Tag: REH

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule to update the Medicare fee-for-service outpatient prospective payment system (OPPS) effective Jan. 1,  2025.

The proposed rule:

• Provides a net 2.3% increase to the OPPS conversion factor from $87.38 to $89.38 for hospitals that report quality measure data.
• Increases the outlier fixed-dollar threshold by 3.2% from the current $7,750 to $8,000.
• Modifies the timeframe for standard review of prior authorization requests for hospital outpatient department services from 10 business days to seven calendar days.
• Uses 2023 claims data and the most updated cost report data from the healthcare cost report information system, primarily from 2022, to set payment rates.
• Adds three services (CPT codes 0894T, 0895T and 0896T) for liver allograft-related procedures to the 2025 Inpatient-Only List.
• Updates the core based statistical areas used to determine a hospital’s wage index, consistent with other 2025 proposed rules.
• Adds two new status indicators (H1 and K1) to identify healthcare common procedure coding system/current procedural terminology (HCPCS/CPT) codes representing separately payable, non-opioid post-surgical pain management products as authorized by the Consolidated Appropriations Act of 2023.
• Establishes separate payment for diagnostic radiopharmaceuticals with a per-day cost exceeding $630.
• Excludes qualifying cell and gene therapies from comprehensive ambulatory payment classification packaging.
• Adopts three measures related to health equity for the Outpatient, ambulatory surgical center (ASC) and rural emergency hospital quality reporting programs, and extending voluntary data reporting for two hybrid measures in the inpatient quality reporting program.
• Establishes new conditions of participation for hospitals and critical access hospitals focused on obstetrical services and maternal care.
• Extends the virtual direct supervision of therapeutic and diagnostic services under the physician fee schedule (PFS) through Dec. 31, 2025. The CMS also proposes to extend virtual direct supervision under the OPPS through Dec. 31, 2025, to maintain alignment between the PFS and OPPS.
• Adds 20 medical and dental procedures to the ASC covered procedures list.
• Updates the hospital outpatient quality reporting program requirements.
• Updates requirements for the rural emergency hospital quality reporting program.

The MHA will provide a hospital-specific impact analysis within the next few weeks and encourages members contact Vickie Kunz by Aug. 30 regarding issues identified. Hospitals are encouraged to review the proposed rule and its impact on operations and submit comments to the CMS by Sept. 9.  The CMS is expected to release a final rule around Nov. 1 for the Jan. 1, 2025, effective date.

Members with questions may contact Vickie Kunz at the MHA.