The Centers for Medicare & Medicaid Services (CMS) on Nov. 1 released the calendar year (CY) 2023 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule, and provided additional details in a fact sheet and press release. The AAMC previously submitted comments to the CY 2023 OPPS proposed rule [refer to Washington Highlights, Sept. 16].
Listed below are summaries of the finalized CY 2023 provisions of importance to health care delivery at academic medical centers.
The CMS finalized a general payment rate of average sales price plus 6% for drugs and biologics acquired through the 340B Drug Pricing Program. The agency acknowledged this change is being made in light of the Supreme Court decision in June rejecting cuts to 340B hospitals [refer to Washington Highlights, June 17]. As required by statute, the CMS will implement a -3.09% reduction in payment rates for non-drug services to achieve budget neutrality for the 340B rate change for CY 2023. The CMS stated in the final rule it will address the remedy for 340B-acquired drug payments for years 2018 through 2022 in future rulemaking prior to the CY 2024 OPPS/ASC proposed rule.
The agency finalized an increase in payment rates by 3.8% under the OPPS for CY 2023. The increase is based on a hospital market basket percentage increase of 4.1% reduced by a productivity adjustment of a 0.3 percentage point. Hospitals that successfully meet the hospital Outpatient Quality Reporting program requirements would be eligible for the full update.
Claims data from CY 2021 will be used to set CY 2023 OPPS and ASC rates. To account for the impacts of the COVID-19 public health emergency (PHE), the agency will use cost report data from the June 2020 extract from Healthcare Cost Report Information System, which includes cost report data through CY 2019.
The agency will remove eleven services from the Inpatient Only List and will add four procedures to the ASC Covered Procedures List. These finalized proposals are modifications from the proposed rule.
The CMS will continue the current policy to separately pay for non-opioid pain management drugs and biologics that function as supplies in the ASC setting. Under this policy, for CY 2023, the agency finalized a separate payment in the ASC setting for five non-opioid pain management drugs that function as surgical supplies, including certain local anesthetics and ocular drugs, that meet the criteria in 42 CFR 416.174.
Behavioral health services using telecommunications technology furnished to beneficiaries in their homes by clinical staff of hospital outpatient departments (HOPDs), including staff of critical access hospitals, will be considered by the agency as covered outpatient services and paid under the OPPS. The finalized policy will require beneficiaries to have an in-person service within six months prior to the first telehealth visit and an in-person visit within 12 months thereafter. The six-month in-person visit will not apply to beneficiaries who began receiving mental health telehealth services during the PHE or during the 151-day period at the end of the PHE. Some exceptions will be permitted.
The CMS finalized the policy to exclude research organs from the calculation of Medicare’s share of organ acquisition costs and require a cost offset. Certain hospital costs typically incurred when donors die from cardiac death will be covered as organ acquisition costs to promote organ procurement and enhance equity.
The agency finalized the policy to provide payment adjustments under the inpatient prospective payment system (IPPS) and the OPPS for domestically made, NIOSH-approved surgical N95 masks. The policy applies to cost reporting periods beginning on or after Jan. 1, 2023.
The CMS will exempt excepted off-campus, provider-based departments of rural sole community hospitals (SCHs) from the site neutral payment policy for clinic visits. Rural SCHs will be paid the full OPPS payment rate for clinic visits furnished in these departments.
The CMS finalized policies to:
- Make the reporting of the OP-31 Cataracts Function measure voluntary, effective with CY 2025 reporting period, in recognition of COVID-19 pandemic constraints and changes to patient case volumes;
- Align patient encounter quarters for reporting chart-abstracted measures with the calendar year two years prior to the payment determination year, transitioning fully for the CY 2024 reporting period for CY 2026 payment; and
- Add a new data validation targeting criterion for the CY 2023 reporting period for hospitals with a two-tailed confidence interval less than 75% and less than four quarters of data due to receiving an extraordinary circumstances exception for one of more quarters.
The agency amended codified language for the program to state the use of publicly available measure results on the Care Compare website to “a quarter from within the previous twelve months,” rather than the prior year. For example, if the ratings were next updated in July 2023, the CMS could use quality performance data refreshed in July 2022, October 2022, January 2023, April 2023, or July 2023.