CMS Introduces 2024 Medicare PFS, Rules Proposed by OPPS – MedLearn Publishing

The OPPS proposal did not contain references to several high-profile issues on which industry leaders awaited reform.

Federal officials yesterday unveiled a pair of proposed rules, with potential adjustments to the Medicare Physician Fee Schedule (PFS) and Outpatient Prospective Payment System (OPPS) for calendar year 2024.

The Centers for Medicare & Medicaid Services (CMS) announcement highlighted rate updates, promoting health equity, and expanding access to critical medical services such as behavioral health care and select oral health services, also serving to advance the Biden-Harris administrations Cancer Moonshot mission to accelerate the fight against cancer all in one PFS-proposed rule.

At CMS, our mission is to expand access to health care and ensure that health care coverage is meaningful for the people we serve, CMS Chiquita Administrator Brooks-LaSure said in a statement. CMS’s proposals in the proposed physician payment rule would help people with Medicare navigate cancer treatment and gain access to more types of behavioral health providers, strengthen primary care, and, for the first time, enable the Medicare payment for services provided by community health workers.

CMS continues to demonstrate a commitment to promoting health equity and building a stronger Medicare program, said Meena Seshamani, CMS deputy administrator and director of the Center for Medicare. If finalized, the proposals in this rule ensure that the people we serve experience coordinated care focused on treatment of the whole person, considering each person’s unique history and individualized needs in physical health, behavioral health, oral health, social determinants of health and are inclusive of caregivers, all of whom are so important to providing the care people with Medicare deserve.

Officials said overall the proposed payment amounts under the PFS would be reduced by 1.25% compared to 2023, in accordance with factors specified by the law. CMS has proposed payment increases for many visiting services, such as primary care, which require offsets and budget neutrality adjustments for all other services paid for under PFS. The proposed 2024 PFS conversion factor is $32.75, a decrease of $1.14, or 3.34%, from 2023.

The proposed rule also includes adjustments to the coding and payment of several new services to help underserved populations, including what officials have described as addressing unmet health-related social needs that can potentially interfere with the diagnosis and treatment of medical problems. . This included a proposal to pay for some health worker training services in specific circumstances and the introduction of separate coding and payment for community health integration services.

The Cancer Moonshot provision aims to ensure that everyone diagnosed with cancer has access to services intended to help patients navigate the treatment of it and other serious illnesses, to include care involving peer support specialists. These changes also included the proposed provision of coding and payment availability for social determinants of health (SDoH) risk assessments, which could be provided as an addition to an annual wellbeing visit or in conjunction with an assessment and management visit ( E&M).

The press release on the proposed rule issued by CMS also cited recently proposed access to oral and dental health services for beneficiaries, support for patients’ emotional and mental well-being through their behavioral health care, and the Department of Health and United States Human Services (HHS) Initiative to Strengthen Primary Care.

CMS is also continuing to promote whole-person care in the Medicare Shared Savings Program, the largest Accountable Care Organization (ACO) program in the country, the release said. CMS is proposing changes to the assignment methodology that would better promote accountable care access for individuals who see nurse practitioners, physician assistants, and clinical nurse specialists for their primary care services. CMS is also proposing changes to the financial benchmarking methodology to better encourage ACO participation in serving complex populations. In total, these proposals are expected to increase participation in the shared savings program by approximately 10-20%, which will provide additional opportunities for beneficiaries to receive coordinated assistance from ACOs.

In a related announcement, CMS noted that it is seeking to strengthen the Medicare Diabetes Prevention Program (MDPP) expanded model to further increase participation and access in underserved communities. His proposal would extend public health emergency (PHE) flexibility for four years, which officials say would allow all MDPP providers to continue offering MDPP services virtually using remote learning delivery until 2027, a provided they maintain a Centers for Disease Control and Prevention (CDC) person.

For the OPPS proposed rule, a 60-day comment period will end in mid-September and will be followed by a final rule expected in November. In addition to proposing payment rates, the rule included proposed policies that overlap in some ways with the PFS plan: promote health equity, expand access to behavioral health care, improve transparency in the health care system, promote safe, effective and patient-focused and address shortage of medical products.

Officials said OPPS policies will affect about 3,500 hospitals and about 6,000 outpatient surgical centers (ASCs), with proposed hospital price transparency policies impacting more than 7,000 institutions licensed as hospitals.

The new OPPS payment rates for hospitals that meet the applicable quality reporting requirements result in a net increase of 2.8%.

In the OPPS/ASC CY 2019 final rule with commentary period, we finalized a policy to apply the productivity-adjusted hospital market basket update to ASC payment system rates for an interim period of five years (CY 2019 through CY 2023), during which we would evaluate whether there is a migration of procedure performance from the hospital environment to the ASC environment as a result of the use of a productivity-adjusted hospital market basket update, CMS said in a fact sheet. However, the impact of COVID-19 PHE on health care utilization, particularly in CY 2020, has been extremely profound, particularly for elective surgeries, because many beneficiaries have avoided health care facilities whenever possible to avoid possible SARS-CoV-2 virus infections. Therefore, for this proposed OPPS/ASC CY 2024 rule, we propose to extend the five-year interim period by an additional two years through 2024 and 2025. This will allow us to collect additional claims data further removed from the COVID-19 PHE to analyze in more accurately whether the application of the hospital market basket update to the ASC payment system had an effect on the migration of services from the hospital environment to the ASC environment.

The OPPS proposed rule also features a proposal to establish an Intensive Outpatient Program (IOP) under Medicare complete with a scope of benefits, medical certification, coding and billing requirements, and payment rates under the IOP benefit. IOP services would be provided in hospital outpatient departments, community mental health centers (CMHCs), federally qualified health centers (FQHCs), and rural health clinics (RHCs), if finalized, to fill a major gap in the behavioral health coverage in Medicare.

In a related move, CMS is also proposing to establish two outpatient IOP payment classifications (APCs) for each provider type: one for days with three services per day and one for days with four or more services per day.

Dr. Ronald Hirsch, group vice president of regulation and education at R1 RCM Inc. and a fixture of the weekly Monitor Mondays internet radio show (and a longtime RACmonitor contributor), said the announcement of the ‘OPPS has been remarkably silent on several issues, some the industry hoped would be addressed.

For listeners of Monitor Mondays and readers of RACmonitor eNews, the proposed rule makes no significant changes, no changes to the two-hour night rule, no mention of the case-by-case exception, no deletions from the Inpatient List (IOL) , and only a few codes have been proposed to be added to the IOL for newly assigned codes such as HCPCS 0646T transcatheter tricuspid valve implantation, Hirsch said. On the other hand, CMS appears to be dissatisfied with the efforts hospitals have made to comply with price transparency rules and have proposed significant changes to requirements and enforcement methods.

To view a factsheet on the 2024 Physician Fee Regulations proposal online, visit: -rule

To view a factsheet on the OPPS 2024 proposed rule, visit: ambulatory -surgical-center

Mark Spivey is a national correspondent for RACmonitor and ICD10monitor who has been writing and publishing on federal oversight of American health care for nearly 15 years. He can be reached at

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