CMS Issues OPPS and ASC Final Rules for CY 2022, Reverses Course on Inpatient-Only and ASC Codes.

The Centers for Medicare & Medicaid Services (CMS) recently issued the CY 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Final Rule, which finalized Medicare payment rates for hospital outpatient and ASC services. In addition to updating the payment rates, the 2022 Final Rule includes updates to the Inpatient Only and ASC code list, as well as policies aimed at addressing the healthy equity gap, fighting the COVID-19 Public Health Emergency (PHE), encouraging transparency in the health system, and promoting safe, effective, and patient-centered care. The provisions of the final rule take effect January 1, 2022.

When setting the OPPS and ASC rates, CMS typically uses recent available claims data so that the payment rates can accurately reflect estimates of the costs associated with furnishing outpatient services. The recent claims data CMS uses usually reflects the two years prior to the calendar year that is the subject of rulemaking. However, due to the unprecedented impact of COVID-19 PHE-related factors on CY 2020 claims data, CMS has concluded that CY 2019 data is the most recent complete calendar year of data that will generally provide a better approximation of expected costs for CY 2022 hospital outpatient services for rate-setting purposes. As a result, CMS is generally using CY 2019 claims data to set the CY 2022 OPPS and ASC payment system rates.

Since the OPPS was originally established, CMS has maintained the Inpatient Only (IPO) list, which is a list of services that Medicare will only pay for when performed in the inpatient setting, in large part due to their medical complexity. In the CY 2021 OPPS/ASC final rule, CMS finalized a policy to eliminate the IPO list over a three-year period and removed 298 services from the IPO list in the first elimination phase. Following the issuance of the 2021 final rule, CMS reported that it received significant public comments against the IPO elimination policy primarily due to patient safety concerns. In response, CMS is halting the elimination of the IPO list and adding back to the IPO list the 298 services removed in 2021, except for CPT codes 22630 (Lumbar spine fusion), 23472 (Reconstruct shoulder joint), 27702 (Reconstruct ankle joint), and their corresponding anesthesia codes.

Concurrently with the services CMS added back to the IPO list, CMS removed 255 services from the ASC payable list. CMS is keeping just six procedures on the ASC list in the CY 2022 final rule. Three procedures were already on the ASC payable list and three were proposed for removal, but after public comments, CMS elected to keep them. The three codes that were proposed for removal but are being retained are codes 0499T, 54650, and 60512. CMS is also finalizing the adoption of a nomination process, set to begin in March 2022, to allow an external party to nominate a surgical procedure to be added to the ASC payable list. If CMS determines that a surgical procedure meets the requirements to be added to the ASC payable list, now including a surgical procedure nominated by an external party, it would propose to add the surgical procedure to the ASC payable list for January 1, 2023.

For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters. If you or your healthcare entity has any questions pertaining to Medicare payment rates or healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com.