- The 2019 OPPS Final Rule updates Medicare payment rates and policies for hospital outpatient departments, with an overall 1.35% increase in payment rates. Key changes include expanding comprehensive APCs to include new ENT and vascular procedures, removing some procedures from the inpatient only list, and modifying device-intensive procedure criteria.

1. 2019 OPPS Final Rule
Key Points

2. The 2019 Hospital Outpatient Prospective Payment System (OPPS)
Final Rule has been issued and changes are on the way that can
affect your organization’s Medicare reimbursement.
As part of our commitment to help protect and enhance your Medicare
revenue, we’ve developed this expert analysis of the FY 2019 OPPS
Final Rule to quickly give you insight into the most important changes.
BESLER remains your trusted advisor and we look forward to helping
you identify areas of revenue opportunity for your facility.
Jonathan Besler
President & CEO

3. The Medicare Hospital Outpatient Prospective Payment System (IPPS) rates are required by
law to be updated annually.
This report contains key changes to the FY2019 OPPS Final Rule.
You can access the final rule on the Federal Register:
https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24243.pdf

4. • Key themes
• Payment rates
• Comprehensive APCs
• Inpatient only list
• Method to control unnecessary
increases in volume of outpatient services
• Expansion of clinical families of services at excepted off-
campus provider based departments (PBDs) of a
hospital
• Application of 340B drug payment policy to nonexcepted
off-campus provider-based departments of a hospital
• Device-intensive procedure criteria
• Hospitals with protection
• Adjustments
• Ambulatory Surgical Center (ASC) payment update
• Changes to the list of ASC covered surgical procedures
• Device-intensive procedure criteria
• Ambulatory Surgical Center Quality Reporting (ASCQR) Program
• E&M flat rate reimbursement delayed
• Claims submitted with Modifier 25 proposed changes
Contents
• Payment policy for biosimilar biological products without pass-through status that are acquired under 340B

5. Key themes

6. Price Transparency-
Not clarified in the OPPS Final Rule
• All hospitals including CAHs must post prices.
• Format instructions from CMS are unclear.
• Includes all standard charges for items and
services provided by the hospital.

7. Telemedicine
• Medicare payment policies are designed to
promote access to virtual care.
• Includes increased telehealth services and
easier access for seniors for the monitoring
of chronic conditions.
• Telemedicine needs to adhere to a few core
principles of quality for payment in both
urban and rural areas.

8. Expansion of eligible clinicians to
include physical therapists,
occupational therapists, clinical
social workers and clinical
psychologists.
Opt-in for low threshold clinicians.
MIPS
Ending 26 ineffective measures after hearing from stakeholders
Adding 8 quality measures including 4 based on
patient outcome reporting
X
+

9. Reducing physician administrative
burden and burnout
• The rule streamlines documentation
requirements.
• Reduces paperwork burdens that interfere
with a meaningful patient-physician
relationship.
• Intended so providers can spend more time
with patients and quickly locate relevant
information in medical records.

10. OPPS updates

11. For CY 2019, CMS is increasing the payment
rates under the OPPS by an outpatient
department (OPD) fee schedule increase
factor of 1.35 percent.
This increase factor 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 (IPPS), minus the multifactor
productivity (MFP) adjustment of 0.8 percentage
point, and minus a 0.75 percentage point
adjustment required by the Affordable Care Act.
Payment rates

12. For CY 2019, CMS is creating three
new comprehensive APCs (C-APCs)
These new C-APCs include ears,
nose, and throat (ENT) and
vascular procedures
The total number of C-APCs
increases to 65
Comprehensive APCs

13. Inpatient only list
Removing 4 procedures from the list
Adding 1 procedure to the list
X
+

14. Method to control unnecessary
increases in volume of outpatient services
To the extent that similar services are safely provided
in more than one setting, it is not prudent for the OPPS
to pay more for such services because that leads to an
unnecessary increase in the number of those services
provided in the OPPS setting.
Capping the OPPS payment at the Physician Fee
Schedule (PFS)-equivalent rate is an effective method
to control the volume of the unnecessary increases in
certain services because the payment differential that
is driving the site-of-service decision will be removed.

15. Expansion of clinical families of services at
excepted off-campus provider
based departments (PBDs) of a hospital
Proposed that if an excepted off-campus PBD
furnished items and services from a clinical
family of services from which it did not furnish
items and services (and subsequently bill for
those items and services) during a baseline
period, services from the new clinical family of
services would not be covered OPD services.
Instead, services in the new clinical family of
services would be paid under the PFS.
Not finalized

16. Application of 340B drug payment policy
to nonexcepted off-campus provider-based
departments of a hospital
CMS will pay the average sales price (ASP) minus 22.5 percent
under the PFS for separately payable 340B-acquired drugs
furnished by nonexcepted, off-campus provider-based
departments (PBDs) of a hospital.
This is consistent with the payment methodology
adopted in CY 2018 for 340B-acquired
drugs furnished in hospital
departments paid under
the OPPS.

