that will become rural under the new OMB delineations.

Low-Volume Hospitals (Refer Page 613)

Section 105 of the Protecting Access to Medicare Act of 2014 (PAMA) extended the temporary changes to the low-volume hospital payment adjustment for an additional year (through March 31, 2015). CMS is making conforming changes to the regulations.

Medicare Dependent Hospitals (Refer Page 714)

PAMA Section 106 extended the Medicare Dependent Hospital program for an additional year (through March 31, 2015). CMS is making conforming changes to the regulations.

continued

GRADUATE MEDICAL EDUCATION (GME) (REFER PAGES 1,049-1,187)

Rural Teaching Hospitals

Under existing regulations, a rural teaching hospital receives a permanent cap adjustment any time it starts train-ing residents in a brand new program. CMS adopted a policy that, effective Oct. 1, 2014, a rural hospital that has been redesignated as urban (as a result of the implementation of new OMB delineations) can receive a permanent cap adjustment for a new program if it received a letter of accreditation for the new program and/or started training residents in the new program before be-ing redesignated as urban. In addition, CMS finalized changes to the participa-tion of redesignated hospitals in rural training tracks.

Change in the Effective Date of the FTE Cap, Rolling Average and IRB Ratio Cap for New Programs

New teaching hospitals currently have a five-year window to establish new residency programs before the full-time equivalent (FTE) resident caps take ef-fect. FTE residents in new programs also are exempt from the application of the three-year rolling average and the IME intern-and-resident-to-bed (IRB) ratio cap, based on the length of the particu-lar new program. CMS is simplifying and streamlining the timing of these policies by making the FTE resident caps, rolling average and IRB ratio cap effective simultaneously.

OTHER POLICIES

Hospital Price Transparency (Refer Page 1,203)

One of the ACA’s provision to improve the transparency of hospital charges requires that each hospital establish and make public a list of its standard charges for items and services. In this final


rule, CMS reminds hospitals of their obligation to comply with the statutory requirements.

Critical Access Hospitals (CAHs) Affected by OMB Redesignations (Refer Page 1,271)

In light of the recent change to the OMB metropolitan area delineations, some CAHs that were previously located in rural areas may now be located in urban areas, effective Oct. 1, 2014. CMS finalized its proposal to provide affected CAHs with a two-year transition period that begins from the date the redesig-nation becomes effective. During this transition period, the affected CAHs must reclassify as rural to retain their CAH status.

Requirements for Physician Certification of CAH Inpatient Services (Refer Page 1,278)

Current law requires that for payment of inpatient CAH services under Part A, a physician must certify that the individual may reasonably be expected to be discharged or transferred to a hospital within 96 hours of admission to a CAH. In order to provide CAHs with greater flexibility in meeting the statu-tory physician certification requirement, CMS finalized its proposal to amend the regulations for FY 2015 and subsequent years to allow CAHs until no later than 1 day before the date on which the claim for payment for the inpatient CAH service is submitted, to complete all certification requirements except the admission order. The requirements for the admission order are unchanged from current policy.

Medicare DSH (Refer Page 642 and following)

In accordance with the ACA, beginning in FY 2014, hospitals receive 25 percent of the amount they previously would have received under the former statutory

continued

formula for Medicare DSH. The remain-der, equal to an estimate of 75 percent of what otherwise would have been paid as Medicare DSH, will be aggregated nationally and adjusted for decreases in the rate of uninsured individuals and a statutory factor of 0.2 percent and distributed to hospitals based on their relative share of the total amount of uncompensated care. In the FY 2015 rule, CMS will distribute $7.65 billion in uncompensated care payments. This is a decrease from the $8.56 billion estimate in the proposed rule. This de-crease is due to changes in the Office of the Actuary’s estimate of payments that would otherwise be made for Medicare DSH in FY 2015 (due to lower projected hospital inpatient spending) and also the change in the percentage of individ-uals who are uninsured as estimated by the CBO. In addition, CMS is adopting a process to identify hospitals that have merged such that data from all hospitals involved in the merger may be taken into consideration for purposes of deter-mining the remaining provider’s uncom-pensated care payment. In response to public comment, CMS also is providing hospitals with 30 days from display of the final rule to submit corrections to its list of mergers.

CHANGES IN POLICIES AFFECTING LTCHS (REFER PAGES 1,286 AND FOLLOWING AND 2,222 AND FOLLOWING)

Changes to Payment Rates Under LTCH PPS

Under the final rule, LTCH PPS pay-ments will increase by 1.1 percent, or approximately $62 million, for FY 2015. This estimated increase is attributable to several factors, including the rate update of 2.2 percent (based on a marketbasket update of 2.9 percent adjusted by a multifactor productivity adjustment of -0.5 percentage points and an additional


ACA adjustment of -0.2 percentage points); the “one-time” budget neutrality adjustment to the standard federal rate of approximately -1.3 percent under the last year of a three-year phase-in.

Delay in Full Application of the 25 Percent Patient Threshold

Under the 25 percent patient threshold policy, if an LTCH admits more than 25 percent of its patients from a single acute care hospital, Medicare will make payments at a rate comparable to IPPS hospitals for those patients above the 25 percent threshold. The Pathway for Sustainable Growth Rate (SGR) Reform Act of 2013 imposed a four-year mora-torium on the full application of the 25 percent patient threshold rule for most LTCHs, effective retroactive to the ex-piration of the previous statutory delay. Certain “grandfathered” LTCHs are now permanently exempted from the policy by law.

Moratoria on the Establishment of LTCHs and LTCH Satellite Facilities and on the Increase in Number of Beds in Existing LTCHs and Satellite Facilities

The Pathway for SGR Reform Act of 2013 as amended by PAMA imposed moratoria on new LTCHs, LTCH satel-lites and an increase in beds in existing LTCHs and satellites from April 1, 2014, to Sept. 30, 2017.

There are three exceptions to the mora-torium on new LTCHs and satellites (but not on the increase in beds) that are analogous to the original moratorium included in the Medicare, Medicaid and SCHIP Extension Act (MMSEA) of 2007. CMS will implement the new moratoria in a similar manner as the exceptions

continued

to the original moratoria that were included in MMSEA.

Termination of the 5 Percent Readmissions Policy and Continuation of the Current Interrupted Stay Policy

CMS is finalizing its proposal to elimi-nate the “5 percent readmissions” policy under which readmissions from co-located providers in excess of 5 percent are paid a single LTCH payment rather than two payments (one for both the ad-mission and readmission). CMS believes this policy is not necessary as another policy — the interrupted stay policy discussed below — serves the same purpose. Further, the new statutory revisions to the LTCH PPS, which will be implemented for FY 2016 (establish-ing clinical criteria for standard LTCH PPS payment) may obviate the need for the 5 percent policy.

The interrupted stay policy also provides a single payment to the hospital when the patient is discharged and readmitted to an LTCH within nine days from a general acute care hospital. CMS pro-posed to increase the nine-day threshold to 30 days. After considering the com-ments received, CMS is not adopting proposed revisions to the interrupted stay policy, but it may revisit this policy as it gains experience under the new statutory revisions to the LTCH PPS.

LTCH Area Wage Adjustment Updates

CMS will adopt revisions to the LTCH PPS labor market areas based on the new OMB CBSA delineations developed from the 2010 census data and a budget neutral transition methodology consis-tent with the approach finalized under the IPPS.


The material that follows is a section-by-section analysis of major components based on the final rule. It does not follow the order in the regulation.

I. STANDARDIZED PAYMENT RATES (REFER PAGES 592 AND FOLLOWING)For FY 2015, there are three statutory changes to the applicable percentage increase compared to FY 2014. First is a change in the reduction for hospitals that fail to submit quality informa-tion from 2 percent to one-quarter of the applicable marketbasket update.

Second, any hospital that is not a meaningful EHR user will have three-quarters of the appli-cable marketbasket update, reduced by 33 1/3 percent.

Third, for FY 2015, the ACA applies an additional reduction of 0.2 percentage points compared to 0.3 percentage points for FY 2014.

The labor-related portion for areas with wage indexes greater than 1.0000 will remain at 69.6 percent. Areas with wage index values equal to or less than 1.000 remain at 62 percent by law.

The current FY 2014 rates are as follows.

FY 2014 National Adjusted Operating Standardized Amounts(69.6 Percent Labor Share/30.4 Percent Nonlabor if Wage Index Is Greater Than

1.0000)Full Update Reduced Update

Labor-related Nonlabor-related Labor-related Nonlabor-related

$3,737.71 $1,632.57 $3,664.21 $1,600.46

FY 2014 National Adjusted Operating Standardized Amounts(62 Percent Labor Share/38 Percent Nonlabor Share

if Wage Index Is Less Than or Equal to 1.0000)Full Update Reduced Update

Labor-related Nonlabor-related Labor-related Nonlabor-related

$3,329.57 $2,040.71 $3,264.10 $2,000.57

CMS provides the following table to begin addressing the FY 2015 standardized payment amounts — (Refer Page 600 & 2101)

FY 2015

Hospital Submitted

Quality Data and is a

Meaningful EHR User

Hospital Submitted

Quality Data and is NOT a Meaningful EHR User

Hospital Did NOT Submit Quality Data

and is a Meaningful EHR User

Hospital Did NOT Submit Quality

Data and is NOT a Meaningful EHR

User

Marketbasket Rate-of-Increase

2.9 2.9 2.9 2.97

Adjustment for Failure to Submit Quality Data under Section 1886(b)(3)(B)(viii) of the Act

0.0 0.0 -0.725 -0.725

continued


CMS provides the following table to begin addressing the FY 2015 standardized payment amounts — (Refer Page 600 & 2101)

FY 2015

Hospital Submitted

Quality Data and is a

Meaningful EHR User

Hospital Submitted

Quality Data and is NOT a Meaningful EHR User


and is a Meaningful EHR User



User

Adjustment for Failure to be a Meaningful EHR User under Section 1886(b)(3)(B)(ix) of the Act

0.0 -0.725 0.0 -0.725

Multi Factor Productivity (MFP) Adjustment

-0.5 -0.5 -0.5 -0.5

Statutory ACA Adjustment -0.2 -0.2 -0.2 -0.2

Applicable Percentage Increase Applied to Standardized Amount

2.2 1.475 1.475 0.75

The following table illustrates the changes from the FY 2014 national standardized amount. (Refer Pages 2,185-2,187) The unadjusted FY 2014 total rates are $6,078.13 for all columns.

