Oncology Providers Beware: Possible Implications of CMS’ Proposed Rule on Off-Campus Provider-Based Departments

Oncology Providers Beware: Possible Implications of CMS’ Proposed Rule on Off-Campus Provider-Based Departments


On July 7, 2016, the Centers for Medicare & Medicaid Services (CMS) released a proposed rule intended to prohibit hospitals operating certain off-campus provider-based departments (PBDs) from billing under the Outpatient Prospective Payment System (OPPS). In an effort to implement Section 603 of the Bipartisan Budget Act of 2015, CMS says the proposed rule will save about $500 million a year by refocusing payments on the patient rather than the clinical setting.  For a general overview of the proposed rule, go to this postissued on the Waller Healthcare Blog earlier this week.

Providers of oncology services, in particular, should be aware of the following provisions outlined in the proposed rule:

  • Outpatient Chemotherapy Measure.  This measure aims to assess the care provided to cancer patients and encourage quality improvement efforts to reduce the number of potentially avoidable inpatient admissions and emergency department visits among cancer patients receiving chemotherapy in a hospital outpatient setting.  CMS hopes that measuring avoidable admissions and emergency visits for such patients will provide hospitals with an incentive to improve quality of care by taking steps to prevent and better manage side effects and complications from chemotherapy treatment.  The measure, which would be effective for the 2020 calendar year and subsequent years, would capture and report data from both hospital admissions and emergency department visits for symptoms that are potentially preventable through high-quality outpatient care.
  • Brachytherapy.  CMS is proposing to use the costs derived from the 2015 calendar year claims data to set the proposed 2017 calendar year payment rates for brachytherapy sources because the 2015 calendar year data is being proposed for most other items and services under the rule.  In addition, CMS is proposing to continue to pay for low dose rate (LDR) prostate brachytherapy services using the composite ambulatory payment classification (APC) payment methodology that has been proposed and implemented since the 2008 calendar year.
  • Additional Comprehensive Ambulatory Payment Classifications (C-APCs).  CMS is proposing 25 new C-APCs to be paid under the existing policy beginning in the 2017 calendar year, including new codes for breast surgery and excision/biopsy/incision and drainage.  A code has also been proposed for the 2017 calendar year for Level 7 Radiation Therapy.  

Comment Period

Comments to the proposed rule are due by 5:00 p.m. EDT, September 6, 2016, and the final rule is expected to be announced no later than November 1, 2016.  Waller attorneys are available to aid stakeholders in drafting commentary to the proposed rule.

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