News: 2021 OPPS proposed rule eliminates inpatient-only list

CMS has released the 2021 Outpatient Prospective Payment Systems (OPPS) and Ambulatory Surgical Center (ASC) PPS proposed rule, Revenue Cycle Advisor reported. The rule proposes to eliminate the Inpatient-Only Procedure (IOP) list over the next three years. This process would begin with the removal of roughly 300 musculoskeletal surgeries from the list in the upcoming fiscal year 2021.

CMS believes that elimination of the IOP list should positively impact facilities’ bottom lines as payment for these surgeries will be allowed through either Part A or Part B claim processing mechanism. This means that facilities will no longer have to assume or hope that surgeons will understand that payment for a particular procedure is limited by which patient status is selected, reported Revenue Cycle Advisor.

For all surgeries not designated at “inpatient-only” but billed under Part A, Medicare contractors will issue determinations and appeals for those services furnished to beneficiaries under Original Medicare as usual. If the OIP list is entirely eliminated, all surgeries submitted for payment under Part A will be subject to the two-midnight rule for reimbursement purposes.

It appears, however, that Medicare Advantage plans will continue not using the two-midnight rule with respect to inpatient services. This keeps providers in a poor position and places upon them a large burden in respect to patient status designation, according to Revenue Cycle Advisor. While it is improper for providers to make medical decisions or render services to similarly situated beneficiaries based on financial or insurance consequences, there is the question of how CMS expects providers to comply with the objective time-based two-midnight rule under Original Medicare and the subjective Medicare Advantage plans’ “reasonable and medically necessary” standard. This is an issue that has been ongoing since the implementation of the two-midnight rule and is something that CMS should address.

Editor’s note: The 2021 OPPS and ASC PPS proposed rule can be found here. This coverage by Revenue Cycle Advisor can be found here. To learn more about the inpatient PPS proposed rule, click here.