OPPS Payments Would Increase $5.2 Billion Under 2015 Proposed Rule

CMS has released a Proposed rule that is designed to change Medicare payment policies and rates for outpatient hospital departments and ambulatory surgical centers (ASCs) for calendar year (CY) 2015. CMS proposes to increase the outpatient prospective payment system (OPPS) market basket for CY 2015 by 2.1 percent. The CMS rule also proposes to: (1) update ASC payments by 1.2 percent; (2) develop a more comprehensive Ambulatory Payment Classification (APC) policy; (3) remove three quality measures from the hospital Outpatient Quality Reporting (OQR) program; (4) add one claims based measure to the OQR program; and (5) add one measure to the ASC Quality Reporting program (ASCQR).

OPPS Payment Update

The OPPS payment update is based upon the proposed market basket increase of 2.7 percent minus a 0.4 percentage point adjustment for multi-factor productivity and a 0.2 percentage point adjustment required by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). CMS says the changes would result in a $5.2 billion rise in OPPS payments in CY 2015, a 2.2 percent payment increase from CY 2014.

Packaging Changes

In a 2014 Final Rule, CMS proposed an APC policy that would expand the services covered under a single comprehensive payment when hospital stays involve multiple services ancillary to the primary care. For CY 2015, CMS proposes to expand that APC policy to include all ancillary services when the geometric mean cost of the ancillary services is $100 or less. This would represent an expansion of the APC policy that CMS now uses which packages only those services that are integral to primary services.

ASC Update

The Consumer Price Index update for all urban consumers (CPI-U) is projected to be 1.7 percent and the multifactor productivity (MFP) adjustment to the ASC annual update is .5 percent. Accordingly, the adjusted ASC annual update is 1.2 percent, which CMS projects will result in in a $243 million increase in ASC payments from CY 2014.

Quality Measures

CMS is also proposing to eliminate three quality measures for hospitals including: a cardiac care measure and two prophylactic antibiotic surgery measures. CMS reasoned that performance in those areas is high and CMS has seen little variation among hospitals regarding quality in those areas. CMS did propose adding OP-32: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy, a claim based measure for payment determinations to go into effect in CY 2017. CMS proposes to add the measure for the OQR and the ASCQR programs.

The agency will accept comments until September 2, 2014. CMS expects to publish the Final rule on or around November 1, 2014.