Summary of the 2015 Proposed Hospital Outpatient Rule

On July 3, 2014, the Centers for Medicare and Medicaid Services (CMS) released the 2015 Hospital Outpatient Prospective Payment System (HOPPS) proposed rule, covering payments and related policies for services provided in the hospital outpatient setting. CMS proposes to update the HOPPS market basket by 2.1 percent for calendar year (CY) 2015. The increase is based on the projected hospital market basket increase of 2.7 percent minus both a 0.4 percentage point adjustment for multi-factor productivity and a 0.2 percentage point adjustment required by law. The ACC is currently reviewing the rule in preparation to submit comments at the end of the summer. Some of the key provisions include:

Certification of Inpatient Admissions

The requirements for physician certification of inpatient admissions would be revised under this proposal to apply only for long-stay cases and costly outlier cases. CMS believes that in most cases, the admission order, medical record and notes contain sufficient information to support the medical necessity of an inpatient admission, eliminating the need for the additional certification.

Establishment of Comprehensive Ambulatory Payment Classifications

For 2015, CMS proposes to implement 28 Comprehensive Ambulatory Payment Classifications (APCs) after delaying this proposal in 2014. Services assigned to the comprehensive APCs will be defined as primary services, with payment for all supplies and ancillary services reported under the hospital stay included within the payment for the primary service. Payment for automatic implantable cardiac defibrillators and pacemakers would be made under the new comprehensive APCs. While payment for add-on codes would be also packaged as part of the primary procedure, CMS proposes a methodology to allow for a complexity adjustment when use of particular add-on codes may reflect a significant increase in the complexity and resources of the procedure.

Packaging of Certain Ancillary Services

In order to make the HOPPS operate more as a prospective payment system, and less as a fee schedule, CMS proposes to expand the list of packaged items and services to include certain ancillary procedures with a geometric mean APC payment of $100 or less. Services on this list would not receive separate payment if provided on the same date of service as a primary procedure. APC 0099 (Electrocardiograms/Cardiography) is included as part of this proposal.

Off-Campus Provider-Based Departments

To better understand the effect of hospital-owned practices on payment trends, CMS proposes to create a Healthcare Common Procedure Coding System modifier to be reported with every code furnished in this setting beginning Jan. 1, 2015. The Medicare Payment Advisory Commission and some in the provider community continue to question the appropriateness of increased Medicare payment and beneficiary cost-sharing when physician offices become hospital outpatient departments.

Performance Measures

For 2017 and subsequent years, CMS proposes to remove three measures from the Hospital Outpatient Quality Reporting Program (OQR): OP-4: Aspirin at Arrival (NQF #0286), as well as two prophylactic antibiotic surgery measures. CMS considers these measures to be "topped out," meaning that performance among hospitals is so high and unvarying that meaningful distinctions and improvements in performance can no longer be made. Hospitals that fail to meet the OQR reporting requirements will continue to face a 2 percent point reduction in payment.

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