On November 2, CMS published its CY 2019 hospital outpatient prospective payment and ambulatory surgical center payment systems and quality reporting programs final rule.
In the final rule CMS implements its proposal to pay clinic visit services performed in excepted off-campus provider-based departments (PBDs) a Medicare Physician Fee Schedule – equivalent payment rate. These services are currently paid under the Medicare outpatient prospective payment system (OPPS). CMS also implements its proposal to apply 340B drug payment policy to non-excepted off-campus PBDs. Currently, Medicare pays non-excepted off-campus PBDs the Average Sale Price (ASP) plus 6 percent for 340B program drugs. In comparison, Medicare pays excepted off-campus PBDs for 340B drugs an adjusted amount of ASP minus 22.5 percent. In CY 2019, Medicare will pay ASP minus 22.5 percent for 340B-acquired drugs furnished by non-excepted off-campus PBDs paid under the Medicare Physician Fee Schedule. In the final rule CMS did not adopt its proposal that an excepted off-campus PBD could continue to be paid under Medicare OPPS rates for a service only if that service was within 19 “clinical family of services” and a service within that clinical family of services had been furnished in the PBD before November 2, 2015 and billed to Medicare. Consequently, in CY 2019 an excepted off-campus PBD will be paid under the OPPS for all services furnished regardless whether it provided such services prior to November 2, 2015, so long as the PBD remains excepted (continues to comply with the relocation and change of ownership requirements). CMS does explain that it will continue to monitor the expansion of services in excepted off-campus PBDs and may in the future implement a limitation on the expansion of excepted services.
A fact sheet summarizing the final rule is available here.
The final rule itself is accessible here.