The long-awaited 2019 Hospital Outpatient Prospective Payment System (OPPS) final rule has arrived – and it came with at least one surprise. The Centers for Medicare and Medicaid Services (CMS) elected NOT to finalize the rule pertaining to the “clinical family of services” at Provider Based Departments (PBD).

CMS had proposed limiting OPPS payments to excepted off-campus PBD for only those “clinical family of services” that were provided during a baseline period. Any expansion of services within the 19 approved “clinical families” would be paid at the physician fee schedule rate under the OPPS proposed rule. Rather than finalizing this portion of the proposed rule, CMS opted to continue monitoring the expansion of services in off-campus provider-based departments, thereby leaving the door open for implementation of this particular rule at a later date.

For 2019, CMS also took a step back from the proposed rule regarding documentation and reimbursement for Evaluation and Management (E/M) visits. Current coding and billing structure, using 1995 or 1997 E/M documentation guidelines, will remain in effect for 2019 and 2020, while the option to bill based on time and the single rate payment for E/M visit Levels 2 through 4 will not take effect until 2021. However, a major change for 2019 is a reduction in payment for E/M visits performed in off-campus provider-based locations. To eliminate the differential between reimbursement under the OPPS and physician fee schedule for the same services provided in different locations, CMS will implement a phased approach to move toward making payment the same, regardless of where the service is provided. Payment will be reduced to 70% of the OPPS rate in 2019, then reduced further, to 40%, in 2020 and beyond. CMS predicts the change will result in $380 million in savings in 2019, as well as reduced out of pocket costs for beneficiaries.

In 2018, CMS began paying hospitals 22.5% less than the average sale price for drugs purchased through 340B; and for 2019, that reduction has been extended to all non-excepted off-campus provider-based locations. CMS also extended the reduction in reimbursement for provider-based locations established after November 1, 2015. As in 2018, those locations will be paid 40% of the OPPS amount.

Furthermore, the OPPS final rule adds 12 cardiovascular CPT codes to the ASC CPL, removing certain measures from the Hospital Outpatient Quality Reporting Program and the Ambulatory Surgical Center Quality Reporting Program, and updating OPPS payment rates by 1.35%.