OPPS Proposed Rule FY 2023

On , in Documents, by AQ-IQ LLC

CMS has issued a proposed rule to revise the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for Calendar Year (CY) 2023 based on CMS’ continuing experience with these systems. In this proposed rule, CMS describes the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. Also, this proposed rule would update and refine the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, the ASC Quality Reporting (ASCQR) Program, and the Rural Emergency Hospital Quality Reporting (REH) Program. CMS is also proposing updates to the requirements for Organ Acquisition, Rural Emergency Hospitals, Prior Authorization, and Overall Hospital Quality Star Rating. CMS is establishing a new provider type for rural emergency hospitals (REHs), and has proposals regarding payment policy, quality measures, and enrollment policy for REHs. Finally, CMS is soliciting comments on the use of CMS data to drive competition in healthcare marketplaces, and an alternative methodology for counting organs.

The Addenda relating to the OPPS are available at: https://www.cms.gov/?Medicare/?Medicare-Fee-for-Service-Payment/?HospitalOutpatientPPS/?Hospital-Outpatient-Regulations-and-Notices.

The Addenda relating to the ASC payment system are available at: https://www.cms.gov/?Medicare/?Medicare-Fee-for-Service-Payment/?ASCPayment/?ASC-Regulations-and-Notices.

Review this Proposed Rule in the Federal Register https://www.federalregister.gov/documents/2022/07/26/2022-15372/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment (342 pages)

Below is the Table of Contents from this Proposed Rule

I. Summary and Background

  • A. Executive Summary of This Document
  • B. Legislative and Regulatory Authority for the Hospital OPPS
  • C. Excluded OPPS Services and Hospitals
  • D. Prior Rulemaking
  • E. Advisory Panel on Hospital Outpatient Payment (the HOP Panel or the Panel)
  • F. Public Comments Received on the CY 2022 OPPS/ASC Final Rule With Comment Period

II. Proposed Updates Affecting OPPS Payments

  • A. Proposed Recalibration of APC Relative Payment Weights
  • B. Proposed Conversion Factor Update
  • C. Proposed Wage Index Changes
  • D. Proposed Statewide Average Default Cost-to-Charge Ratios (CCRs)
  • E. Proposed Adjustment for Rural Sole Community Hospitals (SCHs) and Essential Access Community Hospitals (EACHs) Under Section 1833(t)(13)(B) of the Act for CY 2023
  • F. Proposed Payment Adjustment for Certain Cancer Hospitals for CY 2023
  • G. Proposed Hospital Outpatient Outlier Payments
  • H. Proposed Calculation of an Adjusted Medicare Payment From the National Unadjusted Medicare Payment
  • I. Proposed Beneficiary Copayments

III. Proposed OPPS Ambulatory Payment Classification (APC) Group Policies

  • A. Proposed OPPS Treatment of New and Revised HCPCS Codes
  • B. Proposed OPPS Changes—Variations Within APCs
  • C. Proposed New Technology APCs
  • D. Universal Low Volume APC Policy for Clinical and Brachytherapy APCs
  • E. OPPS APC-Specific Policies

IV. Proposed OPPS Payment for Devices

  • A. Proposed Pass-Through Payment for Devices
  • B. Proposal to Publicly Post OPPS Device Pass-Through Applications
  • C. Proposed Device-Intensive Procedures

V. Proposed OPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals

  • A. Proposed OPPS Transitional Pass-Through Payment for Additional Costs of Drugs, Biologicals, and Radiopharmaceuticals
  • B. Proposed OPPS Payment for Drugs, Biologicals, and Radiopharmaceuticals Without Pass-Through Payment Status
  • C. Proposal in Physician Fee Schedule Proposed Rule To Require HOPDs and ASCs to Report Discarded Amounts of Certain Single-Dose or Single-Use Package Drugs

VI. Proposed Estimate of OPPS Transitional Pass-Through Spending for Drugs, Biologicals, Radiopharmaceuticals, and Devices

  • A. Amount of Additional Payment and Limit on Aggregate Annual Adjustment
  • B. Proposed Estimate of Pass-Through Spending for CY 2023

VII. Proposed OPPS Payment for Hospital Outpatient Visits and Critical Care Services

VIII. Proposed Payment for Partial Hospitalization Services

  • A. Background
  • B. Proposed PHP APC Update for CY 2023
  • C. Outpatient Non-PHP Mental Health Services Furnished Remotely to Partial Hospitalization Patients After the COVID-19 PHE
  • D. Outlier Policy for CMHCs

IX. Proposed Services That Will Be Paid Only as Inpatient Services

  • A. Background
  • B. Proposed Changes to the Inpatient Only (IPO) List

X. Nonrecurring Policy Changes

  • A. Mental Health Services Furnished Remotely by Hospital Staff to Beneficiaries in Their Homes
  • B. Comment Solicitation on Intensive Outpatient Mental Health Treatment, Including Substance Use Disorder (SUD) Treatment Furnished by Intensive Outpatient Programs (IOPs)
  • C. Direct Supervision of Certain Cardiac and Pulmonary Rehabilitation Services by Interactive Communications Technology
  • D. Use of Claims Data for CY 2023 OPPS and ASC Payment System Ratesetting Due to the PHE
  • E. Supervision by Nonphysician Practitioners of Hospital and CAH Diagnostic Services Furnished to Outpatients
  • F. Coding and Payment for Category B Investigational Device Exemption Clinical Studies and Devices
  • G. OPPS Payment for Software as a Service
  • H. Proposed Payment Adjustments Under the IPPS and OPPS for Domestic NIOSH Approved Surgical N95 Respirators
  • I. Proposal To Exempt Rural Sole Community Hospitals From the Method To Control Unnecessary Increases in the Volume of Clinic Visit Services Furnished in Excepted Off-Campus Provider-Based Departments (PBDs)

