Hospital Outpatient PPS

Spotlights

Submit Comments by September 13^th – Calendar Year 2023 Proposed Rule

CMS issued the Calendar Year 2023 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule that announces proposed Medicare payment rates for hospital outpatient and ASC services. See a summary of key provisions. Proposals include:

• Updating OPPS and ASC payment rates by 2.7% for facilities meeting quality reporting requirements.
• Establishing provider enrollment procedures and payment rates for rural emergency hospitals.
• Continuing payment after the end of the public health emergency for remote behavioral health services provided by clinical staff of hospital outpatient departments.
• Adjusting payment under the OPPS and Inpatient Prospective Payment System to reflect additional costs for domestic surgical N95 respirators.
• Exempting rural Sole Community Hospitals from the clinic visit payment policy.
• Continuing our current policy of paying the average sales price (ASP) minus 22.5% for 340B-acquired drugs and biologicals, including when furnished in nonexcepted off‑campus provider-based departments paid under the Physician Fee Schedule.  But, in light of the Supreme Court’s decision, we fully anticipate adopting, in the final rule, a policy of paying the ASP plus 6% for 340B-acquired drugs and biologicals.
• Requesting information about enhancing transparency and competition in the health care system.

We encourage you to review the rule, and submit formal comments by September 13, 2022.

 

COVID-19: New HCPCS Code for Convalescent Plasma in Outpatient Setting

On December 28, the FDA revised the emergency use authorization for COVID-19 convalescent plasma with high titers of anti-SARS-CoV-2 antibodies. It’s authorized for treatment of COVID-19 in patients with immunosuppressive disease or getting immunosuppressive treatment, in the outpatient or inpatient setting.

CMS created HCPCS code C9507 for COVID-19 convalescent plasma for use in the outpatient setting, effective on or after December 28. For billing & payment information, see the April 2022 Addendum B on the OPPS Addendum A and Addendum B Updates webpage.

 

OPPS Drugs and Biologicals with Quarterly Restated Payment Rates

Some drugs and biologicals based on ASP methodology may have payment rates that are corrected retroactively. These retroactive corrections typically occur on a quarterly basis as a part of the OPPS payment system quarterly update change request. Beginning with the January 2015 OPPS payment system quarterly update change request, the list of drugs and biologicals with corrected payments rates, for a particular quarter, are accessible from the left menu link titled "Restated Drug and Biological Payment Rates".