Hospitals currently have discretion as to how they choose to display the standard charges in the machine-readable file; however, CMS now proposes to require hospitals to display the required data using a CMS template, which would be offered as a CSV "wide" format, a CSV "tall" format, and a JavaScript object notation (JSON) schema. remove the Left Without Being Seen measure beginning with the CY 2024 reporting period/2026 payment determination, modify the COVID19 Vaccination Coverage Among Healthcare Personnel (HCP) measure beginning with the CY 2024 reporting period/CY 2026 payment determination, modify the Cataracts: Improvement in Patients Visual Function Within 90 Days Following Cataract Surgery measure beginning with the voluntary CY 2024 reporting period, modify the Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients measure beginning with the CY 2024 reporting period/CY 2026 payment determination, readopt with modification the Hospital Outpatient Volume Data on Selected Outpatient Procedures measure beginning with the voluntary CY 2025 reporting period and mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination, adopt the Risk-Standardized Patient Reported Outcome-Based Performance Measure (PRO-PM) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) in the HOPD Setting (THA/TKA PRO-PM) beginning with the voluntary CYs 2025 and 2026 reporting periods, and mandatory reporting beginning with the CY 2027 reporting period/CY 2030 payment determination, adopt the Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Hospital Level Outpatient) measure, beginning with the voluntary CY 2025 reporting period and mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination, amend multiple codified regulations to replace references to "QualityNet" with "CMS-designated information system" or "CMS website," and to make other conforming technical edits, to accommodate recent and future systems requirements and mitigate confusion for program participants. These roles are not explicitly funded; instead they are built into a hospital's overall cost structure and supported by revenues received from providing direct patient care. No. Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A) and Internet Only Manual (IOM) Publication 100-02, Chapter 16, Section 120. CMS finalizes the addition of four procedures to the list of ASC covered surgical procedures: 38531, 19307, 37193, and 43774. CMS finalized codifying the definition of primary road for CAH eligibility to reduce burden and provider greater flexibility on the distance requirement. CMS proposes adding nine services and corresponding CPT codes to the IPO list for CY 2024 and is soliciting comments on the appropriateness of adding these codes to the list. Therefore, CMS will recognize SaaS CPT add-on codes and pay separately for them. Keep in mind there are additional requirements before an REH can exist, including that the respective state has licensed the REH designation and then the REH is licensed/approved accordingly. CAH 2019 Actual. In addition, CMS finalizes setting the payment rate for C-APC 8010 at the same payment rate for APC 5863 (the maximum partial hospitalization per diem payment rate for a hospital) and that the hospital continue to be paid the payment rate for C-APC 8010. The Final Rule provides that a grandfathered off-campus PBD will receive payments under the OPPS for all billed items and services, regardless of whether it furnished such items and services prior to [November 2, 2015], as long as the excepted off-campus PBD remains excepted; that is, it meets the relocation and change of ownership requirements adopted in the Final Rule and discussed further below. Providers are not required to seek a determination from CMS that all of their provider-based components satisfy the provider-based rules at 42 CFR 413.65, but they may voluntarily seek such determinations. Despite commenters requests, the Final Rule does not provide for an exception for off-campus PBDs that were mid-build as of November 2, 2015. Note: This article contains a general, condensed summary of statutes, regulations, and opinions for information purposes. -Only HOPD claims for HOPD patients and IPO claims for IPO patients are included in . Promoting Interoperability (PI) Programs. CMS would also require that an REH receiving the additional monthly facility payments must maintain detailed information as to how the facility used the monthly facility payments and must make this information available upon request. For CY 2023, rural sole community hospitals, childrens hospitals, and PPS-exempt cancer hospitals will continue to use the TB modifier to identify 340B drugs for informational purposes. Hospitals that participate in Medicare (including psychiatric hospitals) Hospitals must post (in a form specified by the Secretary of the U.S. Department of Health and Human Services) the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor, and whether the hospital participates in t. CMS finalizes a budget neutrality adjustment to the CY 2023 OPPS conversion factor of 0.9691. Build a Morning News Digest: Easy, Custom Content, Free! - Only HOPD claims for HOPD patients and IPO claims for IPO patients are . This program would cover mental health services for Medicare beneficiaries who need frequent but less intensive care than what is provided at inpatient settings. For more information, or if your