CHA News

CMS Issues CY 2023 OPPS Proposed Rule

The Centers for Medicare & Medicaid Services (CMS) issued its calendar year (CY) 2023 outpatient prospective payment system (OPPS) proposed rule on July 15. CMS estimates that Medicare expenditures under the OPPS will increase by $6.2 billion relative to estimated current year payments, based on changes in the proposed rule.  

Comments on the proposed rule are due by 2:00 (PT) on Sept. 13. Key provisions of the rule are summarized below.  

  • Payment Update: CMS proposes updating OPPS and ambulatory surgery center (ASC) payment rates for entities that meet quality reporting requirements by 2.7% (market basket increase of 3.1%, reduced by 0.4% productivity adjustment). 
  • Payment for Separately Payable Drugs Acquired Under the 340B Program: The rule proposes continuing paying for separately payable drugs acquired under the 340B program at average sales price minus 22.5%. CMS states that due to the timing of the Supreme Court’s decision in American Hospital Association v. Becerra, it was unable to adjust the proposed payment rates and budget neutrality calculations. However, CMS anticipates finalizing a rate of ASP plus 6% for 340B drugs in the final rule for CY 2023 in accordance with the Supreme Court ruling. The proposed rule notes CMS is evaluating how to apply the decision to prior calendar years. 
  • Inpatient-Only (IPO) List: CMS proposes removing 10 services from the IPO list as the agency believes these codes meet the current criteria for removal. 
  • ASC Covered Procedures List (CPL): CMS is proposing to add one procedure, a lymph node biopsy or excision, to the ASC CPL. 
  • Behavioral Telehealth Services Furnished by Hospital Staff to Patients in Their Homes: CMS proposes that behavioral health services delivered remotely by the staff of hospital outpatient departments — including critical access hospitals — using telecommunications technology to beneficiaries in their homes are covered and paid for under the OPPS. CMS also proposes that audio-only interactive telecommunications systems may be used and considered covered services in certain circumstances.  
  • IPPS/OPPS Payment Adjustment for Domestically Produced N-95s: CMS proposes payment adjustments for the inpatient prospective payment system and OPPS that offset the additional marginal costs incurred by purchasing domestically produced N-95 masks. Under this proposal, these payments would be provided biweekly as interim lump-sum payments to the hospital that would be reconciled at cost report settlement.  
  • Expanding Prior Authorization: CMS proposes requiring prior authorization for an additional service category — Facet Joint Injections and Nerve Destruction. 
  • Sole Community Hospital (SCH) Exemption to Site-Neutral Clinic Visit Policy: CMS proposes exempting rural SCHs from the site-neutral payment policy for clinic visits furnished in excepted off-campus provider-based departments (PBDs). If finalized, services provided in SCH-excepted PBDs would be paid at the full OPPS rate.  
  • Hospital Outpatient Quality Reporting (OQR) Program and Hospital Star Ratings: CMS does not propose any new measures for the hospital OQR program but revises certain program requirements and seeks comments on future measures under consideration. CMS also provides clarifications for the Overall Hospital Quality Star Rating, including that while it intends to publish Star Ratings in 2023, it may apply its suppression policy should data analysis demonstrate that the COVID-19 public health emergency substantially affects the underlying measure data. 
  • Organs Procured for Research/Request for Information on Organ Procurement: CMS proposes a method of accounting for research organs that will improve payment accuracy and lower the costs to procure and provide research organs to the research community. The rule also proposes addressing financial barriers to organ donation after cardiac death. 

The agency also requests information on possible alternative methodologies for counting organs to calculate Medicare’s share of organ acquisition costs for transplant hospitals and organ procurement organizations. 

  • Rural Emergency Hospital (REH) Payments: CMS proposes considering all covered outpatient department services covered under the OPPS as REH services. These services provided by REHs will receive an additional 5% payment. REHs will also receive a monthly facility payment starting in CY 2023 that will increase in subsequent years by the hospital market basket percentage increase. 

REHs may provide outpatient services that are not paid under the OPPS as well as post-hospital extended care services furnished in a unit of the facility that is a distinct part of the facility licensed as a skilled nursing facility. However, these services will not be considered REH services. They will be paid under the applicable fee schedule and not be eligible for the additional 5% payment increase that CMS proposes to apply to REH services. CMS has prepared a fact sheet specific to the REH proposals.  

CHA is reviewing the proposed rule and will make a detailed summary available to members via CHA News in the coming weeks. Additional information is available in a CMS fact sheet