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CMS Releases CY 2020 OPPS Final Rule

November 8, 2019

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PRESS CONTACTS
Andrew Amari, Hospital Policy and Regulatory Specialist
Mary Mullaney, Director, Hospital Payment Policies
Phoebe Ramsey, Sr. Regulatory Analyst, Quality & Payment Policy

The Centers for Medicare and Medicaid Services (CMS) Nov. 1 released the calendar year (CY) 2020 Outpatient Prospective Payment System (OPPS) final rule. The AAMC submitted a comment letter on the proposed rule [see Washington Highlights, Sept. 27].

Notably, CMS will continue its phase-in of payment reductions for clinic visits in off-campus provider-based departments (PBDs) for 2020, despite a federal district court’s order to vacate the relevant portions of the rule [see Washington Highlights, Oct. 25]. CMS will also continue to pay a reduced reimbursement rate, average sales price (ASP) minus 22.5%s, for drugs acquired under the 340B Drug Pricing Program, and announced its intent to collect drug acquisition cost data for 340B-acquired drugs. A federal district court judge ruled that the cuts exceeded CMS’s authority earlier this year [see Washington Highlights, Jan. 11].

Additionally, the price transparency proposals that were part of the proposed rule are not included in this final rule with comment. Instead, CMS will publish a separate final rule addressing price transparency, which is expected to be released before the end of the year. 

Below are highlights of key finalized proposals. 

Payment Provisions

Payment Rate. Increase OPPS payment rates by 2.6%.

Site-Neutral Implementation. Implement second year phase-in of reductions in payment for clinic visit services described by HCPCS code G0463 furnished in excepted off-campus PBDs, as finalized in the CY 2019 OPPS final rule. While acknowledging the U.S. District Court for the District of Columbia’s ruling to vacate this policy for CY 2019, CMS notes that it does not believe “it is appropriate at this time to make a change to the second year of the two-year phase-in of the clinic visit policy.” CMS notes that it is evaluating its appeal rights.

340B Drug Pricing Program. Continue to pay drugs acquired under the 340B Program at ASP minus 22.5% when furnished in nonexempt off-campus PBDs. Comments for a potential remedy for CYs 2018 and 2019 in the event of an unfavorable decision for CMS’s appeal are summarized in the rule. CMS announced its intent to conduct a 340B hospital survey to collect drug acquisition cost data for CY 2018 and 2019 and data from that survey may be used to craft a remedy.

Wage IndexApply fiscal year (FY) 2020 Inpatient Prospective Payment System (IPPS) post-reclassified wage index to OPPS to determine wage adjustments for the OPPS payment rate and the copayment standardized amount.

Comprehensive Ambulatory Payment Classifications (C-APCs)Create two new C-APCs: C-APC 5182 (Level 2 Vascular Procedures) and C-APC 5461 (Level 1 Neurostimulator Related Procedures), which increases the total number of C-APCs to 67.

Inpatient Only (IPO) ListRemove Total Hip Arthroplasty from the IPO. Establish a two-year exemption from certain medical review activities for procedures removed from the IPO beginning CY 2020 and subsequent years.

Changes to the List of ASC Covered Surgical Procedures. Add eight procedures to the ASC list of covered surgical procedures, including total knee arthroplasty procedure, knee mosaicplasty, six coronary intervention procedures, and 12 surgical procedures with new CPT codes to the ASC for CY 2020.

Innovative Technologies. Establish an alternative pathway to qualify for device pass-through payment status for innovative technologies and treatments that meet the Food and Drug Administration’s Breakthrough Device designation and would not subject these technologies and treatments to the “substantial clinical improvement” criterion.

Prior Authorization. Implement a prior authorization process for Blepharoplasty, Botulinum Toxin Injections, Panniculectomy, Rhinoplasty, and Vein Ablation as a method to control unnecessary increases in volume of services.

Section 5506 Graduate Medical Education Slot Distribution. CMS initiated Rounds 16 and 17 of its section 5506 application and selection process to redistribute slots from two closed hospitals: Hahnemann University Hospital, located in Philadelphia, Penn., and Ohio Valley Medical Center, located in Wheeling, W. Va.

Quality Provisions

Hospital Outpatient Quality Reporting (OQR) Program. Finalize the removal of one web-based measure for the CY 2022 Program Year from the Hospital OQR program (External Beam Radiotherapy for Bone Metastases [OP-33]).

Future OQR Measurement Topics. Preview future measurement topics for the OQR, including potential alignment of measures with the Ambulatory Surgical Center Quality Reporting Program and an intent to move towards greater user of outcome measures.

Quality and Price Transparency Request for Information (RFI). CMS notes that it received over 63 comments on its RFI seeking stakeholder input on how to relate quality measurement with the Agency’s price transparency efforts.

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