Comparison of FY 2014 Standardized Amounts to the FY 2015Standardized Amounts

Hospital Submitted Quality

Data and is a Meaningful

EHR User

Hospital Submitted

Quality Data and is NOT a

Meaningful EHR User


and is a Meaningful EHR

User



User

FY 2014 Base Rate after removing:

If Wage Index is Greater Than 1.0000:

Labor (69.6%):$4,230.38

Nonlabor(30.4%):$1,847.75

(Combined labor and nonlabor = $6,078.13)

If Wage Index is Greater Than 1.000

Labor (69.6%):$4,230.38

Nonlabor(30.4%):$1,847.75



Labor (69.6%):$4,230.38

Nonlabor(30.4%):$1,847.75



Labor (69.6%):$4,230.38

Nonlabor(30.4%):$1,847.75


1. FY 2014 Geographic Reclassification Budget Neutrality (0.990718)

2. FY 2014 RuralCommunity HospitalDemonstrationProgram BudgetNeutrality (0.999415)

continued





EHR User

Hospital Submitted


Meaningful EHR User



User



User

3.CumulativeFactor: FY 2008, FY 2009, FY 2012, FY 2013, and FY 2014 Documentation and Coding Adjustment as Required under Sections 7(b)(1)(A) and 7(b)(1)(B) of Pub. L. 110-90 and Documentation and Coding Recoupment Adjustment as required under Section 631 of the American TaxpayerRelief Act of 2012 (0.9403)

If Wage Index is less Than or Equal to 1.0000:

Labor (62%):$3,768.45


Labor (62%):$3,768.45


Labor (62%):$3,768.45


Labor (62%):$3,768.45

4. FY 2014Operating OutlierOffset (0.948995)

Nonlabor(38%):$2,309.70


Nonlabor(38%):$2,309.70


Nonlabor(38%):$2,309.70


Nonlabor(38%):$2,309.70


FY 2015 Update Factor

1.022 1.01475 1.01475 1.0075

FY 2015 MS-DRG Recalibration and Wage Index Budget Neutrality Factor

0.998982 0.998982 0.998982 0.998982

FY 2015 Reclassification Budget Neutrality Factor

0.990406 0.990406 0.990406 0.990406

FY 2015 Rural Community Demonstration Program Budget Neutrality Factor

0.999310 0.999310 0.999310 0.999310

FY 2015 Operating Outlier Factor

0.948998 0.948998 0.948998 0.948998

continued





EHR User

Hospital Submitted


Meaningful EHR User



User



User

Cumulative Factor: FY 2008, FY 2009,FY 2012, FY 2013, FY 2014 and FY 2015 Documentation and Coding Adjustment as Required under Sections 7(b)(1)(A) and 7(b)(1)(B) of Pub. L. 110-90 and Documentation and Coding Recoupment Adjustment as required under Section 631 of the American Taxpayer Relief Act of 2012

0.9329 0.9329 0.9329 0.9329

FY 2015 New Labor Market Delineation Wage Index Transition Budget Neutrality Factor

0.998859 0.998859 0.998859 0.998896

National StandardizedAmount for FY 2015 if Wage Index is Greater Than 1.0000; Labor/Non-Labor SharePercentage(69.6/30.4)

Labor:$3,780.13

Labor:$3,753.31

Labor:$3,753.31

Labor:$3,726.50

Non-labor:$1,651.09

Non-labor:$1,639.38

Non-labor:$1,639.38

Non-labor:$1,627.66

National StandardizedAmount for FY 2015 if Wage Index is less Than or Equal to 1.0000; Labor/Non-Labor SharePercentage (62/38)

Labor:$3,367.36

Labor:$3,343.47

Labor:$3,343.47

Labor:$3,319.58

Non-labor:$2,063.86

Non-labor:$2,049.22

Non-labor:$2,049.22

Non-labor:$2,034.58

COMMENTThe method of incorporating quality and EHR use results in additional standardized payment adjustment values. This, coupled with revised area wage index changes (see below), need careful review.

If you add the current labor and nonlabor amounts and divide by the four factors above, the result will match CMS’ FY 2015 rates before the budget neutrality factors are applied.

continued


Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2015 (Refer Pages 1,245 & 2,200)

The FY 2015 capital rate is $434.26. The update changes from FY 2014 are shown in the fol-lowing table.

Comparison of Factors and Adjustments: FY 2014 Capital Federal Rateand FY 2015 Capital Federal Rate

FY 2014 FY 2015 Change Percent Change

Update Factor1 1.0090 1.0150 1.0150 1.50

GAF/DRG Adjustment Factor 0.9987 0.9986 0.9957 -0.14

Outlier Adjustment Factor2 0.9393 0.9374 0.9980 -0.21

Capital Federal Rate 429.31 434.26 1.0086 1.15

1 The update factor and the GAF/DRG budget neutrality adjustment factors are built permanently into the capital federal rates. Thus, for example, the incremental change from FY 2014 to FY 2015 resulting from the application of the 0.9986 GAF/DRG budget neutrality adjustment factor for FY 2015 is a net change of 0.9986 (or –0.14 percent).2 The outlier reduction factor is not built permanently into the capital federal rate; that is, the factor is not applied cumulatively in determining the capital federal rate. Thus, for example, the net change resulting from the application of the FY 2015 outlier adjustment factor is 0.9373/0.9393, or 0.9979 (or -0.21 percent).

Outlier Payments (Refer Page 2,177)

CMS is setting an outlier fixed-loss cost threshold for FY 2015 equal to the prospective pay-ment rate for the DRG, plus any IME and DSH payments, and any add-on payments for new technology, plus $24,758. The current amount is $21,748.

CMS’ current estimate, using available FY 2013 claims data, is that actual outlier payments for FY 2013 were approximately 4.86 percent of actual total MS-DRG payments.

CMS currently estimates that, using the latest cost-to-charge ratio (CCR) from the March 2014 update of the provider-specific file (PSF), actual outlier payments for FY 2014 will be approxi-mately 5.71 percent of actual total MS-DRG payments, approximately 0.61 percentage point higher than the 5.1 percent projected when setting the outlier policies for FY 2014. This esti-mate of 5.71 percent is based on simulations using the FY 2013 MedPAR file (discharge data for FY 2013 claims).

COMMENTIf, in fact, CMS’ estimate of FY 2014 outliers exceeding 5.1 percent proves correct, it will be the first time in many many years that CMS has paid more than the 5.1 percent set aside.

Changes to Payment Rates for Excluded Hospitals: Rate-of-Increase Percentages for FY 2015 (Refer Page 2,220)

Payments for services furnished in children’s hospitals, 11 cancer hospitals and hospitals lo-cated outside the 50 states, the District of Columbia and Puerto Rico (that is, short-term acute care hospitals located in the U.S. Virgin Islands, Guam, the Northern Mariana Islands and American Samoa) that are excluded from the IPPS are made on the basis of reasonable costs based on the hospital’s own historical cost experience, subject to a rate-of-increase ceiling.

The rate of increase update will be 2.9 percent.

continued


II. CHANGES TO THE HOSPITAL WAGE INDEX FOR ACUTE CARE HOSPITALS (REFER PAGES 427-586)CMS will implement the new OMB delineations as described in the Feb. 28, 2013, OMB Bulletin No. 13-01, for the FY 2015 IPPS wage index.

Counties Losing Urban Status

CMS’ analysis shows that a total of 37 counties (and county equivalents) and 12 hospitals that were once considered part of an urban CBSA will be considered to be located in a rural area.

The wage data for all hospitals currently located in the 37 urban counties listed will be consid-ered rural under the new OMB delineations when calculating their respective state’s rural wage index.

Counties That Will Lose Urban Status

County StatePrevious CBSA

Number CBSA

Greene County IN 14020 Bloomington, IN

Anson County NC 16740 Charlotte-Gastonia-Rock Hill, NC-SC

Franklin County IN 17140 Cincinnati-Middletown, OH-KY-IN

Stewart County TN 17300 Clarksville, TN-KY

Howard County MO 17860 Columbia, MO

Delta County TX 19124 Dallas-Fort Worth-Arlington, TX

Pittsylvania County VA 19260 Danville, VA

Danville City VA 19260 Danville, VA

Preble County OH 19380 Dayton, OH

Gibson County IN 21780 Evansville, IN-KY

Webster County KY 21780 Evansville, IN-KY

Franklin County AR 22900 Fort Smith, AR-OK

Ionia County MI 24340 Grand Rapids-Wyoming, MI

Newaygo County MI 24340 Grand Rapids-Wyoming, MI

Greene County NC 24780 Greenville, NC

Stone County MS 25060 Gulfport-Biloxi, MS

Morgan County WV 25180 Hagerstown-Martinsburg, MD-WV

San Jacinto County TX 26420 Houston-Sugar Land-Baytown, TX

Franklin County KS 28140 Kansas City, MO-KS

Tipton County IN 29020 Kokomo, IN

Nelson County KY 31140 Louisville/Jefferson County, KY-IN

Geary County KS 31740 Manhattan, KS

Washington County OH 37620 Parkersburg-Marietta-Vienna, WV-OH

Pleasants County WV 37620 Parkersburg-Marietta-Vienna, WV-OH

George County MS 37700 Pascagoula, MS

Power County ID 38540 Pocatello, ID

Cumberland County VA 40060 Richmond, VA

King and Queen County VA 40060 Richmond, VA

continued


Counties That Will Lose Urban Status


Number CBSA

Louisa County VA 40060 Richmond, VA

Washington County MO 41180 St. Louis, MO-IL

Summit County UT 41620 Salt Lake City, UT

Erie County OH 41780 Sandusky, OH

Franklin County MA 44140 Springfield, MA

Ottawa County OH 45780 Toledo, OH

Greene County AL 46220 Tuscaloosa, AL

Calhoun County TX 47020 Victoria, TX

Surry County VA 47260 Virginia Beach-Norfolk-Newport News, VA-NC

Rural Counties That Will Become Urban Under the New OMB Delineations

A total of 105 counties (and county equivalents) and 81 hospitals that were located in rural areas will be located in urban areas under the new OMB delineations.

The wage data for hospitals located in these 105 rural counties will be included in their new respective urban CBSAs.