XI. Proposed CY 2023 OPPS Payment Status and Comment Indicators

  • A. Proposed CY 2023 OPPS Payment Status Indicator Definitions
  • B. Proposed CY 2023 Comment Indicator Definitions

XII. MedPAC Recommendations

  • A. Proposed OPPS Payment Rates Update
  • B. Proposed ASC Conversion Factor Update
  • C. Proposed ASC Cost Data

XIII. Proposed Updates to the Ambulatory Surgical Center (ASC) Payment System

  • A. Background
  • B. Proposed ASC Treatment of New and Revised Codes
  • C. Proposed Update to the List of ASC Covered Surgical Procedures and Covered Ancillary Services
  • D. Proposed Update and Payment for ASC Covered Surgical Procedures and Covered Ancillary Services
  • E. ASC Payment System Policy for Non-Opioid Pain Management Drugs and Biologicals That Function as Surgical Supplies
  • F. Proposed New Technology Intraocular Lenses (NTIOLs)
  • G. Proposed ASC Payment and Comment Indicators
  • H. Proposed Calculation of the ASC Payment Rates and the ASC Conversion Factor

XIV. Requirements for the Hospital Outpatient Quality Reporting (OQR) Program

  • A. Background
  • B. Hospital OQR Program Quality Measures
  • C. Administrative Requirements
  • D. Form, Manner, and Timing of Data Submitted for the Hospital OQR Program
  • E. Payment Reduction for Hospitals That Fail To Meet the Hospital OQR Program Requirements for the CY 2023 Payment Determination

XV. Requirements for the Ambulatory Surgical Center Quality Reporting (ASCQR) Program

  • A. Background
  • B. ASCQR Program Quality Measures
  • C. Administrative Requirements
  • D. Form, Manner, and Timing of Data Submitted for the ASCQR Program
  • E. Proposed Payment Reduction for ASCs That Fail To Meet the ASCQR Program Requirements

XVI. Requirements for the Rural Emergency Hospital Quality Reporting (REHQR) Program

  • A. Background
  • B. REHQR Program Quality Measures
  • C. Quality Reporting Requirements Under the REH Quality Reporting (REHQR) Program

XVII. Organ Acquisition Payment Policy

  • A. Background of Organ Acquisition Payment Policies
  • B. Counting Research Organs To Calculate Medicare’s Share of Organ Acquisition Costs
  • C. Costs of Certain Services Furnished to Potential Deceased Donors
  • D. Technical Corrections and Clarifications to 42 CFR 405.1801, 412.100, 413.198, 413.402, 413.404, 413.420 and Nomenclature Changes to 42 CFR 412.100 and 42 CFR Part 413, Subpart L
  • E. Clarification of Allocation of Administrative and General Costs
  • F. Organ Payment Policy—Request for Information on Counting Organs for Medicare’s Share of Organ Acquisition Costs, IOPO Kidney SACs, and Reconciliation of All Organs for IOPOs

XVIII. Rural Emergency Hospitals (REH): Payment Policies, Conditions of Participation, Provider Enrollment, Use of the Medicare Outpatient Observation Notice, and Physician Self-Referral Updates

  • A. Rural Emergency Hospitals (REH) Payment Policies
  • B. REH Conditions of Participation
  • C. REH Provider Enrollment
  • D. Use of the Medicare Outpatient Observation Notice by REHs
  • E. Physician Self-Referral Updates

XIX. Request for Information on Use of CMS Data To Drive Competition in Healthcare Marketplaces

  • A. Background
  • B. Request for Public Comment

XX. Addition of a New Service Category for Hospital Outpatient Department (OPD) Prior Authorization Process

  • A. Background
  • B. Controlling Unnecessary Increases in the Volume of Covered OPD Services

XXI. Overall Hospital Quality Star Rating

  • A. Background
  • B. Veterans Health Administration Hospitals
  • C. Frequency of Publication and Data Used
  • D. Overall Hospital Quality Star Ratings Suppression

XXII. Files Available to the Public via the Internet

XXIII. Collection of Information Requirements

  • A. Statutory Requirement for Solicitation of Comments
  • B. ICRs for the Hospital OQR Program
  • C. ICRs for the ASCQR Program
  • D. ICRs for Rural Emergency Hospitals (REH) Physician Self-Referral Law Update
  • E. ICRs for Addition of a New Service Category for Hospital Outpatient Department (OPD) Prior Authorization Process
  • F. ICRs for Proposed Payment Adjustments for NIOSH-Approved Domestic Surgical N95 Respirators
  • G. ICRs for Proposed REH Provider Enrollment Requirements

XXIV. Response to Comments

XXV. Economic Analyses

  • A. Statement of Need
  • B. Overall Impact of Provisions of This Proposed Rule
  • C. Detailed Economic Analyses
  • D. Regulatory Review Costs
  • E. Regulatory Flexibility Act (RFA) Analysis
  • F. Unfunded Mandates Reform Act Analysis
  • G. Conclusion
  • H. Federalism Analysis

Regulations Text

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