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CMS Releases CY 2015 OPPS Final Rule

November 7, 2014—The Centers for Medicare and Medicaid Services (CMS) Oct. 31 released the calendar year (CY) 2015 Outpatient Prospective Payment System (OPPS) final rule with comment period 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 rule also updates and refines 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 certain sections of the final rule are due Dec. 30.

CMS finalized a payment update that is estimated to increase overall OPPS payments by 2.3 percent for CY 2015. This update is based on a projected market basket increase of 2.9 percent, less a productivity adjustment of 0.5 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 payment increase also includes other payment changes, such as increased estimated total outlier payments. For major teaching hospitals, CMS estimates the impact resulting from the combined effects of all changes in the rule will be an increase of 3.1 percent, compared to 2.0 percent for both nonteaching hospitals and minor teaching hospitals.

To continue movement from fee-for-service to a more prospective payment system, CMS finalized the Comprehensive-APC policy as proposed for 25 out of the proposed 28 C-APCs. Three of the proposed APCs (APCs 0427, 0622, and 0652) will not be converted to C-APCs because CMS found a significant number of higher cost non-comprehensive services are often performed with the services assigned to these APCs and a single payment for the comprehensive service would result in significant underpayment for these select procedure combinations.

For CY 2015, CMS will conditionally package all 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 finalized this proposal over AAMC objections in comments  that the policy disproportionately affects teaching hospitals because of the types of patients these hospitals serve. When these ancillary services are furnished by themselves, CMS will make separate payment for these services. Exceptions to the ancillary services packaging policy include preventive services, psychiatry-related services, and drug administration services.

CMS also finalized collecting data on services furnished in off-campus provider-based departments by requiring hospitals to report a modifier for these services and by requiring physicians and other eligible practitioners to report these services using a new place of service code on professional claims. CMS took into account comments that the proposed effective date of Jan. 1, 2015 was not administratively feasible for all hospitals and adopted a policy that data collection will be voluntary in 2015 and required beginning on Jan. 1, 2016.

The CY 2015 OPPS final rule also revises 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 inpatient prospective payment system (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 finalizes a policy that that an order will still be required for all inpatient admissions, but the order will no longer be part of the certification process, and certification will only be necessary for cases of 20 inpatient days or more and for outlier cases.

Regarding the quality provisions in the CY 2015 OPPS final rule, CMS adopted one new outcome measure for the Outpatient Quality Reporting (OQR) and Ambulatory Surgical Centers Quality Reporting (ASCQR) programs starting CY 2018: Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy.

The agency also finalized its proposal to remove Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery from the OQR and ASCQR measure sets for CY 2016 and to make this a voluntarily measure in CY 2017. CMS also finalized the removal of two “topped-out” prophylactic antibiotic surgery measures, and clarified the data submission requirements for Influenza Vaccination Coverage among Healthcare Personnel.


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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.

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Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806