Counties That Will Gain Urban Status


Number CBSA

Utuado Municipio PR 10380 Aguadilla-Isabela, PR

Linn County OR 10540 Albany, OR

Oldham County TX 11100 Amarillo, TX

Morgan County GA 12060 Atlanta-Sandy Springs-Roswell, GA

Lincoln County GA 12260 Augusta-Richmond County, GA-SC

Newton County TX 13140 Beaumont-Port Arthur, TX

Fayette County WV 13220 Beckley, WV

Raleigh County WV 13220 Beckley, WV

Golden Valley County MT 13740 Billings, MT

Oliver County ND 13900 Bismarck, ND

Sioux County ND 13900 Bismarck, ND

Floyd County VI 13980 Blacksburg-Christiansburg-Radford, VA

De Witt County IL 14010 Bloomington, IL

Columbia County PA 14100 Bloomsburg-Berwick, PA

Montour County PA 14100 Bloomsburg-Berwick, PA

Allen County KY 14540 Bowling Green, KY

Butler County KY 14540 Bowling Green, KY

St. Mary’s County MD 15680 California-Lexington Park, MD

continued




Number CBSA

Jackson County IL 16060 Carbondale-Marion, IL

Williamson County IL 16060 Carbondale-Marion, IL

Franklin County PA 16540 Chambersburg-Waynesboro, PA

Iredell County NC 16740 Charlotte-Concord-Gastonia, NC-SC

Lincoln County NC 16740 Charlotte-Concord-Gastonia, NC-SC

Rowan County NC 16740 Charlotte-Concord-Gastonia, NC-SC

Chester County SC 16740 Charlotte-Concord-Gastonia, NC-SC

Lancaster County SC 16740 Charlotte-Concord-Gastonia, NC-SC

Buckingham County VA 16820 Charlottesville, VA

Union County IN 17140 Cincinnati, OH-KY-IN

Hocking County OH 18140 Columbus, OH

Perry County OH 18140 Columbus, OH

Walton County FL 18880 Crestview-Fort Walton Beach-Destin, FL

Hood County TX 23104 Dallas-Fort Worth-Arlington, TX

Somervell County TX 23104 Dallas-Fort Worth-Arlington, TX

Baldwin County AL 19300 Daphne-Fairhope-Foley, AL

Monroe County PA 20700 East Stroudsburg, PA

Hudspeth County TX 21340 El Paso, TX

Adams County PA 23900 Gettysburg, PA

Hall County NE 24260 Grand Island, NE

Hamilton County NE 24260 Grand Island, NE

Howard County NE 24260 Grand Island, NE

Merrick County NE 24260 Grand Island, NE

Montcalm County MI 24340 Grand Rapids-Wyoming, MI

Josephine County OR 24420 Grants Pass, OR

Tangipahoa Parish LA 25220 Hammond, LA

Beaufort County SC 25940 Hilton Head Island-Bluffton-Beaufort, SC

Jasper County SC 25940 Hilton Head Island-Bluffton-Beaufort, SC

Citrus County FL 26140 Homosassa Springs, FL

Butte County ID 26820 Idaho Falls, ID

Yazoo County MS 27140 Jackson, MS

Crockett County TN 27180 Jackson, TN

Kalawao County HI 27980 Kahului-Wailuku-Lahaina, HI

Maui County HI 27980 Kahului-Wailuku-Lahaina, HI

Campbell County TN 28940 Knoxville, TN

Morgan County TN 28940 Knoxville, TN

Roane County TN 28940 Knoxville, TN

Acadia Parish LA 29180 Lafayette, LA

Iberia Parish LA 29180 Lafayette, LA

continued




Number CBSA

Vermilion Parish LA 29180 Lafayette, LA

Cotton County OK 30020 Lawton, OK

Scott County IN 31140 Louisville/Jefferson County, KY-IN

Lynn County TX 31180 Lubbock, TX

Green County WI 31540 Madison, WI

Benton County MS 32820 Memphis, TN-MS-AR

Midland County MI 33220 Midland, MI

Martin County TX 33260 Midland, TX

Le Sueur County MN 33460 Minneapolis-St. Paul-Bloomington, MN-WI

Mille Lacs County MN 33460 Minneapolis-St. Paul-Bloomington, MN-WI

Sibley County MN 33460 Minneapolis-St. Paul-Bloomington, MN-WI

Maury County TN 34980 Nashville-Davidson--Murfreesboro-- Franklin, TN

Craven County NC 35100 New Bern, NC

Jones County NC 35100 New Bern, NC

Pamlico County NC 35100 New Bern, NC

St. James Parish LA 35380 New Orleans-Metairie, LA

Box Elder County UT 36260 Ogden-Clearfield, UT

Gulf County FL 37460 Panama City, FL

Custer County SD 39660 Rapid City, SD

Fillmore County MN 40340 Rochester, MN

Yates County NY 40380 Rochester, NY

Sussex County DE 41540 Salisbury, MD-DE

Worcester County MA 41540 Salisbury, MD-DE

Highlands County FL 42700 Sebring, FL

Webster Parish LA 43340 Shreveport-Bossier City, LA

Cochise County AZ 43420 Sierra Vista-Douglas, AZ

Plymouth County IA 43580 Sioux City, IA-NE-SD

Union County SC 43900 Spartanburg, SC

Pend Oreille County WA 44060 Spokane-Spokane Valley, WA

Stevens County WA 44060 Spokane-Spokane Valley, WA

Augusta County VA 44420 Staunton-Waynesboro, VA

Staunton City VA 44420 Staunton-Waynesboro, VA

Waynesboro City VA 44420 Staunton-Waynesboro, VA

Little River County AR 45500 Texarkana, TX-AR

Sumter County FL 45540 The Villages, FL

Pickens County AL 46220 Tuscaloosa, AL

Gates County NC 47260 Virginia Beach-Norfolk-Newport News, VA-NC

Falls County TX 47380 Waco, TX

continued




Number CBSA

Columbia County WA 47460 Walla Walla, WA

Walla Walla County WA 47460 Walla Walla, WA

Peach County GA 47580 Warner Robins, GA

Pulaski County GA 47580 Warner Robins, GA

Culpeper County VA 47894 Washington-Arlington-Alexandria, DC-VA- MD-WV

Rappahannock County VA 47894 Washington-Arlington-Alexandria, DC-VA- MD-WV

Jefferson County NY 48060 Watertown-Fort Drum, NY

Kingman County KS 48620 Wichita, KS

Davidson County NC 49180 Winston-Salem, NC

Windham County CT 49340 Worcester, MA-CT

Urban Counties That Will Move to a Different Urban CBSA Under the New OMB Delineations

In certain cases, adopting the new OMB delineations will involve a change only in CBSA name or number while the CBSA continues to encompass the same constituent counties.

CMS has identified 19 counties that will remain in a CBSA that experienced a change in name or number under the new delineations but will retain the same constituent counties.

Counties That Will Remain in CBSA That Changed Number

CBSA Number CBSA Number County State

14484 14454 Norfolk County MA

14484 14454 Plymouth County MA

14484 14454 Suffolk County MA

47644 47664 Lapeer County MI

47644 47664 Livingston County MI

47644 47664 Macomb County MI

47644 47664 Oakland County MI

47644 47664 St. Clair County MI

26180 46520 Honolulu County HI

29140 29200 Benton County IN

29140 29200 Carroll County IN

29140 29200 Tippecanoe County IN

42044 11244 Orange County CA

42060 42200 Santa Barbara County CA

44600 48260 Jefferson County OH

continued


Counties That Will Remain in CBSA That Changed Number

CBSA Number CBSA Number County State

44600 48260 Brooke County WV

44600 48260 Hancock County WV

13644 43524 Frederick County MD

13644 43524 Montgomery County MD

Counties That Will Change to Another CBSA

The following chart lists the urban counties that will move from one urban CBSA to another urban CBSA.

Prior CBSA New CBSA County State11300 26900 Madison County IN

11340 24860 Anderson County SC

14060 14010 McLean County IL

37764 15764 Essex County MA

16620 26580 Lincoln County WV

16620 26580 Putnam County WV

16974 20994 DeKalb County IL

16974 20994 Kane County IL

26100 24340 Ottawa County MI

31140 21060 Meade County KY

34100 28940 Grainger County TN

35644 35614 Bergen County NJ

35644 35614 Hudson County NJ

20764 35614 Middlesex County NJ

20764 35614 Monmouth County NJ

20764 35614 Ocean County NJ

35644 35614 Passaic County NJ

20764 35084 Somerset County NJ

35644 35614 Bronx County NY

35644 35614 Kings County NY

35644 35614 New York County NY

35644 20524 Putnam County NY

35644 35614 Queens County NY

35644 35614 Richmond County NY

35644 35614 Rockland County NY

35644 35614 Westchester County NY

37380 19660 Flagler County FL

continued


Prior CBSA New CBSA County State37700 25060 Jackson County MS

37964 33874 Bucks County PA

37964 33874 Chester County PA

37964 33874 Montgomery County PA

39100 20524 Dutchess County NY

39100 35614 Orange County NY

41884 42034 Marin County CA

48900 34820 Brunswick County NC

TRANSITION PERIOD (REFER PAGES 447 AND FOLLOWING)

Transition for Hospitals in Urban Areas That Will Become Rural

For hospitals that are currently located in an urban county that will become rural under the new OMB delineations and will have no form of wage index reclassification or redesignation in place for FY 2015 (that is, MGCRB reclassifications under Section 1886(d)(10) of the act, redesignations under Section 1886(d)(8)(B) of the act or rural reclassifications under Section 1886(d)(8)(E) of the act), CMS is adopting its proposed policy to assign them the urban wage index value of the CBSA in which they are physically located for FY 2014 for a period of three fiscal years (with the rural and imputed floors applied and with the rural floor budget neutral-ity adjustment applied to the area wage index).

CMS has identified relatively few hospitals that are located in urban counties that will become rural and fewer yet that do not have a reclassification or redesignation in effect for FY 2015.

Transition for Hospitals That Will Experience a Decrease in Wage Index under the New OMB Delineations

CMS will apply a one-year blended wage index for all hospitals that will experience any de-crease in their actual payment wage index (that is, a hospital’s actual wage index used for pay-ment, which accounts for all applicable effects of reclassification and redesignation) exclusively due to the implementation of the new OMB delineations.

In FY 2015, a post-reclassified wage index with the rural and imputed floor applied will be computed based on the hospital’s FY 2014 CBSA (that is, using all of its FY 2014 constituent county/ies), and another post-reclassified wage index with the rural and imputed floor applied will be computed based on the hospital’s new FY 2015 CBSA (that is, the FY 2015 constituent county/ies). CMS will compare these two wage indexes. If the FY 2015 wage index with FY 2015 CBSAs is lower than the FY 2015 wage index with FY 2014 CBSAs, a blended wage index will be computed, consisting of 50 percent of each of the two wage indexes added together. This blended wage index will be the hospital’s wage index for FY 2015.

continued


IMPACT OF PROPOSED ADOPTION OF NEW OMB LABOR MARKET AREA DELINEATIONSThe following table shows the impact of the adoption of the new OMB delineations on hospi-tals’ FY 2015 wage indexes, comparing the FY 2015 occupational mix adjusted post-reclassified wage indexes with rural floor budget neutrality applied under the FY 2014 CBSAs and the FY 2015 CBSAs using the new OMB delineations. (This analysis does not include the effects of the out-migration adjustment, the frontier floor, the three-year hold harmless transition wage indexes or the one-year transition blended wage indexes.)

Percent Change in FY 2015 Wage Index

Number of Post- Reclassified Rural Hospitals based on FY 2014 CBSA

Number of Post- Reclassified Urban Hospitals based on

FY 2014 CBSA

Total Number

of Hospitals

Decrease greater than or equal to 10.0 1 6 7

Decrease greater than or equal to5.0 but less than 10.0

28 50 78

Decrease greater than or equal to2.0 but less than 5.0

33 88 121

Decrease greater than 0.0 but less than 2.0

158 253 411

No change 0 8 8

Increase greater than 0.0 but less than 2.0

376 2,331 2,707

Increase greater than or equal to 2.0 but less than 5.0

7 41 48

Increase greater than or equal to 5.0 but less than 10.0

18 14 32

Increase greater than or equal to 10.0 11 23 34

Total 632 2,814 3,446

Frontier Floor Values

Forty-six hospitals will receive the frontier floor value of 1.0000 for their FY 2015 wage index. These hospitals are located in Montana, North Dakota, South Dakota and Wyoming.

Reclassifications

There were 309 hospitals approved for wage index reclassifications by the MGCRB starting in FY 2015. There were 155 hospitals approved for wage index reclassifications in FY 2013, and 270 hospitals approved for wage index reclassifications in FY 2014. There are 734 hospitals in reclassification status for FY 2015. CMS notes 23 hospitals have terminated their reclassifica-tion status since the proposed rule was published.

continued


New 2013 Occupational Mix Survey for the FY 2016 Wage Index (Refer Page 489)

A new 2013 survey will be applied to the FY 2016 wage index. Hospitals were required to submit their completed 2013 surveys to their Medicare Administrative Contractor (MAC) by July 1, 2014.

The FY 2015 occupational mix adjusted national average hourly wage (based on the new OMB delineations) is $39.2591.

The FY 2015 national average hourly wages for each occupational mix nursing subcategory are as follows.

Occupational Mix Nursing Subcategory Average Hourly WageNational RN 37.420970136

National LPN and Surgical Technician 21.782291180

National Nurse Aide, Orderly, and Attendant 15.311077250

National Medical Assistant 17.251053917

National Nurse Category 31.769556957

Effects of Implementation of New OMB Labor Market Area Delineations on Reclassified Hospitals

CMS notes that if CBSAs are split apart or if counties shift from one CBSA to another under the new OMB delineations, it raises the question of how to continue a hospital’s reclassification for the remainder of its three-year reclassification period, if that area to which the hospital reclas-sified no longer exists, in whole or in part.

