CMS Releases Final Rule to Update OPPS

The Centers for Medicare and Medicaid Services (CMS) recently released a final rule to update the Medicare fee-for-service (FFS) outpatient prospective payment system (OPPS) effective Jan. 1, 2023.

The rule restores 340B drug payments to the default rate, generally average sales price (ASP) plus 6%, up from the previous ASP minus 22.5%, in response to the recent federal Supreme Court (SC) ruling.  The CMS notes that the agency is still evaluating how to apply the SC’s decision in the American Hospital Association (AHA) v Becerra case which ordered the CMS to restore payments. The CMS will address this in future rulemaking prior to the 2024 OPPS proposed rule.  

The MHA, along with the AHA and others, continue to urge the Court to order the CMS to promptly repay hospitals harmed by the unlawful cuts implemented in 2018 and ensure that no hospitals are not penalized.  Other provisions of the final rule include:

  • Increasing the conversion factor by a net 1.7% after budget neutrality adjustments from $84.18 to $85.59 for hospitals that comply with the CMS outpatient quality reporting (OQR) program requirements.
  • Establishing the new rural emergency hospital provider type to allow critical access hospitals and rural hospitals with less than 50 beds to continue providing essential outpatient services while eliminating inpatient services.
  • Exempting rural sole community hospitals from the site neutral clinic visit cuts and instead paying the full OPPS rate for visits provided at grandfathered off-campus hospital outpatient departments.
  • Increasing the cost outlier threshold by 40% from $6,175 to $8,625, to maintain outlier payments at the targeted 1% of total OPPS payments, resulting in fewer cases qualifying for an outlier payment.
  • Removing 11 services from the inpatient only list and adding 8 services that were newly created by the American Medical Association Common Procedural Terminology Editorial Panel.
  • Implementing a permanent 5% cap on wage index decreases.
  • Adding four procedures to the Ambulatory Surgical Center covered procedures list.
  • Requiring prior authorization for an additional service category,­ facet joint interventions, beginning dates of service on or after July 1, 2023.
  • Continuing payment for virtual behavioral health services with an in-person service required within six months prior to the initiation of the virtual service and then annually thereafter, with exceptions made based on beneficiary circumstances. The CMS clarified that the requirement for an in-person visit within six months prior to the initial services is not required for patients who began receiving services during the public health emergency (PHE) or during the 151-day period following the end of the PHE.
  • Maintaining the current policy of providing separate payment for non-opioid pain management drugs and biologicals that function as supplies in the ASC setting.
  • Implementing a payment adjustment for costs incurred for domestically manufactured National Institute for Occupational Safety and Health (NIOSH)-approved surgical N95 respirators with payments provided biweekly as interim lump-sum payments and reconciled at cost report settlement for cost reporting periods beginning on or after Jan. 1, 2023.
  • Creating a new G-code for dental rehabilitation services that require monitored anesthesia and the use of an operating room and assigning it to APC 5871 (Dental Procedures), effectively increasing the payment from roughly $200 to approximately $2,000.
  • Changes to the hospital OQR program including:
  • Making the Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery (OP-31) measure voluntary rather than mandatory beginning with the 2025 reporting period and 2027 payment determination.
  • Aligning the patient encounter quarters for chart-abstracted measures to the calendar year for annual payment update determinations.
  • Adding a targeting criterion for measure data validation.

The MHA will provide hospitals with an updated impact analysis and additional details of the rule in the coming weeks.

Members with questions should contact Vickie Kunz at the MHA.