CMS Finalizes Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Rule

Alerts / November 9, 2021

On Nov. 2, 2021, the Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2022 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System (OPPS) final rule. The final rule takes effect on Jan. 1, 2022.

Some highlights under the CY 2022 OPPS final rule include the following:
  • Hospital Price Transparency: CMS modified the Hospital Price Transparency regulation as follows:
    • Effective Jan. 1, 2022, CMS is increasing the minimum civil monetary penalty (CMP) to a $300-per-day base rate. Hospitals with more than 30 beds will be charged $10 per bed per day, with a cap not to exceed $5,500 per day. Annually, CMPs for noncompliance will be capped at $2,007,500 per hospital.
    • CMS also updated the price transparency rules so that state forensic hospitals that exclusively treat individuals in the custody of penal authorities will be deemed compliant.
    • The new final rule also includes updates to the requirements for hospitals to make their machine-readable files accessible to automated searches and direct downloads.
  • Hospital Outpatient Quality Reporting (OQR) Program: CMS finalized proposals that include:
    • Adopting three new measures, including the COVID-19 vaccination of healthcare personnel.
    • Updating the validation policies of the Hospital OQR Program to reduce provider burden and improve processes.
  • Ambulatory Surgical Center Quality Reporting (ASCQR) Program: CMS finalized proposals to:
    • Adopt the COVID-19 vaccination of healthcare personnel.
    • Make the reporting of six voluntary or suspended measures mandatory.
  • Payment for Non-Opioid Pain Management Drugs and Biologicals Under Section 6082 of the SUPPORT Act: CMS modified its current policy to provide for separate payment for non-opioid pain management drugs and biologicals that function as surgical supplies in the ambulatory surgical center ASC setting when those products meet certain criteria. Beginning Jan. 1, 2022, such drugs and biologicals will be eligible for separate payment when such product is Food and Drug Administration (FDA) approved, is FDA indicated for pain management or as an analgesic, and has a per-day cost above the OPPS drug packaging threshold.
  • Changes to the ASC Covered Procedures List: CMS reinstated the ASC Covered Procedures List (CPL) criteria that were in effect in CY 2020, removed several of the procedures that were added to the ASC CPL in CY 2021 and added six procedures to the CPL. CMS also adopted a nomination process, under which stakeholders may nominate procedures they believe meet the requirements to be added to the ASC CPL. CMS will provide subregulatory guidance on the nomination process in early 2022, with procedure nominations due in March 2022, and the formal nomination process beginning in CY 2023.
  • ASC Payment Update: CMS increased payment rates under the ASC payment system by 2.0 percent for ASCs that meet the quality reporting requirements under the ASCQR Program.
  • 2-Midnight Rule: CMS exempted procedures that are removed from the inpatient only (IPO) list under the OPPS beginning on or after Jan. 1, 2022, from site-of-service claim denials, Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) referrals to recovery audit contractors (RAC) for persistent noncompliance with the 2-midnight rule, and RAC reviews for “patient status” for a time period of two years.
  • Cancer Hospital Payment Adjustment: CMS will continue to provide additional payments to cancer hospitals. The payment adjustments will be the additional payments needed to result in a payment-to-cost (PCR) equal to 0.89 for each cancer hospital.
  • Changes to the IPO List: CMS paused the elimination of the IPO list and added the services removed in 2021, except for CPT codes 22630 (lumbar spine fusion), 23472 (reconstruct shoulder joint), 27702 (reconstruct ankle joint) and the corresponding anesthesia codes (00630, 00670, 01486 and 0643T).
  • Radiation Oncology Model (RO Model): CMS finalized proposed provisions related to the additional delayed implementation of the RO Model due to the Consolidated Appropriations Act, 2021, as well as modifications to certain RO Model policies not related to the delay.
  • Equitable Adjustment for Device Category, Drugs and Biologicals with Expiring Pass-through Status: CMS is using its equitable adjustment authority under 1833(t)(2)(E) to provide up to four quarters of separate payment for 27 drugs and biologicals and one device category whose pass-through payment status will expire between Dec. 31, 2021, and Sept. 30, 2022.
  • Beneficiary Coinsurance for Colorectal Cancer Screening Test: All surgical services furnished on the same date as a planned screening colonoscopy or a planned flexible sigmoidoscopy could be viewed as being furnished in connection with, as a result of and in the same clinical encounter as the screening test for purposes of determining the coinsurance required of Medicare beneficiaries for planned colorectal cancer screening tests that result in additional procedures furnished in the same clinical encounter.
  • Comment Solicitation on Temporary Policies for the PHE for COVID-19: CMS is now seeking comment on whether there are certain temporary policies that should be made permanent.
  • 340B-Acquired Drugs: CMS is continuing its current policy regarding 340B-acquired drugs.

For additional information on this rule, see the press release published by CMS.

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