Additional Details
Payment Updates
- OPPS Rate: CMS is proposing to update OPPS payment rates for hospitals that meet applicable quality reporting requirements by 3.1%, which is based on a projected hospital market basket update of 3.3% and a 0.2 percentage point reduction for the productivity adjustment. CMS is also finalizing its proposal to maintain the statutory 2.0 percentage point reduction in payment for hospitals that fail to meet the hospital outpatient quality reporting requirements.
- ASC Rate: In CY 2019, CMS finalized its proposal to apply the productivity-adjusted hospital market basket update that is applied to the OPPS system to the ASC payment system for an interim period of five years (CY 2019 to CY 2023). In this rule, CMS is finalizing its proposal to continue this policy for an additional two years, through CY 2024 and CY 2025. As such, CMS is finalizing a CY 2024 payment update for ASC rates of 2.8%.
- Rural Emergency Hospitals (REHs), Indian Health Service (IHS) Facilities, and Tribal Facilities: For tribal and IHS hospitals that convert to an REH, CMS is finalizing its proposal to pay providers under the same all-included rate (AIR) methodology that would apply to IHS and tribal facilities that are not an REH. CMS is also finalizing a policy that would provide REH monthly facility payments to IHS and tribal facilities that convert to REHs. CMS notes that the intent of these policies is to bring stability to IHS and tribal facilities that convert to REHs and to promote access to these hospitals.
- 340B Drugs: CMS is finalizing, without modification, the proposal to continue to pay 340B-eligible hospitals at the statutory default rate, generally ASP plus 6%, for 340B-acquired drugs and biologicals.
- Of note, CMS issued a related proposed rule on July 7, 2023, discussing the proposed remedy for underpayment to 340B-eligible hospitals for 340B-acquired drugs from CY 2018 to CY 2022. This remedy would include an estimated $9 billion lump sum payment for roughly 1,600 hospitals, which would be funded by future reductions to OPPS payments to all hospitals spread over a 15-year period. See ECG’s summary of that release here.
Behavioral Health Programmatic Changes and Proposals
- Changes to PHP: The PHP is an intensive outpatient program designed to serve as an alternative to psychiatric hospitalization and is paid on a per diem basis under the OPPS. CMS is finalizing its proposal to expand the PHP’s existing rate structure by adding two Ambulatory Payment Classifications (APCs) to include one rate for days with three services per day and one rate for days with four or more services per day. CMS notes that this policy will appropriately increase payment rates for higher-intensity days in all settings. This payment structure would also apply to the newly proposed IOP outlined below.
- IOP: CMS is finalizing the establishment of the IOP under Medicare. An IOP is a distinct outpatient program of psychiatric services provided for individuals who have an acute mental illness or substance use disorder.
- CMS is finalizing the policy that IOP services may be furnished in hospital outpatient departments, Community Mental Health Centers (CMHCs), Federally Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs).
- CMS is finalizing a consolidated list of service codes to be included in the IOP that were previously paid as part of the PHP benefit or more generally under the OPPS. CMS is also finalizing the establishment of two APCs (one rate for days with three services, and one for days with four or more services) and will base payment rates on cost per day using a broader set of OPPS data that includes both PHP days and non-PHP days.
- For CY 2024, CMS is also finalizing its proposal to extend IOP coverage to include opioid treatment programs (OTPs). CMS is establishing a weekly payment adjustment via an add-on code for IOP services furnished by OTPs.
- Changes to CMHC Condition of Participation (CoP): To implement provisions established by the Consolidated Appropriations Act (CAA) of 2023, CMS is finalizing its proposal to modify requirements for CMHCs to include IOP services throughout the CoPs. CMS is also finalizing modifications to personnel qualifications to include a revised definition of a mental health counselor (MHC) and add marriage and family therapists (MFTs). Finally, CMS is finalizing the addition of MFTs and MHCs to the list of practitioners who can lead interdisciplinary team meetings when deemed necessary.
Quality Programs
- CMS is finalizing several changes to the Hospital Outpatient Quality Reporting (OQR) and the Ambulatory Surgical Center Quality Reporting (ASCQR) Programs, as follows:
- Finalized Measures for Adoption:
- Risk-Standardized Patient-Reported Outcomes Following Elective Primary Total Hip and/or Total Knee Arthroplasty measure to provide specific insight into the quality of care of a common procedure
- (Proposed for adoption in Hospital OQR only) Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in adults electronic clinical quality measure (eCQM) to promote patient safety
- Finalized Measures for Modification:
- COVID-19 Vaccination Coverage Among Healthcare Personnel (HCP) measure to align with the updated Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network measure specifications
- Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery measure survey instrument to further standardize data collection and reduce facility burden
- Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients measure to align with updated clinical guidelines
- Of note, CMS is not finalizing the proposal to re-adopt Hospital Outpatient/ASC Facility Volume Data on Selected Outpatient Surgical Procedures following public feedback.
- CMS is also not finalizing the proposal to remove the Left without Being Seen measure.
- Within the Rural Emergency Hospital Quality Reporting (REHQR) Program, CMS is finalizing its proposal to adopt four initial measures, including three claims-based measures and one chart-abstracted measure as follows:
- Abdomen CT: Use of Contrast Material
- Median Time from Emergency Department (ED) Arrival to ED Departure for Discharged ED Patients
- Facility 7‑Day Risk‑Standardized Hospital Visit Rate after Outpatient Colonoscopy
- Risk-Standardized Hospital Visits within Seven Days after Hospital Outpatient Surgery
Other Updates
- To strengthen compliance around use of hospital price transparency data, CMS is finalizing its proposal to modify the standard charge display requirements at 45 CFR 180.50 and the proposed enforcement provisions at 45 CFR 180.70 to streamline the transparency of the enforcement process.
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Edited by: Matt Maslin
Published November 2, 2023
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