Blog | Medicare Payment and Reimbursement

In 2022 OPPS rule, CMS plans to reinstate policies pertaining to the inpatient-only and ASC covered-procedures lists

Blog | Medicare Payment and Reimbursement

In 2022 OPPS rule, CMS plans to reinstate policies pertaining to the inpatient-only and ASC covered-procedures lists

The 2022 proposed rule for the Outpatient Prospective Payment System would reverse 2021 policies that began to phase out the inpatient-only list of procedures and expanded the covered-procedures list for ambulatory surgical centers.

A substantial increase in the penalty range for noncompliance with price transparency requirements potentially poses concerns for hospitals and health systems, but some other policy components of a new payment rule for outpatient care could be more advantageous.

The 2022 proposed rule for the Outpatient Prospective Payment System includes a reversal of two 2021 policies that some hospital stakeholders had opposed: A phase-out of the inpatient-only (IPO) list and a relaxation of the criteria for adding services to the ambulatory surgical center covered-procedures list (ASC CPL).

The changes indicate that CMS leadership in the Biden administration is less likely than the Trump administration was to look to expand site-of-care options if doing so means overturning longstanding protocols.

Restoring services to the IPO list

The 2021 OPPS rule established that the IPO list would be eliminated over a three-year period, starting with the removal of 298 primarily musculoskeletal-related services this year. That meant those services were payable by Medicare if provided on an outpatient basis.

According to a fact sheet on the 2022 rule, however, CMS since has received “a large number of stakeholder comments” opposing elimination of the IPO list “primarily due to patient safety concerns, stating that the IPO list serves as an important programmatic safeguard.”

The 298 services would be added back to the IPO list for 2022. Before being removed from the list in 2022 or later, all IPO services would need to be reviewed “against Medicare’s longstanding IPO list criteria to determine if it is appropriate for Medicare to pay for the provision of the service in the outpatient setting.”

CMS also proposes to shorten the exemption from medical review activities for services removed from the IPO list. The exemption would last for two years, as was the case before the proposal to phase out the list.

Because elimination of the list would have made hundreds of additional services subject to the two-midnight rule, the 2021 OPPS rule had included an indefinite exemption of those services from site-of-service reviews. Now that a much smaller number of procedures would be affected in any given year, CMS believes a two-year exemption is appropriate.

Dialing back additions to the ASC covered procedures list

The 2021 OPPS rule also had added 267 procedures to the ASC CPL after revising longstanding patient safety criteria that previously decided additions to the list. CMS at the time stated that “it was important that we adapt the ASC CPL in light of significant advances in medical practice, surgical techniques and ASC capabilities.” The change also furthered the agency’s goal of promoting site-neutral payments.

The 2022 rule proposes to reinstate the patient safety criteria and remove 258 procedures that were added last year. In part due to stakeholder feedback, CMS has modified its position and believes that “the 2021 policy may not appropriately assess the safety of performing surgical procedures on a typical Medicare beneficiary in an ASC.”

CMS proposes that starting with the 2023 payment year, stakeholders be allowed to nominate procedures for addition to the list. Such a process would allow for “the expansion of the ASC CPL in a more gradual fashion, which would better balance the goals of increasing patient choice and expanding site-neutral options with patient safety considerations,” CMS states in the proposed rule.

About the Author

Nick Hut

is a senior editor with HFMA, Westchester, Ill. (nhut@hfma.org).

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