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  • Washington Highlights

    CMS Releases CY 2022 Outpatient Prospective Payment System Final Rule


    Mary Mullaney, Director, Hospital Payment Policies
    Phoebe Ramsey, Director, Physician Payment & Quality
    Andrew Amari, Hospital Policy and Regulatory Specialist

    On Nov. 2, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2022 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule. The AAMC submitted comments on several policies in the proposed rule on Sept. 15 [refer to Washington Highlights, Sept. 17]. Provisions of the final rule are effective Jan. 1, 2022, unless otherwise indicated in the rule.

    Notably, the rule finalizes the proposed changes to the price transparency requirements for hospital standard charges. Specifically, the civil monetary penalties (CMPs) for noncompliance with the price transparency requirements will increase based on bed count and some activities that present barriers to accessing machine-readable files will be prohibited.

    Additionally, CMS did not address the distribution of the 1,000 Medicare graduate medical education (GME) slots or other GME provisions included in the Consolidated Appropriations Act of 2021 (P.L. 116-260)  in the final rule [refer to Washington Highlights, Dec. 23, 2020].

    Listed below are summaries of the finalized provisions of importance to AAMC-member institutions.

    Payment Provisions

    Payment Update: The final rule increased payment rates for hospitals that meet applicable quality reporting requirements by 2%. This update is based on the projected hospital market basket increase of 2.7%, reduced by 0.7 percentage point for the productivity adjustment.

    Ratesetting Data Set: Due to several COVID-19 public health emergency-related factors, CMS believes that the CY 2020 data are not the best overall approximation of expected outpatient hospital services in CY 2022, and therefore used CY 2019 data to set the CY 2022 OPPS and the ASC payment system rates.

    Hospital Price Transparency: The final rule imposed a minimum CMP of $300 per day for hospitals with 30 or fewer beds. A penalty of $10 per bed per day would apply to hospitals with a bed count greater than 30, not to exceed a maximum daily dollar amount of $5,500. Under this approach, for a full calendar year of noncompliance, the minimum total penalty amount would be $109,500 per hospital, and the maximum total penalty amount would be $2,007,500 per hospital.  CMS also finalized its policy to require that machine-readable files be accessible to automated searches and direct downloads.

    340B-Acquired Drugs: The rule maintained the payment rate of average sales prices minus 22.5% for certain separately payable drugs or biologics acquired through the 340B Drug Pricing Program.

    Site-Neutral Payments: Payment reductions for hospital outpatient clinic visits (HCPCS code G0463) when furnished by excepted off-campus, provider-based departments are continued.

    Inpatient Only (IPO) List: The final rule halted elimination of the IPO list and reinstates the majority of the services removed in CY 2021, except for CPT codes 22630 (lumbar spinal fusion), 23472 (reconstruct shoulder joint), 27702 (reconstruct ankle joint), and their corresponding anesthesia codes. The rule codifies longstanding criteria for removal of procedures from the IPO list to make clear in regulatory text how future procedures will be evaluated for removal. The rule also exempts procedures removed from the IPO list beginning on or after Jan. 1, 2022, from site-of-service and noncompliance with the Two-Midnight Rule for two years.

    ASC Covered Procedures List (ASC CPL): The rule reinstated patient safety criteria for adding a procedure to the ASC CPL that were in place in CY 2020 and removes from the ASC CPL 255 procedures that were added in CY 2021. The final rule also adopts a nomination process that, beginning March 2022, will allow an external party to nominate a surgical procedure to be added to the ASC CPL. If CMS determines that a surgical procedure meets the requirements to be added to the ASC CPL, including a surgical procedure nominated by an external party, it will propose to add the surgical procedure to the ASC CPL for Jan. 1, 2023. CMS will provide subregulatory guidance on the nomination process in early 2022.

    ASC Payment for Non-Opioid Products: The rule modified current policy for CY 2022 that provides for separate payments for non-opioid pain management drugs and biologicals that function as supplies in the ASC setting when such product is Food and Drug Administration (FDA) approved, indicated for pain management or as an analgesic by the FDA, and has a per-day cost above the OPPS drug packaging threshold.

    Beneficiary Coinsurance for Colorectal Cancer Screening Tests: Flexible sigmoidoscopies and colonoscopies are considered as screening in the final rule, regardless of whether tissue or other matter is removed during the screening test beginning Jan. 1, 2022. The rule gradually reduces beneficiary cost-sharing for these services beginning Jan. 1, 2022, so that for services furnished on or after Jan. 1, 2030, the coinsurance will be zero.

    Quality Provisions

    Outpatient Quality Reporting (OQR) Program

    The final rule adopted three new measures:

    • Breast cancer screening recall rates (OP-39) is claims-based and begins with a data collection period of July 2020 to June 2021.
    • COVID-19 vaccination coverage among health care personnel measure (OP-38), which begins with CY 2022 reporting to the Centers for Disease Control and Prevention through the National Healthcare Safety Network system.
    • ST-Segment Elevation Myocardial Infarction (STEMI) eCQM (OP-40) will begin with one quarter of data for CY 2024 reporting, after a year of voluntary reporting in CY 2023. Two chart-abstracted measures, OP-2 and OP-3, are removed as a result, and these measures will no longer need to be reported beginning with CY 2023 reporting.

    The final rule also mandated the reporting of the Outpatient and Ambulatory Surgical Consumer Assessment of Healthcare Providers and Systems, or OAS CAHPS (OP-37a-e, measures currently suspended from the program) and the cataracts measure (OP-31, currently voluntary) beginning with CY 2024 reporting and CY 2025 reporting, respectively.

    The rule also updated the validation policies to reduce the reporting period from 45 days to 30 days beginning with validations of CY 2022 reporting.

    CMS also reviewed comments the agency received in response to requests for information regarding a transition to digital quality measurement and addressing health equity in hospital quality programs.