Knowledge Base Article

CMS published the CY 2024 OPPS/ASC Proposed Rule on July 13, 2023. By now, many news outlets have authored articles about this proposed rule. This article highlights topics that historically our clients have reached out to us to learn about.

Medicare Inpatient Only (IPO) Procedure List

Although CMS received several requests recommending services for removal from the IPO list, CMS did not find sufficient evidence that met the criteria and did not propose to remove any service from the IPO list for CY 2024.

CMS has proposed to add nine services with newly created codes by the AMA CPT Editorial Panel which will be in effect January 1, 2024 to the list and to reassign CPT code 0646T (Transcatheter tricuspid valve implantation (ttvi)/replacement with prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker insertion, and selective right ventricular or right atrial angiography, when performed) from status indicator “E1” to status indicator “C.” The proposed changes are available in Table 47 of the proposed rule.

OPPS Payment Methodology for 340B OPPS Payment Methodology for Purchased Drugs and Biologicals

On July 7, 2023, CMS published a proposed rule, referred to as “remedy proposed rule” to address reduced payment amounts to 340B hospitals for CYs 2018 through 2022 and to comply with the statutory requirement to maintain budget neutrality. The “remedy proposed rule” proposes changes to the calculation of the OPPS conversion factor beginning in CY 2025.

In the “remedy proposed rule,” CMS proposes to make one time lump-sum payments to each of the approximately 1,600 340B covered entity hospitals. Addendum AAA to the proposed rule lists the proposed lump-sum payment for each eligible hospital.

For CY 2024, CMS proposes to continue to pay the statutory default rate, which is generally ASP plus 6 percent.

340B Modifiers “JG” and “TB”

The Inflation Reduction Act of 2022 expanded the provider types that must report one of these modifiers no later than January 1, 2024 to now include critical access hospitals, Maryland All-Payer or Total Cost of Care Model Hospitals, and Non-excepted off-campus provider-based departments (PBD).

In the CY 2023 OPPS/ASC final rule, CMS maintained the requirements that 340B hospitals report one of two modifiers, “JG” – Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes, or “TB” – Drug or biological acquired with 340B drug pricing program discount, reported for informational purposes for select entities.

In the CY 2024 OPPS/ASC proposed rule, CMS notes they “now believe utilizing a single modifier will allow for greater simplicity, especially because both modifiers are used for the same purpose: to identify separately payable drugs and biologicals acquired under the 340B program.”

CMS is proposing that all 340B covered entity hospitals would report the “TB” modifier effective January 1, 2025, even if the hospital previously reported the “JG” modifier. The “JG” modifier will remain effective through December 31, 2024. Beginning January 1, 2025, the “JG” modifier would be deleted.

CMS notes hospitals currently using the “JG” modifier could choose to continue to use it in CY 2024 or choose to transition to the “TB” modifier during that year.

Payment for Intensive Cardiac Rehabilitation Services (ICR) Provided by an Off-Campus Non-Excepted Provider Based Department (PBD) of a Hospital

CMS identified a disparity in payment for ICR services between services provided in a physician’s office and the same services provided by an off-campus, non-excepted PBD and notes that this “creates a significant barrier to beneficiary access to an already underutilized service.”

To eliminate this unintended outcome CMS is proposing the following:

“Pay for ICR services provided by an off-campus, non-excepted provider-based department of a hospital at 100 percent of the OPPS rate for CR services (which is also 100 percent of the PFS rate) rather than at 40 percent of the OPPS rate,” and

“Effective January 1, 2024, we propose to exclude ICR from the 40 percent Relativity Adjuster policy at the code level by modifying the claims processing of HCPCS codes G0422 (Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session) and G0423 (Intensive cardiac rehabilitation; with or without continuous ECG monitoring without exercise, per session) so that 100 percent of the OPPS rate for CR is paid irrespective of the presence of the “PN’’ modifier (signifying a service provided in a non-excepted off-campus provider-based department of a hospital) on the claim.”

Proposed Additions to the ASC Covered Procedures List (CPL) for CY 2024

CMS is proposing to update the ASC CPL by adding 26 dental surgical procedures. They note that they “expect to continue to gradually expand the ASC CPL, as medical practice and technology continue to evolve and advance in future years,” and encourage stakeholders to submit procedure recommendations to be added to the ASC CPL.

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging

Although this falls under the purview of the CY 2024 Physician Fee Schedule Proposed Rule, I often receive questions from clients regarding when CMS plans to fully implement this program.

In the proposed rule, CMS notes that they “exhausted all reasonable options for fully operationalizing the AUC program,” and “propose to pause implementation of the AUC program for reevaluation and rescind the current AUC program regulations from §414.94.” They “expect this to be a hard pause to facilitate thorough program reevaluation and, as such…are not proposing a time frame within which implementation efforts may recommence.”

The comment period for the CY 2024 Hospital OPPS/ASC and Physician Fee Schedule Proposed Rules ends on September 11, 2023. I encourage you to take the time to review the proposed rules and submit comments.

Resources

Hospital Outpatient Prospective Payment-Notice of Proposed Rulemaking with Comment Period CY

2024: https://www.federalregister.gov/documents/2023/07/31/2023-14768/medicare-program-hospital-outpatient-prospective-payment-and-ambulatory-surgical-center-payment

Hospital Outpatient Prospective Payment Remedy for the 340B-Acquired Drug Payment Policy-Notice of Proposed Rulemaking with Comment Period: https://www.cms.gov/medicare/medicare-fee-service-payment/hospitaloutpatientpps/hospital-outpatient-regulations-and/cms-1793-p

MLN Fact Sheet: Medicare Part B Inflation Rebate Guidance: Use of the 340B Modifier (MLN4800856 March 2023): https://www.cms.gov/files/document/mln4800856-medicare-part-b-inflation-rebate-guidance-use-340b-modifier.pdf

CY 2024 Physician Fee Schedule Proposed Rule: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched