2018 QPP and MPFS Final Rules Released

November 2017~

On November 1, CMS released final rules for the 2018 Medicare Physician Fee Schedule (MPFS) and the Quality Payment Program (QPP). The rules, scheduled to take effect January 1, 2018, address changes within the fee schedule as well as other Medicare Part B payment policies, such as changes to the Medicare Shared Savings Program and both rules include a number of substantial changes to reimbursement.

MPFS Final Rule

  • Site-Neutral Payment Rule
    • A PFS Relativity Adjuster of 40% has been adopted for CY 2018. Payment for items and services furnished by nonexcepted PBDs will be reimbursed at a rate of 40% of the applicable OPPS rate for CY 2018. CMS noted that it will have a full year of data (CY 2017) available when it undertakes PFS rate setting for CY 2019 and that it intends to use that data to ensure that Medicare payment to hospitals billing for nonexcepted items and services furnished by nonexcepted off-campus PBDs under the PFS would reflect the relative resources involved in furnishing the items and services relative to other PFS services.
    • CMS states that the “adjustment will provide a more level playing field for competition between hospitals and physician practices by promoting greater payment alignment.”
  • Payment for Biosimilar Biological Products under Part B
    • Biosimilar products under Medicare Part B will be separately coded and reimbursed in 2018. Newly approved biological biosimilar products with a common reference product will not be grouped into the same billing code.
    • CMS noted that “a solution that increases provider and patient choice is superior to existing policy and may lead to additional cost savings over the long-term,” officials wrote. “By encouraging innovation and greater manufacturer participation in the marketplace, we believe that this policy change will result in the licensing of more biosimilar products, thus creating a stable and robust market, driving competition and decreasing uncertainty about access and payment.”
  • Medicare Shared Savings Program
    • Changes to the ACO beneficiary assignment methodology, changes to quality reporting requirements, relaxed application submission requirements, changes to TIN exclusivity rules and modifications regarding how the calculation of MSSP payments will interact with other CMS demonstration projects.
  • Medicare Diabetes Prevention Program
    • Changes to the MDPP in the PFS Final Rule, including the delay of effective date of MDPP services in order to permit MDPP suppliers sufficient time to enroll, changes to the set of MDPP services and changes related to beneficiary eligibility.

OPPS Final Rule

  • 340B Reimbursement
    • CMS will pay for separately payable, nonpass-through drugs and biologicals (other than vaccines) purchased through the 340B Program at the average sales price (ASP) minus 22.5% (rather than ASP plus 6%). Rural Sole Community Hospitals, PPS-exempt Cancer Hospitals, and Children’s Hospitals will be excepted from this policy for CY 2018. Drugs not purchased under the 340B drug program will continue to be paid for at a rate of ASP plus 6%.
    • CMS says it is implementing this policy “in a budget neutral manner by offsetting the projected decrease in drug payments of $1.6 billion by redistributing an equal amount for non-drug items and services across the OPPS.”
  • Site of Service Price Transparency
    • The Medicare inpatient-only (IPO) list includes procedures that are typically only provided in the inpatient setting and therefore are not paid under the OPPS. Each year, CMS uses established criteria to review the IPO list and determine whether or not any procedures should be removed from the list. For CY 2018, total knee arthroplasty is being removed from the IPO list as well as five other procedures and one procedure will be added to the IPO list. In addition, CMS is precluding the Recovery Audit Contractors from conducing “site of service” reviews of outpatient total knee arthroplasty procedures for a period of two years.
    • CMS anticipates that the website and additional subregulatory guidance will be made publicly available in early 2018.
  • Supervision of Outpatient Therapeutic Services in Critical Access Hospitals (CAHs) and Small Rural Hospitals
    • CMS has extended its non-enforcement instruction for Medicare Administrative Contractors (MACs) to not evaluate or enforce direct supervision requirements for therapeutic services provided to outpatients in CAHs and small rural hospitals with 100 or fewer beds.
  • Laboratory 14-Day Rule
    • New exception added to the 14-Day Rule that will enable laboratories performing Criterion (A) ADLTs and molecular pathology tests excluded from the OPPS packaging policy to bill Medicare directly for those tests instead of requiring them to seek payment from the hospital for tests ordered within 14 days of a patient’s discharge if the specimen was collected from a hospital outpatient during a hospital outpatient encounter and the test was performed following the patient’s discharge from the outpatient department.
  • Hospital Outpatient Quality Reporting (OQR) Program
    • Delay the mandatory implementation of the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey (OAS CAHPS) under the Hospital OQR Program beginning with the CY 2018 data collection.
    • Removal of 6 measures intended to balance the value of quality data with efforts to limit provider burden, resulting in a burden reduction of 457,490 hours and $16.7 million with respect to requirements for the CY 2020 payment determination. Measures to be removed include:
      • OP-21: Median Time to Pain Management for Long Bone Fracture, which measures the median time from emergency department (ED) arrival to time of initial oral, nasal, or parenteral pain medication (opioid and non-opioid) administration for emergency department patients with a principal diagnosis of long bone fracture.
      • OP-26: Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures, which assesses the aggregate count of selected, higher volume, surgical procedures performed in Hospital Outpatient Departments.
      • OP-1: Median Time to Fibrinolysis, which assesses the median time from ED arrival to administration of fibrinolytic therapy in ED patients with ST-segment elevation on the ECG performed closest to ED arrival and prior to transfer.
      • OP-4: Aspirin at Arrival, which assesses the rate of patients with chest pain or possible heart attack who received aspirin within 24 hours of arrival or before transferring from the emergency department.
      • OP-20: Door to Diagnostic Evaluation by a Qualified Medical Professional, which assesses the time from ED arrival to provider contact for emergency department patients.
      • OP-25: Safe Surgery Checklist Use, which assesses whether a hospital employed a safe surgery checklist that covered each of the three critical perioperative periods (prior to administering anesthesia, prior to skin incision, and prior to patient leaving the operating room) for the entire data collection period.

For more information on these rules, see the MPFS Fact Sheet and QPP Fact Year 2 Sheet.

Source(s): CMS Press Release; 2018 Medicare Physician Fee Schedule (MPFS) Final RuleQuality Payment Program (QPP) Final Rule; MPFS Fact Sheet;  QPP Fact Year 2 Sheet; Modern Healthcare; Healthcare Information and Management Systems Society (HIMSS); Medscape;
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