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Final Payment Rules – Calendar Year (CY) 2022

November 9, 2021

On November 2, 2021, the Centers for Medicare & Medicaid Services (CMS) issued the final rules for Calendar Year (CY) 2022 Outpatient Prospective Payment System (OPPS), CY 2022 Physician Fee Schedule, and CY 2022 Home Health PPS.

KEY UPDATES FROM THE CY 2022 OPPS FINAL RULE:

CY 2022 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule (CMS-1753-FC).

OPPS & ASC Payment Rates

Both the OPPS and ASC payment rates for hospitals that meet applicable quality reporting requirements will be increased by 2.0 percent (2.7 percent less 0.7 percentage point productivity adjustment.

Price Transparency

Proposed Increase in Civil Monetary Penalties (CMP) for noncompliance will be scaled by bed size (range $109,500 to $2,007,500 per hospital). Smaller hospitals with 30 or fewer beds are subject to a fine equal to $300 per day. Hospitals with a bed count between 31-550 beds are subject to a fine between $310 to $550 per day with a maximum penalty $2,007,500. Hospitals with a bed count of 551 or greater beds, are subject to a fine equal to $2,007,500 per hospital.

CMS is also requiring machine-readable files are accessible for automated searches and direct downloads.

Toyon’s Take

These fines emphasize CMS’s push to provide public access to pricing information.

Use of CY 2019 Claims Data for CY 2022 OPPS/ASC Ratesetting

CMS believes the best available data for projecting expected cost and OPPS/ASC payment derives from calendar year 2019, prior to the COVID-19 Public Health Emergency (PHE). Conventionally, CMS would have used the most recent data (from 2020) for ratesetting.

Toyon’s Take

Toyon recommends providers regularly evaluate CY 2022 OPPS/ASC payments to ascertain the reasonableness of CMS’s projection that CY 2022 cost and volumes will be more reflective of 2019 levels as compared to 2020. When areas of the country “normalize” from COVID-19 PHE, then it is best to use data from prior to the outbreak to project CY 2022 OPPS/ASC payments. Notably, CY 2020 data may not be used in future rates.

Changes to the Medicare Inpatient Only (IPO) List

In CY 2022 CMS will add back all codes to the IPO list, except CPT codes 22630 (Lumbar spine fusion), 23472 (Reconstruct shoulder joint), 27702 (Reconstruct ankle joint) and their corresponding anesthesia codes. Also, the planned elimination of the IPO list will be put on hold until further notice. See this link.

Toyon’s Take

Requiring certain services as inpatient only is a noteworthy change in course from the CY 2021 OPPS/ASC final rule initially eliminating 298 services from the IPO list. CY 2021 was also scheduled to be year one of a three-year process to phase out the entire IPO list. However, CMS listened to stakeholder comments and agrees patient safety is the main concern. Medicare continuously desires to provide their beneficiaries a choice, therefore is using additional time to review procedures and outcomes of IPO services.

OPPS and 340B

CMS is continuing to pay hospitals 22.5 percent less the Average Sales Price (ASP) for select 340B drugs.

Click here for the link to the display copy of the OPPS/ASC final rule; the document is scheduled to be published in the federal register on 11/16/2021.

KEY UPDATES FROM THE CY 2022 PHYSICIAN FEE SCHEDULE FINAL RULE:

CY 2022 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule (CMS-1751-F).

Telehealth Expansion for Behavioral Health

The COVID-19 PHE shows gaps in healthcare delivery and the need for technology to treat patients, especially patients located in remote communities. CMS, in this rule, is eliminating barriers and will allow patients to access telehealth services in their homes, for the diagnosis, evaluation, and treatment of mental health disorders.

Medicare will also cover mental health visits in Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) through telehealth technologies, including audio only calls.

Increasing Access to Physician Assistants’ (PA) Services

CMS will institute a change that will authorize Medicare to make direct Medicare payments to Physician Assistants (PAs) for professional services they furnish under Part B. Beginning January 1, 2022 PAs are permitted to bill Medicare directly. This change allows greater access to care for Medicare beneficiaries.

