4 Things to Watch From the OPPS 2018 Proposed Rule

outpatient hospital

We’re back for another installment of “what does 2018 (maybe) have in store”? We just covered the QPP proposed rule, and now we’ll take a look at the 2018 hospital outpatient prospective payment system (OPPS) proposed rule. CMS expects an overall 2 percent payment increase in 2018 (except for the changes mentioned in question 3 below). What has people talking?

1. Are Joint Replacements Moving to Outpatient?

The proposed rule takes total knee replacement off the inpatient-only list, opening the door to performing the procedure in a hospital outpatient setting. Experts note outpatient reimbursement could be roughly half the inpatient rate. Given the amounts at stake, your inpatient team should work carefully through how to support any procedures performed in the inpatient setting (and all that entails) using thorough documentation.

Watch for: CMS also asked for comments on allowing the knee replacements to be performed in ASCs and on allowing hip replacements in hospital outpatient and ASC settings.

2. Will Therapy Require Direct Supervision?

Years ago, CMS posted a clarification that hospital outpatient therapeutic services require direct physician supervision, but it wasn’t enforced for critical access hospitals (CAHs) and small rural hospitals. The most recent moratorium expired at the end of 2016, and the proposed rule reinstates non-enforcement for 2018 and 2019 for CAHs and small rural hospitals having 100 or fewer beds.

3. Will 340B Program Changes Go Through?

Currently Medicare pays the average sales price (ASP) plus 6 percent for drugs. The proposed rule indicates a change to 22.5 percent less than the ASP for drugs bought with a 340B program discount. (Vaccines would continue to follow current method.) The AHA’s post about the proposed rule showed that organization is firmly against this change and its potential impact on patients and the facilities that serve them.

4. Will DOS Policy Change for Labs to Bill Medicare Directly?

Current policy is that if a lab test is ordered less than 14 days after a patient’s discharge date, the hospital bills Medicare and then pays the lab, if the lab provided the test under arrangement. CMS is considering allowing labs to bill Medicare directly for molecular pathology tests and advanced diagnostic laboratory tests (ADLTs). The reason given is to help reduce operational burdens for hospitals and labs.

What About You?

What do you think about the proposed rule? Comments are being accepted until Sept. 11, 2017. Will you be commenting to CMS?



Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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