The hospital outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) payment system final rule was published Nov. 1, 2022, finalizing Medicare payment rates for the 2023 calendar year starting Jan. 1.

Additional updates include an increase in 340B drug and rural sole community hospital payment rates, coverage of virtual behavioral health services under OPPS, extensive coding changes and details on the implementation of the new Medicare provider type, rural emergency hospitals.

Below is a list of key takeaways from the final rule.

Payment Rate + Policy Changes

• OPPS and ASC payment rates will increase 3.8% for hospitals and ASCs meeting applicable quality reporting requirements.
• Payment rates for drugs acquired through the 340B Program will increase to average sales price (ASP) plus 6% compared to rate in effect since 2018 of ASP minus 22.5%.
• Virtual behavioral health services currently covered under the Public Health Emergency will be covered under the OPPS, but certain criteria are being considered, including requirements for an in-person service within six months prior to the first remote session and an in-person service without the use of communications technology within 12 months of each remote service. Exceptions are being considered when the provider and patient agree that the risks and burdens on an in-person service outweigh the benefits.
• Payment for non-opioid pain management drugs and biologics that function as supplies in the ASC setting will continue to be paid separately, including certain local anesthetics and ocular drugs that meet the criteria.
• Rural Sole Community Hospitals will be reimbursed at the full OPPS rate this year, compared to the physician fee schedule equivalent of roughly 40% less than the OPPS rate.
• Payment adjustments will be provided under IPPS and OPPS to offset the additional cost associated with procuring domestically made NIOSH-approved surgical N95 respirators.
• Four devices qualified for transitional device pass-through status effective Jan. 1, 2023, including AprevoTM Intervertebral Fusion Device which received preliminary approval. No additional quarters of separate payment will be provided for any device category whose pass-through payment status will expire between Dec. 31, 2022 and Sept. 30, 2023.

New Prior Authorization Requirements

• Facet Joint Interventions will require prior authorizations effective Jul. 1, 2023.

CPT Coding + CDM Updates

• More than 500 changes to CPT/HCPCS codes; extensive updates to the evaluation and management (E&M) codes; minor updates to codes on the inpatient only list; and 69 changes to Category III codes that represent a variety of new and emerging services.
• SaaS add-on codes related to software-as-a-service technologies that assist practitioners in making clinical assessments will be assigned to identical ambulatory payment classifications (APCs) and have the same status indicator assignments as their standalone codes, allowing for separate payment for these services.
• New codes added to cover dental services, including an increase in payment from $200 to $2000 for dental rehabilitation services that required monitored anesthesia and the use of an operating room.

New Medicare Provider Type: Rural Emergency Hospitals

• The implementation of the new Medicare provider type, Rural Emergency Hospital (REH), will go into effect Jan. 1, 2023.
• Critical access hospitals and rural hospitals with less than 50 beds that meet the outlined conditions of participation are eligible to convert to an REH to continue providing emergency services, observation care and additional outpatient services as elected.
• REHs will be paid the OPPS rate plus 5% for covered services in addition to a monthly facility payment.

Request for Additional Information:

• CMS is requesting comments to promote equity within the transplant ecosystem and inform potential future organ acquisition payment policy.
• Considerations are being made for how to reduce inequity in healthcare outcomes, including expanding efforts to report quality measure results stratified by patient social risk factors and demographic variables.

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Contact one of our revenue cycle experts today if your organization needs support preparing for and implementing these changes.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Neither Ensemble Health Partners, nor any of its employees, are your lawyers. Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.