On October 31, 2014, CMS issued the Medicare Outpatient Prospective Payment System (“OPPS”) Final Rule for calendar year 2015.

The final rule is available at the Office of the Federal Register Public Inspection Desk until its publication in the November 10, 2014 Federal Register.

Some of the highlights of the final rule are as follows:

CMS estimates that the policies implemented in the final rule will result in a 2.3 percent increase in payments to providers in 2015, an increase of US$5.1 billion in total expenditures compared to calendar year 2014.

“This increase is based on the final hospital inpatient market basket percentage increase of 2.9 percent for inpatient services paid under the hospital inpatient prospective payment system . . . minus the multifactor productivity . . . adjustment of 0.5 [percent], and minus a 0.2 percentage point adjustment required by the Affordable Care Act,” said CMS.

In the fiscal year 2014 Inpatient Prospective Payment System final rule, CMS adopted a policy under which it would presume that hospital inpatient admissions are reasonable and necessary when beneficiaries receive medically necessary services for at least two midnights (the “Two Midnight Rule”).

As part of the Two Midnight Rule, CMS requires a physician certification, including an admission order and certain additional elements, for all inpatient admissions. The 2015 OPPS final rule implemented a change to the requirement that certifications must be provided for all inpatient admissions.

Going forward, CMS will require physician certification only for outlier cases and long-stay cases of 20 days or more. An admission order will continue to be required for all inpatients when that patient has been formally admitted to the hospital.

CMS implemented a data collection policy for services furnished in off-campus provider-based hospital departments in the 2015 OPPS final rule.

Identified as an initiative to assist CMS with studying an “increased trend toward hospital acquisition of physician practices, integration of those practices as a department of the hospital, and the resultant increase in the delivery of physicians’ services in a hospital setting,” CMS will require that all claims for services performed in an off-campus provider based hospital department include a new HCPCS modifier.

Use of the modifier will be voluntary in calendar year 2015, but will be mandatory on every CMS-1500 claim form for physicians’ services and UB-04 form for hospital outpatient services in 2016.

CMS established new comprehensive Ambulatory Payment Classifications (“C-APCs”) under which CMS will make single payments for a hospital’s provision of primary services and adjunctive services and supplies supporting the delivery of the primary service.

CMS established 25 C-APCs for calendar year 2015, representing device-dependent services or single session services with multiple components.

CMS increased payment rates for community mental health centers (“CMHCs”) and for hospital-based partial-hospitalization services (“PHPs”). CMS updated the PHP per diem costs “based on geometric mean cost levels calculated using the most recent claims and cost data for each provider type.”

Those updates mean per-diem costs range from US$100.15 for CMHC Level I (3 services) partial hospitalization to US$203.01 for PHP Level II (4 or more services) partial hospitalization.

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