Medicare Reimbursement

The 4 Things Labs Need to Know About the 2022 OPPS Payments Rule

On Nov. 2, CMS posted the final Outpatient Prospective Payment System (OPPS) Rule for 2022. If for some reason you don’t feel like reading all 1,394 pages of the Rule, here’s a high-level summary of the four notable changes that managers of labs providing services to hospital and ambulatory surgical center (ASC) outpatients need to know about.

  1. 2022 OPPS Payment Rates

After last year’s 2.6 percent increase, CMS is hiking overall 2022 OPPS payment rates for hospitals and ASCs by 2.0 percent based on the following factors:

  • Hospital market basket increase of 2.7 percent; minus
  • The Affordable Care Act (ACA)-required multifactor productivity adjustment of -0.7 percent.

In establishing OPPS and ASC payment rates, CMS normally relies on rates data from the previous two years. However, the agency notes that the COVID-19 public health emergency has skewed the CY 2020 data. As a result, the CY 2022 payment rates are based on claims data from CY 2019.

  1. Restoration of Services Eliminated from Inpatient Only (IPO) List 

The OPPS 2021 final rule provides for eliminating the IPO list of services that Medicare will only pay for on an inpatient basis over a 3-year period. However, in response to public comments defending the IPO List as an important program safeguard, CMS has decided to eliminate the elimination plan and is restoring services that were removed from the list in 2021, except for CPT codes 22630 (Lumbar spine fusion), 23472 (Reconstruct shoulder joint), 27702 (Reconstruct ankle joint) and their corresponding anesthesia codes.

  1. Changes to ASC Covered Procedures List

Last year, CMS revised its long-standing safety criteria for adding covered surgical procedures to the ASC Covered Procedures List (ASC CPL) and established a notification process for surgical procedures the public believes can be added to the ASC CPL under the criteria. Using these revised criteria, CMS added 267 surgical procedures to the ASC CPL beginning in CY 2021. For CY 2022, CMS is reinstating the criteria for adding procedures to the ASC CPL that were in place in CY 2020. The agency is keeping six procedures and removing 255 procedures proposed for removal. The three codes that were proposed for removal that are being retained include CPT codes 0499T, 54650, and 60512.

  1. Changes to Hospital Price Transparency Rules

There have been reports of hospitals concluding that paying fines for violating the controversial new price transparency rules would be cheaper than complying with them. Accordingly, the final rule increases minimum Civil Monetary Penalties (CMPs) for hospitals that violate price transparency rules to $300 per day with hospitals of 30 beds or fewer and $10 per bed per day for hospitals with more than 30 beds up to $5,500 per day. Result: The minimum penalty for a year’s worth of non-compliance would be $109,500 for a small hospital and $2,007,500 for a large hospital.


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