On November 27, 2013, the Centers for Medicare & Medicaid Services (CMS) finalized the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) rules updating Medicare payment policies and rates for hospital outpatient and ASC services beginning January 1, 2014. Total CY 2014 OPPS payments are projected to increase by $4.4 billion or 9.5 percent, and CY 2014 Medicare payments to ASCs are projected to increase by approximately $143 million or 5.3 percent as compared to CY 2013.
The final rule updates the OPPS market basket by 1.7 percent for CY 2014; the ASC payments update is 1.2 percent. The annual update is reduced by two percent for ASCs that fail to meet ASC Quality Reporting Program requirements.
The final rule expands the categories of related items and services packaged into a single payment for a primary service under the OPPS. When the OPPS began in 2000, the payment system provided for the packaging of a limited number of items and services, such as anesthesia and surgical supplies. CMS expanded the categories of packaged items and services in 2008 and 2009 by adding a number of additional categories, including image processing services and implantable biologicals. CMS had proposed to package an additional seven categories of services for 2014. However, based on public comments, CMS decided not to finalize packaging of two of the seven proposed categories. This final rule with comment period expands the categories of packaged items and services by adding five additional categories of supporting services. In addition to packaging these five categories, CMS proposed to create 29 comprehensive APCs to replace 29 existing device-dependent APCs for 2014. After considering public comment, CMS is finalizing this policy with a delayed implementation date of CY 2015.
In addition, the final rule streamlines the current five levels of outpatient clinic visit codes, replacing them with a single Healthcare Common Procedure Coding System (HCPCS) code describing all clinic visits. A single code and payment for clinic visits is more administratively simple for hospitals and better reflects hospital resources involved in supporting an outpatient visit. The current five levels of outpatient visit codes are designed to distinguish differences in physician work. However, the final rule does not finalize the proposal to replace the current five levels of codes for each type of emergency department visits. CMS intends to consider options to improve the codes for these services in future rulemaking.
The rule also finalizes the proposal to continue paying at ASP+6 percent for non-pass-through drugs and biologicals that are payable separately under the OPPS.
The rule finalizes the proposal to update the two payment rates for community mental health centers and the two payment rates for hospital-based PHPs (partial hospitalization programs). For community mental health centers, the final CY 2014 geometric mean per diem cost for Level I (three services) is $99 and for Level II (four or more services), $112. For hospital-based PHPs, the final CY 2014 geometric mean per diem cost is $191 for Level I and $214 for Level II.
The rule finalizes four new measures for the Outpatient Quality Reporting (OQR) program, affecting the payment determination for CY 2016 and subsequent years, with data collection beginning in CY 2014:
- Influenza Vaccination Coverage among Healthcare Personnel
- Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average-Risk Patients.
- Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use
- Cataracts: Improvement in Patient’s Visual Function Within 90 Days Following Cataract Surgery
The final rule also removes two measures for the CY 2015 payment determination and subsequent years:
- Transition Record with Specified Elements Received by Discharged ED Patients
- Cardiac Rehabilitation Measure: Patient Referral from an Outpatient Setting
These final rules were published in the December 10 Federal Register and may be accessed here: https://federalregister.gov/a/2013-28737