Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs

Summary of Major Provisions

 General

• 340B Drug Pricing: CMS is proposing changes to our current Medicare Part B drug payment methodology for 340B hospitals that they believe will better reflect the resources and acquisition costs that these hospitals incur. These changes will allow the Medicare program and Medicare beneficiaries to share in some of the savings realized by hospitals participating in the 340B program. For CY 2018, CMS is proposing to exercise the Secretary’s authority to adjust the applicable payment rate for separately payable drugs and biologicals (other than drugs on pass-through and vaccines) acquired under the 340B program from average sales price (ASP) plus 6 percent to ASP minus 22.5 percent. In addition, CMS intends to establish a modifier to identify whether a drug billed under the OPPS was purchased under the 340B Drug Discount Program.

 Prospective Payment System (PPS) Specific

• OPPS Update: For FY2018, CMS is proposing to increase payments rates by 1.75%.  This increase raises total payments under OPPS to approximately $70 billion.
• Device Pass-through Applications: For CY 2018, CMS is going to evaluate five devices for eligibility to receive pass through payments and is seeking comments on whether each of these items meet the criteria for device pass-through status.
• Rural Adjustment: CMS is proposing to continue the adjustment of 7.1 percent to the OPPS payments to certain rural sole community hospitals (SCHs), including essential access community hospitals (EACHs). This proposed adjustment would apply to all services paid under the OPPS, excluding separately payable drugs and biologicals, devices paid under the passthrough payment policy, and items paid at charges reduced to cost.
• Changes to the Inpatient Only List: There are proposed changes to the procedures covered by this listing.  For example, CMS is proposing to remove total knee arthroplasty form the inpatient only list.  However, please review for the proposed Federal Register for a comprehensive listing.

Critical Access Hospital (CAH) Specific

• Supervision of Hospital Outpatient Therapeutic Services: In the CY 2009 and CY 2010 OPPS/ASC proposed rule and final rule with comment period, CMS clarified that direct supervision is required for hospital outpatient therapeutic services covered and paid by Medicare that are furnished in hospitals, CAHs, and in provider-based departments (PBDs) of hospitals, as set forth in the CY 2000 OPPS final rule. For several years, there has been a moratorium on the enforcement of the direct supervision requirement for CAHs and small rural hospitals, with the latest moratorium on enforcement expiring on December 31, 2016.  In this proposed rule, CMS is proposing to reinstate the nonenforcement of direct supervision enforcement instruction for outpatient therapeutic services for CAHs and small rural hospitals having 100 or fewer beds for CY 2018 and CY 2019.

Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program

Summary of Major Provisions

Payment Rates for Non-excepted Off-campus Provider-Based Hospital Departments Paid Under the PFS

Telehealth 

• HCPCS code G0296 (counseling visit to determine low dose computed tomography (LDCT) eligibility);
• CPT codes 90839 and 90840 (Psychotherapy for crisis; first 60 minutes) and (Psychotherapy for crisis; each additional 30 minutes (List separately in addition to code for primary service))

• CPT code 90785 (Interactive complexity (List separately in addition to the code for the primary procedure))
• CPT codes 96160 and 96161 (Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument) and (Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument))
• HCPCS code G0506 (Comprehensive assessment of and care planning for patients requiring chronic care management services (list separately in addition to primary monthly care management service)) Because institutional claims do not use a POS code, we propose for distant site practitioners billing under CAH Method II to continue to use the GT modifier on institutional claims.

New Care Coordination Services and Payment for Rural Health Clinics (RHCs) and Federally-Qualified Health Centers (FQHCs)

• CPT 99490 - 20 minutes or more of CCM services
• CPT 99487 - at least 60 minutes of complex CCM services
• HCPCS G0507 - 20 minutes or more of behavioral health integration (BHI) services

Improvement of Payment Rates for Office-based Behavioral Health Services

Physician Quality Reporting System (PQRS)

Medicare Shared Savings Program Rules

• Revisions to the assignment methodology to reflect the requirement that for performance years beginning on or after January 1, 2019, the Secretary determine an appropriate method to assign Medicare Fee-for-Service beneficiaries to an ACO based on their utilization of services furnished by rural health clinics (RHCs) or federally qualified health centers (FQHCs);
• The addition of three new chronic care management codes (CCM) and behavioral health integration (BHI) codes to the definition of primary care services used in the ACO assignment methodology; and
• Reduction of burden for stakeholders submitting an initial Shared Savings Program application and the application for use of the skilled nursing facility (SNF) 3-Day Rule Waiver.

 2018 Value Modifier

• Reducing the automatic downward payment adjustment for not meeting minimum quality reporting requirements from negative four percent to negative two percent (-2.0 percent) for groups of ten or more clinicians; and from negative two percent to negative one percent (-1.0 percent) for physician and non-physician solo practitioners and groups of two to nine clinicians;
• Holding harmless all physician groups and solo practitioners who met minimum quality reporting requirements from downward payment adjustments for performance under quality-tiering for the last year of the program; and
• Aligning the maximum upward adjustment amount to 2 times the adjustment factor for all physician groups and solo practitioners.

Comment Solicitation Only: Evaluation and Management Services

• History of Present Illness (History);
• Physical Examination (Exam); and
• Medical Decision Making (MDM).

Emergency Department Visits