CMS Finalizes Medicare OPPS, ASC Rates and Policies for 2019
December 2018 ~
On November 2, CMS released the final 2019 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) rule.
Increasing Choices and Encouraging Site Neutrality
The final rule contains a number of policies that reduce payment differences between hospitals and ambulatory surgical centers so that patients may better benefit from high quality care at lower costs, while receiving care that is provided safely and is clinically appropriate.
Method to Control for Unnecessary Increases in Utilization of Outpatient Services
CMS finalized its policy to extend a site-neutral payment policy to off-campus PBDs for HCPCS code G0463 (clinic visit). In other words, the PFS rate of 40 percent of the OPPS rate will now apply to G0463 provided at an off-campus PBD. (CMS refers to this 40 percent rate as the PFS relativity adjuster.) This policy will not be done in a budget-neutral manner, meaning the savings will not be redistributed within the OPPS. In response to comments, CMS will phase this policy in over two years. In CY 2019, the payment reduction will be transitioned by applying 50 percent of the total reduction in payment that would apply if these departments were paid the site-specific PFS rate for the clinic visit service. So in CY 2019, payment will be reduced to 70 percent of the previous OPPS rate, and reduced fully to 40 percent of the OPPS rate in CY 2020.
ASC Covered Procedures List
For CY 2019, CMS is finalizing the proposal to include additional CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range on the CPL. As a result, CMS is finalizing its proposal to add twelve cardiovascular codes to the ASC CPL and adding five additional codes as a result of stakeholder comments the agency received. Additionally, CMS reviewed all procedures added to the ASC CPL within the past three years to reassess recent experience with the procedures in the ASC and to determine whether such procedures should continue to be on the ASC CPL. CMS is not finalizing any changes to the ASC CPL as a result of that review.
High Cost/Low Cost Threshold for Packaged Skin Substitutes
CMS is finalizing the proposal to continue the policy established in CY 2018 to assign skin substitutes to the low cost or high cost group. Additionally, CMS presented several payment ideas to change how skin substitute products are paid under the OPPS and solicited comments on these ideas to be used for future rulemaking.
New Technology Payment Policy for Low-Volume Services
CMS is finalizing the proposal 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. Specifically, CMS is finalizing the proposal to use up to four years of data to calculate the geometric mean, the median, and the arithmetic mean and to adopt through rulemaking the method that should be used to establish payment for the new technology service for the upcoming year, both for purposes of assigning the service to a new technology APC and ultimately, to a clinical APC.
Device Intensive Procedures
CMS finalized reducing the threshold in determining device intensive APCs from 40% to 30% to better recognize the cost of high price devices in the hospital outpatient and ASC settings
Device Pass-through Applications
CMS is approving the remedē® System Transvenous Neurostimulator for device pass-through payment status for CY 2019.
Policy to Apply 340B Drug Payment Policy to Nonexcepted Off-Campus Provider-Based Departments (PBDs)
Beginning January 1, 2018, Medicare pays an adjusted amount of ASP minus 22.5 percent for separately payable, nonpass-through drugs and biologicals that are acquired through the 340B Program by outpatient departments, including excepted off-campus PBDs of a hospital. In the CY 2019 OPPS/ASC final rule with comment period, CMS is finalizing a policy to pay ASP minus 22.5 percent for 340B-acquired drugs furnished by non-excepted off-campus PBDs paid under the Physician Fee Schedule.
Meaningful Measures/Patients Over Paperwork
This final rule will reduce the number of measures ASCs and hospital outpatient departments are required to report under the Ambulatory Surgical Center Quality Reporting and Hospital Outpatient Quality Reporting Programs. These removals are arrived at after a careful and holistic review of all current, required quality measures.
Hospital Outpatient Quality Reporting (OQR) Program
In the CY 2019 OPPS/ASC final rule, CMS is removing certain measures from the Hospital OQR Program. In the CY 2019 OPPS/ASC final rule, CMS is finalizing policies to:
- Update the Code of Federal Regulations to retain measures from a previous year’s Hospital OQR Program measure set for subsequent years’ measure sets.
