2021 OPPS and ACS final rule released
January 11, 2021
CMS released the 2021 Outpatient and Prospective Payment System (OPPS) and ambulatory surgical center (ASC) final rule in December. This final rule advances CMS’s commitment to reducing provider burden and removes regulatory barriers so hospitals and ASCs can operate with increased flexibility and patients are provided with more affordable choices on where to obtain care with potential lower out-of-pocket costs. Highlights of this rule include elimination of the Inpatient Only (IPO) list and updated criteria for determining the ASC Covered Procedures List (CPL).
CMS will begin eliminating the IPO list, allowing more than 1,700 services to be paid when rendered in the hospital outpatient setting over a three-year transitional period with the list completely phased out by 2024. In 2021, CMS will remove 298 procedures from the IPO list, including 266 musculoskeletal-related services (37 reported by OMSs). Once removed, these procedures will be eligible for Medicare reimbursement when rendered in the hospital outpatient setting when outpatient care is appropriate or in the hospital inpatient setting when inpatient care is necessary as determined by the physician. It is important to keep in mind, elimination of the IPO list does not make a procedure eligible for payment in an ASC.
In 2021, CMS revises its criteria used to add surgical procedures to the ASC CPL to include those procedures not separately paid under the OPPS, not designated as requiring inpatient care as of Dec. 31, 2020, not only reported by an unlisted CPT code or not otherwise excluded.
As a result of the new criteria, 267 additional surgical procedures will be added to the ASC CPL (16 reported by OMSs). While CMS has simplified its criteria to determine procedures on the ASC CPL, it expects physicians to still consider the following safety factors when determining the site of service beginning Jan. 1. The covered procedure:
- Is not expected to pose a significant safety risk when performed in an ASC.
- Is one for which standard medical practice dictates the beneficiary would not typically be expected to require active medical monitoring and care at midnight following the procedure.
- Generally results in extensive blood loss.
- Requires major or prolonged invasion of body cavities.
- Directly involves major blood vessels.
- Is generally emergent or life-threatening in nature.
- Commonly requires systemic thrombolytic therapy.
The following supporting documents mentioned in the final rule may be found on the CMS website:
- Addendum A: Final 2021 OPPS APC rates
- Addendum AA: Final ASC CPL
- Addendum EE: Final list of codes excluded from payment when rendered in the ASC. (These codes are payable only when performed in the hospital outpatient or inpatient.)