On 2nd Dec 2020, the Centers for Medicare & Medicaid Services released the calendar year 2021 outpatient prospective payment system/ambulatory surgical center (OPPS/ASC) final rule. Earlier on August 4, 2020, CMS proposed policies which will increase patient choice by making Medicare payment available for more services in different sites of service and adopting policy changes under the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System.

This final rule will reduce provider burden so that hospitals and ambulatory surgical centers can operate with increased flexibility, and patients are better equipped to be active healthcare consumers.

ASC Covered Procedures List

  • CMS has expanded the number of procedures that Medicare would pay for when performed in an ASC, which would give patients more choice on where to receive care and ensure CMS payment policies do not favor one type of care setting over another. 
  • For CY 2021, CMS added eleven procedures to the ASC covered procedures list (CPL), including total hip arthroplasty (CPT 27130).  
  • Additionally, CMS proposed two alternatives to further expand services payable in ASCs that would give beneficiaries more choices on where to get care. Under the first alternative, CMS proposed to modify certain criteria for adding a procedure to the ASC-CPL and to establish a nomination process under which external stakeholders, such as professional specialty societies, would use suggested parameters to nominate procedures that can be safely performed in the ASC setting. CMS would select nominated procedures to propose and finalize adding to the ASC CPL through annual rulemaking.  
  • Under the other alternative proposal, they would revise the ASC CPL criteria under 42 CFR 416.166, keeping the general standard criteria (i.e., the procedure would not be expected to pose a significant safety risk to a beneficiary when performed in an ASC or to require active medical monitoring and care at midnight following the procedure) and eliminating five general exclusion criteria.
  • Under this final rule, they would add approximately 270 potential surgery or surgery-like procedures to the ASC-CPL that are not on the CY 2020 IPO list and that meet the revised regulatory criteria. Additionally, under this alternative proposal, CMS solicit comment on whether the conditions for coverage for ASCs (the baseline health and safety requirements for Medicare-participating ASCs) should be revised given the nature of the services that would be added under this alternative. 
  • When receiving care in an ASC rather than a hospital outpatient department, patients can potentially lower their out-of-pocket costs for certain services. For example, for one of the most common cataract surgeries, currently, on average, a Medicare beneficiary pays $101 if the procedure is done in a hospital outpatient department compared to $51 if done in a surgery center. Since 2018, CMS has added 28 procedures to the ASC-CPL.

Ambulatory Surgical Center Quality Reporting (ASCQR) Program

CMS proposed changes to update and refine requirements for the Ambulatory Surgical Center Quality Reporting (ASCQR) Programs to further meaningful measurement and reporting for quality of care in the outpatient surgical setting while limiting burden. CMS proposed to revise and codify previously finalized administrative procedures and to propose and codify an expanded review and corrections process to further align the ASCQR Programs while clarifying program requirements. 

PHP Per Diem Rates

CMS proposed to maintain the unified rate structure established in CY 2017, with a single PHP Ambulatory Payment Classification (APC) for each provider type for days with three or more services per day. CMS proposed to use the CMHC and hospital-based PHP (HB PHP) geometric mean per diem costs, consistent with existing policy, using updated data for each provider type and a cost floor equal to the CY 2019 final geometric mean per diem cost for each provider type. Accordingly, CMS proposed to calculate the CY 2021 PHP APC per diem rate for HB PHPs based on updated cost data and to calculate the rate for CMHCs based on the proposed cost floor.

Boost to ASC Payment Rates

In the CY 2019 OPPS/ASC final rule with comment period, CMS finalized a proposal to apply the hospital market basket update to ASC payment system rates for an interim period of 5 years (CY 2019 through CY 2023). Using the hospital market basket, CMS is proposed to update the ASC rates for CY 2021 by 2.6 percent. 

The proposed update applies to ASCs meeting relevant quality reporting requirements. This change is based on the projected hospital market basket increase of 3 percent minus a 0.4 percentage point adjustment for MFP. This proposed change would also help to promote site-neutrality between hospitals and ASCs and encourage the migration of services from the hospital setting to the lower cost ASC setting.



Proposed Rule: CY 2021 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule (CMS-1736-P)

Published By - Medical Billers and Coders
Published Date - Feb-04-2021 Back

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