Centers for Medicare and Medicaid Services

Department of Health and Human Services

Attention:  CMS-1404-P

P.O. Box 8013

Baltimore, MD  21244-1850

**Comments**

**for**

**The Centers for Medicare and Medicaid Services**

**File Code: CMS-1404-P**

**Regarding the July 18, 2008**

**42 CFR Parts 410 and 419**

**Medicare Program: Proposed Changes to Outpatient Prospective Payment
System and CY 2009 Payment Rates**

The following comments are provided regarding the proposed regulations
published in the Federal Register (FR) on July 3, 2008 to update the
hospital outpatient prospective payment system for CY 2009.

1.  Please see the attached table concerning the historic rates of OPPS
    Psychotherapy Services and Medication Management.

+-------------+-----------+-------------+--------------+-------------+
| **Rate      | **APC     | **APC 323** | **APC 324**  | ***APC***   |
| Year**      | 322**     |             |              |             |
|             |           |             |              | ***325***   |
+-------------+-----------+-------------+--------------+-------------+
| **2001**    | \$65.46   | \$91.75     | \$92.74      | *\$76.88*   |
+-------------+-----------+-------------+--------------+-------------+
| **2002**    | \$59.05   | \$88.57     | \$137.95     | *\$70.25*   |
+-------------+-----------+-------------+--------------+-------------+
| **2003**    | \$69.23   | \$96.91     | \$128.35     | *\$74.28*   |
+-------------+-----------+-------------+--------------+-------------+
| **2004**    | \$69.85   | \$101.97    | \$133.53     | *\$81.10*   |
+-------------+-----------+-------------+--------------+-------------+
| **2005**    | \$73.60   | \$100.23    | \$161.59     | *\$83.62*   |
+-------------+-----------+-------------+--------------+-------------+
| **2006**    | \$73.22   | \$97.59     | \$137.58     | *\$79.95*   |
+-------------+-----------+-------------+--------------+-------------+
| **2007**    | \$72.52   | \$104.90    | \$132.97     | *\$66.17*   |
+-------------+-----------+-------------+--------------+-------------+
| **2008**    | \$74.71   | \$102.19    | \$150.42     | *\$63.14*   |
+-------------+-----------+-------------+--------------+-------------+
| **P-2009**  | \$87.77   | \$107.72    | \$164.64     | *\$62.66*   |
+-------------+-----------+-------------+--------------+-------------+
| **% Change  | +19.9%    | +10.38%     | +19.66%      | *           |
| Since       |           |             |              | \<21.62%\>* |
| 2006**      |           |             |              |             |
+-------------+-----------+-------------+--------------+-------------+

> As detailed within the table above all psychotherapy APC's
> encompassing CPT Codes 90801 through 90806 have been reasonably
> consistently valued since 2005/2006 and as far back as 2001. The
> proposed rates for RY 2009 also are valued consistently from RY 2007,
> [with the major exception of Group Psychotherapy, CPT Codes 90853 and
> 90849 mapping to APC 325. The proposed rate of \$62.66 represents a
> proposed cumulative decrease from RY 2006 of 21.62%.]{.underline}
>
> The APC's listed above to include APC 325 are often utilized within
> Hospital Outpatient Psychiatric Treatment Services (OPTS) representing
> a range of services in a continuum of ambulatory psychiatric services.
> This range of services provides for the diagnosis and active treatment
> to individuals with mental disorders using a variety of modalities.
> Generally patients who need more than eleven (11) hours of psychiatric
> services per week are considered for PHP services rather than this
> OPTS level of care. The consequences of these continued rate
> reductions will be and are significant for the Hospital, its patients,
> and the community. The Hospital's mental health services are a
> significant part of the overall medical care of the community and of
> the 'safety net' for citizens with mental health disorders. State
> hospital closures and downsizing have reduced options for mental
> health care. The Medicare outpatient benefit has historically
> encouraged the treatment of patients in the community, so that
> psychiatric hospitalization can safely be avoided when clinically
> appropriate. Reduced availability of Hospital mental health services
> as a result of rate cuts can only worsen access to needed care for
> beneficiaries. ***In order for hospitals to maintain this important
> level of care, at a lesser cost when compared to inpatient psychiatry
> and partial hospitalization, it is recommended that CMS increase the
> rate for APC 325 Group Psychotherapy to \$93.25 which represents the
> average (16.65%) increase from RY 2006 to RY 2009 for the remaining
> psychotherapy APC's.***