CMS-1613-P

Medicare and Medicaid Programs:  Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Physician-Owned Hospitals:  Data Sources for Expansion Exception; Physician Certification of Inpatient Hospital Services; Medicare Advantage Organizations and Part D Sponsors:  Appeals Process for Overpayments Associated with Submitted Data

This proposed rule would revise the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2015 to implement applicable statutory requirements and changes arising from our continuing experience with these systems.  In this proposed rule, we describe the proposed changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system.  In addition, this proposed rule would update and refine the requirements for the Hospital Outpatient Quality Reporting (OQR) Program and the ASC Quality Reporting (ASCQR) Program.

In this document, we also are proposing changes to the data sources used for expansion requests for physician owned hospitals under the physician self-referral regulations; changes to the physician certification requirements for hospital inpatient admissions to make the existing certification of the reason for hospitalization, the estimated time the patient will need to remain in the hospital, and the plan of posthospital care (if applicable), only applicable to long-stay cases and outlier cases; and changes to establish a three-level appeals process for Medicare Advantage (MA) organizations and Part D sponsors that would be applicable to CMS-identified overpayments associated with data submitted by these organizations and sponsors. 

The proposed rule (CMS-1613-P) is available in the "Related Links" section below. The supporting files are located in the "Downloads" section below:

Addendum AA - a list of covered surgical procedures under the revised ASC payment system, including Category I and Category III CPT and Level II HCPCS codes. Included are surgical procedures that receive packaged payment through the payment for covered surgical procedures, as well as those that are paid separately. Payment indicators (defined in Addendum DD1) designate each procedure's payment status.

Addendum BB - a list of radiology services and other covered ancillary services eligible for ASC payment under the revised ASC payment system when provided integral to an ASC covered surgical procedure. Included are ancillary services that receive packaged payment through the payment for covered surgical procedures, as well as those that are paid separately. Payment indicators (defined in Addendum DD1) designate each service's payment status.

Addendum DD1 - a list of ASC payment indicators used in Addenda AA and BB to provide payment information regarding covered surgical procedures and covered ancillary services, respectively, under the revised ASC payment system. The payment indicators represent policy-relevant characteristics of HCPCS codes related to their payment status in ASCs; for example, whether a code is designated as packaged, office-based, or device-intensive.

Addendum DD2 - a list of ASC comment indicators.

Addendum EE - a list of surgical procedures excluded from Medicare payment in ASCs. The surgical procedures on that exclusionary list are those that are on the OPPS inpatient list, CPT unlisted codes, surgical procedures that are not recognized for payment under Medicare, and those that CMS medical advisors determined pose a significant risk to beneficiary safety or would be expected to require an overnight stay when provided in ASCs.

Addendum A - This Excel file lists, in APC order, the proposed name, payment status indicator, relative weight, payment rate, and copayment amount(s) for the proposed 2015 APC groups.