Opps Status Video Download
Reymundo Ramirez
These new services are described by the CPT codes 0790T, 22836, 22837, 22838, 61889, 76984, 76987, 76988 and 76989 (described by placeholder codes X114T, 2X002, 2X003, 2X004, 619X1, 7X000, 7X001, 7X002, and 7X003, respectively, in the CY 2024 OPPS/ASC Proposed Rule). Upon clinical review, it was determined that these services require a hospital inpatient admission or stay and are not suitable for payment under the OPPS. Therefore, these services will be assigned to status indicator "C" (Inpatient Only) for CY 2024.
In the Proposed Rule, CMS sought feedback on what evaluations of health equity should be included in its economic analysis of OPPS and ASC policies. To gain insight into how OPPS and ASC policies affect health equity, CMS is considering adding elements to its economic analysis that would detail how OPPS and ASC policies impact particular beneficiary populations that are typically underserved by the healthcare system. Currently, OPPS impacts are presented by provider type, rural versus urban area, geographic region, teaching status and ownership type. CMS sought comments about structuring an impact analysis that addresses how OPPS and ASC changes may impact beneficiaries of different groups. CMS also requested input on what health equity questions should be examined, what categories or measures should be included and any other feedback on ways to continue building an OPPS health equity framework.
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If the procedure poses a higher risk to the patient, the procedure may be as classified as "inpatient only," and therefore, will not be paid in an ASC or APC setting. Inpatient-only procedures are assigned a "C" status indicator, indicating that those procedures will be reimbursed on an inpatient-only basis.
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The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. To accomplish this goal, CAHs receive certain benefits, such as cost-based reimbursement for Medicare services. (see What are the benefits of CAH status?)
Critical Access Hospital (CAH) status does not guarantee a better financial situation. Some hospitals will find the cost-based reimbursement advantageous, and some will not. Each hospital must perform its own financial analysis to determine if being a Prospective Payment System (PPS) hospital or a CAH would result in a better financial return. For financially distressed hospitals, even if CAH status leads to increased reimbursement, it may not put the hospital in the black. In fact, some hospitals have closed even after converting to CAH status. The Flex Monitoring Team releases an annual CAH Financial Indicators Report that can be helpful in understanding financial performance of CAHs.
CAH status should be considered or maintained only if it is appropriate for the community need and hospital service area. In particular, consideration should be given to the bed limit for CAHs and potential service lines and whether they are sufficient to meet community need.
CAH status does not necessarily mean fewer services are offered compared to other facilities. Services offered by a CAH should be aimed to meet the community's unique needs. Therefore, the number and type of services offered in one community may be different than in another community. A CAH can utilize a Community Health Needs Assessment (CHNA) to guide its review of current and future services needs.
Facilities applying to become Critical Access Hospitals must be currently participating in the Medicare program and have a current license as an acute care hospital. Hospitals closed after November 29, 1989, and hospitals that have downsized to health clinic or health center status may also qualify for CAH status if they meet all of the CAH Conditions of Participation.
Critical Access Hospitals that were granted Necessary Provider designation prior to January 1, 2006, and choose to rebuild in a new location that does not meet the current distance requirements, are treated in the same manner as if they were building a replacement facility at the original location. In order to maintain CAH status and the necessary provider designation, the new facility must satisfy the following requirements:
A facility interested in CAH status should contact its state survey agency to request application materials. The state agency will review and forward the application to a CMS regional office. The CMS regional office will authorize a survey, and the state agency will then contact the facility to arrange a survey date. The survey will verify that the CAH meets the federal facility requirements. Details about the survey process are available in Appendix W of the CMS State Operations Manual.
Additionally, facilities may obtain deemed status if accredited by a CMS-approved Medicare accreditation organization. In the case of a deemed provider, the state agency does not conduct an initial survey. While the facility seeking deemed status must still contact the state agency to acquire the Medicare and/or Medicaid certification materials, initial certification and subsequent recertification is performed by the accrediting organization. CMS maintains a list of Approved Accreditation Organization Contacts for Prospective Clients. The following accreditation organizations are approved for CAH certification:
The United States Congress established the Rural Emergency Hospital (REH) as a new Medicare provider type in the Consolidated Appropriations Act, 2021. Effective January 1, 2023, this law will allow Critical Access Hospitals and other small rural hospitals meeting eligibility criteria to convert to Rural Emergency Hospital (REH) status. REHs will be reimbursed at 105% of the outpatient prospective payment system (OPPS) for emergency and outpatient care services in addition to a fixed monthly payment. Unlike Critical Access Hospitals, REHs will not be allowed to provide inpatient services.
CMS will be removing CPT code 27447 (arthroplasty, knee, condyle and plateau; medical and lateral compartments with or without patella resurfacing [total knee arthroplasty]) from the inpatient-only list in 2018 after soliciting provider feedback on the procedure over the last two rulemaking cycles. The procedure has been assigned to APC 5115 and status indicator J1 (paid through a comprehensive APC).
Additionally, CMS will prohibit Recovery Auditors from reviewing patient status for total knee arthroplasty procedures performed in the inpatient setting for two years while providers gain experience with performing the procedure in the outpatient setting. The agency will still permit reviews for other reasons, such as medical necessity.
CMS added one code to the inpatient-only list, 92941 (percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, single vessel), which has been assigned status indicator C (inpatient-only procedure procedure not paid under OPPS).
The proposed rule reduces the CY 2016 conversion factor by 2.0 percent to account for $1 billion in inflation in the OPPS payments due to overestimated packaged payment under prior OPPS conversions. The proposed rule also changes the laboratory test packaging policy by adding a new conditional packaging status indicator for lab tests, so hospitals can receive separate payments for tests that are not tied to other OPPS services.
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