Resources.hthu.net



Inpatient-only Procedures For 2021, Inpatient-only Procedures For 2021, CMS proposes to eliminate the inpatient only (IPO) list. The IPO List was established with the implementation of the OPPS in the CY 2000 OPPS/ASC final rule The list was created to identify services that require inpatient care because of the invasive nature of the procedure, the need for at least 24 hours of postoperative recovery time, or the underlying physical condition of the patient who would require the surgery and, therefore, the service would not be paid by Medicare under the OPPS. For example, the list includes certain surgically invasive services on the brain, heart, and abdomen, such as craniotomies, coronary-artery bypass grafting, and laparotomies.Since the IPO list was established in 2000, CMS has stated that regardless of how a procedure is classified for purposes of payment, it expects that in every case the surgeon and the hospital will assess the risk of a procedure or service to the individual patient, taking site of service into account, and will act in that patient’s best interests. CMS has stated that the decision regarding the most appropriate care setting for a given surgical procedure is a complex medical judgment made by the physician based on the beneficiary’s individual clinical needs and preferences and on the general coverage rules requiring that any procedure be reasonable and necessaryCMS has concluded that it no longer believes there is a need for the IPO list in order to identify services that require inpatient care. CMS agrees that the physician should use his or her clinical knowledge and judgment, together with consideration of the beneficiary’s specific needs, to determine whether a procedure can be performed appropriately in a hospital outpatient setting or whether inpatient care is required for the beneficiary, subject to the general coverage rules requiring that any procedure be reasonable and necessary. CMS also believes that since the IPO list was established, there have been significant developments in the practice of medicine that have allowed numerous services to be provided safely and effectively in the outpatient setting.There have been many new technologies and advances in surgical techniques and surgical care protocols, including the use of minimally invasive surgical procedures such as laparoscopy, improved perioperative anesthesia, expedited rehabilitation protocols, as well as significant enhancements to postoperative processes, such as improvements in pain management, that have reduced the inpatient length of stay and as well as the need for postoperative care following a surgical service. In considerationProposed Change to the Level of Supervision of Outpatient Therapeutic Services Non-Surgical Extended Duration Therapeutic Services (NSEDTS) describes services that have a significant monitoring component that can extend for a lengthy period of time, that are not surgical, and that typically have a low risk of complications after the assessment at the beginning of the service. The minimum default supervision level of NSEDTS was established in the CY 2011 OPPS/ASC final rule as being direct supervision during the initiation of the service, which may be followed by general supervision at the discretion of the supervising physician or the appropriate nonphysician practitioner. In this case, initiation means the beginning portion of the NSEDTS which ends when the patient is stable and the supervising physician or the appropriate nonphysician practitioner determines that the remainder of the service can be delivered safely under general supervision. In the CY 2020 OPPS/ASC final rule, CMS changed the generally applicable minimum required level of supervision for most hospital outpatient therapeutic services from direct supervision to general supervision for hospitals and CAHs. CMS made this change because it believed it is critical that hospitals have the most flexibility possible to provide the services Medicare beneficiaries need while minimizing provider burden. In the IFC issued March 31, 2020, the agency assigned, on an interim basis, a minimum required supervision level of general supervision for NSEDTS services, including during the initiation portion of the service, during the PHE. Changing the minimum level of supervision to general supervision during the PHE gives providers additional flexibility to handle the burdens created by the PHE for the COVID–19 pandemic. (pg. 642)CMS believes changing the level of supervision for NSEDTS permanently for the duration of the service would be beneficial to patients and outpatient hospital providers as it would allow greater flexibility in providing these services and reduce provider burden, and improve access to these services in cases where the direct supervision requirement may have otherwise prevented some services from being furnished due to lack of availability of the supervising physician or nonphysician practitioner.Medical Review of Certain Inpatient Hospital Admissions under Medicare Part A for CY 2021 and Subsequent Years (2-Midnight Rule) CMS finalized their proposal with modifications. Instead of the two-year exemption, procedures removed from the IPO list on or after January 1, 2021 will be indefinitely exempted from site-of-service claim denials under Medicare Part A, eligibility for Beneficiary Family Centered Care-Quality Improvement Organization (BFCC-QIO) referrals to Recovery Audit Contractors (RACs) for noncompliance with the 2- midnight rule, and RAC reviews for “patient status” indefinitely, until the procedure is more commonly performed in the outpatient setting then the inpatient setting. As a result, in order for the exemption to end for a specific procedure, CMS will require claims data for the service indicating that the procedure is performed more commonly on an outpatient rather than inpatient basis in a given year. Thus, for the exemption to end for a specific procedure, in a single calendar year CMS would need to have Medicare claims data indicating that procedure was performed more than 50 percent of the time in the outpatient setting. CMS will revisit in rulemaking whether and when an exemption for a procedure should be ended. Thus, for each procedure removed from the IPO list on or after January 1, 2021, the exemption will continue until terminated in future rulemaking. CMS may consider additional metrics in the future that could assist in determining when the exemption period should end for a procedure. This will only apply to procedures removed from the IPO list beginning in CY 2021. CMS may revisit procedures that were removed from the IPO list prior to January 1, 2021 and extend their exemption if necessary. Conversely, CMS may shorten the exemption period for a procedure if necessary. In the future, CMS may examine the exemption status of any procedure that was formerly on the IPO list and lengthen, shorten or end their exemption. (pgs. 672-673)Prior Authorization Process and Requirements for Certain Hospital Outpatient Department Services In the CY 2020 OPPS/ASC final rule, CMS established a prior authorization process for certain hospital OPD services. CMS will now require prior authorization for two new service categories: Cervical Fusion with Disc Removal and Implanted Spinal Neurostimulators. CMS will add these service categories to be effective for dates of services on or after July 1, 2021.2-Midnight Rule/Short Inpatient Hospital Stays The 2-midnight benchmark is applicable once procedures have been removed from the inpatient-only list. Procedures that are removed from the list are also subject to initial medical reviews of claims for shortstay inpatient admissions conducted by BFCC–QIOs. BFCC–QIOs may also refer providers to the RACs for further medical review due to exhibiting persistent noncompliance with Medicare payment policies, including, but not limited to having high denial rates; consistently failing to adhere to the 2-mor failing to improve their performance after QIO educational intervention. (pg 658)CMS has finalized the policy to eliminate the IPO list in CY 2021 with a transitional period of three years. For CY 2021, CMS finalized to remove all musculoskeletal procedures from the IPO list. The elimination of the IPO list will mean that procedures currently on the IPO list will be subject to the 2-midnight rule (both the 2-midnight benchmark and 2-midnight presumption). CMS believes that with the elimination of the IPO list, the 2-midnight benchmark will remain an important metric to help guide when Part A payment for inpatient hospital admissions is appropriate. With more services available to be paid in the hospital outpatient setting, it will be important for physicians to use clinical judgment in determining the generally appropriate clinical setting for their patient to receive a procedure. Removal of a service from the IPO list does not mean that a beneficiary cannot receive the service as a hospital inpatient. Physician should use his or her judgment to determine the appropriate setting on a case by case basis. (pg 658-659)CMS has also finalized that procedures removed from the IPO list on or after January 1, 2021 will be indefinitely 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” indefinitely. They will be exempted until the procedure is more commonly performed in the outpatient setting then the inpatient setting. As a result, in order for the exemption to end for a specific procedure,CMS will require claims data for the service indicating that the procedure is performed more commonly on an outpatient rather than inpatient basis in a given year. For the exemption to end for a specific procedure, in a single calendar year CMS will need to have Medicare claims data indicating that procedure was performed more than 50 percent of the time in the outpatient setting. CMS will revisit in rulemaking whether and when an exemption for a procedure should be ended. In summary, for each procedure removed from the IPO list on or after January 1, 2021, the exemption will continue until terminated in future rulemaking. (pg. 672) ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download