E2 Not paid by Medicare when submitted on outpatient claims (any outpatient bill type). We are finalizing with modification to define a Track Three for the RO Model, where Track One would be the same: it would include those Professional participants and Dual participants who follow all RO requirements, including CEHRT, and that we expect will qualify as an Advanced Alternative Payment Model (APM) and a Merit-Based Incentive Program (MIPS) APM. Beneficiaries will not be charged coinsurance on the additional 5% payment. In addition, for CY 2023, CMS is proposing to resume our usual process of using claims data from two years prior to the year to set rates for the calendar year; specifically, CY 2021 claims data for CY2023 OPPS rate setting. Payment Rates CMS proposed to use CY 2021 claims data for ratesetting for CY 2023 which follows the usual 2-year difference in data for ratesetting due to allowance for 1 -year of timely filing for billing. during an episode before treatment is complete, CMS will consider this an incomplete episode and RT services will be paid the traditional Medicare rate instead of being paid under the RO Model; The RO Model will include an extreme and uncontrollable circumstances policy. Under the outpatient prospective payment system, hospitals are paid a set amount of money (called the payment rate) to give certain outpatient services to people with Medicare. CMS is supporting organ procurement and research in this proposed rule. Federal government websites often end in .gov or .mil. On June 30, 2022 CMS published a rule proposing the Conditions of Participation (CoPs) for Rural Emergency Hospitals. MLN6922507 - Medicare Payment Systems - June 2023 An official website of the United States government. In accordance with Medicare law, CMS is proposing to update OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.7%. of these devices, and final determinations on whether the devices qualify (or continue to qualify) for transitional device pass-through status will be made in the CY 2023 OPPS/ASC final rule. In addition, CMS is soliciting comments on the use of remote behavioral health services for PHP patients during the COVID-19 PHE. Overarching Principles for Measuring Healthcare Quality Disparities Across CMS Quality Programs. The proposed policies will affect 3,411 hospitals and approximately 5,500 ASCs. Use of CY 2019 Claims Data for CY 2022 OPPS and ASC Payment System Ratesetting Due to the PHE. We are still evaluating how to apply the Supreme Courts recent decision to prior calendar years. However, due to a number of COVID-19 PHE-related factors, CMS believes that the CY 2020 data are not the best overall approximation of expected outpatient hospital services in CY 2022. The purpose of the provider enrollment process is to help confirm that providers and suppliers seeking to bill Medicare meet all federal and state requirements to do so. CMS Proposes Rule to Advance Health Equity, Improve Access to Care, and Promote Competition and Transparency, CY 2023 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule (CMS 1772-P), CMS OPPS/ASC Final Rule Increases Price Transparency, Patient Safety and Access to Quality Care, CY 2022 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule (CMS-1753-P), CMS Proposes Rule to Increase Price Transparency, Access to Care, Safety & Health Equity. Consistent with our typical practice, for CY 2023 we propose to use claims data from CY 2021. For qualifying biosimilar biological products for which payment is first made using ASP between October 1, 2022, through December 31, 2027, the 5-year period begins on the first day of the calendar quarter during which such payment is first made. In this rule, CMS seeks comment on if there is additional data that should be released to further promote transparency and competition, and if there are additional provider types where information regarding mergers, acquisitions, consolidations, and changes in ownership should be released to the public. Payment for ambulatory surgical center (ASC) services is also based on rates set under Medicare Part B. Section 1861(kkk)(7) of the Social Security Act, as added by section 125(a)(1)(B) of Division CC of the CAA, requires the Secretary to establish quality measurement reporting requirements for Rural Emergency Hospitals (REHs). https:// On December 28, 2022, the FDA revised theemergency use authorizationfor COVID-19 convalescent plasma with high titers of anti-SARS-CoV-2 antibodies. Rural Sole Community Hospital Exemption to the Clinic Visit Payment Policy. CMS is also proposing to align Hospital OQR Program patient encounter quarters for chart-abstracted measures to the calendar year for annual payment update (APU) determinations, and add a targeting criterion in the selection of hospitals for data validation, for hospitals withfewer than four quarters of data subject to validation, due to receiving an extraordinary circumstance exception for one or more quarters. This policy change was made to accommodate the unprecedented number of procedures being removed from the IPO list beginning in CY 2021 due to the elimination of the IPO list. It also specifically identified that hospital consolidation has left many areas, especially rural communities, without good options for convenient and affordable health care services, and that hospitals in consolidated markets charge far higher prices. Therefore, in accordance with section 11403 of the IRA, the OPPS and ASC addenda files will reflect the temporary increased amount for qualifying biosimilar biological products beginning with the October 2022 file. Under the final rule, rural sole community hospitals, childrens