For HOPPS/ASC:
The OPPS rate is a national unadjusted payment amount which include the Medicare and beneficiary payment. It is divided into a labor-related and nonlabor-related amount, and the labor-related amount is adjusted based on the locality in which the hospital is located. For CY 2020 CMS is:
- Updating OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.6 percent under the Outpatient Department (OPD) fee schedule.
- Continuing to implement a statutory 2.0 percentage reduction for hospitals failing to meet the hospital outpatient quality reporting requirements set forth by the Hospital Outpatient Quality Reporting (OQR) Program.
- Maintaining the rural adjustment factor of 7.1% to the HOPPS payments to certain rural sole community hospitals (SCHs), including essential access community hospitals (EACHs) for CY 2020 and subsequent years.
Ambulatory Payment Classification (APC) Relative Payment Weights are revised at least annually. APCs group services which are considered clinically comparable to each other in terms of resource utilization and associated cost. Ancillary services or items which are necessary components of the primary service are packaged into the APC rates and not separately reimbursed.
CMS will continue using HCPCS code G0463, hospital outpatient clinic visits for assessment and management of a patient, in APC 5012 (Level 2 Examinations and Related Services) as the standardized code for the relative payment weights. A relative payment weight of 1.00 will continue to be assigned to APC 5012 (code G0463). CMS will use the factor of 1.00 and then dividing the geometric mean cost of each APC by the geometric mean cost of APC 5012 to derive the unscaled relative payment weight for each APC.
As a result of the annual review of existing C-APCs, CMS is creating two new C-APCs for CY 2020. This now brings the total number of C-APCs to 67. Of interest is C-APC 5182 (Level 2 Vascular Procedures).
In the CY 2019 final rule and for subsequent years, CMS modified criteria for device-intensive procedures to potentially allow a greater number of procedures to qualify as device-intensive. One of the criteria is the device offset amount must exceed 30 percent of the procedure’s mean cost. CMS determined the device offset percentage for CPT® code 36904 exceeds the 30 percent threshold and is therefore assigned device-intensive status for CY 2020:
36904 – Percutaneous transluminal mechanical thrombectomy and/or infusion for thrombolysis, dialysis circuit, any method, including all imaging and radiological supervision and interpretation, diagnostic angiography, fluoroscopic guidance, catheter placement(s), and intraprocedural pharmacological thrombolytic injection(s)
In the CY 2020 final rule, CMS is changing the minimum required level of supervision from direct supervision to general supervision for all hospital outpatient therapeutic services provided by hospitals and Critical Access Hospitals (CAHs). Hospitals and physicians will now have the ability to set the supervision level as they believe is appropriate, this could result in direct or personal supervision for some outpatient therapeutic services.
The CY 2020 HOPPS/ASC final rule is located in its entirety at the following link:
