The Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2023 hospital outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment system final rule (CMS 1772-FC).

Here’s what you need to know:

  • In accordance with Medicare law, CMS is updating OPPS payment rates for hospitals that meet applicable quality reporting requirements by 3.8%. Using the hospital market basket update, CMS is finalizing a productivity-adjusted hospital market basket update factor to the ASC rates for CY 2023 of 3.8%.
  • There has been a growing concern that closures of rural hospitals and critical access hospitals (CAHs) are leading to a lack of services for people living in rural areas. Section 125 of the Consolidated Appropriations Act, 2021 (CAA) established a new Medicare provider type called Rural Emergency Hospitals (REHs), effective January 1, 2023.
  • For CY 2023, in light of the Supreme Court’s decision in American Hospital Association v. Becerra (No. 20-1114, 2022 WL 2135490), CMS is finalizing a general payment rate of average sales price (ASP) plus 6% for drugs and biologicals acquired through the 340B Program, consistent with our policy for drugs not acquired through the 340B program. As required by statue, CMS is implementing a –3.09% reduction to the payment rates for non-drug services to achieve budget neutrality for the 340B drug payment rate change for CY 2023.
  • For CY 2023, CMS is maintaining its current policy to provide for separate payment for those non-opioid pain management drugs and biologicals that function as supplies in the ASC setting that CMS determines are FDA approved, have an FDA-approved indication for pain management or as an analgesic, and have a per-day cost above the OPPS drug packaging threshold.
  • CMS is finalizing its proposal to consider behavioral health services furnished remotely by clinical staff of hospital outpatient departments, including staff of critical access hospitals (CAHs), through the use of telecommunications technology to beneficiaries in their homes, covered outpatient services for which payment is made under the OPPS.
  • CMS is finalizing the proposal to provide payment adjustments under the IPPS and OPPS that would reflect, and offset, the additional marginal resource costs that hospitals face in procuring domestically made NIOSH-approved surgical N95 respirators.
  • In order to maintain access to care in rural areas, CMS is finalizing its proposal to pay for clinic visits furnished in excepted off-campus provider-based departments (PBDs) of Rural Sole Community Hospitals (SCHs) at the full OPPS rate.
  • CMS is finalizing its proposal for a method of accounting for research organs that will improve payment accuracy and maintain organ availability for the research community.
  • For CY 2023, CMS is finalizing an exception to the general packaging policy for SaaS add-on codes.
  • CMS is finalizing coding changes for billing of covered dental services in the CY 2023 OPPS/ASC final rule with comment period.
  • The CY 2023 OPPS/ASC final rule updates Medicare payment rates for partial hospitalization program (PHP) services furnished in hospital outpatient departments and community mental health centers (CMHCs).
  • CMS is finalizing changes and responding to requests for comment for the Hospital Outpatient Quality Reporting (OQR), Ambulatory Surgical Center Quality Reporting (ASCQR), and Rural Emergency Hospital Quality Reporting (REHQR) Programs to further meaningful measurement and reporting for quality of care in the outpatient setting.

Source: U.S. Centers for Medicare & Medicaid Services (CMS)

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