Hospital Outpatient PPS

Hospital Outpatient Prospective Payment System Rulemaking

The CY2013 Hospital Outpatient Prospective Payment - Final Rule with Comment Period including related links to the CY2013 Payment Rate addenda and wage index files are available on the CMS website at: http://cms.hhs.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1589-FC.html

Previously published OPPS Rulemaking is available on the CMS OPPS Regulations and Notices Page at: http://cms.hhs.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices.html

CMS Will Not Enforce Supervision Requirements for Outpatient Therapeutic Services in Critical Access Hospitals and Certain Small Rural Hospitals for CY 2013 (see downloads below)

Centers for Medicare & Medicaid Services August 24, 2010 Listening Session: Hospital Observation Care; View transcript of the public Listening session held by CMS on August 24, 2010 on the increasing use of extended observation care in the hospital outpatient department. CMS held this session to gain a better understanding of beneficiary and provider experiences with observation care (see downloads below).

CMS has posted guidance for manufacturers who will be submitting ASP for radiopharmaceuticals in CY 2010. These instructions can be viewed by clicking on the document (see Downloads section below). Please note that in light of the imminent deadline for submitting ASP data for OPPS payment beginning on January 1, 2010, we encourage manufacturers wishing to submit ASP data for the January 2010 OPPS update to contact us immediately through the OPPS mailbox at OutpatientPPS@cms.hhs.gov (see Related Links Inside CMS below) so we can facilitate the submission process.

Section 4523 of the Balanced Budget Act of 1997 (BBA) provides authority for CMS to implement a prospective payment system (PPS) under Medicare for hospital outpatient services, certain Part B services furnished to hospital inpatients who have no Part A coverage, and partial hospitalization services furnished by community mental health centers. The provisions of this section were further modified by sections 201 and 202 of the Balanced Budget Refinement Act of 1999 (BBRA).

All services paid under the new PPS are classified into groups called Ambulatory Payment Classifications or APCs. Services in each APC are similar clinically and in terms of the resources they require. A payment rate is established for each APC. Depending on the services provided, hospitals may be paid for more than one APC for an encounter.

Section 4523 of the BBA also changed the way beneficiary coinsurance is determined for the services included under the PPS. A coinsurance amount will initially be calculated for each APC based on 20 percent of the national median charge for services in the APC. The coinsurance amount for an APC will not change until such time as the amount becomes 20 percent of the total APC payment. In addition, Section 204 of the BBRA provides that no coinsurance amount can be greater than the hospital inpatient deductible in a given year.

Both the total APC payment and the portion paid as coinsurance amounts will be adjusted to reflect geographic wage variations using the hospital wage index and assuming that the portion of the payment/coinsurance that is attributable to labor is 60 percent.

CMS's final rule for the new system was published in the Federal Register on April 7, 2000 (65 FR 18434). The new system went into effect on August 1, 2000.

HOSPITAL CENTER
For a one-stop resource web page focused on the informational needs and interests of Medicare Fee-for-Service (FFS) hospitals, go to the Hospital Center (see under "Related Links Inside CMS" below). Mailbox: OutpatientPPS@cms.hhs.gov.

For files to order, see Limited Data Set Files - Hospital Outpatient Prospective Payment System and the Identifiable Data Files - Hospital Outpatient Prospective Payment System.