CMS Releases 2019 Hospital Outpatient Prospective Payment System Final Rule

On Nov. 2, the Centers for Medicare and Medicaid Services (CMS) released the 2019 Hospital Outpatient Prospective Payment System (OPPS) final rule. Under the final rule, OPPS payment rates will increase by 1.35 percent for 2019. The rule addresses payment to hospital outpatient departments and ambulatory surgical centers (ASCs).

Below are updates on items specifically addressed within ACC's comments on the proposed OPPS rule:

Capping payment for clinic visits provided in all off-campus provider-based departments (PBDs) at a rate equivalent to the Physician Fee Schedule (PFS)

  • To control the volume of unnecessary increases in certain services driven by the payment differential between the OPPS and PFS, CMS is finalizing the proposal to pay for clinic visits (HCPCS G0463) provided in all off-campus PBDs at the PFS facility rate. CMS will phase in this policy for excepted off-campus PBDs (those paid at the OPPS rate in 2018) by paying 70 percent of the OPPS rate in 2019, then reducing payment to 40 percent of the OPPS rate for 2020 and future years. This phase-in policy allows CMS to implement site-neutrality for clinic visits while addressing concerns from stakeholders that a full payment reduction in 2019 may lead to instability.

Limiting the expansion of clinical families of services at excepted off-campus PBDs

  • To limit the expansion of services offered by these sites, CMS proposed limiting OPPS payments to services within an approved clinical family that were provided during a historical baseline period. Any new services provided outside of these families would be paid at the PFS rate. CMS did not finalize this proposal but will continue to monitor the expansion of services in off-campus PBDs.

Maintaining Imaging Ambulatory Payment Classification (APC) structure

  • CMS is maintaining the APC payment categories for imaging without contrast (Levels 1 – 4) and with contrast (Levels 1 – 3). CMS considered comments regarding payment classifications for select echocardiography, cardiac computed tomography angiography and cardiac magnetic resonance procedures but finalized no payment changes, stating that payment assignments for these services are appropriate based on available cost data.

Endovascular APCs

  • CMS did not finalize any changes to the APC structure for endovascular procedures but remains concerned regarding payment differentials that may occur due to the use of drug-coated balloons and non-drug-coated balloons. CMS will continue to evaluate if future changes are needed.

Adding diagnostic cardiac catheterization to the ASC Covered Surgical Procedures list

  • CMS finalized the addition of 12 diagnostic cardiac catheterization services to the list of covered procedures that can be performed in an ASC. Based on comments from the Society for Cardiovascular Angiography and Interventions (SCAI) and the ACC, CMS also added five codes to the list (CPT 93566, 93567, 93568, 93571, 93572). The ACC and SCAI proposed the addition of 19 concomitant procedures; CMS stated the agency will reassess the addition of the remaining 14 codes if new clinical data becomes available regarding their safety in an ASC.

ACC Advocacy staff will continue to review the final rule to identify additional topics of interest to ACC members. More information will be forthcoming in the Advocate newsletter and on These adjustments will also be discussed during ACC's Cardiovascular Summit, taking place Feb. 14 – 16 in Orlando, FL.

Keywords: ACC Advocacy, Healthcare Common Procedure Coding System, Centers for Medicare and Medicaid Services, U.S., Medicare, Fee Schedules, Medicaid, Ambulatory Care, Prospective Payment System

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