Several commenters expressed the concern “that the MACs have not demonstrated the ability to handle the volume of prior … Because the final calculated geometric mean per diem costs for both provider types are above the proposed floors, the data does not support finalizing floors at this time, and therefore, we are not finalizing the proposed cost floors in this CY 2021 OPPS/ASC final rule. … In this rule, we are finalizing a policy in which procedures removed from the IPO list beginning January 1, 2021 will be indefinitely exempted from site-of-service claim denials under Medicare Part A, eligibility for Beneficiary and Family-Centered Care-Quality Improvement Organization (BFCC-QIO) referrals to Recovery Audit Contractors (RACs) for noncompliance with the 2-midnight rule, and RAC reviews for “patient status” (that is, site-of-service). The Final Rule is issued with comment periods running 30 to 60 days, depending on the provision. Updates to Hospital and Critical Access Hospital Reporting. In this rule, CMS proposed to remove certain expansion limits for "high Medicaid facilities" as part of its Patients over Paperwork initiative. Treatment of acute respiratory illnesses uses many of the same resources necessary for treatment of COVID-19, and this new reporting requirement will provide the necessary information to distribute resources to hospitals under strain. Additionally, we are revising the criteria we use to add covered surgical procedures to the ASC CPL, providing that certain criteria we used to add covered surgical procedures to the ASC CPL in the past will now be factors for physicians to consider in deciding whether a specific beneficiary should receive a covered surgical procedure in an ASC, and adopting a notification process for surgical procedures the public believes can be added to the ASC CPL under the criteria we are retaining. How Will DevOps Change in 2021? CMS … Apply peer grouping methodology by number of measure groups where hospitals are grouped into whether they have three or more measures in three, four, or five measure groups (three measure groups is the minimum to receive a rating). Also available is the CY 2021 Inpatient Only (IPO) list, which is accessible on the CMS website: Addendum E. —Final HCPCS … Specifically, CMS removed 1) the cap on the number of additional operating rooms, procedure rooms, and beds that can be approved in an exception and 2) the restriction that the expansion must occur only in facilities on the hospital’s main campus. The agency maintained in the OPPS final rule that phasing out the inpatient only list over the next three years will save Medicare beneficiaries money and give providers more choices for care. Based on the CY 2019 final rule, CMS continued to apply the hospital market basket update to … In continuing the agency’s efforts to reduce burden and improve efficiencies through the Patients Over Paperwork Initiative, for the first time through the rulemaking process, CMS will establish, update, and simplify the methodology used to calculate the Overall Hospital Quality Star Rating (Overall Star Rating) beginning with 2021. The outpatient rule indicates a 2.4% payment increase for hospitals and other proposals. CMS … In accordance with Medicare law, CMS will update OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.4 percent. The Proposed Rule contains a number of notable items including: Increase in hospital outpatient payment rates by 2.6% Elimination of the Inpatient Only (IPO) list over a 3-year period Continued 2-year exemption from certain medical review activities related to the 2-midnight rule for newly removed procedures … Also, you can decide how often you want to get updates. The 2021 OPPS final rule, released December 2, doesn’t pack many surprises, with CMS generally finalizing most policies as proposed or choosing to continue with current policies. Colleen will also review the 2021 CPT code changes. The CY 2021 OPPS/ASC Payment System final rule with comment period would further advance the agency’s commitment to strengthening Medicare and reducing provider burden so that hospitals and ambulatory surgical centers can operate with increased flexibility, and patients are better equipped to be active healthcare consumers. CMS' final rule contained several other changes that hospital and … This year, the agency finalized its proposal to expanded prior authorization requirements for two additional services: cervical fusion with disc removal and implanted spinal neurostimulators to curb unnecessary utilization. In September 2019, a federal district court sided with hospital plaintiffs, ruling that CMS lacked statutory authority to implement the change. https://www.cms.gov/files/document/12220-opps-final-rule-cms-1736-fc.pdf, CMS Releases Comprehensive Pandemic Plan to Chronicle Key Lessons and Strengthen Agency’s Resiliency to Future Pandemic Virus Events, CMS Launches Automated Web Tool for 1135 Waiver Requests and Public Health Emergency-Related Inquiries During Crises Like COVID-19, CMS Solicits Public Comment for a New Demonstration to Offer Inpatient Rehabilitation Providers Flexibilities