Monday, July 29, 2019

July 29, 2019: CMS Releases CY2020 PFS, OPPS, and ESRD/DME Rules

On July 20, 2019, several weeks later than normal, CMS issued its annual proposed rulemaking for the PFS (Part B) setting, the hospital outpatient and ASC setting (OPPS), and the annual rulemaking for ESRD and DME.

Below I clip the CMS consolidated brief press release, which contains links to each rule-specific press release and each rule-specific FAQ sheet.    The short press release focuses on Trump administration programs for price transparency, which is just one part of each bundle of policies.

Actual Rulemaking Links
  • OPPS Here .  Fed Reg version August 9, here.  84 Fed Reg 39398-39644
  • PFS Here.   Fed Reg version, August 14, here.  84 Fed Reg 40482-41263.
  • ESRD/DME Here.  Fed Reg version, AAugust 6, here.  84 Fed Reg 38330-38421.
  • The three rules and three fact sheets in a Cloud zip file (50 mb) here.
Hospital Negotiated Rates by Payer

The "big deal" in these rules is in the OPPS rule, requiring hospitals to post negotiated rates by payer by procedure.  There's much ink spilled on this one all over the trade press; for one article on legal aspects here.

The OPPS rules contain some detailed proposed tweaks to Date of Service rules (p. 667-689).  These include leaving both ADLTs and human molecular pathology tests unbundled, but leaving only the ADLTs exempt from date of service rules.  For example, on first rading, it looks like an Oncotype-type mRNA-based test would be billable, but only by the hospital within 14 days, unless, it gets ADLT status, in which case, it would be billing by the lab.  Whew.  (P. 685-686).

Outpatient Surgery Prior Authorization
Generally, Part A and B fee for service program's don't have prior authorization (outside of a few DME categories.)  CMS proposed Prior Authorization for just a few categories of hospital outpatient services that is apparently sees as high risk of lack of necessity.  These are (a) blepharoplasty (eyelid surgery), (b) botulinum toxin injections, (c) panniculectomy ("tummy tuck" if nonmedical), (d) rhinoplasty, (e) vein ablation (varicose veins; covered if medically necessary.)   Remark "these services are most often considered cosmetic...only covered [in] very rare circumstances."  They state, for example, "panniculectomy services were combination with procedures performed on the patient's chest region" (p. 39603ff).  See more on Prior Auth rulemaking in a section at the bottom of this blog.

For general entry points in 2018/2019 to a lot of people very aggravated by prior authorization, here.

CMS proposed changes to how DME rates for novel equipment are gapfilled and how these may be revised downward, pp. 146-179; new rules about DME prior authorization (184-208, esp. 203-208), including an acknowledgement of current "overlapping rules and guidance;" and new rules for diabetic strip competitive bidding, 249ff, including changes triggered by the Balance Budget Act of 2018 (253ff; Section 50414 of BBA).

60 Days
Public Comment periods run 60 days, to about September 27, but CMS must finalize the rules by first half of October to meet its November 1 publication deadline (being 60 days before 1/1/2020).

CMS Announces Landmark Price Transparency Proposals that Benefit ConsumersAdditional proposed rules Advance Agency’s Patients Over Paperwork and Meaningful Measures Initiatives, Strengthen Quality Incentives, and Build on Commitment to Improving the Lives of Patients with Kidney Disease 

Today, the Centers for Medicare & Medicaid Services (CMS) is announcing three important Medicare proposed payment rules that support the transformation of the healthcare system and deliver on providing quality care for patients.

Calendar Year (CY) 2020 Medicare Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule
This proposed rule contains historic changes as a result of President Trump’s recent Executive Order on price and quality transparency that lays the foundation for a patient-driven healthcare system. CMS is putting forward price transparency requirements that will increase competition among all hospitals by requiring them to make pricing information publicly available. Each year, CMS issues a proposed rule to update CY Medicare payment policies and rates under the OPPS and the ASC Payment System.

For more information, see the following links:

Calendar Year (CY) 2020 Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP) Proposed Rule
This proposed rule updates payment policies for clinicians paid for the services they provide to Medicare beneficiaries under the PFS and QPP. The proposed policy changes will ensure clinicians spend more time providing high-value care for patients instead of on cumbersome paperwork. As part of CMS’s annual changes to the PFS and QPP, the agency is reducing burden, rewarding clinicians for the time they spend with patients, removing unnecessary measures they have to report, and making it easier for them to be on the path towards value-based care. This proposed rule builds on the Trump Administration’s efforts to establish a patient-driven healthcare system that focuses on better health outcomes.

For more information, see the following links:

Calendar Year (CY) 2020 Medicare End Stage Renal Disease (ESRD) and Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) Proposed Rule

The ESRD and DMEPOS CY 2020 proposed payment rule would update payment policies and rates under the ESRD Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries and the DMEPOS Competitive Bidding Program (CBP) and Fee Schedule Amounts. This proposed rule puts forth updates to the acute kidney injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI. The proposal would also make changes to the ESRD Quality Incentive Program (QIP), introduce a methodology for calculating fee schedule payment amounts for new DMEPOS items and services, adjustments the fee schedule amounts established using supplier or commercial prices if such prices decrease within five years of establishing the initial fee schedule amounts, and also revises existing policies related to the competitive bidding program for DMEPOS.

For more information, see the following links:


Prior Author Additional...

CMS discusses how Prior Auth for surgeries would work (p. 695ff).  Authorization would not be binding on the contractor if later medical review found the services unnecessary.  Getting prior auth would, however, be binding on the surgeon/hospital for any of the listed CPT codes.  Surgeons would be exempt if they have a 90% pass rate.  "CMS or its contractor will review a prior authorization request for compliance with applicable Medicare coverage, coding, and payment rules (new regs proposed at 42 CFR 419.82)."  This suggest MACs might have to have LCDs or articles published for all the codes, to furnish a review standard.  CMS simply states that prior auth cases must provide all documentation necessary to determine compliance on a case by case basis - it would also be hard to submit this without a published guidance.  CMS would give itself 10 days to turn around P.A.  documents.  Upon a denial, a provider may resubmit.   Associated services (e.g. anesthesiology) would also be deniable.  

Data for which US surgeons were top providers of these services would be available by name and address (sorted by CPT code) in a public Medicare database updated through 2017 (here).  CMS makes this download easy, by providing all the relevant CPT codes in Table 38.   AMA and CMS data for 2017 indicate about 2400 cases of the basic panniculectomy code 15830.  However, when I checked that 2017 Part B data for codes 15830, 15847, 15877, there were only a handful of surgeons providing each, collectively having done about 100 cases for 15830, and typically 10-20 per surgeon (this database doesn't show surgeons with <10 cases of any given code).   I may be missing something, but otherwise the 2300 cases must be largely provided by surgeons with <10 Medicare cases per surgeon.