CMS Issues CY 2023 Proposed Rules for Medicare Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgery Center (ASC)
On July 15, 2022, the Centers for Medicare and Medicaid Services (CMS) issued the proposed rule for the Medicare Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgery Center (ASC) Prospective Payment System. These proposed rules cover outpatient hospital and ASC services furnished to beneficiaries on or after January 1, 2023. Highlights are described below.
For Outpatient Hospital:
- CMS proposed a Conversion Factor of $86.785 for hospitals that meet the hospital outpatient quality (OQR) reporting program requirements; and a CF of $85.093 for hospitals that fail to meet the hospital OQR requirements.
- for hospitals that meet the hospital OQR reporting program requirements; and a continuation of 2.0 percent reduction in payment for hospitals that fail to meet the hospital OQR requirements.
- CMS proposed to continue a 7.1% adjustment factor to payments to certain rural sole community hospitals; and proposed a budget neutrality factor for the rural adjustment at 1.0000.
- For the 340B acquired drugs and biologicals policy, CMS proposed an alternate payment file for the rates which take in to account the shift from average sales price (ASP) -22.5 percent to ASP +6 percent, resulting in CMS returning money to hospitals. CMS will also need to determine how to address the 2018-2022 payment rates at the time and how the additional monies are paid back in a budget neutral manner.
- No proposed changes to the Ambulatory Payment Classification (APC) payment policy or packaging policy.
- CMS proposed to continue to use code G0463 for the standardized code on which to base the relative payment weights.
- CMS proposed to remove 10 integumentary and musculoskeletal procedures from the Inpatient Only List (IOL) and add 8 procedures that were newly created by the AM CPT® Editorial Panel for CY 2023, including hernia repair with mesh.
- CMS proposed to clarify the definitions of general and personal supervision within the text of the codified policy for supervision by nonphysician practitioners of diagnostic services in the outpatient hospital setting.
- CMS addressed payment for Software as a medical Service (SaaS), specifically how these services should be distinguished from the imaging test or professional services; how the costs should be identified; and what specific payment approach should be used.
For Ambulatory Surgery Centers:
- CMS proposed a payment rates increase by 2.7 percent for hospitals that meet the Ambulatory Surgical Center Quality Reporting (ASCQR) Program; and a continuation of a 2.0 percent reduction in payment for ASCs that fail to meet the ASCQR program requirements.
- CMS proposed Conversion Factor of $51.315 for ASCs that meet the ASCQR Program requirements; and a CF of $50.315 for hospitals that fail to meet the ASCQR Program requirements.
- For the complexity adjustment payments, CMS proposed to assign each eligible code combination a new C code that describes the primary and add-on code procedures performed. The new C codes would be added to the ASC CPL and when an ASC bills the C code, they will be paid the higher payment rate.
- CMS proposed to maintain the criteria used to review and update the ASC covered procedure list (ASC CPL). Based on their review, they have proposed to add one lymphatic procedure for CY 2023. Codes 92985 and 93986 are proposed to continue to be on the ASC covered surgical procedures list designated as temporary office-based.
The complete HOPPS/ASC proposed rule summary can be found on the GORE Coding Resource Center website under “Education – CMS Rules Updates”.
