OPPS/ASC 2019 proposed rule updates ASC payment rates

The Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2019 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Centers (ASCs) Payment System proposed rule. AGA, ACG and ASGE are currently reviewing the details of the proposed rule, which appears in the Federal Register, and are working on comments for CMS by the Sept. 24, 2018, deadline. 

This communication offers a topline summary of the proposed changes to the payment rates and policies for Medicare services paid under the Medicare OPPS/ASC. 

• • ASC inflationary update: After over a decade of advocacy by the GI societies and other stakeholder organizations, CMS is proposing to update ASC payment rates using the hospital market basket rather than the consumer price index-urban (CPI-U) for 2019-2023. The GI societies support payment adequacy by site of service. In the proposed rule, CMS states that this change will help to promote site-neutrality between hospitals and ASCs and will encourage the migration of services from the hospital setting to the lower cost ASC setting. We applaud the change in the update and will continue to advocate for adequate payment based on site of service.

• • ASC conversion factor: CMS proposes a CY 2019 conversion factor of $46.50, an adjusted update factor of 2.0 percent. Review proposed ASC payment rates for GI services.

• • OPPS update: For CY 2019, CMS proposes a conversion factor of $79.54, a 1.25 percent increase over of CY 2018. Review proposed OPPS payment rates for GI services. 

• • Modifications to the Quality Reporting System: As part of its “Meaningful Measures” initiative, CMS is proposing to remove from the Hospital Outpatient Quality Reporting (OQR) Program and ASC Quality Reporting (ASCQR) Program two colonoscopy measures. The measures would be removed beginning with the CY 2021 payment determination (CY 2019 reporting year). CMS noted that the removal is justified, in part, because the measures are available for reporting by gastroenterologists through the Merit-Based Incentive Payment System.
    • • ASC-9 / OP-29: Appropriate Follow-up Interval for Normal Colonoscopy in Average Risk Patients (NQF #0658) 
    • • ASC-10 / OP-30: Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use (NQF #0659)

Additionally, CMS is proposing for both the Hospital OQR and ASCQR Program to change the reporting period for OP-32: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy from one year to three years beginning with the CY 2020 payment determination (which would use claims data from Jan. 1, 2016, through Dec. 31, 2018) and for subsequent years. 

For the CY 2021 payment determination, CMS is instead proposing the following measures for the ASCQR Program. 

• • ASC-12: Facility 7-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy

• • ASC-13: Normothermia Outcome

• • ASC-14: Unplanned Anterior Vitrectomy

• • ASC-15a: OAS CAHPS – About Facilities and Staff 

• • ASC-15b: OAS CAHPS – Communication About Procedure

• • ASC-15c: OAS CAHPS – Preparation for Discharge and Recovery

• • ASC-15d: OAS CAHPS – Overall Rating of Facility

• • ASC-15e: OAS CAHPS – Recommendation of Facility

The ASCQR and OQR requires facilities to meet the program requirements or face a 2.0 percentage points reduction in payment.

• • Controlling utilization of outpatient services: In the rule, CMS has proposed making equal Medicare payments for all G0463 services regardless of where the service is performed. Previously, certain hospital off-campus provider-based departments were reimbursed more for G0463, because they were hospital-based. We will be evaluating the impact of the “PO” proposal on GI services in the Hospital Outpatient Department.