CMS Releases 2023 OPPS Proposed Rule: New Payment Rates & Other Changes

CMS Releases 2023 OPPS Proposed Rule: New Payment Rates & Other Changes

The Centers for Medicare & Medicaid Services (CMS) has released its annual proposed Medicare payment rates for hospital outpatient and Ambulatory Surgical Center (ASC) services. There will be a 60-day comment period for the 2023 OPPS proposed rule, which ends on September 13, 2022, with the final rule issued in early November.

Certainly, new payment rates are proposed, but per CMS, “This year’s rule includes proposals that align with several key goals of the Administration, including advancing health equity in rural areas, promoting competition in the health care system, and promoting safe, effective, and patient-centered care. The proposed rule would further the agency’s commitment to strengthening Medicare and use the lessons learned from the COVID-19 PHE to inform the approach to quality measurement” (CMS, 2022).

2023 opps proposed rule

The CMS Press Release discusses the following proposals:

  • Establishing Payment Policies for Rural Emergency Hospitals to Improve Access to Care in Rural Communities
  • OPPS Payment for Remote Behavioral Health Services
  • Payment Adjustments for Additional Costs of Domestic NIOSH-Approved N95 Surgical Respirators
  • Request for Information on Competition

Per the CMS Fact Sheet, these “proposed policies will affect 3,411 hospitals and approximately 5,500 ASCs.” Some specifics of the Proposed Rule (CMS-1772-P) include the following:

Updates to OPPS and ASC Payment Rates

CMS proposes a payment rate increase of 2.7% for OPPS and ASC facilities that meet the quality reporting requirements.

Cost Report Data for CY 2023

CMS proposes using CY 2021 claims data with cost report data through CY 2019 (before the PHE) to set CY 2023 OPPS and ASC payment system rates. The same cost report data was used to set CY 2022 OPPS rates. CMS believes it is the best approximation of expected costs for CY 2023 hospital outpatient services for rate-setting purposes.

Changes to the Inpatient Only List

The Inpatient Only (IPO) list defines the list of services that, due to their medical complexity, are only covered by Medicare in the inpatient setting.

For CY 2023, CMS proposes removing ten services from the IPO list, determined to meet the current criteria for this list.

CPT codes 16036, 22632, 21141, 21142, 21143, 21194, 21196, 21347, 21366, and 21422 from APC 5165 have been proposed to be removed from the IPO list. The procedures range from escharotomy and posterior interbody arthrodesis to facial reconstruction procedures and facial open fracture treatment. For the complete Table, including the CPT Long Descriptors, see Table 46 in the Proposed Rule.

Changes to the ASC Covered Procedures List

The ASC Covered Procedures List (CPL) identifies the procedures that can safely be performed in an ASC. CMS proposes adding one procedure, 38531, Biopsy or excision of lymph node(s); open, inguinofemoral nodes(s), to the ASC CPL. See Table 57 in the Proposed Rule.

Review the CMS Fact sheet in its entirety here.

The unpublished Proposed Rule is available here.

The Proposed Rule is expected to be published on 07/26/2022 when it will be available at the CMS site. Once available, the summary of the 2023 Final Rule will be published on the YES Blog.

Additional Resources for 2023 Coding Updates:

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Ann Zeisset

Ann Zeisset, RHIT, CCS, CCS-P Contract Educator
2023 opps proposed rule

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