Calendar Year 2013 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Final Rule Released by CMS


[author: Aaron Rabinowitz]

On November 1, 2012, CMS issued the Calendar Year (CY) 2013 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) final rule, updating Medicare payment policies and rates for hospital outpatient and ASC services. In addition, the final rule changes how relative payment weights are calculated and makes several changes to the quality reporting program for outpatient departments. The final rule may be viewed here.

Changes to the OPPS

CMS anticipates that total payments to hospitals under the OPPS for CY 2013 will be approximately $48.1 billion, and that payments to ASCs will be approximately $4.1 billion.

The final rule will increase payment rates under the OPPS by 1.8 percent in CY 2013. This reflects the 2.6 percent projected hospital market basket update, minus 0.8 percent in statutory reductions.

Among other changes, the final rule will:

  • Base relative payment weights on geometric mean costs rather that median costs. According to CMS, basing the OPPS payments on mean costs better reflects average costs of services and aligns the metric used in rate-setting for the OPPS with the IPPS.
  • Make changes to the quality-reporting program for outpatient departments. CMS did not add any new measures to the 22 that were finalized for the CY 2014 payment determination. However, CMS did confirm the removal of one measure, deferred data collection for another measure, and confirmed the suspension of data collection for a third measure. CMS also finalized proposed revisions to several procedural requirements that apply to reporting and quality data.
  • Streamline the operations of Quality Improvement Organizations, increase their transparency, and make them more responsive to beneficiary complaints concerning quality of care. The final rule also establishes a new alternative dispute resolution option called “Immediate Advocacy” to resolve beneficiary complaints.

Changes to ASC Payments

Under the final rule, payment rates to ASCs will increase by 0.6 percent in CY 2013. The increase reflects a projected rate of inflation of 1.4 percent, minus a productivity adjustment of 0.8 percent.

The final rule also implements changes to the ASC Quality Reporting (ASCQR) program, including requirements for claims-based measures concerning dates for submission, payment of claims and data completeness, and a methodology for reducing payment to ASCs that do not meet the program’s reporting requirements.

Other Changes

CMS also addressed Inpatient Rehabilitation Facility (IRF) quality-reporting proposals, including an application of the catheter-associated urinary tract infection measure for the IRF quality-reporting program for the FY 2014 annual payment update determination.

The final rule will be published on November 15, 2012. It will take effect January 1, 2013 with a comment period that closes on December 31, 2012.


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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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