• News New Blog Banner

  • CMS Issues Proposed Rule on Outpatient Prospective Payment

    The rule proposed July 3 by the Centers for Medicare and Medicaid Services (CMS) includes a 2.1% increase in payment rates for 2015 under the outpatient prospective payment system (OPPS) and changes to hospital admissions requirements.

    The proposed rules affect hospital outpatient departments and ambulatory surgical centers beginning January 1, 2015. Proposals include the implementation of comprehensive payments for certain services, clarification of the requirement for an admission order for all hospital inpatient admissions, and a change that will require physician certification for hospital inpatient admissions only for long-stay cases and outlier cases, not short stays.

    Informed by comments received regarding the requirements for a physician certification of hospital short stays, CMS clarifies that admission orders are a condition of payment for all inpatient hospital admissions. However, CMS will require a physician certification only for long-stay cases (20 days or more) and outlier cases. CMS states that the admission order, medical record, and progress notes must contain sufficient information to support the medical necessity of an inpatient admission without a separate requirement of an additional, formal, physician certification for shorter stays.

    The rule also proposes the implementation of the 2014 OPPS final rule policy creating 28 comprehensive ambulatory payment classifications (APCs) to handle payment for the most costly device-dependent services. The policy would treat all individually reported codes as components of a comprehensive service, resulting in a single prospective payment based on the cost of all individually reported codes. CMS will make a single payment for the comprehensive service based on all charges on the claim, and charges for services that cannot be covered separately by Medicare Part B or that are not payable under the OPPS will not be reimbursed. Further, CMS proposes to conditionally package certain ancillary services when they are integral, ancillary, supportive, dependent, or adjunctive to a primary service.

    In addition, CMS proposes to change its consideration of requests the expansion of physician-owned hospitals under the physician self-referral regulations and establishes an appeal process for Medicare Advantage organizations regarding CMS-identified overpayments.

    Most physical therapy services provided in the outpatient hospital department are not paid under the OPPS and are paid instead under the Medicare Physician Fee Schedule (PFS) (see related news story on the proposed PFS for 2015), though a small subset of ‘‘sometimes therapy’’ physical therapy services are paid under the OPPS when they are not furnished as therapy, meaning not under a certified therapy plan of care. CMS provides an annual update of these “sometimes therapy” services subject to direct supervision requirements. The update can be found at http://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html.

    The proposed rule will be published in the July 11, 2014, Federal Register. Comments on the rule are due September 2, 2014. APTA will submit comments on behalf of its members. A detailed summary of the rule will be available for APTA members shortly.


    • I listened to a CMS conference in September 2014, given by Pat Zachmann, during which she stated that out-pt. therapies did not have to worry about recert time, but that the recerts are done every 10 days. Is this accurate? or Do we need to get recerts every 60 days as it had been?

      Posted by Patricia A. Thibodeau, PT on 11/25/2014 3:42 PM

    Leave a comment
    Name *
    Email *