The CY 2019 Outpatient PPS/ASC Payment System Proposed Rule August - PowerPoint PPT Presentation

The CY 2019 Outpatient PPS/ASC Payment System Proposed Rule August 14, 2018

CY 2019 OPPS/ASC Proposed Rule Timeline  Proposed rule released July 25  Published in July 31 Federal Register  Comments due by Sept. 24  Final Rule will be issued around Nov. 1  Effective on Jan. 1, 2019

Agenda  Proposed Expansion of Site-neutral Payment Policies for CY 2019  Other Outpatient Prospective Payment System (OPPS) Payment Policy Proposals  Hospital Outpatient Quality Reporting (OQR) Program Proposed Changes  Ambulatory Surgical Center (ASC) Payment System Proposed Changes  ASC Quality Reporting (ASCQR) Program Proposed Changes  Inpatient Quality Reporting HCAHPS Pain Questions  Requests for Information

Site-neutral Payment Policy Background  Sec. 603 of BiBA mandated site-neutral payment for non- ED services in certain “new” off-campus provider-based departments (PBDs) – those that first were paid under OPPS after Nov. 2, 2015.  For 2017: “Non-excepted” (non-grandfathered) services paid under the Physician Fee Schedule (PFS) at 50% of OPPS rate.  For 2018, non-excepted services paid at 40% OPPS rate  For 2019, CMS proposes to continue to pay for non- excepted services at 40% OPPS rate.

Additional “Site-neutral” Payment Cuts Proposed  For 2019, CMS proposes to:  Reduce payment for hospital outpatient clinic visits in excepted off-campus PBDs  Reduce payment for new families of services furnished in excepted off-campus PBDs  Reduce payment for 340B-acquired drugs in non-excepted off-campus PBDs  CMS announces a data collection for all services in off- campus emergency departments (EDs)

Proposed Cut for Clinic Visits in Excepted Off-campus PBDs  Would pay for clinic visits (G0463) in excepted off-campus PBDs at “PFS-equivalent” rate of 40% of OPPS amount  Cites authority under SSA 1833(t)(2)(F) to propose “a method for controlling unnecessary increases in volume of covered OPD services”  Claims OPPS spending growth was “unnecessary” because it resulted from differences in payment between settings rather than from patient acuity.  No change in billing would be required – clinic visits still would be considered “excepted” service (billed using “PO” modifier), but paid at reduced rate.  Proposed NOT to be budget-neutral  CMS requests comment on how to expand this proposal to more items and services with “unnecessary” increases in PBD utilization. Estimated Impact: -$760 million in CY 2019

AHA View on Proposed Clinic Visit Cut  CMS misinterprets Congressional intent by cutting excepted off-campus PBDs that are explicitly protected from site-neutral cuts in law.  Fails to recognize critical role PBDs play in providing access for most vulnerable patients  Ignores other factors outside of hospitals’ control driving increases in OPPS expenditures.

Site-neutral Cuts for Expanding “Families of Services” in Excepted Off-campus PBDs  CMS says allowing service line expansion in excepted off-campus PBDs is inconsistent with intent of Sec. 603  So, for 2019, excepted services would ONLY include services in “clinical families of service” that the excepted off-campus PBD billed during a baseline period of Nov. 1, 2014-Nov. 1, 2015 (i.e. the year prior to Sec. 603 enactment).  Any services billed in 2019 that fall outside the clinical families of service that the off-campus PBD billed during baseline period would be non-excepted (“PN” modifier) and paid under the PFS at the site-neutral rate of 40% of the OPPS amount.  Would require excepted off-campus PBDs to identify the clinical families of services they billed during baseline period. Estimated Impact: TBD