organization would like help to navigate the effect of the reimbursement reductions related to site-neutral payments and extension of the 340B reductions, contact a PYA executive below at (800) 270-9629. CMS also proposes hospitals include a footer at the bottom of the hospitals homepage that links to the webpage that includes the machine-readable file and requires hospitals to ensure that a .txt file is included in the root folder of the publicly available website chosen by the hospital for posting its machine-readable file. CMS exempts these services from having staff be physically located in the hospital/HOPD when furnishing services remotely using communication technology. With respect to other services provided by an REH that are not covered under the OPPS, CMS finalizes those to be reimbursed under their respective fee schedule. As it did for the hospital OPPS, CMS alerts ASC readers that the 2023 PFS rule includes policies related to HOPDs and ASCs. CY 2017 OPPS Proposed Rule sets new off-campus HOPD requirements Economic Recovery Act of 2009. (2016). Two of three New Technology APCs assigned in CY 2023 received revised classifications in the CY 2024 proposed rule. Requests submitted on the same day as the requested date of service. Post signage identifying it as a department of the main provider. CMS finalizes a market basket of 4.1% reduced by the productivity adjustment of 0.3% resulting in a CMS states that this requirement can be met using existing cost reporting requirements for outpatient hospital facilities that would include REHs. Impact on State Licensure Hospital requests to add a provider-based location to the state hospital license that the hospital will also be adding to the hospital CMS Certification Number (CCN): If uses of shared space Last fall, a new law was passed which significantly changed Medicare reimbursement of PBDs. CMS Issues Final Rule on Off-Campus Hospital Department Reimbursement CMS has requested public commentary on how potential approaches to such a limitation might work. Example: Prior authorization request submitted July 5 with a requested date of service July 10. The North Carolina certificate number is 26858. When performing outpatient procedures, many orthopaedic surgeons operate in either an ambulatory surgery center (ASC) or a hospital-based outpatient department (HOPD). Claim page 3 extended, press F11 two times. 1. Starting January 1, the Centers for Medicare & Medicaid Services (CMS) will require a new billing policy for hospital off-campus provider-based departments. The original justification for higher payment to HOPDs was that their costs to provide services were higher than a typical physician practice. CMS also proposed several changes to hospital transparency requirements. Although the Final Rule does not discuss expansion directly, CMSs commentary related to the relocation of grandfathered off-campus PBDs suggests that the PBDs physical expansion will not jeopardize the PBDs grandfathered status if that expansion does not change the grandfathered PBDs address (including suite number). The facility payment is equal to CAH payments in 2019 compared to what those payments would have been if paid under the OPPS system. CMS proposes to apply a 2.8 percent productivity-adjusted hospital market basket update factor to the CY 2023 ASC conversion factor for ASCs meeting the quality reporting requirements to determine the CY 2024 ASC payment amounts. CMS exempts REHs from existing site neutral payments related to off-campus provider-based departments.. Medicare spending prior to receiving ambulatory care. As of January 1, 2017, hospitals will receive lower Medicare reimbursement for items and services provided at certain off-campus provider-based facilities. Those include exceptions for physician recruitment, obstetrical malpractice insurance subsidies, retention payments in underserved areas, and assistance to compensate a nonphysician practitioner. The Centers for Medicare & Medicaid Services (CMS) released the 2023 proposed payment rule for ASCs and hospital outpatient departments (HOPD) on July 15, 2022. PDF Provider-Based Status - HCCA Official Site CMS finalizes using the OPPS complexity-adjusted C-APC rate for each corresponding code combination to calculate the OPPS relative weight for each corresponding ASC payment system C code for procedures being performed together. However, CMS indicates that only the rural provider exception would be applicable to an REH. Provide proof of financial and clinical integration. First Name (required) 8. CMS finalizes that audio-only interactive telecommunications systems may be used to furnish these services in instances where the beneficiary is not capable of, or does not consent to, the use of two-way, audio/video (synchronous) technology. New modifier and POS code for off-campus provider-based departments If a hospital receives a warning notice for noncompliance, CMS proposes to require the hospital to submit an acknowledgment of receipt of the warning notice in the form and manner and by the deadline specified in the notice of violation issued by CMS to the hospital. In addition, effective January 1, 2017, the 21st Century Cures Act establishes an exception for PBDs of cancer hospitals that meet certain requirements. On August 4, 2020, the Centers for Medicare & Medicaid Services (CMS) proposed policies that are consistent with the directives