hospitals, and PPS-exempt cancer hospitals would continue to be excepted from this policy. In the CY 2022 OPPS/ASC proposed rule, CMS requested comment on whether any of the 258 procedures proposed for removal from the ASC CPL met the proposed reinstated criteria. Behavioral Health Services Furnished Remotely by Hospital Staff To Beneficiaries in Their Homes. In order to mitigate the impact of some of the temporary changes in hospitals' cost report data from CY 2020, CMS is proposing to use cost report data from the June 2020 Healthcare Cost Report Information System (HCRIS), which only includes cost report data through CY 2019, predating the PHE. Section 340B of the Public Health Service Act (340B) allows participating hospitals and other providers to purchase certain covered outpatient drugs from manufacturers at discounted prices. Using these revised criteria, CMS added 267 surgical procedures to the ASC CPL beginning in CY 2021. Discontinued Codes Not paid under OPPS or any other Medicare payment system. OPPS Transitional Pass-through Payment for Drugs, Biologicals, and Devices. After reviewing the public comments, we are not finalizing our original proposal to package HCPCS code P9099 into the associated primary procedure. CMS is committed to ensuring consumers have the information they need to make fully informed decisions regarding their health care. This includes 27 drugs and biologicals that CMS is using the equitable adjustment authority under section 1833(t)(2)(E), since CY 2019 rather than CY 2020 claims data is used to inform CY 2022 ratesetting, to provide up to four quarters of separate payment whose pass-through payment status will expire between December 31, 2021 and September 30, 2022. The final rule will also further the agencys commitment to strengthening Medicare and uses the lessons learned from the COVID-19 PHE to inform the approach to quality measurement, focusing on changes that will help to close the health equity gap. This includes, using the equitable adjustment authority under section 1833(t)(2)(E), since, The Radiation Oncology (RO) Model is designed to test whether making payments to. The calendar year (CY) 2023 Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System Proposed Rule is published annually and will have a 60-day comment period, which will end on September 13, 2022. Hospital Outpatient Prospective Payment System (OPPS) Guidance for the Hospital Outpatient Prospective Payment System (OPPS). Sign up to get the latest information about your choice of CMS topics in your inbox. CMS and the nations hospitals work collaboratively to publicly report hospital quality performance information on the Care Compare website located at, Care Compare displays hospital performance data in a consistent, unified manner to ensure the availability of credible information about the care delivered in the nations hospitals. SUBJECT: January 2021 Update of the Hospital Outpatient Prospective Payment System (OPPS) EFFECTIVE DATE: January 1, 2021 *Unless otherwise specified, the effective date is the date of service. The three codes that were proposed for removal and are being retained are CPT codes 0499T, 54650, and 60512. You must have file compression software on your computer in order to take advantage of the zipped format. You can decide how often to receive updates. Under this proposal, these payments would be provided biweekly as interim lump-sum payments to the hospital and would be reconciled at cost report settlement. Interested parties have indicated that they are still recovering from the COVID-19 PHE, and that the requirement to report ASC-11 would be burdensome due to national staffing and medical supply shortages, coupled with unprecedented changes in patient case volumes. Non-PHP Outpatient Behavioral Health Services Furnished Remotely to Partial Hospitalization Patients. Currently hospitals are required to report (1) three self-selected electronic clinical quality measures (eCQMs), and (2) the Safe Use of Opioids eCQM for the CY 2022 reporting period and subsequent years for the Hospital IQR Program and the Medicare Promoting Interoperability Program. This RUN applies to Chapter 4, section 50.8 (Annual Updates to the OPPS Pricer for Calendar Year (CY) 2007 and Later). Hospital price transparency helps people know what a hospital charges for the items and services it provides. CMS is also seeking comment on the future reimplementation of the Hospital Outpatient Volume on Selected Outpatient Surgical Procedures (OP26) measure or the future adoption of another volume indicator as a quality measure. The Overall Hospital Quality Star Rating was first introduced and reported on our Hospital Compare website in July 2016 (now reported on its successor website at https://www.medicare.gov/care-compare) and has been refreshed multiple times, with the most current refresh planned for 2022. The Outpatient Prospective and Ambulatory Surgical Center payment systems generally use the Medicare Average Sales Price Payment Methodology for biosimilars. In the CY 2021 OPPS/ASC final rule, CMS established a policy in which procedures removed from the IPO list beginning January 1, 2021 would be indefinitely exempted from certain medical review activities related to the two-midnight policy. PDF CY 2023 Hospital Outpatient Prospective Payment System (HOPPS) Final Interested parties have indicated that they are still recovering from the COVID-19 PHE, and that the requirement to report OP-31 would be burdensome due to national staffing and medical supply shortages, coupled with unprecedented changes in patient case volumes. CMS is finalizing its proposal to maintain the existing unified