Today’s article will build on last week’s publication, which highlighted for our readers some of the key takeaways from the 2023 Outpatient Prospective Payment System (OPPS) Final Rule (FR) that was released earlier this month by the Centers for Medicare and Medicaid Services (CMS). Below are some additional details arising from the FR that hospital leaders and decision-makers will want to review. Again, the following is based, in part, on a fact sheet released by CMS that attempts to summarize the key provisions of the 2023 OPPS FR.

Remote Behavioral Health Services

Pursuant to the FR, CMS is finalizing its proposal to ensure OPPS payment coverage of behavioral health services that are furnished remotely by clinical staff of hospital outpatient departments, including staff of critical access hospitals (CAHs), through the use of telecommunications technology to beneficiaries in their homes. Currently, this flexibility is available through the public health emergency (PHE) policy, i.e., Hospitals Without Walls (HWW), but the emergency waivers that enable this flexibility will expire when the PHE for COVID-19 ends.

CMS is finalizing its proposal to require that payment for behavioral health services furnished remotely to beneficiaries in their homes may only be made if the beneficiary receives an in-person service within six months prior to the first time hospital clinical staff provide the behavioral health services remotely, and that there must be an in-person service without the use of communications technology within 12 months of each behavioral health service furnished remotely by hospital clinical staff. The FR permits exceptions to the in-person visit requirement when the hospital clinical staff member and beneficiary agree that the risks and burdens of an in-person service outweigh the benefits of it, among other requirements.

CMS is also clarifying that, in instances where there is an ongoing clinical relationship between practitioner and beneficiary at the time the PHE ends, the in-person requirement for ongoing (not newly initiated) treatment will apply. CMS is also finalizing its proposal that audio-only interactive telecommunications systems may be used to furnish these services in instances where the beneficiary is unable to use, does not wish to use, or does not have access to two-way, audio/video technology.

N95 Respirators

The supply of surgical N95 respirators became limited in hospitals in the early stages of the COVID-19 pandemic. Sustaining a sufficient level of domestically produced respirators that are approved by the National Institute for Occupational Safety and Health (NIOSH) would help to provide some assurance going forward, but hospitals may incur additional costs when purchasing such respirators.

Given the above, CMS is finalizing a proposal to provide payment adjustments under the IPPS and OPPS (hospital inpatient and outpatient payment systems) that would reflect, and offset, the additional marginal resource costs that hospitals face in procuring domestically made NIOSH-approved surgical N95 respirators. Under this policy, these payments would be provided biweekly as interim lump-sum payments to the hospital and would be reconciled at cost report settlement. The rule also outlines the information that would be collected on the cost report to determine payments under this policy, which would apply to cost reporting periods beginning on or after January 1, 2023.

Clinic Visit Payment Policy

CMS currently pays an equivalent of the Medicare Physician Fee Schedule (PFS) payment rate for a clinic visit service when provided at an excepted off-campus provider-based department (PBD) paid under the OPPS. The purpose of this current policy is to control the unnecessary increases in volume CMS had observed for that covered outpatient department service. The PFS-equivalent payment rate is approximately 40 percent of the OPPS payment rate, and the clinic visit is the most frequently billed service under the OPPS.

In order to maintain access to care in rural areas, CMS is finalizing its proposal to exempt Rural Sole Community Hospitals (SCHs) from this policy and pay for clinic visits furnished in excepted off-campus PBDs of these hospitals at the full OPPS rate. This exemption for rural SCHs is in keeping with prior CMS policies to provide rural SCHs a 7.1 percent add-on payment for OPPS services, to account for their higher costs compared to other hospitals.

Skin Substitutes

The FR establishes a policy to eliminate HCPCS code C1849, which is the code that providers have been using under OPPS to report the usage of synthetic skin substitute products. Providers are to use product-specific HCPCS codes for synthetic skin substitute products that are currently described by HCPCS code C1849. Furthermore, the FR assigns any synthetic skin substitute product that (a) is currently described by HCPCS code C1849, (b) would have been described by HCPCS code C1849, or (c) is assigned a code in the HCPCS A2XXX series, to the high-cost skin substitute group. These products will be assigned to the high-cost skin substitute group even if cost and pricing data are not available for any individual product.

Prior Authorization

In the 2023 OPPS FR, CMS is adding facet joint interventions to the list of services that require prior authorization. While CMS believes prior authorization can be an effective mechanism to ensure Medicare beneficiaries receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in volume, the agency is not adding new documentation requirements for providers. The implementation date for prior authorization for the facet joint interventions service category is set for July 1, 2023, per the FR.