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CMS to Reprocess CY 2019 Claims for Clinic Visits Provided at Excepted Off-Campus Provider Based Departments

For CFOs, finance & reimbursement staff

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The Centers for Medicare & Medicaid Services (CMS) will begin reprocessing claims for outpatient clinic visit services provided at excepted off-campus provider-based departments (PBDs). 

The claims will be paid at 70% of the full outpatient prospective payment system (OPPS) rates – the same rate as non-excepted off-campus PBDs. This affects claims with dates of service between Jan. 1 and Dec. 31, 2019. 

While no action is required by hospitals, providers should be aware they may owe money as result of the claims reprocessing. CMS will begin reprocessing these claims by July 1, 2021.  

In the calendar year 2019 OPPS final rule, CMS finalized that certain outpatient clinic visit services provided at excepted off-campus PBDs would be paid at 70% of the OPPS rate – the same rate as non-excepted off-campus PBDs for those services under the physician fee schedule.  

On Sept. 17, 2019, the U.S. District Court for the District of Columbia declared the reduction for clinic visits provided at excepted off-campus PBD invalid, and CMS reprocessed claims paid at the reduced payment rate in accordance with the court decision paying them at 100% of the OPPS rate.  

On July 17, 2020, the U.S. Court of Appeals for the D.C. Circuit reversed the district court ruling, upholding CMS’ site-neutrality payment policy for off-campus outpatient hospital clinic visits. Therefore, CMS is reprocessing claims.