CMS is including the following descriptions of specific situations where it has determined that reassignment of reclassification areas is appropriate.

(1) Reclassifications to CBSAs That Are Subsumed by Other CBSAsCMS has identified 63 counties that are currently located in CBSAs that would be subsumed by another CBSA. For any hospital that is reclassified to a CBSA that no longer exists, and all of the CBSA’s constituent counties moved to another CBSA under the new OMB delineations, CMS has assigned that hospital’s reclassification to the subsuming CBSA to which all of the original constituent counties in the FY 2014 CBSA are transferred.

(2) Reclassification to CBSAs Where the CBSA Number or Name Changed or to CBSAs Containing Counties That Moved to Another CBSAHospitals that were reclassified to a CBSA that had one or more counties that split off and moved to another CBSA under the new OMB delineations are reclassified to a CBSA that will contain the most proximate county that (1) is located outside of the hospital’s FY 2015 geographic labor market area and (2) is included in the current CBSA to which they are reclas-sified. Group reclassifications are assigned to the CBSA under the new OMB delineations to which the majority of hospitals in that group reclassification are geographically closest and that (1) is located outside of the hospital’s FY 2015 geographic labor market area and (2) is included in the current CBSA to which they are reclassified.

continued


CMS said 69 hospitals have been identified as reclassified counties that would split off and move to a new CBSA or a different existing CBSA. There are 27 hospitals that would maintain the same reclassified CBSA number. Another 28 hospitals would be reassigned to a reconfig-ured CBSA that would include a similar number of counties from their current reclassified CBSA. The remaining 14 reclassified hospitals would have a different CBSA number from the labor market area to which they are currently reclassified (under the current FY 2014 delineations).

Applications for Reclassifications for FY 2016

Applications for FY 2016 reclassifications are due to the MGCRB by Sept. 2, 2014 (the first working day of September 2014).

Applications and other information about MGCRB reclassifications are available at www.cms.gov/Regulations-and-Guidance/Review-Boards/MGCRB/index.html or by calling the MGCRB at 410/786-1174. The mailing address of the MGCRB is 2520 Lord Baltimore Drive, Suite L, Baltimore, MD 21244-2670.3.

Redesignation of Hospitals Under Section 1886(d)(8)(B) of the Act

Section 1886(d)(8)(B)(i) of the act requires the secretary to “treat a hospital located in a rural county adjacent to one or more urban areas as being located in the urban metropolitan statisti-cal area to which the greatest number of workers in the county commute” if certain adjacency and commuting criteria are met.

Hospitals located in these counties have been known as “Lugar” hospitals, and the counties themselves are often referred to as “Lugar” counties. By applying the new OMB delineations, the number of qualifying counties will increase from 98 to 127.

Rural Counties With Hospitals Redesignated as Urban Under Section 1886(d)(8)(B) of the Act

(Based on New OMB Delineations and Census 2010 Data)

RURAL COUNTY LUGAR DESIGNATED CBSA NEW

County Name State CBSA CBSA Name

Chambers County AL 12220 Auburn-Opelika, AL New

Cherokee County AL 40660 Rome, GA

Cleburne County AL 11500 Anniston-Oxford-Jacksonville, AL New

Macon County AL 12220 Auburn-Opelika, AL

Talladega County AL 11500 Anniston-Oxford-Jacksonville, AL

Denali Borough AK 21820 Fairbanks, AK New

Hot Spring County AR 26300 Hot Springs, AR

Litchfield County CT 35300 New Haven-Milford, CT

Bradford County FL 27260 Jacksonville, FL

Levy County FL 23540 Gainesville, FL

Washington County FL 37460 Panama City, FL New

Chattooga County GA 40660 Rome, GA

Jackson County GA 12060 Atlanta-Sandy Springs-Roswell, GA

continued

http://www.cms.gov/Regulations-and-Guidance/Review-Boards/MGCRB/index.html

http://www.cms.gov/Regulations-and-Guidance/Review-Boards/MGCRB/index.html






Lumpkin County GA 12060 Atlanta-Sandy Springs-Roswell, GA

Polk County GA 40660 Rome, GA

Talbot County GA 17980 Columbus, GA-AL

Oneida County ID 36260 Ogden-Clearfield, UT New

Christian County IL 44100 Springfield, IL

Iroquois County IL 28100 Kankakee, IL

Logan County IL 44100 Springfield, IL

Mason County IL 37900 Peoria, IL

Ogle County IL 40420 Rockford, IL

Union County IL 16060 Carbondale-Marion, IL

Clinton County IN 29200 Lafayette-West Lafayette, IN

Greene County IN 14020 Bloomington, IN New

Henry County IN 26900 Indianapolis-Carmel-Anderson, IN

Marshall County IN 43780 South Bend-Mishawaka, IN-MI New

Parke County IN 45460 Terre Haute, IN New

Spencer County IN 21780 Evansville, IN-KY

Starke County IN 23855 Gary, IN

Tipton County IN 26900 Indianapolis-Carmel-Anderson, IN New

Warren County IN 29200 Lafayette-West Lafayette, IN

Boone County IA 11180 Ames, IA

Buchanan County IA 47940 Waterloo-Cedar Falls, IA

Cedar County IA 26980 Iowa City, IA

Delaware County IA 20220 Dubuque, IA New

Iowa County IA 26980 Iowa City, IA New

Jasper County IA 19780 Des Moines-West Des Moines, IA New

Franklin County KS 28140 Kansas City, MO-KS New

Nelson County KY 31140 Louisville/Jefferson County, KY-IN New

Assumption Parish LA 12940 Baton Rouge, LA

Jefferson Davis Parish LA 29340 Lake Charles, LA New

St. Landry Parish LA 29180 Lafayette, LA New

Oxford County ME 30340 Lewiston-Auburn, ME New

Caroline County MD 12580 Baltimore-Columbia-Towson, MD New

Franklin County MA 44140 Springfield, MA New

Allegan County MI 24340 Grand Rapids-Wyoming, MI

Ionia County MI 24340 Grand Rapids-Wyoming, MI New

continued






Lenawee County MI 11460 Ann Arbor, MI New

Newaygo County MI 24340 Grand Rapids-Wyoming, MI New

Shiawassee County MI 29620 Lansing-East Lansing, MI

Tuscola County MI 40980 Saginaw, MI

Goodhue County MN 33460 Minneapolis-St. Paul-Bloomington, MN-WI New

Meeker County MN 33460 Minneapolis-St. Paul-Bloomington, MN-WI New

Rice County MN 33460 Minneapolis-St. Paul-Bloomington, MN-WI New

Pearl River County MS 25060 Gulfport-Biloxi-Pascagoula, MS

Stone County MS 25060 Gulfport-Biloxi-Pascagoula, MS New

Dade County MO 44180 Springfield, MO

Otoe County NE 30700 Lincoln, NE New

Douglas County NV 16180 Carson City, NV New

Lyon County NV 16180 Carson City, NV

Los Alamos County NM 42140 Santa Fe, NM

Cayuga County NY 45060 Syracuse, NY

Cortland County NY 27060 Ithaca, NY New

Genesee County NY 40380 Rochester, NY

Greene County NY 10580 Albany-Schenectady-Troy, NY

Lewis County NY 48060 Watertown-Fort Drum, NY New

Montgomery County NY 10580 Albany-Schenectady-Troy, NY New

Schuyler County NY 27060 Ithaca, NY

Seneca County NY 40380 Rochester, NY New

Camden County NC 47260 Virginia Beach-Norfolk-Newport News, VA-NC

New

Caswell County NC 15500 Burlington, NC

Granville County NC 20500 Durham-Chapel Hill, NC

Greene County NC 24780 Greenville, NC New

Harnett County NC 39580 Raleigh, NC

Polk County NC 43900 Spartanburg, SC

Wilson County NC 40580 Rocky Mount, NC New

Traill County ND 24220 Grand Forks, ND-MN New

Ashtabula County OH 17460 Cleveland-Elyria, OH

Champaign County OH 44220 Springfield, OH

Columbiana County OH 49660 Youngstown-Warren-Boardman, OH-PA

Harrison County OH 48260 Weirton-Steubenville, WV-OH New

Preble County OH 19380 Dayton, OH New

continued






Clinton County PA 48700 Williamsport, PA

Fulton County PA 25180 Hagerstown-Martinsburg, MD-WV New

Greene County PA 38300 Pittsburgh, PA

Lawrence County PA 38300 Pittsburgh, PA New

Schuylkill County PA 39740 Reading, PA

Susquehanna County PA 13780 Binghamton, NY

Adjuntas Municipio PR 38660 Ponce, PR New

Coamo Municipio PR 41980 San Juan-Carolina-Caguas, PR New

Las Marías Municipio PR 32420 Mayagüez, PR New

Maricao Municipio PR 32420 Mayagüez, PR New

Salinas Municipio PR 25020 Guayama, PR New

Clarendon County SC 44940 Sumter, SC

Colleton County SC 16700 Charleston-North Charleston, SC New

Lee County SC 44940 Sumter, SC

Marion County SC 22500 Florence, SC New

Newberry County SC 17900 Columbia, SC New

Meigs County TN 17420 Cleveland, TN

Blanco County TX 12420 Austin-Round Rock, TX New

Bosque County TX 47380 Waco, TX

Calhoun County TX 47020 Victoria, TX New

Fannin County TX 19124 Dallas-Plano-Irving, TX

Grimes County TX 17780 College Station-Bryan, TX

Harrison County TX 30980 Longview, TX

Henderson County TX 46340 Tyler, TX

Hill County TX 23104 Dallas-Plano-Irving, TX New

Milam County TX 12420 Austin-Round Rock, TX

Van Zandt County TX 19100 Dallas-Fort Worth-Arlington, TX

Willacy County TX 15180 Brownsville-Harlingen, TX

King and Queen County VA 40060 Richmond, VA New

Louisa County VA 40060 Richmond, VA New

Madison County VA 16820 Charlottesville, VA New

Orange County VA 47900 Washington-Arlington-Alexandria, DC-VA-MD-WV

New

Page County VA 25500 Harrisonburg, VA

Shenandoah County VA 49020 Winchester, VA-WV

continued






Southampton County VA 47260 Virginia Beach-Norfolk-Newport News, VA-NC

New

Surry County VA 47260 Virginia Beach-Norfolk-Newport News, VA-NC

New

Island County WA 42644 Seattle-Bellevue-Everett, WA

Mason County WA 36500 Olympia-Tumwater, WA

Jackson County WV 16620 Charleston, WV

Morgan County WV 25180 Hagerstown-Martinsburg, MD-WV New

Roane County WV 16620 Charleston, WV

Green Lake County WI 22540 Fond du Lac, WI

Jefferson County WI 33340 Milwaukee-Waukesha-West Allis, WI

Walworth County WI 33340 Milwaukee-Waukesha-West Allis,

Rural Counties No Longer Meeting the Criteria to be Redesignated as Lugar

The number of rural counties that will no longer meet the qualifying criteria to be redesignated as “Lugar” effective Oct. 1, 2014, is 30. Those that are geographically located in an urban area under the new OMB delineations for FY 2015 are as follows.

continued

• Windham County, CT

• Flagler County, FL

• Walton County, FL

• Morgan County, GA

• Peach County, GA

• De Witt County, IL

• Allen County, KY

• St. James Parrish, LA

• Montcalm County, MI

• Fillmore County, MN

• Davidson County, NC

• Lincoln County, NC

• Cotton County, OK

• Linn County, OR

• Adams County, PA

• Monroe County, PA

• Falls County, TX

• Buckingham County, VA

• Floyd County, VA

• Green County, WI

Counties that would fail to meet the 25 percent threshold in FY 2015 are as follows.