- Update the Code of Federal Regulations to use the regular rulemaking process to remove a measure for circumstances that do not raise specific patient safety concerns.
- Update the Code of Federal Regulations to immediately remove measures as a result of patient safety concerns.
- Remove one quality measure beginning with the CY 2020 payment determination and seven quality measures beginning with the CY 2021 payment determination. CMS notes that it is not finalizing the proposals to remove the Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients (OP-29) and the Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (OP-31) measures.
- Extend the reporting period from one to three years for OP-32: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy beginning with the CY 2020 payment determination and for subsequent years.
- Update the Code of Federal Regulations the factors to be considered when removing measures from the program and codify measure removal policies.
- Change the frequency of the Hospital OQR Program Specifications Manual release beginning with CY 2019 and for subsequent years such that they will be released once every twelve months with addenda as necessary – a modification from what was proposed.
- Update requirements related to participation status, including removal of the Notice of Participation form for the for the CY 2020 payment determination.
Ambulatory Surgical Center Quality Reporting (ASCQR) Program
In the CY 2019 OPPS/ASC final rule, CMS is removing certain measures from the ASCQR Program. CMS is finalizing policies to:
- Remove one quality measure beginning with the CY 2020 payment determination and one quality measure beginning with the CY 2021 payment determination. CMS is not finalizing proposals to remove the Mammography Follow-up Rates (ASC-9) and Thorax Computed Tomography (CT) Use of Contrast Material (ASC-11).
- Extend the reporting period from one to three years for ASC-12: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy beginning with the CY 2020 payment determination and for subsequent years.
- Update the factors to be considered when removing measures from the program and update the Code of Federal Regulations to better reflect measure removal policies.
CMS is not finalizing its proposals to remove the following four ASCQR patient safety measures:
- (ASC-1) Patient Burns;
- (ASC-2) Patient Falls;
- (ASC-3) Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant; and
- (ASC-4) All-Cause Hospital Transfer/Admission.
CMS is retaining these measures in the ASCQR Program and suspending their data collection beginning with the CY 2021 payment determination until further action in rulemaking with the goal of updating the measures.
PPS-Exempt Cancer Hospital Quality Reporting (PCHQR) Program
In the FY 2019 IPPS/LTCH PPS final rule (83 FR 41613), CMS announced that it would defer a final decision on its proposed removal of two NHSN measures from the PCHQR Program in order to conduct additional data analyses to assess measure performance based on new information provided by the Centers for Disease Control and Prevention (CDC). In the CY 2019 OPPS/ASC final rule, CMS is not finalizing the removal of these two NHSN measures. The specific measures are:
- Catheter-Associated Urinary Tract Infection Outcome Measure (CAUTI) (NQF #0138)
- Central Line-Associated Bloodstream Infection Outcome Measure (CLABSI) (NQF #0139)
Updates to OPPS Payment Rates
In accordance with Medicare law, CMS is updating OPPS payment rates by 1.35 percent. This update is based on the hospital market basket increase of 2.9 percent minus both a 0.8 percentage point adjustment for multifactor productivity (MFP) and a 0.75 percentage point adjustment required by law.
Partial Hospitalization Program (PHP) Rate Setting
The CY 2019 OPPS/ASC final rule updates Medicare payment rates for PHP services furnished in hospital outpatient departments and Community Mental Health Centers (CMHCs). The PHPs are structured intensive outpatient programs consisting of a group of mental health services paid on a per diem basis under the OPPS, based on PHP per diem costs.
Update to PHP Per Diem Rates
The CY 2019 OPPS/ASC final rule maintains the methodology established in CY 2017, which implemented a unified rate structure with a single PHP APC for each provider type for days with 3 or more services per day. In establishing the final rates for CY 2019, CMS used CY 2017 claims data to calculate the CMHC and hospital-based PHP (HB PHP) geometric mean per diem costs, consistent with existing regulations.
