In late July, the Centers for Medicare & Medicaid Services (CMS) released its 2020 outpatient prospective payment system (OPPS) and ambulatory surgery center (ASC) proposed rule. In a few weeks, around November 1, CMS is expected to release its final rule.
Here are seven of the key takeaways from the proposed rule and what to watch for in the final rule.
1. CMS proposed the addition of total knee arthroplasty (TKA) to the ASC-covered procedures list. Total joint procedures are already commonplace in ASCs. Expect volume to surge as these procedures receive Medicare coverage.
2. CMS proposed adding several new coronary intervention procedures to the ASC-covered procedures list. Cardiology is already a growing specialty for surgery centers. Expanding the number of cardiology procedures on the list will further fuel that growth.
3. CMS proposed to remove total hip arthroplasty (THA) from the inpatient-only (IPO) list. This would allow the service to be paid in hospital inpatient and outpatient settings. TKA was initially removed from the IPO list before CMS proposed its addition to the ASC-covered procedures list. We can anticipate that THA will follow a similar path.
4. CMS sought comments on the possible removal of several spine services from the IPO list. We can expect spine procedures to continue their migration to the outpatient setting. ASCs already perform numerous spine procedures and that volume is likely to grow in the coming years.
5. CMS is pushing for greater price transparency. The proposed rule includes new guidance concerning how hospitals would need to make their standard charges publicly available. The proposal also includes a proposed mechanism for enforcement involving monitoring and monetary penalties for non-compliance (up to $300/day).
6. CMS proposed to continue payment cuts for outpatient clinic visits in grandfathered, off-campus, provider-based departments (i.e., hospital outpatient departments). In 2019, CMS paid for clinic visits in grandfathered departments at 70% of the OPPS rate. This was the first year in a two-year phase-in period. In 2020, CMS is proposing to complete the phase-in and pay for clinic visit service in grandfathered, off-campus departments at 40% of the OPPS rate. This site-neutral policy is facing a court challenge from the American Hospital Association, Association of American Medical Colleges and member hospitals.
7. CMS proposed to require prior authorization for several categories of outpatient services that have both cosmetic and therapeutic indications. These are blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation. CMS points to what it says is “unnecessary increases in volume” for these services as justification for the proposed authorization.
The final rule will become effective Jan. 1, 2020.