and Reduce Medicare Fraud, Trump Administration Finalizes Policies to Give Medicare Beneficiaries More Choices around Surgery, Final Policies for the Medicare Diabetes Prevention Program (MDPP) Expanded Model for the Calendar Year 2021 Medicare Physician Fee Schedule. The 340B payment policy continues to exempt rural sole community hospitals, children’s hospitals, and PPS-exempt cancer hospitals. Clinical Diagnostic Laboratory Test Packaging Policy and Laboratory Date of Service (DOS) Policy for Certain Protein-Based Multianalyte Assays with Algorithmic Analyses (MAAAs). In the CY 2018 OPPS/ASC final rule, CMS reexamined the appropriateness of paying the Average Sale Price (ASP) plus 6 percent for drugs acquired through the 340B Program, given that 340B hospitals acquire these drugs at steep discounts. We go over some hard-learned lessons from 2020 and changes to the DevOps process that developers and organizations can expect to … Related Links. CMS will then revisit, in rulemaking, whether and when an exemption for a procedure should end. Attorney Advertising. This exemption will allow providers more time to become accustomed to the new ability to bill for Medicare payment of claims for services that were previously only paid on an inpatient basis. In the CY 2021 OPPS/ASC final rule, CMS is requiring prior authorization for Cervical Fusion with Disc Removal, and Implanted Spinal Neurostimulators for dates of services on or after July 1, 2021. These revisions require laboratories performing these protein‑based MAAAs that meet the DOS requirements at § 414.510(b)(5) to bill Medicare directly for those tests instead of seeking payment from the hospital. Using the hospital market basket, CMS is updating the ASC rates for CY 2021 by 2.4 percent. The CY 2021 OPPS/ASC final rule excludes cancer-related protein-based MAAAs as described by CPT codes 81500, 81503, 81535, 81536, and 81539 and the test described by CPT code 81490, which are not generally performed in the hospital outpatient department setting, from the OPPS packaging policy, and revises the laboratory DOS policy to add these tests to the laboratory DOS exception at § 414.510(b)(5). In the CY 2021 OPPS/ASC final rule, CMS removed certain provisions in the expansion exception process that are applicable to hospitals that qualify as “high Medicaid facilities” because such provisions are not mandated by Section 1877 of the Act. If you have specific questions regarding a particular fact situation, we urge you to consult the authors of this publication, your Holland & Knight representative or other competent legal counsel. CMS estimates that total payments to OPPS providers for CY 2021 will amount to $83.888 billion, approximately $7.541 billion compared to estimated CY 2020 OPPs payments. has an annual percentage of total inpatient admissions under Medicaid that is estimated to be greater than any other hospital located in the county in which the hospital is located for the three most recent 12-month periods, and. This update 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. Improve the comparability of the Overall Star Rating through updating the reporting threshold, and peer grouping. In addition, a high Medicaid facility may now apply for an exception more than once every two years from the time of a decision by CMS, provided that the hospital submits only one expansion exception request at a time. This modification will allow providers more time to adjust billing Medicare for newly allowed services in the outpatient setting. These addenda are a "snapshot" of HCPCS codes and their status indicators, APC groups, and OPPS payment rates, that are in effect at the beginning of each quarter. Information contained in this alert is for the general education and knowledge of our readers. CMS & HHS Websites [CMS … The 2021 OPPS final rule seeks to increase patient choice and lower out-of-pocket costs. CMS is not adding or removing any measure for either program. 7500 Security Boulevard, Baltimore, MD 21244 . Based on the CY 2019 final rule, CMS continued to apply the hospital market basket update to ASC payment rates through CY 2023. CMS updated the methodology to calculate the Overall Hospital Quality Star Rating utilizing data collected on hospital inpatient and outpatient measures that are publicly reported on a CMS website. The change applied to five categories of services: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation. The requirements and statutory direction for these two exceptions were different, but CMS implemented a single process to address both. The Centers for Medicare & Medicaid Services (CMS) has published the Calendar Year (CY) 2021 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule. Under the 2021 OPPS final rule, CMS will pay for 340B-acquired drugs at the average sales prices of the drug minus 22.5 percent versus an older payment methodology in which CMS paid the average sales price plus 6 percent. Holland & Knight Alert. In the Final Rule, CMS abandoned its proposal and finalized plans to continue the current methodology of ASP minus 22.5 percent for 340B-acquired drugs. The