rate structure, with a single PHP Ambulatory Payment Classification (APC) for each provider type for days with three or more services per day. Hospital Outpatient PPS | CMS Sustaining a level of domestic production of National Institute for Occupational Safety and Health (NIOSH)-approved surgical N95 respirators would help to maintain that assurance. We are proposing to permit exceptions to the in-person visit requirement when the hospital clinical staff member and beneficiary agree that the risks and burdens of an in-person service outweigh the benefits of it, among other requirements. Catherine Howden, DirectorMedia Inquiries Form OPPS Payment for Drugs Acquired Through the 340B Program. charges for the items and services it provides. CMS believes that the CY 2020 cost report data are not the best overall approximation of expected outpatient hospital services, because half of the cost reports that typically would be used for CY 2023 rate setting have cost reporting periods that overlap with parts of the CY 2020 and would include data from the start of the PHE. Back to Glossary Index Its authorized for treatment of COVID-19 in patients with immunosuppressive disease or getting immunosuppressive treatment, in the outpatient or inpatient setting. Using the proposed hospital market basket update, CMS is proposing to update the ASC rates for CY 2023 by 2.7%. As a result, CMS is proposing to use CY 2021 claims data with cost report data through CY 2019 (prior to the PHE) to set CY 2023 OPPS and ASC payment system rates. Rural Emergency Hospital (REH) Provider Enrollment. ASCs that do not meet the programs reporting requirements receive a reduction of 2.0 percentage points in their annual fee schedule update. CMS continued this policy in CYs 2019 through 2022. Medicare Program: Hospital Outpatient Prospective Payment and CMS is also proposing that REHs may provide outpatient services that are not otherwise paid under the OPPS (such as services paid under the Clinical Lab Fee Schedule) as well as post-hospital extended care services furnished in a unit of the facility that is a distinct part of the facility licensed as a skilled nursing facility; however, these services will not be considered REH services and, therefore, will be paid under the applicable fee schedule for such services and will not receive the additional 5% payment increase that CMS proposes to apply to REH services. TMA has opted to exempt cancer and children's hospitals from . As with these other rules, CMS is publishing this final rule to meet the legal requirements to update Medicare payment policies for OPPS hospitals and ASCs on an annual basis. is intended to incentivize the meaningful use of certified electronic health record technology (CEHRT) by eligible hospitals and critical access hospitals (CAHs). In accordance with the Medicare statute, CMS is updating the CY 2022 OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.0 percent. Hospital Inpatient Quality Reporting (IQR) Program and Medicare Promoting Interoperability Program. On July 27, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS-1783-F) to update Medicare payment policies and rates for the Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) for fiscal year (FY) 2024. The discounts are 3.5 percent (Professional Component) and 4.5 percent (Technical Component); Brachytherapy is not included on the list of included modalities under the RO Model; it will, In cases where a beneficiary switches from traditional Medicare to Medicare Advantage. The Hospital Outpatient Prospective Payment System (HOPPS) is used by CMS to reimburse for hospital outpatient services. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. For the OPPS and ASC rate setting process, we use the best available data so that the payment rates accurately reflect estimates of the costs associated with furnishing outpatient services. The ASCQR Program requires ASCs to meet program requirements or receive a reduction of 2.0 percentage points in their annual fee schedule update. Also, you can decide how often you want to get updates. In the CY 2018 OPPS/ASC final rule with comment period, CMS reexamined the appropriateness of paying the average sales price (ASP) plus 6% for drugs acquired through the 340B Program, given that 340B hospitals acquire these drugs at steep discounts. However, CMS is still determining how it will remedy underpayments to hospitals following the 340B reimbursement cuts in 2018, but has instituted a -3. . We believe that not requiring an initial application, which generally takes longer for a Medicare Administrative Contractor (MAC) to process than a change of information application, would help expedite the CAH-to-REH conversion. In addition to proposing payment rates, this years rule includes proposals that align with several key goals of the Administration, including advancing health equity in rural areas, promoting competition in the health care system, and promoting safe, effective, and patient-centered care. In this proposed rule, we describe the proposed changes to the amounts and factors used to . Vizient has offered a statement in response to the Centers for Medicare and Medicaid Services (CMS) CY 2024 Outpatient Prospective Payment System (OPPS) Proposed Rule. Outpatient Prospective Payment System | ACS - The American College of For CY 2023, we are also seeking comments on the specific payment approach we might use for these services under the OPPS as SaaS-type technology becomes more widespread. In alignment with the proposal in the Hospital OQR Program, CMS is proposing to update the Cataracts: Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery (ASC-11) measure to be voluntary due to the ongoing COVID-19 public health emergency (PHE). Hospital Outpatient and Ambulatory Surgery Center Payment System Elizabeth Bowden MSN MBA RN CPHQ CPPS' Post - LinkedIn Policy Hospitals Share On November 1, 2022, the Centers for Medicare & Medicaid Services (CMS) finalized Medicare payment rates for hospital outpatient and ambulatory surgical center (ASC) services. 