2018 CMS OPPS/ASC Final Rule Overview

News | Published: Friday, November 3, 2017 6:00 am


MedAxiom and the Cardiology Advocacy Alliance have summarized the major provisions of the 2018 final OPPS/ASC rule that was published on November 1. The summary highlights major policy changes, including those impacting cardiology. Members get access to payment tables associated with various procedures identified by MedAxiom as most relevant for its CV community. 


Hospital Outpatient Prospective Payment System (OPPS)

The CMS Fact Sheet for this rule can be found at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-01.html.  

Overall Payments

  • Final payment rates are estimated to increase an average of 1.35% compared to 2017

Composite APCs

  • Composite APCs provide single payment for groups of services that are typically performed together during a single clinical encounter and that result in the provision of a complete service
  • CMS will continue this policy for certain services, including mental health and multiple imaging services

Comprehensive APCs (C-APCs)

  • C-APCs represent a payment policy that packages payment for all procedures on a claim into one payment, as opposed to making separate payments for separate procedures
  • CMS is implementing no new C-APCs at this time (62 C-APCs in total)

Inpatient Only List

  • CMS removed 6 procedures from the inpatient list, including Total Knee Replacement – no cardiovascular related procedures were removed
  • One cardiovascular procedure was added to this list (CPT 92941) and will no longer be payable in the hospital outpatient setting

Transitional APC Pass-Through Status

  • Current devices with Pass-Through Status
    • Three devices, including drug-coated balloons, lose their pass-through status effective January 1, 2018 and have been assigned to clinical APCs
  • Five new applications were submitted – none received approval

Fractional Flow Reserve derived from Computed Tomography (FFRCT)

  • CMS received a request to separately pay for services described by CPT 0503T
    • CMS agreed, and CPT 0503T has been assigned to APC 1516 ($1,450.50)

Drug Administration

  • CMS finalized its proposal to package low cost drug administration services assigned to APC 5691 and 5692, which would no longer provide separate payment for these services

Care Management Coding Changes

  • CMS is adopting new CPT codes (CPT 99492-4, 99483-4) to replace G codes (G0502-G0507) for care management services, and finalized the same APC assignment for these new codes

Device Related Policy Changes

  • Hospital payment will continue to be reduced for certain APCs when a partial (>50%) or full device credit is provided – this is a continuation of existing policy

Alternative Payment Methodology for Drugs Purchased under 340B Drug Discount Program

  • Growing program where hospitals receive discounts for purchasing certain outpatient drugs
  • CMS is concerned regarding the increasing burden of beneficiary coinsurance
  • CMS proposed and finalized a different payment methodology for separately payable drugs purchased under the 340B program
    • ASP less 22.5% (instead of ASP + 6%)
    • Modifier “JG” needs to be included on claims to identify drugs purchased under this program
  • CMS estimates this will reduce $1.6 billion in payment for these drugs – these funds will be redistributed to non-drug related services as it is a budget neutral adjustment

Payment Changes for Film X-Ray Services and Proposed Payment Changes for X-Rays Taken Using Computed Radiography Technology

  • CMS continues its policy to reduce OPPS payment for imaging services that are X-rays taken using film by 20% (identified by modifier “FX”)
  • CMS is required to phase-in a reduction in payment for imaging services taken using computed radiography technology
    • Reduced by 7% each year for 2018-2022; Increases to 10% reduction in 2023 and beyond
    • CMS is implementing a new modifier (“FY”) for reporting on claims for these services

Imaging APCs

  • CMS did not finalize its proposal to create an additional APC for imaging without contrast, and the APC structure remains the same from 2017

Supervision of Hospital Outpatient Therapeutic Services

  • CMS reinstated the non-enforcement of direct supervision enforcement instructions for outpatient therapeutic services for CAHs and small rural hospitals having 100 or fewer beds for 2018 and 2019

Partial Hospitalization Program (PHP) Rate Setting

  • CMS is updating Medicare payment for PHP services furnished in outpatient departments and Community Mental Health Centers
  • CMS is maintaining the methodology established in 2017, which includes a unified rate structure with a single PHP payment rate for each provider type for days with 3 or more services per day

Packaged Skin Substitutes

  • CMS finalized its policy of assigning packaged skin substitutes into a “high cost” or “low cost” group based on cost thresholds.
  • CMS’ goal is to maintain similar payment levels while they analyze the payment methodology to determine if further refinements are necessary

Hospital Outpatient Quality Reporting (OQR) Program

  • CMS removed 6 measures for the 2020 payment determination:
    • OP-1, Median Time to Fibrinolysis
    • OP-4, Aspirin at Arrival
    • OP-20, Door to Diagnostic Evaluation by a Qualified Medical Professional
    • OP-21, Median Time to Pain Management for Long Bone Fracture
    • OP-25, Safe Surgery Checklist Use
    • OP-26, Hospital Outpatient Volume Data on Selected Outpatient Surgical Procedures
  • Intent is to alleviate the costs and burden with retaining these measures
  • No additional measures are being added
  • CMS finalized its proposal to delay the implementation of OAS CAHPS survey measures OP-37a-e beginning with the CY 2020 payment determination (2018 data collection)


Ambulatory Surgery Centers (ASCs)

Overall Payments

  • Final payment rates will increase an average of 1.2% compared to 2017

Allowed ASC Services

  • CMS added 3 new procedures to the ASC list, none of which were cardiovascular related

ASC Quality Program

  • CMS is removing 3 measures for the 2019 payment determination
    • ASC-5, Prophylactic IV Antibiotic Timing
    • ASC-6, Safe Surgery Checklist Use
    • ASC-7, ASC Facility Volume Data on Selected Procedures
  • CMS is delaying the implementation of OAS CAHPS survey measures ASC-15a-e beginning with the CY 2020 payment determination (2018 data collection)
  • CMS is adding two measures for the CY 2022 payment determination
    • ASC-17, Hospital Visits after Orthopedic Ambulatory Surgical Center Procedures
    • ASC-18, Hospital Visits after Urology Ambulatory Surgical Center Procedures


 Learn more about membership here. Or contact Nick Hoback at nhoback@medaxiom.com.


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