News: OPPS proposed rule continues push for site-neutral reimbursement

CMS’ 2019 OPPS proposed rule continues the agency’s efforts to enforce site-neutral payments and reduce drug payments by introducing policies to reduce reimbursement for hospital outpatient clinic visits at off-campus, provider-based departments (PBD).

The site-neutral payment policies will impact grandfathered PBDs that, to date, have not had to face any payment reductions for the services they provide, Revenue Cycle Advisor reported.

For calendar year 2019, CMS proposes that when reporting the Healthcare Common Procedure Coding System (HCPCS) code for a hospital outpatient clinic visit for assessment and management of a patient (G0463), providers that append a modifier for excepted service provided at an off-campus, outpatient PBD of a hospital, will be paid at the same rate as those that append the modifier for nonexcepted service provided at an off-campus, outpatient PBD of a hospital.

For 2019, the proposed unadjusted Medicare payment rate under the OPPS for a clinic visit would be approximately $116. The proposed unadjusted Medicare Physician Fee Schedule (MPFS) equivalent rate that clinics would instead be paid is approximately $46, according to Revenue Cycle Advisor.

“This proposal doesn’t come as a huge surprise given CMS’ E/M proposals released a few weeks ago, but what is surprising is that CMS does not address that physician offices and hospital outpatient departments, even off-campus ones, are structurally different in terms of infrastructure, typically serve different acuity patients, have payment rates developed under totally differently methodologies, and, most importantly, have different payment policies in place,” Jugna Shah, MPH, president and founder of Nimitt Consulting Inc., told Revenue Cycle Advisor.

Editor’s note: To read Revenue Cycle Advisor’s coverage of this story, click here. To read the full proposed rule, click here. To read the press release from CMS, click here.