October 24, 2012

Marilyn Tavenner
Acting Administrator
The Centers for Medicare & Medicaid Services
Department of Health and Human Services
200 Independence Avenue, S.W., Room 445-G
Washington, DC 20201

Submitted via email to HOPSupervisionComments@cms.hhs.gov

RE: CMS’ Preliminary Decisions on the Recommendations of the Hospital Outpatient Payment Panel on Supervision Levels for Select Services

Dear Ms. Tavenner:

The Hospital & Healthsystem Association of Pennsylvania (HAP), on behalf of its members, more than 225 acute and specialty hospitals and health systems, appreciates the opportunity to comment on recommendations from the Centers for Medicare & Medicaid Services’ (CMS) Hospital Outpatient Payment (HOP) Panel on supervision levels for select services. HAP supports CMS’ decision to accept many of the panel’s recommendations, which allow for general supervision; however, HAP has concerns regarding some of the recommendations that CMS has rejected, which HAP believes could jeopardize clinical care and oversight that truly is necessary for high-quality patient care and safety.

Areas of Agreement

The HOP Panel recommended that the following services could be conducted under general supervision in accordance with the applicable Medicare regulations and policies. HAP agrees with this recommendation, as these services usually do not require the immediate availability of the supervising physician or appropriate non-physician practitioner. HAP appreciates these changes, as several of them will contribute to improved patient access in areas of Pennsylvania where the availability of qualified practitioners is limited.

HCPCS code G0008: Administration of influenza virus vaccine.
HCPCS code G0009: Administration of pneumococcal vaccine.
HCPCS code G0010: Administration of hepatitis B vaccine.
HCPCS code G0127: Trimming of dystrophic nails, any number.
CPT code 11719: Trimming of nondystrophic nails, any number.
CPT code 36000: Introduction of needle or intracatheter, vein.
CPT code 36591: Collection of blood specimen from a completely implantable venous access device.
CPT code 36592: Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified.
CPT code 51702: Insertion of temporary indwelling bladder catheter; simple (e.g. Foley).
CPT code 51705: Change of cystostomy tube; simple.
CPT code 51798: Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging.
CPT code 96360: Intravenous infusion, hydration; initial 31 minutes to 1 hour.
CPT code 96361: Intravenous infusion, hydration; each additional hour (list separately in addition to code for primary procedure).
CPT code 96521: Refilling and maintenance of portable pump.
CPT code 96523: Irrigation of implanted venous access device for drug delivery systems.

Areas of Disagreement

HAP is concerned and disagrees with the following areas where CMS rejected the panel’s recommendation to allow these areas to be conducted under general supervision. CMS’ rejection of the panel’s recommendation will unnecessarily restrict patient access in areas, including rural communities of Pennsylvania, where the supply of physicians and non-physician practitioners is limited. A variety of factors contribute to this limited source of practitioners, but there certainly is no need for CMS to further restrict necessary care to the citizens, particularly in underserved areas. In these areas, highly trained staff provide high-quality care under general supervision using strict clinical protocols and procedures that are developed by physicians. The care is delivered in close communication with the treating physician and the non-physician practitioners, pursuant to state scope of practice.

HCPCS code G0379: Direct admission of patient for hospital observation care.
HCPCS code G9141: Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family).
CPT code 29580: Strapping; Unna boot.
CPT code 29581: Application of multi-layer compression system; leg (below knee), including ankle and foot.
CPT code 51700: Bladder irrigation, simple, lavage and/or instillation.
CPT code 96365: Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour.
CPT code 96366: Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (list separately in addition to code for primary procedure).
CPT code 96367: Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); additional sequential infusion of a new drug/substance, up to 1 hour (list separately in addition to code for primary procedure).
CPT code 96368: Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); concurrent infusion (list separately in addition to code for primary procedure).
CPT code 96372: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular.
CPT code 96374: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intravenous push, single or initial substance/drug.
CPT code 96375: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of a new substance/drug (list separately in addition to code for primary procedure).
CPT code 96376: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (list separately in addition to code for primary procedure).

HAP supports the American Hospital Association’s (AHA) recommendation to consider a different approach for assigning a level of supervision to the wide range of the drugs and conditions the codes represent. This would involve identifying the types of services where there could be a linkage, for example between the infusion and injection administration service codes and specific drug J codes. This would allow a distinction for low-risk drug-specific codes and for general supervision. A similar approach could be used for observation services where less complex diagnoses would be allowable under general supervision.

Additional Recommendations

HAP appreciates that CMS established this panel, and allowed for input on the supervision level of outpatient services, particularly recognizing the dire need for these services and the protection of existing services in rural areas. HAP joins AHA in suggesting the following improvements to the overall process to review:

• Provide more precise and explicit guidance on what constitutes an appropriate presentation; the type of data or evidence that meets CMS’ criteria; and instructions on how to submit a presentation to CMS.
• More prominently post and communicate information about the HOP Panel process, especially upcoming HOP Panel meetings and the related opportunity to testify, and CMS’ preliminary decisions regarding HOP Panel recommendations and the related 30-day opportunity for public comment.
• Immediately acknowledge via electronic response all presentations received, and communicate in a timely manner CMS’ decision regarding whether the hospital will be permitted to present at the HOP Panel meeting.
• Send the full set of materials to HOP Panel members at least seven business days before the meeting date so as to allow panelists sufficient time to adequately review the topics on which they will be expected to discuss and vote.

Again, HAP appreciates the opportunity to comment. If you have any questions about our comments and recommendations, please contact Kelly Thompson, HAP’s senior director, regulatory advocacy, at (717) 561-5325.

Sincerely,

PAULA A. BUSSARD
Senior Vice President,
Policy & Regulatory Services