Medicare Final Rule for CY 2022: Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment

Release Date: November 2, 2021
Federal Register Publication Date: November 16, 2021
Effective Date: January 1, 2022

OPPS/ASC Final Rule:

*Hospitals meet applicable quality reporting requirements. 

The final rule refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program, updates Hospital Price Transparency requirements, and updates and refines the design of the Radiation Oncology Model. Below are some takeaways from the final rule:

• The final rule is finalizing proposed modifications to increase Hospital Price Transparency compliance beginning January 1, 2022. 
  • Minimum Civil Monetary Penalty (CMP) of $300/day applicable to smaller hospitals with a bed count of 30 or fewer and a penalty of $10/bed/day for hospitals with a bed count greater than 30, not to exceed a maximum daily dollar amount of $5,500. For a full calendar year of noncompliance, the minimum total penalty amount would be $109,500 per hospital, and maximum total penalty amount would be $2,007,500 per hospital. 
  • An online price estimator tool that is used in lieu of hospitals posting their standard charges must be in a consumer friendly format for the required shoppable services. 
• Reversal of phased elimination of the Inpatient Only (IPO) list and addition to the list of services removed in 2021, except CPT 22630, 23472 and 27702 and their corresponding anesthesia codes. 
• CMS will finalize OPPS payment of drugs through the 340B program at average sales price minus 22.5 percent for certain separately payable drugs acquired through the 340B program. The final rule excludes rural sole community hospitals, children’s hospitals, and PPS-exempt cancer hospitals. 
• Partial Hospitalization Program (PHP) services furnished in hospital outpatient departments and Community Mental Health Centers (CMHCs) will be paid on a per diem basis under OPPS, based on PHP per diem costs. 
  • CY2019 claims and cost report data will be used for determining the per diem costs to be finalized in CY2021.
  • An aggregate payment for specific mental health services provided by one hospital to a single beneficiary on a single date of service that exceeds the maximum per diem payment rate for partial hospitalization will be paid through composite APC 8010 (Mental Health Services Composite) for CY2022.
  • A geometric mean per diem cost methodology was used to determine the per diem cost for CMHC APC 5863 for mental health services furnished by a hospital on a single date of service. The same payment rate is set for APC 8010.  
• Radiation Oncology (RO) Model will begin on January 1, 2022 with 5 year performance period that may change based on the model’s performance.
  • Baseline period from 2016-2018 to 2017-2019.
  • Lower discounts to 3.5 percent (Professional Component) and 4.5 percent (Technical Component)
  • Liver cancer will no longer be included in the RO Model. 
  • Exclude outpatient departments participating in the Community Transformation track of the Community Health Access and Rural Transformation (CHART) in the RO Model. 
• Cancer Hospital Payment Adjustment is where a Cancer Hospital will continue to receive additional payments so that the hospital’s payment to cost ratio (PCR) after the additional payment is equal to the weighted average PCR for the other OPPS hospitals settled. Payment adjustments will be the additional payments needed to result in a PCR (payment to cost ratio) equal to 0.89 for each cancer hospital. 
• Quality Reporting Program proposed:
  • A 2% reduction in payments for hospitals that fail to meet the hospital outpatient quality reporting requirements. A 0.9804 reporting factor will be applied to the OPPS payments and copayments for applicable services. 
  • For Hospital Outpatient, CMS finalizes three new measures which include COVID-19 Vaccination of Health Care Personnel, make reporting of two voluntary or suspended measures mandatory, remove two measures, and update validation policies.
  • For Ambulatory Surgical Center, CMS adopts one new measure (COVID-19 Vaccination of Health Care Personnel) and makes the reporting of six voluntary or suspended measures mandatory. 

Sources: CMS CY 2022 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1753-FC)