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Final 2019 Medicare Outpatient/ASC Payment Policies


November 8, 2018

With a focus on reducing payment differences across sites of care, the Centers for Medicare & Medicaid Services (CMS) recently issued a final regulation setting payment policies and rates for hospital outpatient departments and ambulatory surgery centers (ASCs) for Calendar Year 2019. CMS also made payment changes affecting medical imaging, quality reporting, and a wide range of procedures:




Site Neutral Payments: CMS finalized its proposal to pay for clinic visits at off-campus provider-based facilities at 40% of the level such visits would be paid if performed in the actual hospital outpatient department. The lower payment is equivalent to the reimbursement level for such visits when they are performed in physician offices. CMS will phase-in the reduction over two years. 


Payment Rates: Overall, CMS will increase the hospital outpatient department payment rate by 1.35% in 2019. ASC payment rates will increase by 2.1% and, reflecting the CMS effort to equalize rates among different types of sites, CMS is using the same hospital market basket inflation rate in calculating payment increases in 2019 as it uses for hospitals. “This change will help promote site-neutrality between hospitals and ASCs and encourage the migration of services from the hospital setting to the lower-cost ASC setting,” said CMS.


Imaging APCs: CMS will maintain the current structure of the seven imaging APCs—four levels without contrast and three levels with contrast.


Cost-to-charge Ratio: CMS decided that, for one more year, it will eliminate data from hospitals that allocate the costs of large moveable equipment, such as CT or MRI, on the basis of the square footage of the equipment. CMS uses cost-to-charge ratios in determining the APC weights and rates, and has urged hospitals to find a more accurate cost-allocation formula than the square-foot method.


Quality Reporting: CMS is reducing the number of quality measures that hospital outpatient departments and ASCs must report. The agency says the measures are duplicative, already performed by most providers, or not cost-effective.


Procedures Performed in ASCs: CMS added 12 cardiac catheterization procedures to the list of covered surgical procedures that can be performed in ASCs, plus five procedures performed during cardiac catheterization. The agency also says it wants to ensure that ASCs remain competitive by stabilizing the differential between ASC payment rates and those in hospital outpatient departments.

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