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Medical Coding News Archives

CMS Policy & Payment Changes for Outpatient Departments and ASCs

 
December 21, 2011:

Karen M Adkins, Clinical/Technical Editor

The final rule updating payment policies and rates for services provided in hospital outpatient departments and ambulatory surgery centers (ASCs) was released by the Centers for Medicare and Medicaid Services (CMS) on November 1, 2011.

The rule increases the number of measures that can be reported under the Hospital Outpatient Quality Reporting Program and creates a new quality reporting program for ASCs. In addition, it seeks to reinforce the hospital Value-Based Purchasing (VBP) program, which will impact hospital payments for inpatient stays effective October 1, 2012.

Other provisions of the final rule include:

  • Establishment of:
    • an electronic reporting pilot that permits additional hospitals, including critical access hospitals (CAHs) to report clinical quality measures (CQMs) effective in 2012 as part of the Electronic Health Record Incentive program
    • an independent advisory review process whose function will be to consider requests that certain outpatient services be subject to a level of supervision other than direct supervision. As part of the process, CMS will search for suggestions from the Ambulatory Payment Classification (APC) Advisory Panel regarding appropriate supervision requirements. The panel was established to offer technical advice and guidance to CMS about assigning items and services furnished in the hospital outpatient department to appropriate payment classifications. The panel will be made up of two small rural prospective payment system (PPS) hospital members and two CAHs to ensure that all hospitals subject to the supervision rules for payment of outpatient therapeutic services are represented; however, because CAHs are not paid under the OPPS, CAH reps will not participate in discussions concerning APC assignments.
    • a quality reporting program for ASCs and the adoption of five quality measures, four of which will measure outcomes and one that will measure surgical infection control, which will begin in 2012 for a 2014 payment determination
      • two structural measures will also be added—one for safe surgery checklist use and one for ASC facility volume data on selected ASC surgical procedures—for reporting in 2013 for a 2015 and 2016 payment determination
  • Increased payment rates:
    • OPPS by 1.9 percent; the increase is based on a projected hospital inpatient market-basket percentage increase of 3.0 percent for inpatient services paid under IPPS less the multifactor productivity adjustment of 1.0 percent and the 0.1 percent point adjustment—both of which are required under the Affordable Care Act
    • ASCs by 1.6 percent to reflect a consumer price index for urban consumers of approximately 2.7 percent, less a 1.1 percent productivity adjustment as authorized by the ACA
  • Increased payments of approximately $71 million to designated cancer hospitals through a payment adjustment required by the ACA
  • Payment for:
    • acquisition and pharmacy overhead costs of separately payable drugs/biologicals at the average sales price (ASP) plus 4 percent; this will not apply to new drugs/biologicals that have pass-through status
    • partial hospitalization (PHP) services in hospital-based PHPs and community mental health centers (CMHCs); payment will be based on the unique cost structures of each program type. For both provider types, CMS proposes to update the four PHP per diem payment rates based upon the median costs calculated using recent claims data for each provider type.
  • Increase in the number of measures that can be reported on in 2012 and 2013 in order to determine payments for 2014 and 2015; modification of the process used to select hospitals for validating reported chart-abstracted measures adopted for 2012 in the 2011 OPPS rule
  • New program requirements for the hospital VBP, including:
    • adding one clinical process measure to protect against urinary catheter infections
    • establishing the weighting, performance periods, and performance standards for the clinical process, patient experience, and outcomes measures for 2014

For more information on the OPPS and ASC payment system final rule, visit http://www.gpo.gov/fdsys/pkg/FR-2011-11-30/pdf/2011-28612.pdf.

 

 
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