• Banks County, GA

• Hendry County, FL

• Bingham County, ID

• Oceana County, MI

• Columbia County, NY

• Sullivan County, NY

• Wyoming County, NY

• Oconee County, SC

• Middlesex County, VA

• Wahkiakum County, WA


III. CHANGES TO MEDICARE SEVERITY DIAGNOSIS-RELATED GROUP (MS-DRG) CLASSIFICATIONS AND RELATIVE WEIGHTS (REFER PAGES 93 AND FOLLOWING)

FY 2015 MS-DRG Documentation and Coding Adjustment (Refer Pages 95 and following)

Section 631 of the ATRA amended Section 7(b)(1)(B) of Pub. L. 110-90 to require the secretary to make a recoup-ment adjustment or adjustments totaling $11 billion by FY 2017.

CMS is finalizing its proposal to make [take] an additional -0.8 percent adjust-ment to the standardized amount for FY 2015. Considering the -0.8 percent adjustment made in FY 2014, CMS expects the combined impact of these adjustments will be to recover $2 billion dollars in overpayments in FY 2015. Combined with the estimated $1 bil-lion adjustment made in FY 2014, CMS estimates $3 billion of the $11 billion in overpayments required to be recovered by Section 631 of the ATRA will be accounted for.

Changes to the MS-DRGs for FY 2015 (Refer Page 137 and following)

The following items are those MS-DRG changes that CMS is making for FY 2015. CMS does address many that are not being adopted.

• CMS is creating new MS-DRG 266 (Endovascular Cardiac Valve Replacement with MCC) and MS-DRG 267 (Endovascular Cardiac Valve Replacement without MCC).

• CMS will collapse MS-DRGs 483 and 484 into a single MS-DRG by deleting MS-DRG 484 and revising the title of MS-DRG 483 to read “Major Joint/Limb Reattachment Procedure of Upper Extremities.”

• CMS will create new MS-DRG 518 (Back & Neck Procedures Except Spinal Fusion with MCC or Disc Device/Neurostimulator), MS-DRG 519 (Back & Neck Procedures Except Spinal Fusion with CC) and MS-DRG 520 (Back & Neck Procedures Except Spinal Fusion without CC/MCC).

• CMS will reassign the following seven diagnoses to the “only secondary diagnosis list” under MS–DRG 795 so that the case would be assigned to MS–DRG 795.

– V17.0 (family history of psychiat-ric condition)

– V17.2 (family history of other neurological diseases)

– V17.49 (family history of other cardiovascular diseases)

– V18.0 (family history of diabetes mellitus)

– V18.19 (family history of other endocrine and metabolic diseases)

– V18.8 (family history of infec-tious and parasitic diseases)

– V50.3 (ear piercing)

• CMS will remove procedure code 39.28 (extracranial-intracranial (EC-IC) vascular bypass) from the non-covered procedure edit, effective FY 2015.

• CMS is finalizing its proposal for MDC 5 to sequence new MS-DRG 266 (Endovascular Cardiac Valve Replacement with MCC) and new MS-DRG 267 (Endovascular Cardiac Valve Replacement without MCC) above MS-DRG 222 (Cardiac Defibrillator Implant with Cardiac Catheterization with AMI/HF/Shock with MCC).

continued


• CMS also is deleting MS-DRG 490 (Back & Neck Procedures Except Spinal Fusion with CC/MCC or Disc Device/Neurostimulator) and MS-DRG 491 (Back & Neck Procedures Except Spinal Fusion without CC/MCC or Disc Device/Neurostimulator) from the surgi-cal hierarchy.

• CMS is sequencing new MS-DRG 518 (Back & Neck Procedure Except Spinal Fusion with MCC or Disc Device/Neurostimulator), new MS-DRG 519 (Back & Neck Procedure Except Spinal Fusion with CC), new MS-DRG 519 (Back & Neck Procedure Except Spinal Fusion with CC) and new MS-DRG 520 (Back & Neck Procedure Except Spinal Fusion without CC/MCC) above MS-DRG 492 (Lower Extremity and Humerus Procedure Except Hip, Foot, Femur with MCC), effective FY 2015.

FY 2015 Status of Technologies Approved for FY 2014 Add-On Payments (Refer pages 289 and following)

CMS is approving the following technologies for FY 2015.

Continued from FY 2014

• Voraxaze®

• Zenith® Fenestrated Abdominal Aortic Aneurysm (AAA) Endovascular Graft

• Kcentra™

• Argus® II Retinal Prosthesis System

• Zilver® PTX® Drug Eluting Peripheral Stent

New for FY 2015

• CardioMEMS™ HF Monitoring System

• MitraClip® System

• RNS® System

COMMENTCMS spends 150 pages discussing new technology issues. This is another reason why the rule is so long. Perhaps listing the changes and placing the long discussion in a separate appendix would help meet the needs of the provider more effectively.

IV. OTHER DECISIONS AND PROPOSED CHANGES TO THE IPPS FOR OPERATING COSTS AND GRADUATE MEDICAL EDUCATION (GME) COSTS

Changes to MS-DRGs Subject to the Post-Acute Care Transfer Policy (refer Pages 588ff)

CMS has identified several MS-DRGs regarding the list of MS-DRGs subject to the post-acute care transfer policy.

continued


List of MS-DRGs That Would Change Post-Acute Care Transfer Policy Status in FY 2015

MS-DRGs MS-DRG Title

Total Cases

Post-Acute Care

Transfers(55th

Percentile:1,471)

Short Stay Post-Acute Care

Transfers

Percent of Short Stay Post

Acute Care Transfers

to All Cases(55th

percentile:7.9060%)

Post-Acute Care Policy Status

266 Endovascular Cardiac Valve Replacement with MCC

4,086 2,851 1,030 25.21% YES

267 Endovascular Cardiac Valve Replacement w/o MCC

4,476 2,800 835 18.66% YES

483 Major Joint/Limb Reattachment Procedure of Upper Extremities

41,372 17,289 2,271 5.49%* NO

518 Back & Neck Procedure Except Spinal Fusion with MCC or Disc Device/Neurostimulator

3,844 2,136 412 10.72% YES

519 Back & Neck Procedure Except Spinal Fusion with CC

15,238 7,405 1,126 7.39%* YES**

520 Back & Neck Procedure Except Spinal Fusion without CC/MCC)

31,792 7,859 0 0.00%* YES**

* indicates a current post-acute care transfer policy criterion that the MS-DRG did not meet** as described in the policy at 42 CFR 412.4(d)(3)(ii)(D), MS-DRGs that share the same base MS-DRG will all qualify under the post-acute care transfer policy if any one of the MS-DRGs that share that same base MS-DRG qualifies

Rural Referral Centers (RRCs) (Refer Page 607)

A rural hospital with less than 275 beds may be classified as an RRC if:

• the hospital’s case-mix index (CMI) is at least equal to the lower of the median CMI for urban hospitals in its census region, excluding hospitals with approved teaching programs, or the median CMI for all urban hospitals nationally; and

• the hospital’s number of discharges is at least 5,000 per year, or, if fewer, the median num-ber of discharges for urban hospitals in the census region in which the hospital is located (The number of discharges criterion for an osteopathic hospital is at least 3,000 discharges.)

CMS is requiring that, in addition to meeting other criteria, if rural hospitals with fewer than 275 beds are to qualify for initial RRC status for cost reporting periods beginning on or after Oct. 1, 2014, they must have a CMI value for FY 2013 that is at least:

• 1.5723; or

• the median CMI value (not transfer-adjusted) for urban hospitals (excluding hospitals with approved teaching programs as identified in § 413.75) calculated by CMS for the census region in which the hospital is located

continued


The CMI values by region are set forth in the following table.

RegionCase Mix Index

Value1 New England (CT, ME, MA, NH, RI, VT) 1.3587

2 Middle Atlantic (PA, NJ, NY) 1.4318

3 South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV) 1.4807

4 East North Central (IL, IN, MI, OH, WI) 1.4938

5 East South Central (AL, KY, MS, TN) 1.4107

6 West North Central (IA, KS, MN, MO, NE, ND, SD) 1.5459

7 West South Central (AR, LA, OK, TX) 1.6039

8 Mountain (AZ, CO, ID, MT, NV, NM, UT, WY) 1.6586

9 Pacific (AK, CA, HI, OR, WA) 1.5658

A hospital, if it is to qualify for initial RRC status for cost reporting periods beginning on or after Oct. 1, 2014, also must have the number of discharges for its cost reporting period that began during FY 2012 a figure that is at least:

• 5,000 (3,000 for an osteopathic hospital); or

• The median number of discharges for urban hospitals in the census region in which the hospital is located

All census regional discharge numbers are greater than 5,000.

Payment Adjustments for Low-Volume Hospitals (Refer Page 613)

CMS is establishing that qualifying low-volume hospitals (that is, the list of “subsection (d)” hospitals with fewer than 1,600 Medicare discharges) and their potential low-volume payment adjustment for FY 2015 discharges occurring before April 1, 2015, (if eligible) will be based on Medicare discharge data from the March 2014 update of the FY 2013 MedPAR file. Table 14 listed in the addendum of this final rule lists the “subsection (d)” hospitals with fewer than 1,600 Medicare discharges based on the March 2014 update of the FY 2013 MedPAR file and their low-volume payment adjustment for FY 2015 discharges occurring before April 1, 2015 (if eligible).

To receive a low-volume hospital payment adjustment under § 412.101, a hospital must notify and provide documentation to its MAC that it meets the discharge and distance requirements.

IME Adjustment Factor for FY 2015 (Refer page 627)

For discharges occurring during FY 2015, the formula multiplier is 1.35.

IME Medicare Part C Add-On Payments to Sole Community Hospitals (SCH) That Are Paid According to Their Hospital-Specific Rates and Proposed Change in Methodology in Determining Payment to SCHs (Refer Page 628)

Effective with discharges occurring in cost reporting periods beginning on or after Oct. 1, 2014, CMS’ final policies are: (1) to provide all SCHs that are subsection (d) teaching hospitals IME add-on payments for Medicare Part C patient discharges in accordance with Section 1886(d)(11) of the act; and (2) for purposes of the comparison of payments based on the federal rate and the hospital-specific rate for SCHs under Section 1886(d)(5)(D) of the act, IME add-on

continued


payments under Section 1886(d)(11) of the act for Medicare Part C patient discharges will no longer be included in the aggregate payment based on the federal rate. After the higher of the fed-eral rate payment or the hospital-specific rate payment under Section 1886(d)(5)(D) of the act is determined, the Part C IME adjustment factor is multiplied by the dederal rate to determine the add-on payment amount under Section 1886(d)(11) of the act, and then any IME add-on payments under section 1886(d)(11) of the act are added to the payment amount under Section 1886(d)(5)(D) of the act for purposes of determining the hospital’s total payment amount.

Payment Adjustment for Medicare DSH (§ 412.106) (Refer Page 638 and following)

Hospitals with less than 500 beds that are currently in urban counties that would become rural under the new OMB delineations and that do not become RRCs would be subject to a maximum DSH payment adjustment of 12 percent.

Payment Adjustment Methodology for Medicare DSHs under Section 3133 of the ACA (§ 412.106)

The three factors used to distribute DSH payments for FY 2015 are the same as the ones used for the current fiscal year.