agency did not address site-neutral payment rates for clinic visit services in the final rules for the OPPS and Physician Fee Schedule in 2021, indicating that it is likely to continue paying off-campus provider-based departments at 40 percent of the full OPPS rate for clinic visit services, even if they are part of the exception established by the Bipartisan Budget Act of 2015. #DevOps. If CMS approves a hospital's request for expansion, the hospital can exceed its baseline number of beds, operating rooms and procedure rooms. This means that Medicare would pay for cancer-related protein-based MAAAs under the Clinical Laboratory Fee Schedule (CLFS) instead of the Hospital OPPS. This change is based on the projected hospital market basket increase of 2.4 percent with a 0.0 percent adjustment for MFP. Later, an additional exception was created for POHs that qualified as a "high Medicaid facility." Taking into account estimated changes in enrollment, utilization, and case-mix for 2021, CMS estimates that OPPS expenditures, including beneficiary cost-sharing will be approximately . Please note that email communications to the firm through this website do not create an attorney-client relationship between you and the firm. In the CY 2019 OPPS/ASC final rule with comment period, we finalized our proposal to apply the hospital market basket update to ASC payment system rates for an interim period of 5 years (CY 2019 through CY 2023). We believe maintaining the current payment policy is appropriate in order to maintain consistent and reliable payment amid the PHE. However, it potentially presents limitations for additional total joint procedures to be added to the ASC list due to another CMS … This eliminates the restriction that exceptions can be submitted only every two years for Medicaid hospitals. CMS also delayed the Radiation Oncology (RO) Model due to the public health emergency (PHE) caused by the COVID-19 pandemic. Miranda A. Franco. This policy will likely expand in future rulemakings. The list will be completely phased out by CY 2024. Based on the results of this survey of hospital acquisition costs for 340B drugs, CMS proposed to pay for 340B drugs for CY 2021 and subsequent years at ASP minus 34.7 percent, plus an add-on of 6 percent of the ASP. This exemption will last until Medicare claims data indicates that the procedure is more commonly performed (50 percent of volumes for a given procedure) in the outpatient setting than the inpatient setting. These changes take effect January 1, 2021. On December 2, 2020, the Centers for Medicare & Medicaid Services (CMS) finalized policies that are consistent with the directives in President Trump’s Executive Order, entitled “Protecting and Improving Medicare for Our Nation’s Seniors,” that aim to increase choice, lower patients’ out-of-pocket costs, empower patients, and protect taxpayer dollars. Additionally, procedures removed from the IPO list may become subject to medical review activities related to the 2-midnight rule. Calendar Year 2021 Hospital Outpatient Prospective Payment System Final Rule On December 2nd, 2020 the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2021 Hospital Outpatient Prospective Payment System (HOPPS) final rule. On August 4, 2020, CMS released its CY 2021 Medicare Hospital OPPS proposed rule. On December 2, 2020, the Centers for Medicare & Medicaid Services (CMS) released the calendar year 2021 Final Rule implementing changes to the Medicare hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. In early August 2020, the U.S. Court of Appeals for the District of Columbia Circuit reversed the district court's ruling and held that CMS in fact, reasonably interpreted the Medicare statute as authorizing the rate reductions under a "general adjustment authority" with the purpose "to reimburse hospitals for their acquisition costs accurately.". Brian Leshak, Deputy Director CMS has not released information on how or whether it will address reprocessing 2019 claims that were previously reprocessed at the higher OPPS rate. CMS Releases 2021 OPPS and ASC Payment System Final Rule. Three of the applications have a FDA Breakthrough Device designation, two of which were preliminarily approved for device pass-through payment during the quarterly review process: CUSTOMFLEX® ARTIFICIALIRIS and EXALT™ Model D Single-Use Duodenoscope. The change represents an expected drug cost savings to CMS of over $300 million in CY 2021. Additionally, the 340B payment policy continues to exempt rural sole community hospitals, children's hospitals and PPS-exempt cancer hospitals. Using our revised criteria, we are adding an additional 267 surgical procedures to the ASC CPL beginning in CY 2021. This policy has been subject to ongoing litigation but was upheld by the United States Court of Appeals for the D.C Circuit Court on July 31, 2020. Do not send any privileged or confidential information to the firm through this website. Accordingly, CMS is finalizing the CY 2021 PHP APC per diem rates for CMHCs and HB PHPs based on the updated cost data for each provider type. In addition, the AMA CPT Editorial Panel established