CMS finalizes outpatient hospital prospective payment system and outpatient surgery center payment system rule

On November 2, 2021, the Centers for Medicare & Medicaid Services (CMS) released the Final Rule for the Prospective Medicare Hospital Payment System for Calendar Year (CY) 2022 and the Outpatient Surgical Center Payment System (OPPS). The final rule will come into effect on January 1, 2022.

Here are some highlights of the CY 2022 OPPS Final Rule:

  • Transparency of hospital prices: CMS amended the regulation on transparency of hospital prices as follows:
    • Effective January 1, 2022, CMS is increasing the Minimum Civil Financial Penalty (MOC) to a base rate of $ 300 per day. Hospitals with more than 30 beds will be charged $ 10 per bed per day, with a cap not exceeding $ 5,500 per day. Each year, CMPs for non-compliance will be capped at $ 2,007,500 per hospital.
    • CMS has also updated pricing transparency rules so that state forensic hospitals that only treat people detained by criminal authorities are deemed compliant.
    • The new final rule also includes updates to the requirements for hospitals to make their machine-readable files accessible for automated searches and direct downloads.
  • Inpatient Quality Reporting (OQR) Program: CMS has finalized the proposals which include:
    • Adopt three new measures, including COVID-19 vaccination of health workers.
    • Update Hospital OQR program validation policies to reduce supplier burden and improve processes.
  • Outpatient Surgery Center Quality Reporting Program (ASCQR): CMS finalized the proposals for:
    • Adopt COVID-19 vaccination of health workers.
    • Make the reporting of six voluntary or suspended measures mandatory.
  • Payment for non-opioid pain medications and biologics under section 6082 of the SUPPORT Act: CMS has changed its current policy to provide separate payment for drugs and non-opioid biologics for pain management that function as surgical supplies under the ASC outpatient surgery center when those products meet certain criteria. As of January 1, 2022, these drugs and biologics will be eligible for separate payment when such a product is approved by the Food and Drug Administration (FDA), is indicated by the FDA for pain management, or as a pain reliever, and has a cost per day greater than the Packaging Threshold for OPPS drugs.
  • Changes to the list of procedures covered by ASC: CMS reinstated the criteria for the ASC Covered Procedures List (CPL) that were in effect during the year 2020, removed several of the procedures that were added to the ASC CPL in 2021 and added six procedures at the CPL. CMS has also adopted a nomination process, whereby stakeholders can nominate procedures that they believe meet the requirements to be added to the ASC CPL. CMS will provide sub-regulatory guidance on the nomination process in early 2022, with procedural nominations due in March 2022, and the formal nomination process starting in CY 2023.
  • Updating ASC payments: CMS increased payment rates under the ASC payment system by 2.0% for ASCs who meet the quality reporting requirements under the ASCQR program.
  • 2-Midnight rule: CMS-exempt procedures that are removed from the inpatient-only (IPO) list under the OPPS effective January 1, 2022, Service Site Claim Denials, Organization for the Improvement of Quality of Client and Family Centered Care (BFCC-QIO) Referrals to Recovery Audit Providers (RACs) for persistent non-compliance with the 2-midnight rule, and RAC exams for “patient condition” during a period of two years.
  • Adjustment of payment for cancer hospitals: CMS will continue to provide additional payments to cancer hospitals. Payment adjustments will be the additional payments required to result in a payment-at-cost (PCR) of 0.89 for each cancer hospital.
  • Changes to the list of SOPs: CMS suspended elimination from the IPO list and added services removed in 2021, with the exception of CPT codes 22630 (lumbar spine fusion), 23472 (shoulder joint reconstruction), 27702 (ankle joint reconstruction) and the corresponding anesthesia codes (00630, 00670, 01486 and 0643T).
  • Radiation oncology model (RO model): CMS finalized the proposed provisions related to the additional delayed implementation of the RO model due to the Consolidated Appropriations Act, 2021, as well as changes to some non-delay related RO model policies.
  • Fair adjustment for device category, drugs and biologics whose transfer status expires: CMS uses its fair adjustment power under 1833
  • Beneficiary coinsurance for colorectal cancer screening: All surgical services provided on the same date as a scheduled screening colonoscopy or a scheduled flexible sigmoidoscopy could be considered to be provided as part of, following, and in the same clinical encounter as the screening test for the purposes of determine the coinsurance required of Medicare beneficiaries for scheduled colorectal cancer screening tests that result in additional procedures provided during the same clinical encounter.
  • Soliciting comments on temporary policies for PHE for COVID-19: CMS is now seeking comments on whether there are any temporary policies that should be made permanent.
  • 340B-Acquired Drugs: CMS continues its current policy regarding drugs purchased at 340B.

For more information on this rule, see the press release issued by CMS.


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Elaine R. Knight

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