19 Proposed Clinical Families of Service Clinical Families APCs Airway Endoscopy 5151-5155 Blood Product Exchange 5241-5244 Cardiac/Pulmonary Rehabilitation 5771; 5791 Diagnostic/Screening Test and Related 5721-5724, 5731-5735, 5741-5743 Procedures Drug Administration and Clinical 5691-5694 Oncology Ear, Nose, Throat (ENT) 5161-5166 General Surgery and Related 5051-5055; 5061; 5071-5073; 5091-5094; 5361-5362 Procedures Gastrointestinal (GI) 5301-5303; 5311-5313; 5331; 5341 Gynecology 5411-16 Major Imaging 5523-5525; 5571-5573; 5593-5594 Minor Imaging 5521-5522; 5591-5592 Musculoskeletal Surgery 5111-16; 5101-02 Nervous System Procedures 5431-5432; 5441-5443; 5461-5464; 5471 Ophthalmology 5481; 5491-5495; 5501-5504 Pathology 5671-5674 Radiation Oncology 5611-5613; 5621-5627; 5661 Urology 5371-5377 Vascular/Endovascular/Cardiovascular 5181-5184; 5191-5194; 5200; 5211-5213, 5221-5224; 5231-5232 Visits and Related Services 5012; 5021-5025; 5031-5035; 5041; 5045, 5821-5823

AHA View on Proposed “Families of Services” Policy  CMS misinterprets Congressional intent by cutting excepted PBDs that are explicitly protected from site- neutral cuts in law.  We are disappointed that CMS has resurrected the expansion of services policy the agency previously rejected.  Policy would penalize off-campus PBDs that offer new kinds of services to their communities and would prevent them from accommodating the changing needs of their patients.

340B Policy: Expansion to Non-excepted Off-campus PBDs  Would expand current policy reducing payment for most 340B- acquired drugs to non-excepted off-campus PBDs, beginning in CY 2019 .  Rationale: CMS believes the payment differential between excepted and non-excepted PBDs could incentivize hospitals to move drug administration services for 340B drugs to non-excepted PBDs.  Rural sole community hospitals, children’s hospitals and PPS- exempt cancer hospitals would remain exempt. Estimated Impact: -$48.5 million in CY 2019

AHA View on Proposed Expansion of 340B Cut  The stepped up assault on 340B hospitals that serve vulnerable communities will harm a significant number of additional hospital outpatient departments.  These proposed cuts – like the previous cuts – are made to a program that requires no federal contributions but instead relies on discounts required of drug companies.  Like the previous cuts, this proposal exceeds CMS’s statutory authority and remain subject to legal challenge.

Services in Off-campus EDs: Data Collection  Starting Jan. 1, 2019, CMS will be collecting data to assess whether OPPS services are shifting to off-campus provider-based EDs.  HCPCS modifier “ER” must be reported with every claim line for services furnished in an off-campus ED.  Cites MedPAC concerns that the growth in the number of off- campus provider-based EDs may be a result of:  Higher Medicare payment rates for services in provider-based EDs compared to similar services in physician offices or urgent care centers.  Section 603’s exemption of services furnished in provider-based EDs.  Sets the stage for possible new site-neutral proposals in the future.

AHA Advocacy Strategy on Site-neutral Proposals Oppose Further Proposed Cuts!  Analysis of the Medicare data  Review specific statutory authorities CMS cites for flaws  Member outreach, including engaging AHA’s Advocacy Alliance for Coordinated Care  Engage congressional allies to weigh in with CMS and potential follow-up legislative solution  Continuing to pursue our litigation on 340B

CY 2019 Payment Update  Proposed payment update of 1.25 percent for CY 2019 OPPS.  Proposed payment update of -0.75 percent for hospitals that do not meet the Outpatient Quality Reporting program reporting requirements  With this update and all other changes in the rule, hospitals would see a net decrease of 0.1 percent in OPPS payment, or about $80 million in CY 2019.

Comprehensive APCs  CMS proposes to create 3 new comprehensive APCs (C- APCs).  C-APC 5163 (Level 3 ENT Procedures)  C-APC 5183 (Level 3 Vascular Procedures)  C-APC 5184 (Level 4 Vascular Procedures).  This would increase the total number of C-APCs to 65.

Proposed Change to the Inpatient-only List  Would remove two services from the inpatient-only list:  CPT code 31241 (Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery), and  CPT code 01402 (Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty).  Would add one service to the inpatient-only list:  HCPCS code C9606 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel).

Payment for Drugs, Biologicals and Radiopharmaceuticals  Would increase drug packaging threshold to $125 per day  Drugs costing more than $125/day separately paid under own APC; those costing less than $125 per day are packaged.  Exception for certain “policy-packaged” drugs  Costs packaged regardless of cost per day  Separately paid drugs (other than 340B-acquired drugs) proposed to be paid at the rate of ASP plus 6%.