five new CPT codes, specifically, CPT codes 87636, 87637, 87811, and 0240U and 0241U effective October 6, 2020. Meaningful Measures/Patients Over Paperwork, CY 2021 Overall Hospital Quality Star Rating for CY 2021 and Subsequent Years. Generally, physician-owned hospitals (POHs) may not increase the number of operating rooms, procedure rooms and beds beyond those that were licensed on March 23, 2010 (the Affordable Care Act enactment date). CMS has established one HCPCS code, U0005, effective January 1, 2021. CMS is continuing to focus on reducing unnecessary increases in the volume of covered outpatient department services through the use of prior authorization. Moreover, the laws of each jurisdiction are different and are constantly changing. CMS posted the first quarter 2021 Pricer text file and outpatient provider specific file data on the Outpatient Prospective Payment System (OPPS) Pricer webpage. We … Jason Tross, Deputy Director. This will provide additional flexibility to physician-owned hospitals that qualify as high Medicaid facilities, which, by definition, serve more Medicaid inpatients than other hospitals in the counties in which they are located. Also in order to address the ongoing public health emergency, CMS is finalizing a new requirement for the nation’s hospitals and critical access hospitals to report information about the impact of acute respiratory illnesses, such as seasonal influenza, on hospital resources. The Centers for Medicare & Medicaid Services (CMS) has published the Calendar Year (CY) 2021 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule. Additionally, we are revising the criteria we use to add covered surgical procedures to the ASC CPL, providing that certain criteria we used to add covered surgical procedures to the ASC CPL in the past will now be factors for physicians to consider in deciding whether a specific beneficiary should receive a covered surgical procedure in an ASC, and adopting a notification process for surgical procedures the public believes can be added to the ASC CPL under the criteria we are retaining. This update 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. This results in a net payment rate of ASP minus 28.7 percent for 340B drugs. In the CY 2021 OPPS/ASC proposed rule, CMS is proposing to remove certain provisions in the expansion exception process that are applicable to hospitals that qualify as “high Medicaid facilities” because such provisions are not mandated by Section 1877 of the Act. CMS concluded that the list is not necessary to identify services that require inpatient care because of changes in medical practice, including new technologies and innovations. 2021 OPPS APC Offset File; 2021 Outlier and Rural Table; 2020 Unlisted CPT Codes; Home. The Centers for Medicare & Medicaid Services (CMS) has published the Calendar Year (CY) 2021 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule. CMS finalized its proposal to eliminate the IPO list over three calendar years, beginning with the removal of approximately 300 musculoskeletal-related services. CMS continues to believe prior authorization is an effective mechanism to ensure Medicare beneficiaries receive medically necessary care, while protecting the Medicare Trust Funds from unnecessary increases in volume by virtue of improper payments, without adding new documentation requirements for providers. On December 2, 2020, the Centers for Medicare & Medicaid Services (CMS) released the Hospital 2021 Outpatient Prospective Payment System (OPPS) final rule, which makes rate and other changes to the Medicare OPPS and ambulatory surgical center (ASC) payment systems for calendar year (CY) 2021. CMS proposed increasing OPPS rates by 2.6 percent in 2021 compared to 2020. Last year, CMS finalized a proposal to establish a process through which hospitals must submit a prior authorization request for a provisional affirmation of coverage before a covered outpatient service is furnished to the beneficiary and before the claim is submitted for processing. Providers are still expected to bill in compliance with the 2-Midnight rule. In the original statutory language, an exception process to this prohibition was included for POHs that qualify as an "applicable hospital." Using the results of its recent 340B drug acquisition cost survey, CMS proposes to adopt a rate of ASP minus 34.7%, … Wholesale Acquisition Cost (WAC) will be used for products without an ASP available. This update is based on the projected hospital market basket increase of 2.4 percent with a 0.0 percent adjustment for multi-factor productivity (MFP). Similar to the previous policy, rural sole community hospitals, PPS-exempt cancer hospitals and children's hospitals are exempt from this lower 340B reimbursement. Requests for expansion may include facilities that are not located on the hospital's main campus. This information is not intended to create, and receipt of it does not constitute, an attorney-client relationship. It is not designed to be, and should not be used as, the sole source of information when analyzing and resolving a legal problem, and it should not be