On November 2, 2023, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2024 Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems Final Rule [CMS-1786-FC]. The rule finalizes payment rates and policy changes affecting Medicare services furnished in hospital outpatient and ambulatory surgical center (ASC) settings for CY 2024.
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For CY 2024, CMS increased payment rates under the Hospital Outpatient Prospective Payment System (OPPS) and the ASC Payment System by a productivity-adjusted market basket factor of 3.1%. Hospitals and ASCs that fail to meet their respective quality reporting program requirements will be subject to a 2% reduction in the CY 2024 fee schedule increase factor. For ASCs, this adjustment reflects the extension of the policy to adjust the ASC payment system using the hospital market basket update for two additional years (2024 and 2025).
Based on the finalized policies, CMS estimates that total payments to OPPS and ASC providers (factoring in beneficiary cost-sharing and estimated changes in enrollment, utilization and case-mix) for CY 2024 will be approximately $88.9 billion and $7.1 billion, respectively. This represents an increase of approximately $6 billion and $207 million, respectively, from CY 2023 program payments.
- The final regulations are available here.
- The press release is available here.
- The fact sheet is available here.
Key Takeaways
- CMS finalized changes to its hospital price transparency requirements, including requiring hospitals to use a template to submit charge information and requiring hospitals to affirm the accuracy of that information.
- CMS finalized its implementation of the intensive outpatient program benefit, including the coding and billing, payment rates and scope of benefit.
- CMS chose not to finalize proposed changes to its bundling policy for diagnostic radiopharmaceuticals.
- CMS will continue to pay the statutory default rate, average sales price (ASP) plus 6%, for 340B-acquired drugs and biologicals.
- CMS finalized its proposal to add 26 dental codes to the ASC covered procedures list for CY 2024, along with 11 additional procedures identified by commenters, including total ankle and total shoulder replacement surgery.
- CMS finalized proposals to add nine services to, and remove none from, the inpatient only list.
- CMS will continue to use the productivity-adjusted hospital market basket update to increase ASC payment system rates for 2024 and 2025.
- CMS finalized its proposal to assign 229 dental codes, plus 14 additional dental codes identified by commenters, to clinical ambulatory payment classifications (APCs).
- CMS finalized a proposal to create two new comprehensive APCs: 5342 for Level 2 Abdominal/Peritoneal/Biliary and Related Procedures, and 5496 for Level 6 Intraocular Procedures.
- CMS maintained the current list of service categories subject to prior authorization.
- CMS generally maintained its site-neutrality policy, but finalized a proposal to reimburse intensive cardiac rehabilitation provided by an off-campus, non-excepted provider-based department of a hospital at 100% of the OPPS rate.
