OPPS Proposed Rule Puts Site-neutral Payments on the Horizon

OPPS Proposed Rule Puts Site-neutral Payments on the Horizon

The long-awaited 2019 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) proposed rule, released July 25, sets the wheels in motion for significant reforms in the way Medicare will pay providers in hospital outpatient settings.

The Centers for Medicare & Medicaid Services (CMS) is moving toward site-neutral payments for clinic visits, which will save patients an estimated $150 million in co-pays for such services provided at off-campus hospital outpatient departments. CMS is also proposing to “close a potential loophole” through which providers are billing patients more for visits in hospital outpatient departments when they create new service lines. These and other reforms are meant to give patients more options on where to obtain care, and advance CMS’ goal for a patient-driven healthcare system that pays providers for value instead of volume.

Here is a summary of the major provisions in the proposed rule.

Control Unnecessary Increases in Utilization of Outpatient Services

CMS is proposing to control unnecessary increases in the volume of covered hospital outpatient department services by applying a Medicare Physician Fee Schedule (MPFS)-equivalent payment rate for the clinic visit services when provided at an off-campus provider-based department (PBD) and paid under the OPPS.

Add to ASC Covered Procedures List (CPL)

CMS is proposing to allow certain CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range to be included on the CPL, as well as proposing to add certain cardiovascular codes to the ASC CPL. CMS is proposing to review and reassess all procedures added to the CPL within the past three years.

Suggest Packaged Skin Substitutes Payments

CMS is proposing to continue its policy established this year to assign skin substitutes to the low-cost or high-cost group. The agency is also seeking comment on several ideas for how skin substitute products are paid under the OPPS.

Evaluate Technology Payment Policy for Low-volume Services

CMS is proposing that services assigned to New Technology Ambulatory Payment Classifications (APCs) with fewer than 100 claims annually would be paid under one of several alternative payment methodologies.

Revise Device Intensive Policy

CMS is proposing to lower the device threshold from 40 percent to 30 percent to further delineate device-intensive procedures (i.e., the device cost exceeds a certain threshold of the total cost of the procedure).

Apply 340B Drug Payment Policy to Non-excepted Off-campus PBDs

CMS is proposing to adopt a policy to pay Average Sales Price minus 22.5 percent for 340B-acquired drugs furnished by non-excepted off-campus PBDs. CMS is also seeking comment on how best to develop a model leveraging authority provided to the agency under the Competitive Acquisition Program (CAP) to strengthen negotiations for prescription drugs.

Reduce Provider Burden

In accordance with the Patients Over Paperwork initiative, CMS would reduce the number of measures ASCs and hospital outpatient departments are required to report under the ASC and Hospital Outpatient Quality Reporting Programs. CMS would remove 15 measures that are either duplicate, “topped out” (commonly performed), or more costly to report than they’re worth.

Hospital Outpatient Quality Reporting (OQR) program measures that would be removed are:

  • Chart-abstracted measures
    • Median Time to ECG (OP5)
  • Claims-based Measures
    • Mammography Follow-up Rates (OP9)
    • Thorax Computed Tomography (CT) Use of Contrast Material (OP11)
    • Simultaneous Use of Brain Computed Tomography (CT) and Sinus CT (OP14)
  • Web-based Tool Measures
    • The Ability for Providers with HIT to Receive Laboratory Data Electronically Directly into Their Qualified/Certified EHR System as Discrete Searchable Data (OP-12)
    • Tracking Clinical Results between Visits (OP-17)
    • Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients (OP-29)
    • Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps-Avoidance of Inappropriate Use (OP-30)
    • Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (OP-31)
  • Federal Data Registry Preventive Care Measures
    • Influenza Vaccination Coverage Among Healthcare Personnel (OP27)

ASC Quality Reporting (ASCQR) program measures that would be removed are:

  • Claims-based Measures
    • Patient Burn (ASC-1)
    • Patient Fall (ASC-2)
    • Wrong Site, Wrong Side, Wrong Procedure, Wrong Implant (ASC-3)
    • All-Cause Hospital Transfer/Readmission (ASC-4)
  • Web-based Tool Measures
    • Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients (ASC-9)
    • Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps-Avoidance of Inappropriate Use (ASC-10)
    • Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (ASC-11)
  • Federal Data Registry Preventive Care Measures
    • Influenza Vaccination Coverage Among Healthcare Personnel (ASC-8)

Update OPPS and ASC Payment Rates

Along with the proposed changes outlined above, CMS has to tend to its usual business of setting OPPS and ASC payment rates. CMS is proposing to update OPPS payment rates in 2019 by 1.25 percent and ASC rates by 2.0 percent.

As mentioned above, CMS is also proposing to pay for services in new clinical families of services furnished at excepted off-campus PBDs under the MPFS instead of the OPPS.

Promote and Get Paid for Non-opioid Drugs

To further address the opioid crisis, CMS is proposing to pay separately at ASP plus 6 percent non-opioid pain management drugs that function as a supply when used in a covered surgical procedure performed in an ASC. CMS is seeking feedback on whether other non-opioid alternatives for acute or chronic pain have evidence demonstrating that they lead to a decrease in opioid prescriptions and addiction.

Request for Information (RFI)

In addition to payment and policy proposals, CMS is seeking feedback on a number of topics:

Ambulatory Surgical Center CASCC

  • The possibility of revising Conditions of Participation related to interoperabilty as a way to increase electronic sharing of data by providers.
  • How best to develop a model leveraging authority provided to the agency under the Competitive Acquisition Program to reduce expenditures while maintaining or improving the quality of care furnished to patients. Specifically, CMS is looking for ways to design a potential model that tests private-sector, vendor-administered payment arrangements for certain separately payable Part B drugs and biologicals, including high-cost therapies.

The proposed rule with comment period (CMS-1695-P) can be downloaded from the Federal Register .

 

Renee Dustman

Renee Dustman

Executive Editor at AAPC
Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.
Renee Dustman

About Has 613 Posts

Renee Dustman, BS, AAPC MACRA Proficient, is an executive editor at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 20 years experience in print production and content management. Follow her on Twitter @dustman_aapc.

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