17. Payment policy for biosimilar biological
products without pass-through
status that are acquired under
the 340B program
For CY 2019, CMS is making payments for
nonpass-through biosimilars acquired under the
340B program at ASP minus 22.5 percent of the
biosimilar’s own ASP rather than ASP minus 22.5
percent of the reference product’s ASP.

18. For CY 2019, CMS is modifying the device-
intensive criteria to allow procedures that
involve single-use devices, regardless of
whether or not they remain in the body
after the conclusion of the procedure, to
qualify as device-intensive procedures.
CMS also are allowing procedures
with a device offset percentage of
greater than thirty percent to
qualify as device-intensive
procedures.
Device-intensive procedure criteria

19. Hospitals with protection
CAHs continue to receive cost reimbursement
with the payment level set at 1% above cost or
101% of cost (before sequestration).
Children’s Hospitals and cancer centers have a
permanent hold harmless protection.
Non-enforcement of direct supervision, which
had previously been in place for outpatient
therapeutic services remains in place for CY
2019 for CAHs and small rural hospitals with
<100 beds.

20. Adjustments
Cancer Hospitals - additional payments to cancer hospitals so that the cancer hospital’s
payment-to-cost ratio (PCR) after the additional payments is equal to the weighted average PCR
for the other OPPS hospitals using the most recently submitted or settled cost report data.
Rural Adjustment - 7.1 percent adjustment to OPPS payments for certain rural SCHs, including
essential access community hospitals (EACHs). This will continue for future years in the absence
of data to suggest a different percentage adjustment should apply.

21. Ambulatory Surgical Center (ASC)
payment update
Using the hospital market basket methodology, for CY
2019, CMS is increasing payment rates under the ASC
payment system by 2.1 percent for ASCs that meet the
quality reporting requirements under the ASCQR
Program.
This increase is based on a hospital market basket
percentage increase of 2.9 percent minus a MFP
adjustment required by the Affordable Care Act of 0.8
percentage point.

22. Changes to the list of ASC covered
surgical procedures
Adding 12 cardiac
catheterization procedures
Includes an additional 5 related
cardiac procedures to the ASC
covered procedures list

23. OP-5: Median Time to ECG
OP-9: Mammography Follow-up Rates;
OP-11: Thorax CT Use of Contrast Material;
OP-12: The Ability for Providers with HIT to Receive Laboratory Data
Electronically Directly into Their Qualified/Certified EHR System as
Discrete Searchable Data;
OP-14: Simultaneous Use of Brain Computed Tomography
(CT) and Sinus CT;
OP-17: Tracking Clinical Results between Visits;
OP-30: Endoscopy/Polyp Surveillance:
Colonoscopy Interval for Patients with
a History of Adenomatous Polyps –
Avoidance of Inappropriate
Use.
CMS did not finalize proposals to remove
the OP-29 or OP-31 measures.
Device-intensive procedure criteria

24. Ambulatory Surgical Center Quality
Reporting (ASCQR) Program
• Extending the reporting period for the ASC-12: Facility Seven-Day Risk-Standardized Hospital
Visit Rate after Outpatient Colonoscopy measure to 3 years.
• Removing the ASC-8: Influenza Vaccination Coverage Among Healthcare Personnel measure.
• Removing the ASC-10: Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a
History of Adenomatous Polyps - Avoidance of Inappropriate Use measure.
• Not finalized: Proposals to remove the following measures: ASC-9: Endoscopy/Polyp
Surveillance Follow-up Interval for Normal Colonoscopy in Average Risk Patients and ASC-11:
Cataracts - Improvement in Patient's Visual Function within 90 Days Following Cataract
Surgery.
• Not finalizing our proposals to remove the following measures: ASC-1: Patient Burn; ASC-2:
Patient Fall; ASC-3: Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant;
and ASC-4: All-Cause Hospital Transfer/Admission.
• CMS is retaining these measures in the ASCQR Program and suspending data collection for
them until further action in rulemaking with the goal of revising the measures.

25. The flat-rate reimbursement and the
documentation relaxation proposed by the
Centers for Medicare & Medicaid Services (CMS)
did not pass for implementation in 2019.
Approved but delayed until 2021 to allow more
time for reconciliation with stakeholders.
E&M flat rate reimbursement delayed

26. Claims submitted with Modifier 25
proposed changes
CMS is comparing an E&M with a
procedure to a surgical encounter in
which multiple payment reductions are
applicable.
CMS feels that there are “efficiencies”
associated with an E&M encounter and
procedure on the same visit that the
multiple payment rule should be
applied to these instances.
Excluded from the OPPS Final Rule

27. BESLER combines best-in-class healthcare finance expertise with
proprietary technology to help hospitals recover more revenue.
Our reimbursement and recovery solutions have delivered more
than $2 billion of additional revenue to hundreds of hospitals
across the United States.
We serve as advocates for hospitals, so that they, in turn, can
better advance the health and well-being of their patients.
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