Beginning with discharges in FY 2014, hospitals that qualify for Medicare DSH payments under Section 1886(d)(5)(F) of the act receive 25 percent of the amount they previously would have received under the statutory formula for Medicare DSH payments.

The remaining amount, equal to an estimate of 75 percent of what otherwise would have been paid as Medicare DSH payments, reduced to reflect changes in the percentage of individuals under age 65 who are uninsured, is available

to make additional payments to each hospital that qualifies for Medicare DSH payments and that has uncompensated care.

CALCULATION OF FACTOR 1 FOR FY 2015 (REFER PAGE 657)Factor 1 is the difference between CMS’ estimates of (1) the amount that would have been paid in Medicare DSH pay-ments for the fiscal year, in the absence of the new payment provision, and (2) the amount of empirically justi-fied Medicare DSH payments that are made for the fiscal year, which takes into account the requirement to pay 25 percent of what would have otherwise been paid under Section 1886(d)(5)(F) of the act. In other words, this factor represents CMS’ estimate of 75 percent (100 percent minus 25 percent) of its estimate of Medicare DSH payments that would otherwise be made, in the absence of Section 1886(r) of the act, for the fiscal year.

The July 2014 Medicare DSH estimate for FY 2015, without regard to the application of Section 1886(r)(1) of the act, is $13,383,462,195.71. This estimate excludes Maryland hospitals participat-ing in the Maryland All-Payer Model, SCHs paid under their hospital-specific payment rate and hospitals participat-ing in the Rural Community Hospital Demonstration.

Therefore, based on this estimate, the es-timate for empirically justified Medicare DSH payments for FY 2015, with the application of Section 1886(r)(1) of the act, is $3,345,865,548.93 (25 percent of the total amount estimated).

(The February 2014 Office of the Actuary estimate for Medicare DSH pay-ments for FY 2015, without regard to the application of Section 1886(r)(1) of the act, was $14.205 billion.)

continued


Therefore, Factor 1 for FY 2015 is $10.038 billion ($13.384 billion X 75 percent)

CALCULATION OF FACTOR 2 FOR FY 2015 (REFER PAGE 669)Section 1886(r)(2)(B)(i) of the act pro-vides that “For each of fiscal years 2014, 2015, 2016 and 2017, a factor equal to 1 minus the percent change in the percent of individuals under the age of 65 who are uninsured, as determined by com-paring the percent of such individuals (I) who are uninsured in 2013, the last year before coverage expansion under the Patient Protection and Affordable Care Act and (II) who are uninsured in the most recent period for which data is available (as so calculated), minus 0.1 percentage points for fiscal year 2014 and minus 0.2 percentage points for each of fiscal years 2015, 2016 and 2017.”

For the FY 2015 final rule, CMS used the Congressional Budget Office’s (CBO) April 2014 estimates of the effects of the ACA on health insurance coverage (available at www.cbo.gov/sites/default/files/cbofiles/attachments/43900-2014-04-ACAtables2.pdf). The CBO’s April 2014 estimate of individuals under the age of 65 with insurance in CY 2014 is 84 percent.

Therefore, the CBO’s most recent esti-mate of the rate of uninsurance in CY 2014 is 16 percent (that is, 100 percent minus 84 percent.) Similarly, the CBO’s April 2014 estimate of individuals under the age of 65 with insurance in CY 2015 is 87 percent. Therefore, the CBO’s most recent estimate of the rate of uninsur-ance in CY 2015 available for this final rule is 13 percent (that is, 100 percent minus 87 percent).

The calculation of the proposed Factor 2 for FY 2015, employing a weighted average of the CBO projections for CY 2014 and CY 2015, is as follows.

• CY 2014 rate of insurance cover-age (April 2014 CBO estimate): 84 percent

• CY 2015 rate of insurance coverage (April 2014 CBO estimate): 87 percent

• FY 2015 rate of insurance coverage: (84 percent * .25) + (87 percent * .75) = 86.25 percent

• Percent of individuals without insurance for 2013 (March 2010 CBO estimate): 18 percent of in-dividuals without insurance for FY 2015 (weighted average): 13.75 percent 1-|((0.1375-0.18)/0.18)|= 1- 0.2361=.7639 (76.39 percent) 0.7639 (76.39 percent) - .002 (0.2 percentage points for FY 2015 under Section 1886(r)(2)(B)(i) of the act) = 0.7619 or 76.19 percent

• Therefore, the final Factor 2 for FY 2015 is 76.19 percent.

• The FY 2015 final uncompensated care amount is $10,037,596,646.78 x 0.7619 = $7,647,644,885.18.

• The proposed amount was 0.8036.

CALCULATION OF FACTOR 3 FOR FY 2015 (REFER PAGE 680)Factor 3 is applied to the product of Factor 1 and Factor 2 to determine the amount of the uncompensated care payment that each eligible hospital will receive for FY 2015 and subsequent fis-cal years; i.e., the pool amount of $7.647 billion.

CMS believes it would be premature to propose the use of Worksheet S-10 data for purposes of determining Factor 3 for FY 2015. CMS is proposing to continue to employ the utilization of

continued

http://www.cbo.gov/sites/default/files/cbofiles/attachments/43900-2014-04-ACAtables2.pdf




insured low-income patients defined as inpatient days of Medicaid patients plus inpatient days of Medicare SSI patients, as defined in § 412.106(b)(4) and § 412.106(b)(2)(i), respectively, to determine Factor 3 for FY 2015.

Hospital Readmissions Reduction Program: Proposed Changes for FY 2015 through FY 2017 (§§ 412.150 through 412.154) (Refer Page 722-822)

CMS will use the CMS Planned Readmission Algorithm Version 3.0, for the AMI, HF, PN, COPD and THA/TKA readmission measures for FY 2015 and subsequent payment determi-nations. CMS also will use this algorithm for the CABG readmission measure proposed for inclusion in the Hospital Readmissions Reduction Program starting in FY 2017.

For FY 2015, consistent with the definition at § 412.152, CMS will use an “applicable period” for the Hospital Readmissions Reduction Program to be the three-year period from July 1, 2010, to June 30, 2013. In other words, CMS is saying that the excess readmissions ratios and the payment adjustment (including aggregate payments for excess readmissions and aggregate payments for all discharges) for FY 2015 would be calculated based on data from the three-year time period of July 1, 2010, to June 30, 2013.

CMS will use the following methodology for FY 2015 as displayed below.

FORMULAS TO CALCULATE THE READMISSIONS ADJUSTMENT FACTOR

Aggregate Payments for Excess Readmissions

• sum of base operating DRG payments for AMI x (Excess Readmissions Ratio for AMI-1)] + [sum of base operating DRG payments for HF x (Excess Readmissions Ratio for HF-1)] + [sum of base operating DRG payments for PN x (Excess Readmissions Ratio for PN-1)] + [sum of base operating DRG payments for COPD) x (Excess Readmissions Ratio for COPD-1)] + [sum of base operating DRG payments for THA/TKA x (Excess Readmissions Ratio for THA/TKA-1)

*Note: If a hospital’s excess readmissions ratio for a condition is less than/equal to 1, then there are no aggregate payments for excess readmissions for that condition included in this calculation.

Aggregate Payments for All Discharges

• sum of base operating DRG payments for all discharges

Ratio

• 1-(aggregate payments for excess readmissions/aggregate payments for all discharges)The proposed readmissions adjustment factor for FY 2015 is the higher of the ratio or 0.9700.

*based on claims data from July 1, 2010, to June 30, 2013, for FY 2015

Hospital VBP Program (Refer Pages 822-976)

Section 1886(o)(7)(B) of the act instructs the secretary to reduce the base operating DRG pay-ment amount for a hospital for each discharge in a fiscal year by an applicable percent. Under Section 1886(o)(7)(A) of the act, the sum total of these reductions in a fiscal year must equal

continued


the total amount available for value-based incentive payments for all eligible hospitals for the fiscal year, as estimated by the secretary.

The size of the applicable percentage has increased to 1.5 percent for FY 2015 and will increase to 1.75 percent for FY 2016, and to 2 percent for FY 2017 and successive fiscal years. CMS estimates that the total amount available for value-based incentive payments for FY 2015 is $1.4 billion.

The FY 2016 Hospital VBP Program includes the following measures.

Finalized Measures for the FY 2016 Hospital VBP Program

Clinical Process of Care Domain

AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival

IMM-2 Influenza Immunization

PN-6 Initial Antibiotic Selection for CAP in Immunocompetent Patient

SCIP-Inf-2 Prophylactic Antibiotic Selection for Surgical Patients

SCIP-Inf-3 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time

SCIP-Inf-9 Urinary Catheter Removed on Postoperative Day 1 or Postoperative Day 2

SCIP-Card-2 Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta-Blocker During the Perioperative Period

SCIP-VTE-2 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery

Patient Experience of Care Domain

HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems Survey

Outcome Domain

CAUTI CAUTI Catheter-Associated Urinary Tract Infection

CLABSI CLABSI Central Line-Associated Blood Stream Infection

MORT-30-AMI Acute Myocardial Infarction (AMI) 30-day Mortality Rate

MORT-30-HF MORT-30-HF Heart Failure (HF) 30-day mortality rate

MORT-30-PN MORT-30-PN Pneumonia (PN) 30-day mortality rate

PSI-90 Complication/ patient safety for selected indicators (Composite)

SSI Surgical Site Infection:• Colon• Abdominal Hysterectomy

Outcome Domain

CAUTI CAUTI Catheter-Associated Urinary Tract Infection

CLABSI CLABSI Central Line-Associated Blood Stream Infection

MORT-30-AMI Acute Myocardial Infarction (AMI) 30-day Mortality Rate

MORT-30-HF MORT-30-HF Heart Failure (HF) 30-day mortality rate

continued


MORT-30-PN MORT-30-PN Pneumonia (PN) 30-day mortality rate

PSI-90 Complication/ patient safety for selected indicators (Composite)

SSI Surgical Site Infection:• Colon• Abdominal Hysterectomy

Efficiency Domain

MSPB-1 Medicare Spending per Beneficiary

NEW MEASURES FOR THE FY 2017 HOSPITAL VBP PROGRAMCMS will add the following 3 new measures.

• MRSA Bacteremia (NQF #1716) is a risk-adjusted outcome measure monitoring hospital onset of MRSA bloodstream infection events using the standardized infection ratio (MRSA bacteremia SIR) among all inpatients in the facility, and is reported through the Center for Disease Control and Prevention’s National Healthcare Safety Network (NHSN).

• C. difficile infection (NQF #1717) is a risk-adjusted outcome measure monitoring hospital onset of C. difficile infection events using the standardized infection ratio (C. difficile SIR) among all inpatients in the facility and is reported via CDC’s NHSN.

• PC-01: Elective Delivery Prior to 39 Completed Weeks Gestation (NQF #0469) is a chart-abstracted measure that was adopted beginning with the FY 2015 payment determination for the Hospital IQR Program in the FY 2013 IPPS/LTCH PPS final rule.

The following table outlines the measures for the FY 2017 Hospital VBP Program This table includes the FY 2017 domains in which CMS would place the previously adopted measures.

CMS said the numerical values for the performance standards displayed below represent esti-mates based on the most recently available data, and it intends to update the numerical values in the FY 2015 IPPS/LTCH PPS final rule.

