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CMS Releases CY 2015 OPPS Proposed Rule

July 11, 2014The Centers for Medicare and Medicaid Services (CMS) July 3 released the calendar year (CY) 2015 Outpatient Prospective Payment System (OPPS) proposed rule updating payment policies and payment rates for services furnished to Medicare beneficiaries in hospital outpatient departments and ambulatory surgical centers (ASCs) beginning Jan. 1, 2015.

The proposed rule also would update and refine the requirements for the Hospital Outpatient Quality Reporting (OQR) program, the ASC Quality Reporting (ASCQR) program, and the Hospital Value-Based Purchasing (VBP) program. Comments on the proposed rule are due Sept. 2, 2014.

CMS proposes a market-basket update for CY 2015 of 2.1 percent for those hospitals that publicly report data on 22 quality measures. This update is based on a projected market basket increase of 2.7 percent, less a productivity adjustment of 0.2 percentage points, and a negative 0.2 percentage point adjustment required by the Affordable Care Act (ACA, P.L. 111-148 and P.L. 111-152).

The overall impact on major teaching hospital is projected to be 2.9 percent, which includes the 2.1 annual update. CMS’ impact table projects a 0.6 percent increase for major teaching hospitals for Ambulatory Payment Classifications (APC) related proposals.

The AAMC is disappointed, however, that CMS did not provide separate impact projections for distinct proposals, making it very difficult to analyze the effect of various APC-related proposals and their unique impacts on teaching hospitals.

To continue movement from fee-for-service to a more prospective payment system, the rule includes a proposal to implement a modified version of the comprehensive-APC policy proposed and adopted through the CY 2014 OPPS rulemaking process.

In the CY 2015 OPPS proposed rule, CMS proposes several additional comprehensive APCs, including some lower cost device-dependent APCs that were not proposed in the 2014 proposed rule.

Additionally, CMS proposed the restructuring and consolidation of some of the current device-dependent APCs with similar costs based on the 2013 claims data. After these changes, CMS is proposing a total of 28 comprehensive APCs (compared to 29 comprehensive APCs that were included in the CY 2014 OPPS final rule).

Modifying another proposal from last year’s OPPS proposed rule, CMS proposes to conditionally package ancillary services.

For CY 2015, CMS proposes that the initial set of conditionally packaged ancillary service APCs would be ancillary services assigned to APCs with a geometric mean cost of $100 or less (before applying the conditional packaging status indicator to the services within these APCs).

CMS proposes a few exceptions to this packaging policy including: preventive services, psychiatry-related services, and drug administration services.

The AAMC appreciates that CMS did not propose to collapse the current five levels of outpatient emergency department (ED) visit codes into a single code. In the CY 2014 OPPS final rule with comment, CMS stated that additional study is “needed to fully assess the most suitable payment structure for ED visits, including the particular number of visit levels that would not underrepresent resources required to treat the most complex patients, such as trauma patients” (78 FR 75040).

CMS still believes there is a need to further explore these issues before potentially proposing changes to the coding and APC assignments for ED visits in future rulemaking.

The CY 2015 OPPS proposed rule also would require hospitals to report a modifier for services furnished in an off-campus provider-based department on both hospital and physician claims. This is intended as a means for CMS to begin collecting data on services furnished in off-campus provider-based departments, as discussed in the CY 2014 OPPS proposed rule.

Additionally, CMS proposes to revise requirements for physician certification of hospital inpatient services (other than psychiatric inpatient services). Under current rules, including the Two Midnight Rule finalized in the FY 2014 IPPS final rule, CMS requires a physician certification, which would include an admission order and other specified elements, for all inpatient admissions.

For CY 2015, CMS proposes that an order would still be required for inpatient admissions, but the order would no longer be part of the certification process, and that certification would only be necessary for cases of 20 inpatient days or more and for outlier cases.

Finally, regarding the quality provisions in the OQR and ASCQR programs, CMS proposes the addition of one new measure starting CY 2017: Facility 7-day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy. The measure assesses all unplanned hospital visits (admissions, observation stays, and emergency department visits) that occur within one week of an outpatient colonoscopy procedure.

CMS is also proposing to delay implementation of the Cataracts — Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery outpatient measure to Jan. 2015, and therefore will not be included in the CY 2016 payment determination measure set. This measure can be voluntarily submitted for CY 2015.

Finally, the agency plans to remove three topped-out measures from the OQR Program starting CY 2017: Aspirin at Arrival, Timing of Antibiotic Prophylaxis, and Prophylactic Antibiotic Selection for Surgical Patients.


Scott Wetzel, M.P.P.
Lead, Quality Reporting
Telephone: 202-828-0495


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