Prospective Payment Systems for Hospital Outpatient Department Services

Basis and scope.

This section establishes the legal basis and scope for the Medicare prospective payment system for hospital outpatient department services.

Basis of payment.

This section defines the methodology for hospital outpatient prospective payment rates, including packaged costs and specific exclusions.

Hospitals subject to the hospital outpatient prospective payment system.

This section specifies which hospitals are subject to the outpatient prospective payment system and identifies categories of excluded facilities.

Hospital services subject to the outpatient prospective payment system.

Except for services described in § 419.22, effective for services furnished on or after July 1, 2000, payment is made under the hospital outpatient prospective payment system for the following:

Hospital services excluded from payment under the hospital outpatient prospective payment system.

The following services are not paid for under the hospital outpatient prospective payment system (except when packaged as a part of a bundled payment):

Base expenditure target for calendar year 1999.

This section outlines the calculation of the aggregate base expenditure target for hospital outpatient services for the 1999 calendar year.

Ambulatory payment classification (APC) system and payment weights.

This section describes the classification of outpatient services into APC groups and the assignment of weighting factors based on resource costs.

Calculation of prospective payment rates for hospital outpatient services.

This section details the calculation of conversion factors and payment rates for hospital outpatient services, including annual adjustments.

Payment concepts.

This section defines the components of outpatient payments, including beneficiary copayment amounts and program payment percentages.

Calculation of national beneficiary copayment amounts and national Medicare program payment amounts.

This provision establishes the methodology for calculating Medicare program payment and beneficiary copayment amounts for hospital outpatient department services, including specific adjustments for drugs, biologicals, and radiopharmaceuticals.

Hospital election to reduce coinsurance.

This provision outlines the requirements and notification process for hospitals electing to reduce coinsurance for specific ambulatory payment classification groups under the Medicare outpatient prospective payment system.

Adjustments to national program payment and beneficiary copayment amounts.

This provision establishes the methodologies for calculating Medicare hospital outpatient prospective payment system adjustments, including wage index, outlier payments, rural and cancer hospital adjustments, and specific payment policies for surgical supplies and non-opioid pain management treatments.

Payment reductions for procedures.

This provision establishes the methodology for calculating Medicare program and beneficiary payment amounts for multiple surgical procedures and interrupted procedures performed in hospital outpatient departments.

Payment and copayment reduction for devices replaced without cost or when full or partial credit is received.

This provision mandates reductions in hospital outpatient prospective payment system payments when implanted devices are replaced at no cost or with full or partial credit to the provider.

Requirements under the Hospital Outpatient Quality Reporting (OQR) Program.

This provision establishes the participation, data submission, validation, and reporting requirements for the Hospital Outpatient Quality Reporting (OQR) Program, which impacts annual payment updates for hospital outpatient departments.

Coding and payment for Category B Investigational Device Exemption (IDE) studies.

This provision establishes the creation of HCPCS codes and payment methodologies for Category B Investigational Device Exemption studies within the hospital outpatient prospective payment system.

Definition of excepted items and services.

This provision defines excepted items and services furnished by hospital departments for the purpose of determining payment eligibility under the outpatient prospective payment system.

Additional payment for technetium-99m (Tc-99m) derived from domestically produced molybdenum-99 (Mo-99).

This provision outlines the criteria for receiving an additional payment for technetium-99m doses derived from domestically produced molybdenum-99 in hospital outpatient settings.

Annual review.

This provision mandates that CMS annually review and update the outpatient prospective payment system, including consultation with an expert advisory panel.

Limitations on administrative and judicial review.

This provision specifies that certain aspects of the outpatient prospective payment system, including payment weights and adjustments, are not subject to administrative or judicial review.

Transitional pass-through payments: General rules.

This provision establishes the general rules and budget neutrality requirements for transitional pass-through payments for innovative medical devices, drugs, and biologicals.

Transitional pass-through payments: Drugs and biologicals.

This provision defines the eligibility criteria and payment methodology for transitional pass-through payments for specific drugs and biologicals in the outpatient setting.

Transitional pass-through payments: Medical devices.

This provision outlines the eligibility criteria, cost requirements, and payment methodology for transitional pass-through payments for medical devices in the outpatient setting.

Transitional adjustments to limit decline in payments.

This provision establishes transitional payment adjustments and hold harmless methodologies for hospital outpatient services under the Medicare prospective payment system.

Payment reduction for certain X-ray imaging services.

This provision establishes a 20 percent payment reduction for film X-ray imaging services and a 7 to 10 percent reduction for computed radiography imaging services.

Basis and scope of this subpart.

This provision establishes the authority and scope for implementing prior authorization requirements for certain hospital outpatient department services.

Definitions.

This provision defines key terms such as prior authorization, provisional affirmation, and the list of services requiring prior authorization for hospital outpatient departments.

Prior authorization for certain covered hospital outpatient department services.

This provision outlines the requirements for submitting prior authorization requests, including expedited review processes and the consequences of claim denial.

List of hospital outpatient department services requiring prior authorization.

This provision identifies the specific service categories subject to prior authorization and outlines the process for technical updates, exemptions, and suspensions.

§§ 419.84-419.89 [Reserved]

These sections are currently reserved.

Basis and scope of subpart.

This provision establishes the authority and scope for payment methodologies applicable to rural emergency hospitals.

Definitions.

This provision defines rural emergency hospitals and rural emergency hospital services for the purpose of Medicare payment.

Payment to rural emergency hospitals.

This provision details the payment methodologies for rural emergency hospital services, monthly facility payments, graduate medical education costs, and Indian Health Service facilities.

Payment for an off-campus provider-based department of a rural emergency hospital.

This provision specifies the payment rules for items and services furnished by off-campus provider-based departments of rural emergency hospitals.

Preclusion of administrative and judicial review.

This provision specifies that determinations regarding rural emergency hospital requirements and payment amounts under the outpatient prospective payment system are not subject to administrative or judicial review.

Requirements under the Rural Emergency Hospital Quality Reporting (REHQR) Program.

This provision establishes the mandatory quality reporting requirements for Rural Emergency Hospitals, including data submission, measure maintenance, public reporting, and electronic clinical quality measure standards.