CMS Proposes OPPS/ASC Policy and Payment Changes for 2015
As they do every year about this time, the Centers for Medicare & Medicaid Services (CMS) issued, July 3, hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) payment system policy changes and payment rates in a proposed rule (CMS-1613-P).
There are no big surprises in this proposed rule. For the most part, CMS is using the 2015 OPPS/ASC proposed rule as a vehicle to implement, revise, or correct a number of provisions finalized in the 2014 OPPS/ASC final rule.
OPPS/ASC Payment Update
CMS proposes to increase OPPS payment rates by an Outpatient Department (OPD) fee schedule increase factor of 2.1 percent, and proposes to increase ASC payment system payment rates by 1.2 percent.
As in the past, hospitals failing to meet the hospital quality reporting requirements will receive a 2.0 percentage point reduction in payments. A 7.1 percent adjustment to OPPS payments (exclusions exist) to certain rural sole community hospitals will continue, and a target payment-to-cost ratio of 0.89 will continue to be applied to payments made to cancer hospitals. CMS estimates a -1.6 percent decrease in 2015 payments to community mental health centers (CMHCs) relative to 2014 payments.
Proposed payment for the acquisition and pharmacy overhead costs of separately payable drugs and biologicals that do not have pass-through status would be set at the statutory default of average sales price (ASP) plus 6 percent.
Ambulatory Payment Classification (APC) Changes
In the 2014 OPPS/ASC final rule, CMS adopted a Comprehensive-APC policy, to be implemented in 2015. In this 2015 OPPS/APC proposed rule, CMS proposes several additional C-APCs, for a total of 28 (see TABLE 7—CY 2015 PROPOSED COMPREHENSIVE APCs).
In an attempt to “clean house,” CMS also proposes to:
- Convert APC 0067 (Single Session Cranial Stereotactic Radiosurgery) and APC 0351 (Level V Intraocular Surgery) into C-APCs.
- Assign the CPT® codes for IORT (77424 and 77425) to C-APC 0648 (Level IV Breast and Skin Surgery).
- Combine C-APCs 0082, 0083, 0104, 0319, and 0656 to form three proposed levels of comprehensive endovascular procedure APCs: C-APC 0083 (Level I Endovascular Procedures); C-APC 0229 (Level II Endovascular Procedures); and C-APC 0319 (Level IV Endovascular Procedures).
- Combine C-APCs 0089, 0090, 0106, 0654, 0655, and 0680 to form three proposed levels of C-APCs within a broader series of APCs for pacemaker implantation and similar procedures as follows: APC 0105 (Level I Pacemaker and Similar Procedures), a noncomprehensive APC; C-APC 0090 (Level II Pacemaker and Similar Procedures); C-APC 0089 (Level III Pacemaker and Similar Procedures); and C-APC 0655 (Level IV Pacemaker and Similar Procedures).
- Delete the clinical family for Event Monitoring with a single CPT® code 33282, and reassign CPT® code 33282 to C-APC 0090.
- Make two levels instead of three for Urogenital Procedures, and to reassign several codes from APC 0195 to C-APC 0202 (Level V Female Reproductive Procedures).
- Rename the arthroplasty family of APCs to Orthopedic Surgery, and reassign several codes from APC 0052 to C-APC 0425, and rename them “Level V Musculoskeletal Procedures Except Hand and Foot.”
- Create three levels of electrophysiologic procedures, using the current inactive APC “0086” instead of APC 0444, to have consecutive APC grouping numbers for this clinical family and renaming APC 0086 “Level III Electrophysiologic Procedures,” and to replace composite APC 8000 with proposed C-APC 0086.
- Create three new clinical families: Gastrointestinal Procedures (GIXXX) for gastrointestinal stents, Tube/Catheter Changes (CATHX) for insertion of various catheters, and Radiation Oncology (RADTX), which would include C-APC 0067 for single session cranial SRS.
Quality Reporting Modifications
CMS is proposing to exclude measure OP-31 (Cataracts: Improvement in Patient’s Visual Function with 90 Days Following Cataract Surgery) from the 2016 payment determination measure set), and to remove three measures for the 2017 payment determination and subsequent years: OP-4 (Aspirin at Arrival), OP-6 (Timing of Antibiotic Prophylaxis), and OP-7 (Prophylactic Antibiotic Selection for Surgical Patients).
CMS is also proposing to adopt one new claims-based measure into the OQR program for the 2017 payment determination and subsequent years: OP-32 (Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy.
Note: CMS corrects a typographical error in this proposed rule: The first deadline for hospitals to submit NHSN HAI measure data is October 1, 2014, not October 1, 2015.
Newly Packaged Items and Services
For 2015, CMS proposes conditional packaging of all ancillary services assigned to APCs with a geometric mean cost of $100 or less. Exceptions exist for preventive services, psychiatry-related services, and drug administration services.
Off-campus, Provider-based Departments
CMS proposes to begin collecting data on services furnished in off-campus, provider-based departments beginning in 2015.
Hospital Outpatient Outlier Payments
CMS proposes that for a hospital to receive an outlier payment under the OPPS, the cost of a service must exceed the multiple threshold of 1.75 times the APC payment rate and exceed the 2015 fixed dollar threshold of the APC payment plus $3,100.
Proposed Treatment of New HCPCS and CPT® Codes
CMS is soliciting public comments on the proposed APC and status indicator assignments, where applicable, for the new HCPCS Level II codes listed in Table 15 of the 2015 OPPS/ASC proposed rule. The proposed payment rates for these codes, where applicable, can be found in Addendum B to this proposed rule.
CMS is also soliciting public comments on the proposed 2015 status indicators, APC assignments, and payment rates for the HCPCS Level II codes and the Category III CPT® codes that were made effective April 1, 2014, and July 1, 2014. These codes are listed in Tables 15, 16, and 17 of the 2015 OPPS/ASC proposed rule.
Commenting instructions can be found in the proposed rule, available on The Office of the Federal Register website.