2015 HOPPS Final Rule Summary

On Oct. 31, 2014, the Centers for Medicare and Medicaid Services (CMS) released the 2015 Hospital Outpatient Prospective Payment System (HOPPS) final rule, covering payments and related policies for services provided in the hospital outpatient setting. Overall hospital outpatient payments are estimated to increase by 2.3 percent in 2015 based on projected market basket increase, statutory payment adjustments and other policy changes set forth in the final rule.  Key provisions of the final HOPPS rule include:

Certification of Inpatient Admissions
CMS policies, including the “two midnight rule”, currently require submission of a physician certification of an inpatient admission along with the admission order and medical documentation, for all inpatient admissions. CMS revised this policy to require physician certification of the inpatient stay only for long-stay cases (20 nights or more) 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 APCs
For 2015, CMS will implement 29 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.

Payment for add-on codes will also be packaged as part of the primary procedure in 2015. CMS finalized a methodology to allow for a complexity adjustment when use of a particular add-on code may result a significant increase in the complexity and resources of the procedure that may not be adequately reflected in the primary procedure APC.

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 will 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 when performed with a primary procedure. Electrocardiograms and cardiography procedures (APC 0099) and chest x-ray procedures (APCs 0260/0261) will be packaged under this policy.

Off-Campus Provider-Based Departments
To better understand the effect of hospital-owned practices on payment trends, CMS finalized the proposal to create a Healthcare Common Procedure Coding System modifier to be reported by facilities with every service furnished in this setting. The modifier will be available for voluntary use beginning on Jan. 1, 2015, with mandatory use starting on Jan. 1, 2016.

Performance Measures
The final rule also addresses changes to the Hospital Outpatient Quality Reporting Program (OQR). Hospitals that fail to meet the OQR reporting requirements will continue to face a 2 percent point reduction in payment. For the 2015 reporting/2017 payment period and subsequent years, CMS proposed to remove OP-4: Aspirin at Arrival (NQF #0286) from the Hospital OQR. CMS considered this measure 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. CMS did not finalize this proposal, recognizing that some hospitals can still improve performance on this clinically meaningful measure.

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