340B: As a result of the Supreme Court decision in favor of hospitals, CMS has restored the ASP + 6% rate for drugs purchased on the 340B program. The Proposed Rule addresses issues such as the enforcement of hospital price transparency requirements, 340B-acquired drugs and . Download the Guidance Document. CMS Proposes Rule to Advance Health Equity, Improve Access to Care, and Promote Competition and Transparency, CY 2022 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1753FC), CMS OPPS/ASC Final Rule Increases Price Transparency, Patient Safety and Access to Quality Care, CY 2022 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule (CMS-1753-P), CMS Proposes Rule to Increase Price Transparency, Access to Care, Safety & Health Equity. Hospital Outpatient Quality Reporting (OQR) Program. There has been a growing concern that closures of rural hospitals and critical access hospitals (CAHs) are leading to a lack of services for people living in rural areas. The Outpatient Prospective and Ambulatory Surgical Center payment systems generally use the Medicare Average Sales Price Payment Methodology for biosimilars. CMS continues to prioritize reducing unnecessary increases in the volume of certain covered outpatient department (OPD) services through the use of a prior authorization process. Outpatient prospective payment system Definition | Law Insider PDF CY2024 Medicare Proposed Rules Issued for Hospital Outpatient Specifically, CMS is clarifying that under the proposal, a hospital could bill for non-PHP outpatient services furnished to a PHP patient, including remote therapy services furnished by a hospital outpatient department. PDF Quick facts about payment for outpatient services for people with See asummary of proposed provisions. The Centers for Medicare & Medicaid Services (CMS) has released the calendar year (CY) 2024 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule. Rural Emergency Hospitals: Payment Policies. Final GENERAL INFORMATION This proposal would ensure Medicare beneficiaries receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in volume by virtue of improper payments without adding new documentation requirements for providers. In the CY 2023 OPPS/ASC proposed rule, CMS is proposing updates to the physician self-referral law for the new REH provider type. The final rule will be issued in early November. CMS is soliciting public comment on all. Since the beginning of the OPPS, CMS has maintained the Inpatient Only (IPO) list, which is a list of services that, due to their medical complexity, Medicare will only pay for when performed in the inpatient setting. This policy change was made to accommodate the unprecedented number of procedures being removed from the IPO list beginning in CY 2021 due to the elimination of the IPO list. The Hospital IQR Program is a pay-for-reporting quality program. This change in policy promotes transparency and ensures that any service removed from the IPO list has been reviewed against Medicares longstanding IPO list criteria to determine if it is appropriate for Medicare to pay for the provision of the service in the outpatient setting. Beginning January 1, 2018, Medicare adopted a policy to pay an adjusted amount of ASP minus 22.5 percent for certain separately payable drugs or biologicals acquired through the 340B Program. Access the below OPPS related information from this page. Significant and persistent inequities in healthcare outcomes exist in the United States. CMS is also proposing to address potential financial barriers to organ donation after cardiac death, which may increase organ procurement and promote equity within the transplant ecosystem. Providers and suppliers are required to enroll in Medicare to receive payments for services and items furnished to Medicare beneficiaries. The rule also outlines the information that would be collected on the cost report to determine payments under this proposal, which would apply to cost reporting periods beginning on or after January 1, 2023. In the CY 2021 OPPS/ASC final rule, CMS established a policy in which procedures removed from the IPO list beginning January 1, 2021 would be indefinitely exempted from certain medical review activities related to the two-midnight policy. This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for Calendar Year (CY) 2021 based on our continuing experience with these systems. The CMS created HOPPS to reduce beneficiary copayments in response to rapidly growing Medicare expenditures for outpatient services and large copayments being made by Medicare beneficiaries. Impacts for both policy options are included in the addenda to the proposed rule. The ASC Covered Procedures List (CPL) specifies the list of procedures that can be safely performed in an ASC. Outpatient Prospective Payment System TRICARE's Outpatient Prospective Payment System (OPPS) was implemented on May 1, 2009. We refer to these technologies as software as a service (SaaS). CMS is proposing changes, as well as requesting comment, for the Hospital Outpatient Quality Reporting (OQR), Ambulatory Surgical Center Quality Reporting (ASCQR), and Rural Emergency Hospital Quality Reporting (REHQR) Programs to further meaningful measurement and reporting for quality of care in the outpatient setting.