Previously Adopted and New Measures for the FY 2017 Hospital VBP Program

Measure Description Domain

CAUTI* Catheter-Associated Urinary Tract Infection (NQF #0138)

Safety

CLABSI** Central Line-Associated Blood Stream Infection (NQF #0139)

Safety

C. difficile*** Clostridium difficile Infection (NQF #1717) Safety

MRSA*** Methicillin-Resistant Staphylococcus aureusBacteremia (NQF #1726)

Safety

PSI-90* Complication/patient safety for selected indicators (composite) (NQF #0531)

Safety

SSI* Surgical Site Infection: (NQF #0753)ColonAbdominal Hysterectomy

Safety

MORT-30-AMI* Acute Myocardial Infarction (AMI) 30-day mortality rate (NQF #0230)

Clinical Care -- Outcomes

MORT-30-HF* Heart Failure (HF) 30-day mortality rate (NQF #0229)


continuedcontinued


Previously Adopted and New Measures for the FY 2017 Hospital VBP Program

Measure Description Domain

MORT-30-PN* Pneumonia (PN) 30-day mortality rate (NQF#0468)


AMI-7a* Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival (NQF #0164)

Clinical Care -- Process

IMM-2* Influenza Immunization (NQF #1659) Clinical Care -- Process

PC-01*** Elective Delivery Prior to 39 Completed Weeks Gestation (NQF #0469)

Clinical Care -- Process

MSPB-1* Medicare Spending per Beneficiary (NQF #2158) Efficiency and Cost Reduction

HCAHPS* Hospital Consumer Assessment of Healthcare Providers and Systems Survey (NQF #0166)

Patient and Caregiver Centered Experience of Care/Care Coordination

* measures readopted for the FY 2017 Hospital VBP Program** measure adopted for the FY 2017 Hospital VBP Program but not previously subject to automatic readoption*** measures adopted for the FY 2017 Hospital VBP Program

Previously Adopted and Proposed Performance Standards for the FY 2017 Hospital VBP Program: Safety, Clinical Care — Outcomes, Clinical Care — Process, and

Efficiency and Cost-Reduction Measures

Measure ID Description Achievement

Threshold Benchmark

Safety Measures

CAUTI Catheter-Associated Urinary Tract Infection

0.8371 0.0000

CLABSI Central Line-Associated Blood Stream Infection

0. 4483 0.0000

C. difficile Clostridium difficile Infection 0.7927 0.0000

MRSA bacteremia Methicillin-Resistant Staphylococcus aureus Bacteremia

0.8613 0.0000

PSI-90* Complication/patient safety for selected indicators

0.577321* 0.397051*

SSI Surgical Site Infection• Colon• Abdominal Hysterectomy

0.71170.7509

0.00000.0000

Clinical Care — Outcome Measures

MORT-30-AMI* Acute Myocardial Infarction (AMI) 30-day mortality rate*

0.851458* 0.871669*

MORT-30-HF* Heart Failure (HF) 30-day mortality rate*

0.881794* 0.903985*

MORT-30-PN* Pneumonia (PN) 30-day mortality rate*

0.882986* 0.908124*

continued


Previously Adopted and Proposed Performance Standards for the FY 2017 Hospital VBP Program: Safety, Clinical Care — Outcomes, Clinical Care — Process, and

Efficiency and Cost-Reduction Measures

Measure ID Description Achievement

Threshold Benchmark

Clinical Care — Process Measures


0.954545 1.000000

IMM-2 Influenza Immunization 0.995882 1.000000

PC-01 Elective Delivery Prior to 39 Completed Weeks Gestation

0.031250 1.000000

Efficiency and Cost Reduction Measure

MSPB-1 Medicare Spending per Beneficiary Median Medicare Spending per Beneficiary ratio across all hospitals during the performance period

Mean of the lowest decile Medicare Spending per Beneficiary ratios across all hospitals during the performance period

*previously adopted performance standards

Proposed Performance Standards for the FY 2017 Hospital VBP Program Patient and Caregiver-Centered Experience of Care/Care Coordination Domain

HCAHPS Survey Dimension FloorAchievement

Threshold Benchmark

Communication with Nurses 56.90% 78.08% 86.41%

Communication with Doctors 62.03% 80.43% 88.71%

Responsiveness of Hospital Staff 36.46% 64.83% 79.62%

Pain Management 49.47% 70.20% 78.18%

Communication about Medicines 42.89% 62.82% 73.15%

Hospital Cleanliness & Quietness 43.46% 65.26% 79.06%

Discharge Information 61.86% 85.59% 91.04%

Overall Rating of Hospital 35.00% 69.81% 84.27%

COMMENTThis is another section with extensive and complex material. CMS will add measures for FY 2018 and addresses possible VBP issues for FY 2019.

Scoring (Page 955) also is discussed, and tables are provided.

continued


Changes to the Hospital-Acquired Condition (HAC) Reduction Program (Refer Page 976)

Section 1886(p)(1) of the act specifies that the amount of payment shall be equal to 99 per-cent of the amount of payment that would otherwise apply to such discharges under Section 1886(d) or 1814(b)(3) of the act, as applicable.

The HAC Reduction Program payment adjustment will be applied after the application of the other program adjustments, including add-on payments consisting of outliers, DSH, uncom-pensated care and IME.

COMMENTThis is another complex discussion lasting some 79 pages.

Suggested Exceptions to the Two-Midnight Benchmark (Refer Page 1,209)

CMS issued regulations at § 412.3(e)(1) that, in addition to services designated as inpatient only, surgical procedures, diagnostic tests and other treatments are generally appropriate for inpatient hospital admission and payment under Medicare Part A when the physician (1) expects the beneficiary to require a medically necessary hospital stay that crosses at least two midnights and (2) admits the beneficiary to the hospital based on that expectation.

Although the FY 2015 IPPS/LTCH PPS proposed rule did not include any proposed regulatory changes relating to the two-midnight benchmark, CMS received numerous public comments on the current regulation.

Updates to the Reasonable Compensation Equivalent (RCE) Limits on Compensation for Physician Services Provided in Providers (§ 415.70) (Refer Page 1,253)

Set forth below are updated RCE limits on the amount of allowable compensation for services furnished by physicians to providers for cost reporting periods beginning on or after Jan. 1, 2015.

CY 2015 RCE LimitsTotal $211,500

General/Family Practice $179,000

Internal Medicine $197,500

Surgery $246,400

Pediatrics $169,700

OB/GYN $237,100

Radiology $271,900

Psychiatry $181,300

Anesthesiology $239,400

Pathology $260,300

CAHs (Refer Page 1,271)

Effective Oct. 1, 2014, a CAH that was previously located in a rural area but is now located in an urban area as a result of a new OMB labor market area delineation will continue to be treated as rural for two years from the date the OMB delineation is implemented.

continued


Any CAH affected by a new OMB delineation that is implemented in the FY 2015 IPPS/LTCH PPS final rule would be required to reclassify as rural by Sept. 30, 2016, to retain its CAH status after Sept. 30, 2016.

QUALITY DATA REPORTING REQUIREMENTS FOR SPECIFIC PROVIDERS AND SUPPLIERS (REFER PAGES 1,438 AND FOLLOWING)

Hospital IQR

CMS will remove five measures from the Hospital IQR Program for the FY 2017 payment determination and subsequent years that begin in the CY 2015 reporting period: (1) AMI-1 aspirin at arrival (NQF #0132); (2) AMI-3 ACEI/ARB for left ventricular systolic dysfunction (NQF #0137); (3) AMI-5 beta-blocker prescribed at discharge (NQF #0160); (4) SCIP Inf-6 appropriate hair removal; and (5) participation in a systematic database for cardiac surgery (NQF #0113).

In summary, for FY 2017 payment determination and subsequent years, CMS is finalizing (1) the adoption of 11 total measures — nine new measures (four of which are voluntary electronic clinical quality measures) and two previously removed measures readopted as voluntary electronic clinical quality measures, and (2) the removal of 19 measures (four of which were previously suspended), 10 of which are being retained as voluntary electronic clinical quality measures. CMS is not finalizing the removal of one of the required chart-abstracted measures (SCIP-Inf-4). This gives a total of 63 measures (47 required and 16 voluntary electronic clinical quality measures) in the Hospital IQR Program measure set.

The following table shows measures previously adopted for the Hospital IQR Program, including suspended measures.

Short Name Measure NameNQF

Number

Submission Methods for FY 2017 Payment Determination

New for FY 2017Payment Determination


NQF#0164

Electronic clinical quality measure or chart-abstracted REQUIRED

SCIP-Inf-4 Cardiac Surgery Patients With Controlled 6 A.M. Postoperative Blood Glucose

NQF#0300

Chart- abstracted only REQUIRED

Sepsis Severe sepsis and septic shock: management bundle

NQF#0500


New for FY 2017

Imm-2 Influenza Immunization NQF#1659


Stroke-1 Venous thromboembolism (VTE) prophylaxis

NQF#0434


ED-1 Median time from ED arrival to ED departure for admitted ED patients

NQF#0495


continued



Number



ED-2 Admit Decision Time to ED Departure Time for Admitted Patients

NQF#0497


Stroke-4 Thrombolytic therapy NQF#0437


Stroke-6 Discharged on statin medication NQF#0439

Electronic clinical quality measure or chart-abstractedREQUIRED

Stroke-8 Stroke education N/A Electronic clinical quality measure or chart-abstractedREQUIRED

VTE-1 Venous thromboembolism prophylaxis

NQF#0371


VTE-2 Intensive care unit venous thromboembolism prophylaxis

NQF#0372


VTE-5 VTE discharge instructions N/A Electronic clinical quality measure or chart-abstracted REQUIRED

VTE-6 Incidence of potentially preventable VTE

N/A Electronic clinical quality measure or chart-abstracted REQUIRED

PC-01 Elective delivery (Collected in aggregate, submitted via Web-based tool or electronic clinical quality measure)

NQF#0469


CLABSI National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure

NQF#0139


continued



Number



SSI American College of Surgeons – Centers for Disease Control and Prevention (ACS-CDC) Harmonized Procedure Specific Surgical Site Infection (SSI) Outcome MeasureColon procedures Hysterectomy procedures

NQF#0753

NHSN REQUIRED

CAUTI National Healthcare Safety Network (NHSN) Catheter- associated Urinary Tract Infection (CAUTI) Outcome Measure

NQF#0138

NHSN REQUIRED

MRSA National Healthcare Safety Network (NHSN) Facility- wide Inpatient Hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) Bacteremia Outcome Measure

NQF#1716

NHSN REQUIRED

CDI National Healthcare Safety Network (NHSN) Facility- wide Inpatient Hospital-onset Clostridium difficile Infection (CDI) Outcome Measure

NQF#1717

NHSN REQUIRED

HCP Influenza vaccination coverage among healthcare personnel (HCP)

NQF#0431 NHSN REQUIRED

MORT-30- AMI Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following acute myocardial infarction (AMI) hospitalization for patients 18 and older

NQF#0230

NHSN REQUIRED

MORT-30- HF Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following heart failure (HF) hospitalization for patients 18 and older

NQF#0229

Claims REQUIRED

MORT-30- PN Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following pneumonia hospitalization

NQF#0468

Claims REQUIRED

COPD Mortality

Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization

NQF#1893

Claims REQUIRED

STK Mortality Stroke 30-day mortality rate N/A Claims REQUIRED

continued



Number



CABG Mortality

Hospital 30-day, all-cause, risk-standardized mortality rate (RSMR) following coronary artery bypass graft (CABG) surgery

N/A Claims REQUIRED

New for FY 2017

READM-30- AMI

Hospital 30-day all-cause risk-standardized readmission rate (RSRR) following acute myocardial infarction (AMI) hospitalization

NQF#0505

Claims REQUIRED

READM-30- HF

Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following heart failure hospitalization

