2021 OPPS final rule starts the clock on inpatient-only elimination, adds services to prior authorization list

Wednesday, December 9, 2020

The 2021 Outpatient Prospective Payment System (OPPS) final rule, released December 2, moves ahead with most of the provisions of the proposed rule. This should come as a relief to hospitals required to implement most of its policies by January 1, 2021.

IPO elimination

CMS’ elimination of the inpatient-only (IPO) list, which is used to identify services covered upon inpatient admission and not as an outpatient paid for under the OPPS, will move forward in a staged approach before all services have been removed from it by January 1, 2024.

For 2021, CMS finalized the removal of the 266 proposed services related to musculoskeletal procedures, as well as an additional 16 services recommended for removal by the Hospital Outpatient Payment (HOP) Panel and additional related anesthesia services (See Table 48 in the final rule for a full list of associated CPT/HCPCS codes). Currently, the IPO list has more than 1,700 services.

CMS previously gave procedures recently removed from the IPO list a two-year grace period before becoming subject to referral to Recovery Audit Contractors (RAC) and RAC patient status reviews. Following that precedent, all procedures removed from the IPO on or after January 1, 2021 will be exempted from site-of-service claim denials under Medicare Part A, eligibility for BFCC-QIO referrals to RACs for noncompliance with the 2-midnight rule, and RAC reviews for patient status. The exemption will be lifted once CMS determines that a procedure is more commonly performed on an outpatient rather than an inpatient basis. The determination will be made based on an annual review of claims data.

The exemption does not protect organizations from medical reviews in cases of fraud, waste, or abuse, and organizations are still expected to abide by the 2-midnight rule.

Prior authorization additions

Once again citing “unnecessary increases” in volume of service for certain procedures, CMS finalized an expansion of its recently introduced prior authorization program for OPPS services for procedures related to cervical fusion with disc removal and implanted spinal neurostimulators effective July 1, 2021.

The new services requiring prior authorization are related to the following CPT® codes:

  • 22551, fusion of spine bones with removal of disc at upper spinal column, anterior approach, complex, initial
  • 22552, fusion of spine bones with removal of disc in upper spinal column below second vertebra of neck, anterior approach, each additional interspace
  • 63650, implantation of spinal neurostimulator electrodes, accessed through the skin
  • 63685, insertion or replacement of spinal neurostimulator pulse generator or receiver
  • 63688, revision or removal of implanted spinal neurostimulator pulse generator or receiver

To learn more details about the final rule’s policies and what payment impact they could have at your facility, attend the webinar “2021 OPPS Final Rule: Implementing the Latest CMS Policies” presented by NAHRI Advisory Board Members Valerie Rinkle, MPA, CHRI, and Jugna Shah, MPH, CHRI.

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