Medicare Ground Ambulance Data Collection System

CMS finalized changes to the Medicare Ground Ambulance Data Collection System including:

Finalizing a new data collection period beginning between January 1, 2023, and December 31, 2023, and a new data reporting period beginning between January 1, 2024, and December 31, 2024, for selected ground ambulance organizations in year three;
Revising the timeline for when the payment reduction for failure to report will begin aligning the timelines for the application of penalties for not reporting data; and
Amending to the Medicare Ground Ambulance Data Collection Instrument. This will improve its clarity and make the instrument less burdensome to complete.

Click here for the link to the display copy of the Physician Fee Schedule; the document is scheduled to be published in the federal register on 11/19/2021.

KEY UPDATES FROM THE CY 2022 HOME HEALTH PPS FINAL RULE:

CY 2022 Home Health Prospective Payment System Rate Update Final Rule (CMS-1747-F & CMS-5531-F)

CY 2022 Updates to the Home Health (HH) PPS rates

The final rule updates CY 2022 Medicare Home Health (HH) payment rates by 2.6 percent and uses the latest Core-Based Statistical Area (CBSA) delineations as well as the latest available pre-reclassified hospital wage data under the Medicare IPPS.

CY 2022 Updates to Home Health Quality Reporting Program

The Home Health QRP is a program that reports quality data to CMS. All HHAs that do not meet reporting requirements receive a 2-percentage point reduction to their annual market basket percentage update for the respective calendar year. In this final rule the OASIS-based measure is removed as it did not demonstrate any meaningful difference in performance. Two claim-based measures will be replaced with a new measure that surrounding attribution and associated with desired patient outcomes.

CMS is finalizing its proposal that effective January 1, 2023, HHAs begin collecting data on the Transfer of Health Information to Provider-Post Acute Care measure, the Transfer of Health Information to Patient-PAC measure, as well as six categories of standardized patient assessment data elements, to support the coordination of care.

Click here for the link to the display copy of the Home Health PPS update; the document is scheduled to be published in the federal register on 11/9/2021

For questions regarding these rules, please contact Scott.Besler@toyonassociates.com.

Hospital OP PPS & ASC Proposed Rules – CY2017

July 6, 2016

From: Federal Register – CMS-1656-P; Filed 7/6/16; Publication 7/14/16

CMS Fact Sheet Excerpt:

On July 6, 2016, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2017 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System policy changes, quality provisions, and payment rates proposed rule (CMS-1656-P). CMS is proposing a number of outpatient prospective payment policies that will improve the quality of care Medicare patients receive.

A key proposal in this year’s rule is to implement Section 603 of the Bipartisan Budget Act of 2015, which will affect how Medicare pays for certain items and services furnished by certain off-campus outpatient departments of a provider (hereinafter referenced as off-campus “provider-based departments” (PBDs)). In addition, CMS has listened to concerns raised by health care providers on the patient experience survey questions about pain management and is proposing to remove the Pain Management dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for purposes of the Hospital Value Based Purchasing Program. In addition to the payment provisions and quality reporting program changes for the OPPS/ASC proposed rule, CMS is also proposing:

Several changes to the objectives and measures of the Medicare EHR Incentive Program. These changes are only applicable for eligible hospitals and critical access hospitals (CAHs) attesting under the Medicare EHR Incentive Program and would not impact eligible hospitals and CAHs attesting under a state’s Medicaid EHR Incentive Program.
To align the definition of “eligible death” and the aggregate donor yield metric in the Organ Procurement Organization (OPO) Conditions for Coverage (CfC) with those of the Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR), as well as revise the OPO CfC to reduce the amount of hard copy documentation that must be sent with the organ, as much of this information is now available to the transplant center electronically.

The OPPS proposed rule is one of several rules for CY 2017 that reflect a broader Administration-wide strategy to create a health care system that results in better care, smarter spending, and healthier people.

SECTION 603 OF THE BIPARTISAN BUDGET ACT OF 2015

Site Neutral Payments Provision (“Section 603”)

We are proposing to implement Section 603 of the Bipartisan Budget Act of 2015 (Pub. L. 114-74). This provision requires that certain items and services furnished by certain off-campus PBDs shall not be considered covered outpatient department services for purposes of OPPS payment and shall instead be paid “under the applicable payment system” beginning January 1, 2017. We make several proposals relating to which off-campus PBDs and which items and services are “excepted” from application of payment changes under this provision.

