News: CY 2022 OPPS final rule released

CDI Strategies - Volume 15, Issue 51

The calendar year (CY) 2022 Outpatient Prospective Payment System (OPPS) final rule has been published. Notable changes include increased price transparency penalties, changes to the inpatient only list, and some payment changes.

The ruling finalized both a process for monitoring hospital compliance and an increase in penalty amounts for noncompliance, Revenue Cycle Advisor reported. CMS may conduct monitoring via complaints made to CMS, CMS’ review of individuals’ or entities’ analysis of noncompliance, and/or CMS’ audit of hospitals’ websites to check for compliance with price transparency and making a public list of standard charges. If CMS determines that a hospital is noncompliant with any of the price transparency requirements, they can take enforcement action such as:

  • Providing a written warning notice to the hospital of the specific violation(s)
  • Requesting a corrective action plan from the hospital if its noncompliance constitutes a material violation of one or more of the transparency requirements
  • Imposing a $300 per day penalty on the hospital and publicizing the penalty on a CMS website if the hospital fails to respond to CMS’ request to submit a corrective action plan or comply with the requirements of a corrective action plan

The CY 2022 OPPS final rule expands enforcement with increased civil monetary penalties (CMP) levied in a scaled approach based on the number of beds at a facility. Thirty or fewer beds is $300, 31-550 beds is $10 per bed per day, and more than 550 beds is $5,500.

For the inpatient only list, the final rule states that CMS will not move forward with the 2021 final rule plan to eliminate the list.

Of the 298 procedures removed from the list in 2021, all but three were added back to the inpatient only list via the 2022 final rule. The following three services were not moved back to the inpatient only list:

  • Lumbar spine fusion (CPT® 22630)
  • Reconstruct should joint (CPT® 23472)
  • Reconstruct ankle joint (CPT® 27702)

The corresponding anesthesia codes (01638 and 01486) will also remain off the inpatient only list.

These rule changes will be codified in regulations under a new section at 42 CFR 419.22. CMS has provided a complete list of the inpatient only services effective January 1, 2022, in Addendum E of the final rule.

In a small section of the rule, CMS finalized the adoption of the Physician Fee Schedule (PFS) equivalent payment rate for hospital outpatient clinic visits reported by HCPCS code G0463 when furnished by an excepted off-campus provider-based department, Revenue Cycle Advisor reported.

The PFS rate is 40% of the OPPS payment. While commenters from the proposed rule raised concerns about the potential financial harm this rate may cause, CMS moved forward with finalizing this policy. CMS did indicate, however, that it would continue to monitor the payment policy, including the volume of the services, to determine whether changes are necessary in the future.

Editor’s note: Portions of this article originally appeared in Revenue Cycle Advisor. The full CY 2022 OPPS final rule can be found here.

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News, Outpatient CDI