substituted for legal advice, which relies on a specific factual analysis. After seeking stakeholder input through multiple public venues on the current methodology used to calculate the Overall Star Rating and our proposal from the CY 2021 proposed rule, CMS is retaining certain aspects of the current methodology (e.g., annual refresh, what measures are included, standardization of measure scores, and the use of k-means clustering to assign a rating) and updating other aspects, such as: These changes will be used to calculate the Overall Star Rating beginning in 2021. Based on the latest data, the geometric mean per diem costs for both CMHCs and hospital-based PHPs are significantly higher than the cost floors that were proposed for CY 2021. Sign up to get the latest information about your choice of CMS topics in your inbox. The CY2021 OPPS/ASC Notice of Final Rulemaking with Comment Period (NFRM) (CMS-1736-FC) including related links to the CY2021 NFRM OPPS Payment Rate addenda are now available. Beginning January 1, 2018, Medicare adopted a policy to pay an adjusted amount of ASP minus 22.5 percent for separately payable drugs or biologicals acquired under the 340B Program. The performing laboratory would bill Medicare directly for the test if the test meets all the laboratory DOS requirements. However, on July 17, 2020, the U.S. Court of Appeals for the District of Columbia Circuit ruled in favor of CMS, holding that the agency's regulation was a reasonable interpretation of the statutory authority to adopt a method to control unnecessary increases in the volume of the relevant service. OPPS Payment Methodology for 340B Purchased Drugs. Join this 3M Quality Webinar as 3M expert Colleen Deighan discusses the Centers for Medicare & Medicaid Services (CMS) Outpatient Prospective Payment System (OPPS) Final Rule, which impacts outpatient payment and quality reporting. The update was based solely on the hospital market basket increase of 2.4 percent, as there was no adjustment for multi-factor productivity (MFP). The CY 2021 OPPS/ASC final rule updates Medicare payment rates for Partial Hospitalization Program (PHP) services furnished in hospital outpatient departments and Community Mental Health Centers (CMHCs). One key difference in the Final Rule was a shift from a guaranteed two-year exemption from certain medical review activities for procedures newly removed from the IPO list to an "indefinite" exemption period. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. In last year's rule, CMS acknowledged the ongoing litigation relating to the lower payment amount, including a district court ruling that the agency exceeded statutory authority in adjusting the payment rate for 340B drugs. Hospital Outpatient Prospective Payment System Rulemaking. In the 2021 OPPS proposed rule, CMS has asked for comments on removing all codes from the IPO list over a three-year period, with a complete elimination of the list by 2024. OPPS Pricer File: January 2021. CMS News and Media Group CMS is finalizing changes to update and refine requirements for the Hospital Outpatient Quality Reporting (OQR) and Ambulatory Surgical Center Quality Reporting (ASCQR) Programs to further meaningful measurement and reporting for quality of care in the outpatient surgical setting, while limiting burden. The Centers for Medicare and Medicaid Services (CMS) on Dec. 2 released the 2021 Outpatient Prospective Payment System final rule, addressing Medicare payment and quality provisions for hospital outpatient services in 2021. In order for a physician-owned hospital to submit claims and receive Medicare payment for services referred by a physician owner or investor (or a physician whose family member is an owner or investor), the physician-owned hospital must satisfy all of the requirements of either the whole hospital exception or the rural provider exception to the physician self-referral law, commonly referred to as the “Stark Law.”. CMS is finalizing its policy to maintain the unified rate structure established in CY 2017, with a single PHP Ambulatory Payment Classification (APC) for each provider type for days with three or more services per day. As CMS continues to review their policies and reimbursement […] This fact sheet discusses the major provisions of the final rule with comment period (CMS-1736-FC), which can be downloaded at: https://www.cms.gov/files/document/12220-opps-final-rule-cms-1736-fc.pdf, Increasing Choice and Encouraging Site Neutrality. Cms continued to apply the hospital market basket, cms updated OPPS payment for. Provides opportunity for surgeries to be paid ASP+6 percent a procedure should end website and..., botulinum toxin injections, panniculectomy, rhinoplasty and cms opps 2021 ablation adjust billing Medicare for newly allowed services in physician! To apply the hospital 's main campus the change applied to five categories of:... Asp minus 28.7 percent for 340B drugs continues to exempt rural sole community hospitals, children ’ s,... Howden, Director Brian Leshak, Deputy Director Jason Tross, Deputy Director Tross. 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