On November 2, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2019 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule. The administration continues to focus on decreasing administrative burden for the health care system.
Key changes to Medicare OPPS and ASC payment rates and policies for CY 2019 include:
ASC Payment Changes
- ASC Inflationary Update: After more than a decade of advocacy by the GI societies and other stakeholder organizations, CMS finalized its proposal to update ASC payment rates using the hospital market basket rather than the consumer price index-urban (CPI-U) for 2019-2023. We applaud the change in the update but emphasize payment adequacy by site of service. CMS polices to set reimbursement rates across sites of service at the lowest reimbursed rate are misguided.
- ASC Payment Update: CMS is updating ASC rates for CY 2019 by 2.1 percent. Click here to access proposed ASC payment rates for GI services.
- Device-Intensive Policy: CMS modified the device-intensive criteria to allow procedures that involve single-use devices, regardless of whether they remain in the body after the conclusion of the procedure, to qualify as device-intensive. CMS also lowered the device-offset percentage used to identify device-intensive procedures from 40 percent to 30 percent, allowing procedures that use high-cost devices to be better recognized in the ASC setting.
Several device-intensive GI procedures benefit from this change, including:
OPPS Payment Changes
- OPPS Payment Update: CMS is updating OPPS payment rates by 1.35 percent. Click here to access proposed OPPS payment rates for GI services.
- Clinic Visit: CMS finalized its proposal to apply a Physician Fee Schedule (PFS)-equivalent payment rate for clinic visits (G0463) provided at an off-campus provider-based department and paid under the OPPS. The policy will be phased in over two years and reduces the CY 2019 OPPS payment rate for clinic visits to $81. The clinic visit is the most common service billed under the OPPS.
OPPS and ASC Quality Reporting Programs
HOPD and ASC Quality Reporting: CMS finalized its proposal to remove ASC-8: Influenza Vaccination Coverage Among Healthcare Personnel, beginning with the CY 2020 payment determination; and ASC-10: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use, beginning with the CY 2021 payment determination. Similarly, CMS has finalized removal of OP-30: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use from the Hospital Outpatient Quality Reporting Program, beginning with the CY 2021 payment year.
CMS had also proposed to remove ASC-9: Endoscopy/Polyp Surveillance: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients, among other measures. However, the Agency decided to retain ASC-9 because it believes there is demonstrated substantial overuse of surveillance colonoscopies among low-risk patients, even though this measure is available for reporting by gastroenterologists under the Merit-based Incentive Payment System.
CMS did not finalize its proposal to remove ASC-1, ASC-2, ASC-3, and ASC-4 but did suspend its data collection beginning with the CY 2019 reporting period. Suspending data collection on these measures will give CMS time to update their data submission method due to concerns relative to data completeness and accuracy.
The table below outlines the ASCQR Program measure set for the CY 2019 reporting period.
Review the fact sheet for the CY 2019 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule.
The OPPS and ASC final rule will appear in the Federal Register on November 21, 2018. The deadline to submit comments to CMS is December 3, 2018. The rule can be downloaded here.