NQF#0330

Claims REQUIRED

READM-30- PN

Hospital 30-day, all-cause, risk-standardized readmission rate (RSRR) following pneumonia hospitalization

NQF#0506

Claims REQUIRED

READM-30- TH/TKA

Hospital-level 30-day, all- cause risk-standardized readmission rate (RSRR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)

NQF#1551

Claims REQUIRED

READM-30- HWR

Hospital-Wide All-Cause Unplanned Readmission (HWR)

NQF#1789

Claims REQUIRED

COPD READMIT

Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization

NQF#1891

Claims REQUIRED

STK READMIT 30-day risk standardized readmission rate (RSMR) following Stroke hospitalization

N/A Claims REQUIRED

CABG READMIT

Hospital 30-day, all-cause, unplanned, risk-standardized readmission rate (RSRR) following coronary artery bypass graft (CABG) surgery

N/A Claims REQUIRED

New for FY 2017

PSI 4 (PSI/NSI) Death among surgical inpatients with serious, treatable complications

NQF#0351

Claims REQUIRED

PSI 90 Patient safety for selected indicators (composite)

NQF#0531

Claims REQUIRED

continued



Number



MSPB Payment-Standardized Medicare Spending Per Beneficiary (MSPB)

NQF#2158

Claims REQUIRED

AMI Payment AMI Payment per Episode of Care

N/A Claims REQUIRED

HF Payment Hospital-level, risk- standardized 30-day episode- of-care payment measure for heart failure

N/A Claims REQUIRED

New for FY 2017

PN payment Hospital-level, risk- standardized 30-day episode- of-care payment measure for pneumonia

N/A Claims REQUIRED

New for FY 2017

Hip/knee complications

Hospital-level risk- standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)

NQF#1550

Claims REQUIRED

Registry Nursing Sensitive Care

Participation in a Systematic Clinical Database Registry for Nursing Sensitive Care

N/A Claims REQUIRED

Registry for General Surgery

Participation in a Systematic Clinical Database Registry for General Surgery

N/A Web-based REQUIRED

Safe Surgery Checklist

Safe Surgery Checklist Use N/A Web-based REQUIRED

HCAHPS HCAHPS + CTM-3 NQF#0166NQF#0228

Web-based REQUIRED

AMI-2 Aspirin Prescribed at Discharge for AMI

NQF#0142

Patient Survey REQUIRED

Voluntary electronic clinical quality measure

AMI-8a Primary PCI Received Within 90 Minutes of Hospital Arrival

NQF#0163

Electronic clinical quality measure


AMI-10 Statin Prescribed at Discharge NQF#0639



SCIP-Inf-1a Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision

NQF#0527



continued



Number



SCIP-Inf-2a Prophylactic Antibiotic Selection for Surgical Patients

NQF#0528



SCIP-Inf-9 Urinary catheter removed on Postoperative Day 1 (POD 1) or Postoperative Day 2 (POD 2) with day of surgery being day zero

NQF#0453



Stroke-2 Discharged on antithrombotic therapy

NQF#0435



Stroke-3 Anticoagulation therapy for atrial fibrillation/flutter

NQF#0436



Stroke-5 Antithrombotic therapy by the end of hospital day two

NQF#0438



Stroke-10 Assessed for rehabilitation NQF#0441



VTE-3 Venous thromboembolism patients with anticoagulation overlap therapy

NQF#0373



VTE-4 Patients receiving un- fractionated Heparin with doses/labs monitored by protocol

N/A Electronic clinical quality measure


PC-05 Exclusive Breast Milk Feeding and the subset measure PC-05a Exclusive Breast Milk Feeding Considering Mother s Choice

NQF#0480



EHDI-1a Hearing Screening Prior to Hospital Discharge

NQF#1354



CAC-3 Home Management Plan of Care (HMPC)Document Given to Patient/Caregiver

N/A Electronic clinical quality measure


HTN Healthy Term Newborn NQF#0716



COMMENTCMS’ discussion on the IQR system is extensive. The material for the hospital program begins on Page 1,438 and continues for more than 300 pages. Based on the number comments addressed by CMS, this material is of vital concern to hospitals.

CMS devotes another 150 pages to the cancer and LTCH quality reporting items.continued


The material includes discussions about the numerous measures and the rationale for their inclusion.

Many issues presented are critical, especially data reporting, time frames, validation aspects and weighting factors.

FINAL COMMENTS1. During the past few years, there has been both consternation and dismay by many states over an ACA amendment that reversed a CMS rule that would have set budget neutrality on a statewide basis when urban areas in a state have a lower wage index value than the statewide rural amount. The ACA requirement imposes such budget neutrality on a national basis. The reversal has been extremely beneficial in New England.

In FY 2014, CMS calculated that 60 hospitals would benefit from the Massachusetts rural floor, resulting in an estimated $167.6 million being received by Massachusetts’ hospitals via the national rural floor budget neutrality adjustment. In FY 2015, fewer Massachusetts hospitals, 51 hospitals, have been identified as benefitting from the rural floor, and the fiscal impact of national budget neutrality has been reduced.

The following is CMS’ FY 2015 estimate of the national budget neutrality calculations.

FY 2015 IPPS Estimated Payments Due to Rural Floor and Imputed Floor With National Budget Neutrality

StateNumber of Hospital

Number of Hospitals That

Will Receive the Rural Floor or Imputed Floor

Percent Change in Payments Due to Application of Rural Floor and Imputed Floor With Budget Neutrality

Difference(in millions)

Alabama 91 2 -0.5 -$8.4

Alaska 6 4 1.5 $2.2

Arizona 57 9 -0.1 -$1.9

Arkansas 45 0 -0.5 -$5.3

California 309 200 1.9 $188.8

Colorado 47 6 0.2 $2.3

Connecticut 31 8 -0.4 -$6.5

Delaware 6 0 -0.6 -$2.4

Washington, D.C. 7 0 -0.6 -$2.6

Florida 169 25 -0.3 -$18.6

Georgia 106 0 -0.5 -$13.3

Hawaii 12 0 -0.4 -$1.3

Idaho 14 0 -0.4 -$1.2

Illinois 127 0 -0.6 -$28.1

Indiana 91 0 -0.6 -$13.2

Iowa 34 0 -0.5 -$4.5

Kansas 53 0 -0.4 -$3.8

Kentucky 65 1 -0.5 -$7.9

Louisiana 100 0 -0.5 -$7.0

Maine 20 0 -0.5 -$2.5

Massachusetts 61 51 4.9 $155.6

Michigan 95 0 -0.5 -$22.9

Minnesota 51 0 -0.5 -$10.0

Mississippi 64 0 -0.5 -$5.3

continued


FY 2015 IPPS Estimated Payments Due to Rural Floor and Imputed Floor With National Budget Neutrality

StateNumber of Hospital

Number of Hospitals That

Will Receive the Rural Floor or Imputed Floor

Percent Change in Payments Due to Application of Rural Floor and Imputed Floor With Budget Neutrality

Difference(in millions)

Missouri 78 0 -0.5 -$11.2

Montana 12 4 -0.3 -$0.8

Nebraska 23 0 -0.4 -$2.6

Nevada 24 6 0.7 $4.6

New Hampshire 13 9 2.2 $10.5

New Jersey 64 15 0.1 $2.7

New Mexico 25 2 -0.2 -$0.7

New York 163 0 -0.6 -$47.4

North Carolina 87 0 -0.5 -$15.8

North Dakota 6 1 -0.3 -$0.9

Ohio 135 10 -0.4 -$16.9

Oklahoma 86 2 -0.5 -$5.7

Oregon 33 0 -0.5 -$4.7

Pennsylvania 154 10 -0.5 -$23.3

Puerto Rico 52 11 0 -$0.1

Rhode Island 11 4 0.5 $1.9

South Carolina 55 7 -0.3 -$5.0

South Dakota 19 0 -0.3 -$1.1

Tennessee 98 16 -0.2 -$5.6

Texas 324 6 -0.5 -$30.3

Utah 33 2 -0.4 -$2.2

Vermont 6 0 -0.3 -$0.7

Virginia 79 1 -0.5 -$12.0

Washington 49 8 -0.2 -$3.0

West Virginia 30 2 -0.4 -$3.1

Wisconsin 65 0 -0.5 -$8.6

Wyoming 11 0 -0.2 -$0.3

2. The major factor for the expected decrease in overall IPPS payments is the result of significant reductions in the amount of Medicare DSH. The legislative intent to reduce DSH payments hinges on the increase in insured individuals.

3. Below is an analysis that compares the current MS-DRG (FY 2014) weights to those for FY 2015 for all MS-DRGs having 100,000 or more discharges.

continued


LIST OF MEDICARE SEVERITY DIAGNOSIS-RELATED GROUPS (MS-DRGS), RELATIVE WEIGHTING FACTORS—FY 2015 Proposed Rule

MS-DRG MS-DRG Title

Final FY 2015 Weights

FY 2014 Weights

PercentageChange

065 INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC OR TPA IN 24 HRS

1.0643 1.0776 -1.23%

189 PULMONARY EDEMA & RESPIRATORY FAILURE 1.2136 1.2184 -0.39%

190 CHRONIC OBSTRUCTIVE PULMONARY DISEASE W MCC

1.1743 1.1708 0.30%

191 CHRONIC OBSTRUCTIVE PULMONARY DISEASE W CC 0.9370 0.9343 0.29%

193 SIMPLE PNEUMONIA & PLEURISY W MCC 1.4491 1.4550 -0.41%

194 SIMPLE PNEUMONIA & PLEURISY W CC 0.9688 0.9771 -0.85%

247 PERC CARDIOVASC PROC W DRUG-ELUTING STENT W/O MCC

2.0586 2.0408 0.87%

291 HEART FAILURE & SHOCK W MCC 1.5097 1.5031 0.44%

c292 HEART FAILURE & SHOCK W CC 0.9824 0.9938 -1.15%

309 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W CC

0.7865 0.7867 -0.03%

310 CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC

0.5493 0.5512 -0.34%

312 SYNCOPE & COLLAPSE 0.7423 0.7228 2.70%

378 G.I. HEMORRHAGE W CC 1.0021 1.0029 -0.08%

392 ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC

0.7388 0.7395 -0.09%

470 MAJOR JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY W/O MCC

2.1137 2.1463 -1.52%

603 CELLULITIS W/O MCC 0.8447 0.8404 0.51%

641 MISC DISORDERS OF NUTRITION,METABOLISM,FLUIDS/ELECTROLYTES W/O MCC

0.7051 0.6992 0.84%

682 RENAL FAILURE W MCC 1.5194 1.5401 -1.34%

683 RENAL FAILURE W CC 0.9512 0.9655 -1.48%

690 KIDNEY & URINARY TRACT INFECTIONS W/O MCC 0.7794 0.7693 1.31%

871 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W MCC

1.8072 1.8527 -2.46%

872 SEPTICEMIA OR SEVERE SEPSIS W/O MV 96+ HOURS W/O MCC

1.0582 1.0687 -0.98%

These 22 MS-DRGs account for approximately 36.2 percent of the nearly 10 million MS-DRG discharges.

Most are declining and will negatively affect case-mix and payment.

Analysis provided for MHA by Larry Goldberg,

Goldberg Consulting

Documents

Issue Brief - MHAweb.mhanet.com/Issue_Brief_CMS_Releases_Final_Rule... · ISSUE BRIEF | CMS Releases Final Rule For FY 2015 IPPS, LTCH PPS 1 4712 Country Club Drive Jefferson City,