in President Donald Trump's Executive Order "Protecting and Improving Medicare for Our Nation's Seniors," that aims to increase choice, lower patients' out-of . (Nov. 14, 2016). CMS Outpatient Department PA program does not change Medicare benefits or coverage requirements, nor does it create new documentation requirements Medicare Coverage: For any item or service to be . CMS finalized rural emergency hospitals will receive $3.2 million annually in facility payments. CMS intends to issue a separate proposed rule detailing a proposed remedy for how to handle 340B payment reductions from CYs 2018 to CY 2022 in advance of the CY 2024 OPPS/ASC proposed rule. 3.8% update. CMS finalizes an in-person service within six months prior to the initiation of the remote service is required for telehealth mental health services beginning after the 152nd day after the end of the PHE with in-person service required every 12 months thereafter. While an on-campus PBD will be treated as excepted, the PBDs subsequent relocation to an off-campus site would result in the PBD no longer being paid under the OPPS. CMS recently released a separate proposed rule, Hospital Outpatient Prospective Payment System: Remedy for 340B-Acquired Drugs Purchased in Cost Years 2018-2022, providing a remedy for the reduced 340B payments hospitals received from 2018 through Sept. 27, 2022, the date on which CMS restored reimbursement for 340B drugs to the full OPPS rate. CMS will revert to prior 340B payments of ASP+6% due to court rulings. Mid-Build PBDs: In June 2016, the United States House of Representatives passed a bill that would reverse Section 603s imposition of site-neutral payments for off-campus PBDs that were mid-build by November 2, 2015, and that meet certain requirements (such as a binding written agreement with an outside, unrelated party before November 2, 2015 for the actual construction of such PBD). In the Proposed Rule, CMS proposed to establish certain clinical families of services and limit a grandfathered PBDs OPPS reimbursement to only those services within the clinical families of services that the PBD provided as of November 1, 2015. CMS also proposes several updates to its enforcement capabilities including: In line with this, CMS issued a request for information (RFI) on evolving and aligning hospital price transparency with transparency in coverage rules and the No Surprises Act regulations. CMS finalizes changes to alter how an organ is counted as a Medicare usable organ for purposes of calculating Medicares share of organ acquisition cost, but due to stakeholder feedback, modifies and clarifies its changes. Ambulatory Surgery Centers Versus Hospital-based Outpatient - AAOS Instead, CMS referred commenters to the relevant state Medicaid agencies. (As a reminder, CMS has already exempted SCH from its 340B payment reductions.). Paperwork Reduction Act (PRA) of 1995. Review CLA's Health Care Innovation and Insight (HI) 340B blost postfor background information on the Court's ruling as well as practical implications for 340B hospitals. CMS also includes other add-ons or supplemental payments, including IPPS new technology payments, outlier claims payments in both the IPPS and the OPPS, clotting factor payments, indirect medical education (IME) payments, Disproportionate Share Hospital (DSH) payments, uncompensated care payments, and low-volume hospital payments. CMS anticipates such exceptions to be both limited and rare and intends to issue additional subregulatory guidance in the future. The adjustment offsets the prior increase of 3.19% that was applied to the conversion factor when the agency implemented the 340B payment policy in CY 2018 in a budget neutral manner. Excepted items and services include those items and services furnished in: Under CMSs finalized policy, excepted PBDs will be permitted to continue to bill for excepted items and services under the OPPS. For C codes that are not assigned device-intensive status, CMS will multiply the OPPS relative weight by the ASC budget neutrality adjustment (or ASC weight scalar) to determine the ASC relative weight and then multiply the ASC relative weight by the ASC conversion factor to determine the ASC payment rate for each C code. For IME and DSH adjustments, CMS estimates an aggregate amount of IME and DSH spending for all CAHs. CMS Eliminates Direct Supervision Requirement for Hospitals The hospital outpatient payment department (HOPD) systems and ambulatory surgery center (ASC) systems are subject to: If the hospital doesn't comply with all the provider-based requirements . CMS is considering this potential separate IPPS payment for cost reporting periods beginning as early as Jan. 1, 2024. The agency believed that performing certain procedures on an outpatient basis would not be safe or appropriate and, therefore, not reasonable and necessary under Medicare rules. Under CMSs interpretation of Section 603, PBDs (defined by the regulations as including both the specific physical facility and the personnel and equipment needed to furnish services at the facility) located off-campus are grandfathered only as they existed at the time [Section 603] was enacted.