Medicare & Insurance

CMS Proposed Rules Incude Increase in 2015 Payment Rates Under OPPS, Comments due Sept 2

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The Centers for Medicare and Services (CMS) have proposed rules that include a 2.1% increase in payment rates for 2015 under the outpatient prospective payment system (OPPS) as well as changes to hospital admissions requirements. The proposed rules affect hospital outpatient departments and ambulatory surgical centers beginning January 1, 2015. A news release from the American Physical Therapy Association (APTA) indicates that the proposals include the implementation of comprehensive payments for specific services and clarification of the requirement for an admission order for all hospital inpatient admissions.

The proposals also include a change that will require physician certification for hospital inpatient admissions only for long-stay cases, 20 days or more, and outlier cases, not short stays, according to APTA. CMS states the admission order, medical record, and progress notes must contain sufficient information to support the medical necessity of an inpatient admission without a separate requirement of an additional, formal, physician certification for shorter stays.

The rule also proposes the implementation of the 2014 OPPS final rule policy creating 28 comprehensive ambulatory payment classifications (APCs) to handle payment for the most costly device-dependent services. The policy would treat all individually reported codes as components of a comprehensive service, resulting in a single prospective payment based on the cost of all individually reported codes, according to APTA.

The APTA news release notes that CMS proposes to change its consideration of requests the expansion of physician-owned hospitals under the physician self-referral regulations and establishes an appeal process for Medicare Advantage organizations regarding CMS-identified overpayments.

A number of physical therapy services provided in the outpatient hospital department are not paid under the OPPS and are paid instead under the Medicare Physician Fee Schedule (PFS), though a small subset of ‘‘sometimes therapy’’ physical therapy services are paid under the OPPS when they are not furnished as therapy, meaning not under a certified therapy plan of care, as indicated on the APTA news release. The annual updates of these “sometimes therapy” services provided CMS can be found at

Comments on the proposed rules are due September 2, 2014.

[Source: APTA]