Proposed Update to the PHP APC Code Set
New, revised, and deleted CY 2019 Category I and III CPT codes were included in Addendum B of the CY 2019 OPPS/ASC proposed rule for the 2019 OPPS update. While PHP is a part of the OPPS, PHP providers may not have seen those proposed changes because CMS did not also include them in the PHP section of the proposed rule. As a result, the CY 2019 OPPS/ASC final rule includes proposals to delete six existing codes from the PHP allowable code set for CMHC APC 5853 and hospital-based PHP APC 5863, and to replace them with nine new codes starting January 1, 2019.
Updates to ASC Payment Rates
CMS finalized the proposal to update ASC payment rates using the hospital market basket rather than the CPI-U for CY 2019 through CY 2023. Using the hospital market basket, CMS is updating ASC rates for CY 2019 by 2.1 percent. The change is based on the hospital market basket increase of 2.9 percent minus a 0.8 percentage point adjustment for MFP. This change will help to promote “site-neutrality” between hospitals and ASCs and encourage the migration of services from the hospital setting to the lower cost ASC setting.
CMS finalized changes to the definition of “surgery” to be provided to Medicare beneficiaries in an ASC for CY 2019 to account for “surgery-like” procedures that are assigned codes outside the CPT surgical range (10000-69999). CMS further explains that these newly-eligible “surgery-like” procedures are procedures that are described by Category I CPT codes that are not in the surgical range but, like procedures described by Level II HCPCS codes or by Category III CPT codes under the current policy, directly crosswalk or are clinically similar to procedures in the Category I CPT surgical range. These Category I CPT codes would be limited to those that CMS has determined do not pose a significant safety risk, would not be expected to require an overnight stay when performed in an ASC, and are separately paid under the OPPS.
For 2019, CMS finalized that it will add 12 cardiac catheterization procedures to the list of covered surgical procedures in ASCs. In response to commenters’ suggestions of additional codes to add to the list, CMS agreed on five others: 93566, 93567, 93568, 93571, and 93572. In total, CMS added 17 codes related to cardiac catheterization procedures.
New Clinical Families of Services at Off-Campus Provider-Based Departments (PBDs) Excepted from Section 603 of the Bipartisan Budget Act of 2015
In CY 2019 OPPS/ASC proposed rule, CMS proposed a policy that off-campus PBDs excepted from Section 603 of the Bipartisan Budget Act of 2015 could continue to be paid at OPPS rates for items and services in each of 19 proposed “clinical families of services” if a PBD furnished and billed for a service in that clinical family of services prior to November 2, 2015. CMS is not finalizing this proposal in the CY 2019 OPPS/ASC final rule with comment period, but notes it will continue to monitor the expansion of services in excepted off-campus PBDs.
Combating the Opioid Crisis
CMS is finalizing the proposal to update the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience of care survey measure by removing the three recently revised pain communication questions. The removal of these questions is effective with October 2019 discharges, for the FY 2021 payment determination and subsequent years, earlier than proposed. As a related modification, CMS will not publicly report the three revised Communication About Pain questions.
In addition, the President’s Commission on Combating Drug Addiction and the Opioid Crisis also recommended that CMS review its payment policies for certain drugs that function as a supply, specifically non-opioid pain management treatments. Payment for drugs that function as a supply in surgical procedures or diagnostic tests is packaged under the OPPS and ASC payment systems. In response to this recommendation as well as stakeholder requests and peer-reviewed evidence, for CY 2019, CMS is finalizing the proposal to pay separately at ASP plus 6 percent for non-opioid pain management drugs that function as a supply when used in a covered surgical procedure performed in an ASC.
For more information, refer to CMS’ Fact Sheet, Press Release, or review the rule it its full text on the Federal Register.