Outpatient and Ambulatory Surgery Rates to Increase in 2015

Hospital Outpatient Prospective Payment System (OPPS) rates will increase by 2.3 percent and ambulatory surgical center (ASC) rates will increase by 1.4 percent in 2015, according to the final rule released by CMS in late October. The rate increases are more than originally proposed by CMS and are expected to affect more than 4,000 hospitals and about 5,300 ASCs.


The final rule included implementation of comprehensive ambulatory payment classifications (C-APCs). These classifications provide a single payment for all related or adjunctive hospital items and services provided to a patient receiving device-dependent primary procedures.


The final rule dropped three of the C-APCs CMS had proposed to receive a single comprehensive payment for services. CMS wrote in its fact sheet that these three APCs were eliminated, “because a significant number of higher cost non-comprehensive services are often performed with the services assigned to these APCs, and a single payment for the comprehensive service would result in significant underpayment for these select procedure combinations.”


Policy Changes


The final rule outlined hospital OPPS policy changes. Some of the policy changes include:


  • Requires physician certification only for outlier cases and long-stay cases of 20 days or more. However, CMS will continue to require narrower admission orders for all inpatient admissions when a patient has been formally admitted as an inpatient of the hospital.


  • “Conditionally” packages all ancillary services assigned to APCs with a geometric mean cost of $100 or less into a single payment for the primary service. Ancillary services will be eligible for separate payment if they are furnished by themselves. The final rule provides exceptions to the ancillary services packaging policy for preventative, psychiatric, and drug administration services, according to the fact sheet.


  • Packages prosthetic supplies as are implantable prosthetic devices and all other supplies in the OPPS when used in conjunction with a surgical or other procedure. Replacement prosthetic supplies associated with an implantable prosthetic device would continue to be available outside of the hospital through the durable medical equipment prosthetic and orthotics supplies fee schedule.


  • Limits OPPS outlier payments to services costing more than the multiple threshold of 1.75 times the APC payment rate and exceeding the 2015 fixed dollar threshold of the APC payment plus $2,775. An estimated 1 percent of total OPPS on outlier payments will be affected by the change.


  • Establishes a process to recover overpayments inked to erroneous payment data submitted by Medicare Advantage organizations or Part D prescription drug plan sponsors. Payment recovery will be limited to specific circumstances, and the program includes an appeals process.


The final rule generally is effective on January 1, 2015. Comments on the final rule are due December 30.


Sources: “Hospital Outpatient, Ambulatory Pay Jumps,” HFMA Weekly News, November 7, 2014); “CMS Final Rule Increases OPPS Payments by 2.3% in 2015,” AHLA Weekly, November 7, 2014)


For a complete description of the changes, please read the CMS fact sheet.




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