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FEDERAL | The FY17 HOPPS/ACS Final Rule and Its Effect on Plastic Surgeons

On November 1, the final rule to determine Medicare payment rates for Medicare services provided in CY 2017 at Hospital Outpatient Departments and Ambulatory Surgical Centers was made public. The rule comes with few surprises.

More Bundled Payments

As laid out in the proposed rule released last summer, the Agency is moving forward with their plan to create 25 new Comprehensive Ambulatory Payment Classifications (APCs), which bundle payments for “adjunctive and secondary items, services and procedures” into the costlier primary procedure. For plastic surgeons, the new policies will impact billing for casting services or where more than one excision, biopsy or breast surgery procedure is billed on the same day. It will also impact hospital billing for skin substitute products.

New Clinical Decision Support Mechanism Requirements (CDSM)

The final rule establishes the requirement for an ordering professional to consult with a qualified CDSM (Clinical Decision Support Mechanism) when ordering an applicable imaging service to the Medicare beneficiaries. Clinicians would need to use CDSMs to access the Appropriate Use Criteria (AUC) during the patient workup. At the onset, CMS has finalized a list of 8 priority clinical areas:

  1. Coronary Artery Disease (suspected or diagnosed)
  2. Suspected Pulmonary Embolism
  3. Headache (traumatic or non-traumatic)
  4. Hip Pain
  5. Low Back Pain
  6. Shoulder Pain (to include suspected rotator cuff injury)
  7. Lung Cancer (primary or metastatic, suspected or diagnosed)
  8. Cervical or Neck Pain

There are exceptions to the AUC mandate, including:

  1. Ordering an imaging service for an emergency medical condition
  2. Ordering an imaging service for an inpatient stay
  3. Ordering an imaging service in a rural area without sufficient Internet access

The Agency has indicated the number of priority clinical areas could be expanded through future rulemaking, but in consultation with physicians and other stakeholders.

Continued Payment Reduction for Hospitals that Fail to Meet Quality Reporting Requirements

CMS will be continuing the 2 percent payment reduction for hospitals that fail to meet quality reporting requirements, but in an effort to reconcile the obligations across different sites of service, the Agency is finalizing a 90-day EHR reporting period for hospitals that have previously demonstrated meaningful use.

Beginning in 2018, the Agency will remove the pain management dimension from the HCAHPS survey and will introduce 7 new quality measures.

Publicly Available Hospital Outpatient Quality Reporting Program OQR Data

Starting with the CY 2018 payment determination, CMS has finalized three considerations for making data collected under the Hospital Outpatient OQR available to the public:

  1. Publicly display data on the Hospital Compare website, or other CMS website, as soon as possible after measure data have been submitted to CMS;
  2. Provide hospitals with approximately 30 days to preview their data;
  3. Announce the preview period timeframes on a CMS website and/or in applicable listservs.

ASPS will provide additional information on this initiative as it becomes available.