[12] Accordingly, CMS believes that allowing unlimited relocation of a grandfathered off-campus PBD would result potentially in relocation to larger facilities with different equipment and staff and unbridled expansion of service lines, yielding an off-campus PBD that is remarkably different than it was prior to November 2, 2015. Facilities that comply with the "mid-build" exception will be eligible for OPPS reimbursement effective January 1, 2018. [3] Payment to Nonexcepted Off-Campus Provider-Based Department of a Hospital, 81 Fed. Citing the persistence and severity of shortages for critical medical products and the additional time, labor and resources required to navigate them, in this rule CMS describes how it could make payments to hospitals under the Inpatient Prospective Payment System (IPPS) for establishing and maintaining access to a buffer stock of essential medicines. CMS proposes to utilize the hospital market basket update of 3 percent, reduced by the productivity adjustment of 0.2 percentage point, resulting in a proposed productivity-adjusted hospital market basket update factor of 2.8 percent for ASCs meeting the quality reporting requirements. This is particularly alarming given the fact that 152 rural . Medicare guidelines. regulatory requirements,1 but less is known about the . Therefore, CMS finalized including numbered federal highways with two or more lanes each way, similar to the description of numbered state highways, and exclud[ing] numbered federal highways with only one lane in each direction.. (See the Holland & Knight alert, "CMS Proposes Returning $9 Billion to More Than 1,600 Hospitals," July 11, 2023.). CMS does allow existing compensation exemptions to apply to REHs. CMS Shares Proposed ASC, HOPD Payment Rule. CMS finalizes biweekly interim lump-sum payments. How are distances between buildings measured for purposes of on-campus location? CMS proposes expanding the rate structure of the partial hospitalization program (PHP) to include an APC for three services a day and an APC for four services daily. Here, CMS indicated that the requirements for physician supervision (i.e., general, direct or personal) applied to hospital outpatient diagnostic services when those services are furnished at an entity with provider-based status.4 Fiscal intermediaries and hospitals were advised to follow the MPFS supervision levels from the 1998 MPFS final rule. The requirement is the result of language in the Infrastructure Investment and Jobs Act (Pub. That reduction has been a negative 22.5% (as opposed to regular reimbursements at average sales price (ASP) +6%) and has been the subject of ongoing litigation. 3. This price leveling between different settings is often referred to as site neutrality.. (July 14, 2016). PDF CMS Manual System - Centers for Medicare & Medicaid Services CMS proposed severe restrictions on excepted off-campus provider-based departments (PBDs), including limitations on hospitals' abilities to relocate or expand excepted sites, offer new service lines at excepted sites, and transfer ownership of excepted sites without triggering payment cuts or losing excepted status. Providers will report the service facility location for an off-campus, outpatient, provider-based department of a hospital as follows on the claim ensuring it is an exact match to what is in PECOS. In addition, Section 603 establishes a grandfathering exception for off-campus PBDs that were furnishing OPPS-reimbursed items and services prior to November 2, 2015. 2023 Williams Mullen All Rights Reserved. CMS proposes to define the program as a distinct and organized intensive ambulatory treatment program offering less than 24 hours of daily care other than in an individuals home or in an inpatient or residential setting. Strictly Necessary Cookie should be enabled at all times so that we can save your preferences for cookie settings. . The process was originally described in CMS' Second Interim Final Rule published on April 30 th to provide hospitals additional . CLAs industry-specialized health care team is happy to talk with you about that or any other hospital-related issue. It is not meant to constitute, and should not be construed as, legal advice. CMS will make several other adjustments, such as Medicare Advantage claims that are not a primary payer, device credits, and sequester reduction. To embed, copy and paste the code into your website or blog: Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra: [Hot Topic] Environmental, Social & Governance, [Ongoing] Read Latest SCOTUS Analysis, All Aspects. The annual payment amount would be divided by 12 to calculate the monthly REH facility payment. This rule includes regular payment updates and policies for the OPPS and ASC systems, but also details important payment and reimbursement aspects for the new Medicare designation, the Rural Emergency Hospital (REH). L. 117 9) enacted in November 2021 that requires manufacturers to provide a refund to CMS for certain discarded amounts from a refundable single-dose container or single-use package drug. If you are interested in a similar discussion, reach out today. The requirement would begin July 1, 2023 and covers CPT codes 64490 64495 and 64633 64636. An adjustment under the OPPS could be considered for future years of rulemaking. Prior Authorization Timelines for HOPD Services - CGS Medicare For CY 2023, CMS finalizes a CY 2023 conversion factor update of $85.585. CMS also proposes an APC relative payment weight that represents the hospital cost of the services included in that APC relative to the hospital cost of the services included in APC 5012 for Clinic Visits and Related Services to address variation in payment due to assignment of APC group. There are requirements for: If a distinct skilled unit is present, the REH would comply with skilled nursing CoPs. For electronic claims, report in the 2310E loop of the 837 institutional claim transaction. Step 1:The total amount of Medicare spending for CAHs in CY 2019 minus the projected Medicare spending for CAHs in CY 2019 if inpatient hospital services, outpatient hospital services, and skilled nursing services had been paid on a prospective basis rather than at 101% of total cost and calculated according to the methodology described. This definition also includes a department of a provider that was billing under the OPPS with respect to covered [outpatient department] services furnished prior to November 2, 2015. CMS will not include adjustments for various quality reporting programs value-based purchasing program payments, hospital readmissions reduction program adjustments, and hospital-acquired condition reduction program because it could find no sufficient way to model these out for CAHs. As the Rules drafters have confirmed, and as reflected in CMSs commentary throughout the Rule, consistent with Section 603s language, all on-campus PBDs whether or not located on campus as of November 2, 2015 are excepted. CMS believes prior authorization for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care - while protecting the Medicare Trust Fund from improper payments and, at the same time, keeping the medical necessity documentation requirements unchanged for providers. The Rule is likely to have a significant impact on hospital campus development as hospitals attempt to maximize provider-based space in which OPPS-reimbursable services may be provided. Section 603 excludes from OPPS coverage items and services furnished at certain off-campus PBDs effective January 1, 2017. CMS proposes creating a single, untimed healthcare common procedure coding system (HCPCS) code that can be reported when a beneficiary receives multiple hours of group therapy per day. CMS is also requesting public comment on 1) patient and workforce safety (including sepsis), 2) behavioral health (including suicide prevention) and 3) telehealth as potential future measurement topic areas in the Hospital OQR Program. CMS finalizes the addition of one C-APC in CY 2023: C-APC 5372 (Level 2 Urology and Related Services). Showing 1 - 10 of 76 entries Show Entries Filter On 1 2 3 4 5 8 Page Last Modified: 07/20/2023 03:29 PM Help with File Formats and Plug-Ins For CY 2023, CMS finalizes utilizing the hospital market basket update of 4.1% reduced by the productivity adjustment of 0.3% point, resulting in a productivity-adjusted hospital market basket update factor of 3.8% for ASCs meeting the quality reporting requirements. 42 CFR 413.65 - Requirements for a determination that a facility or CMS also proposes that hospitals encode all standard charge information, as applicable, that corresponds to a set of required data elements, which would include (but are not limited to): Each hospital would also be required to affirm in its machine-readable file that the hospital, to the best of its knowledge and belief, has included all applicable standard charge information in accordance with the requirements of 45 C.F.R. 79562, 79699 et seq. CMS finalizes various CoPs that generally follow CAH CoPs. [2] CMS has now issued its final rule (Final Rule)[3] and an accompanying interim final rule with comment period (Interim Rule,[4] and, together with the Final Rule, the Rule) outlining CMSs framework for implementing Section 603. On an industry stakeholder call following issuance of the Rule, CMS encouraged providers to direct specific questions related to space and suite expansion to the regional CMS offices. If finalized, this adjustment would be updated based on the Medicare Economic Index and receive the Geographic Adjustment Factor. Section 603 and the key provisions of the Rule are summarized below. Despite ambiguity among these guidelines, there are a few basic principles to always keep in mind when reviewing provider-based compliance: Hospital space must be hospital space 24/7. Thus, the hospital as a whole still is required to meet all applicable conditions of participation and regulations governing the PBDs provider-based status. Recognizing that the proposed policy could be complex operationally and could pose an administrative burden on hospitals, CMS, and contractors in identifying, tracking, and monitoring billing for clinical services, CMS did not finalize the clinical families proposal. CMS proposes to continue additional payments to cancer hospitals so that their payment-to-cost ratio (PCR) after additional payments is equal to the weighted average PCR for other OPPS hospitals. UPDATE: Since this alert was drafted, President Obama signed into law the 21st Century Cures Act (H.R. CMS estimates that total payments to OPPS providers (including beneficiary cost-sharing and estimated changes in enrollment, utilization, and case-mix) for calendar year (CY) 2023 would be approximately $86.5 billion, an increase of approximately $6.5 billion compared to estimated CY 2022 OPPS payments. You can contact me at 404-266-9876. In addition, the rule proposes updated Medicare payment rates for the partial hospitalization program, which is an alternative to psychiatric hospitalization.