Excepted Items and Services – We propose that certain off-campus PBDs would be permitted to continue to bill for excepted items and services under the OPPS. Excepted items and services are:

All items and services furnished in a dedicated emergency department.
Items and services that were furnished and billed by an off-campus PBD prior to November 2, 2015.
Items and services furnished in a hospital department within 250 yards of a remote location of the hospital.

Service Expansions, Relocations, and Changes of Ownership

Service Expansion in an Excepted Off-Campus PBD – While excepted off-campus PBDs will be paid at OPPS rates for items and services furnished and billed as of November 2, 2015, CMS is proposing that additional items and services beyond those within the clinical families of services furnished and billed prior to that date will not be excepted services.
Relocation of Excepted Off-Campus PBDs – CMS is proposing that items and services must continue to be furnished and billed at the same physical address of the off-campus PBD as of November 2, 2015, in order for the off-campus PBD to be considered excepted from Section 603 requirements. CMS is proposing that an excepted off-campus PBD will lose its excepted status if it changes location. CMS is requesting comment on whether there should be exceptions to this proposal for extraordinary circumstances that are outside the control of the hospital.
Changes of Ownership of Excepted Off-Campus PBDs – CMS is proposing that if a hospital has a change of ownership and the new owners accept the existing Medicare provider agreement from the prior owner, the off-campus PBD may maintain its excepted status under the other rules outlined in this regulation.

Applicable Payment System – For CY 2017, CMS proposes the Medicare Physician Fee Schedule (MPFS) to be the “applicable payment system” for the majority of non-excepted items and services furnished in an off-campus PBD. Physicians furnishing such services would be paid based on the professional at the nonfacility rate under the MPFS for services which they are permitted to bill. We intend that this payment proposal would be a one-year transitional policy while we continue to explore operational changes that would allow an off-campus PBD to bill Medicare for its services under a Part B payment system other than the OPPS beginning in 2018. Provided it can meet all Federal and other requirements, a hospital would have the option of enrolling the non-excepted off-campus PBD as the provider/supplier it wishes to bill in order to meet the requirements of that payment system (such as an ASC or group practice).

For CY 2018, we are soliciting comments on regulatory and operational changes that we could make to allow a non-excepted off-campus PBD to bill and be paid for its non-excepted items and services under an applicable payment system (other than the OPPS). We seek other comments in implementation of this provision as well.

OTHER OPPS PAYMENT PROVISIONS

Proposed OPPS Payment Update

CMS proposes to update OPPS rates by 1.55 percent. The change is based on the projected hospital market basket increase of 2.8 percent minus both a 0.5 percentage point adjustment for multi-factor productivity (MFP) and a 0.75 percentage point adjustment required by law. After considering all other policy changes proposed under the OPPS, including estimated spending for pass-through payments, CMS estimates a 1.6 percent payment increase for hospitals paid under the OPPS in CY 2017.

Proposed Comprehensive Ambulatory Payment Classifications (C-APCs) for 2017

A C-APC is an APC that provides for an encounter-level payment for a designated primary procedure(s) and generally, all adjunctive and secondary services provided in conjunction with the primary procedure. There are currently 37 C-APCs, which mostly include procedures for the implantation of costly medical devices. For CY 2017, CMS is proposing 25 new C-APCs, many of which are major surgery APCs within the various existing C-APC clinical families. We are also proposing three new clinical families to accommodate new C-APCs including nerve procedures, excision, biopsy, incision and drainage procedures, as well as airway endoscopy procedures.

C-APC for Bone Marrow Transplants (BMT): In addition, CMS is proposing to develop a C-APC as well as a dedicated cost center for BMT. The creation of a new C-APC for BMT would allow all the costs for services on the same OPPS claim as a BMT to be packaged into the rate setting for the BMT. This would also allow for the payment for the BMT to be representative of payment for all services that are associated with the BMT procedure along with the BMT procedure itself.

Update of the ASC Payment System – January 2016

December 29, 2015

From: CMS MLN Articles – MM9484 -12/29/15

Provider Action Needed

Change Request (CR) 9484 informs MACs about changes to and billing instructions for various payment policies implemented in the January 2016 ASC payment system update. As appropriate, this notification also includes updates to the Healthcare Common Procedure Coding System (HCPCS). Make sure that your billing staff are aware of these changes.

Update of the ASC Payment System – January 2016

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