Release of 2021 Outpatient Prospective Payment System (OPPS) Final Rule Begins Elimination of IPO List
Release of 2021 Outpatient Prospective Payment System (OPPS) Final Rule Begins Elimination of IPO List
CMS released the Final Rule for Hospital Outpatient Prospective Payment System (OPPS), which takes effect on January 1, 2021, on December 2, 2020 (CMS, 2020). The 2021 OPPS Final Rule includes updates to payment rates and changes to the APCs; this includes two new Comprehensive APCs (C-APCs). OPPS rates for hospitals that meet applicable quality reporting requirements will increase by 2.4%.
Elimination of the IPO List
Notable changes for 2021 include the phased-in elimination of the Inpatient Only list (IPO) over a three years. This means the removal of close to 300 services this year. The current IPO list includes procedures for which payment is not made under the OPPS. This is because providers typically perform the procedure in the inpatient setting, due to the nature of the procedure and the need for at least 24 hours of postoperative recovery time or monitoring. There are approximately 1,700 procedures on the list.
CMS is eliminating this list to increase choices for the setting of these procedures. By CY 2024, CMS will have completely phased out the list. All procedures will be eligible for Medicare payment in the hospital outpatient setting when this outpatient care is appropriate as determined by the physician.
The procedures eliminated for 2021 include predominantly musculoskeletal procedures. This includes services such as closed treatment of proximal femur fracture with manipulation, reinsertion of a spinal fixation device, and radical resection of a tumor of the clavicle. In addition, the complete list of procedures eliminated for CY 2021 is available in Addendum B to the Rule (CMS, 2020).
Other Changes
In addition, CMS continued the policy for payment of 340B Purchased drugs at the Average Sale Price (ASP) minus 22.5%. This policy has been involved in ongoing lawsuits, but was upheld by the US Court of Appeals in the D.C. Circuit Court in July 2020.
The Rule also includes approval for five device pass-through applications. These are: the BAROSTIM NEO™ System, Hemospray® Endoscopic Hemostat, the SpineJack® Expansion Kit, CUSTOMFLEX® ARTIFICIALIRIS, and EXALT™ Model D Single-Use Duodenoscope. Furthermore, two categories of service will be subject to the prior authorization process of hospital outpatient departments beginning with dates of service on July 1, 2021: cervical fusion with disc removal and implanted spinal neurostimulators.
Additional Information
More details on the Rule’s provisions are available in the draft copy, CMS-1736 (CMS, 2020). CMS will publish the Final Rule’s official copy in the Federal Register in the coming weeks. We will also feature it on the YES Blog.
For the changes enacted by the 2021 IPPS Final Rule, review our YES Blog article. Also, corporate coding teams that need guidance interpreting these OPPS updates should contact YES HIM Consulting. Our team of credentialed coding and auditing experts can discuss YES’ tailored coding support and education options.
Ann Zeisset, RHIT, CCS, CCS-P, co-authored this article with Teri Jorwic, MPH, RHIA, CCS, CCS-P, FAHIMA.
