CMS OPPS 2023 Final Rule Available Now

CMS OPPS 2023 Final Rule Available Now

CMS issued a press release announcing the Final Rule for CY 2023 Hospital Outpatient Prospective Payment System and Ambulatory Surgery Centers on November 1, 2022. The draft of the CMS OPPS 2023 rule is almost 1,800 pages in length and will be published in the Federal Register. CMS released a Fact Sheet on provisions in the rule. Selected highlights of the rule are noted below. Look for the upcoming YES HIM Consulting CY 2023 Update, Hospital Outpatient Prospective Payment System, and APC Changes for a comprehensive review.

Payment Rate Increase

new cpt codes for 2023

Outpatient hospital payment rates will increase by 3.8% for Calendar Year 2023. Of note, this increase is more than the 2.7% in the proposed rule. If hospitals do not meet the hospital outpatient quality reporting requirements, they will receive a 2.0-point reduction in payments per statute.

Inpatient Only List has Additions and Deletions

Eleven services were removed from the Inpatient Only (IPO) list, including maxillofacial procedures such as 21343, open treatment of depressed frontal sinus fracture. Eight codes were added to the list, representing CPT codes effective on January 1, 2023. The majority of the services represent new codes for abdominal hernia repair procedures.

New Hospital Designation

A new Medicare provider type, Rural Emergency Hospital (REH), is established to begin on January 1, 2023. This rule will allow Critical Access Hospitals (CAHs) and small rural hospitals to convert to a REH, which presents a more sustainable option for those hospitals on the brink of closure. Additionally, it supports access to care in rural and underserved communities. Medicare is reimbursing hospital outpatient departments to deliver behavioral health services remotely to people at home, improving access in rural communities. The REH is one of the centerpieces in promoting health equity. According to HHS Secretary Xavier Becerra, “By helping rural hospitals stay open, we are helping residents of rural areas get the care they need close to home. Having access to care nearby is not only more convenient, but also leads to better health outcomes — and boosts local economies.”

Ambulatory Payment Classification (APC) Updates

The rule includes detail on updates to New APCs with changes in APC assignment and payment rates, along with New Technology APCs that are maintained for CY 2023. APC-specific policies are explored by assigning new codes to APCs and status indicator designations. For example, the New Technology APC for Minimally Invasive Glaucoma Surgery codes 66989 and 66991 were maintained at APC 1563 with a 2023 payment rate of $4,250. The APC for HCPCS code C9770 for mechanical vitrectomy, pars plana approach with subretinal injection of pharmacologic/biologic agent, was reassigned from New Technology APC 1561 ($3,250) to 1562 ($3,750).

APC assignments that are maintained or changed are detailed in the rule. For example, the APC assignment for the Coflex® Interlaminar Implant Procedure represented by CPT code 22867 is maintained at APC 5116 ($21,897). On the other hand, code 68841, insertion of drug-eluting implant, including punctal dilation when performed, is reassigned to APC 5503 ($2,144) from 5694 ($332) to accommodate the injection of Dextenza. The pass-through status for Dextenza expires on December 31, 2022.

Transitional Pass-Through Payments

The rule includes information on transitional pass-through payments for Drugs, Biologicals, and Devices. Beginning eligibility dates and quarterly expiration of device pass-through status are detailed along with new applications. CMS received eight applications for device pass-through status. Aprevo™ intervertebral fusion device had already received preliminary approval via the quarterly review process, and three others, Vivistim®, Evoke Spinal Cord Stimulation System, and the Ureterol 1 were also approved. Four of the devices that had applications submitted were not approved for device pass-through status as they did not meet one or more of the eligibility requirements.

More Details In Final Rule

Many additional provisions are discussed in the final rule, including OPPS payment for drugs acquired through the 340B program, payment for non-opioid products, payment adjustments for additional costs of surgical N95 respirators, and OPPS payment for software as a service. The final rule includes detailed updates to the hospital outpatient quality reporting program. Program requirements must be met, or the hospital will receive a reduction of 2% in the annual payment update. See the final rule for details on these and other provisions.

Comprehensive Review for HIM

Look for the upcoming YES HIM Consulting presentation CY 2023 Update, Hospital Outpatient Prospective Payment System, and APC Changes for a comprehensive review of changes for 2023 relative to HIM.

Additional Coding Updates

Teri Jorwic

Contract Educator, MPH, RHIA, CCS, CCS-P, FAHIMA
cms opps 2023

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