Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments

Provider/Supplier Type(s) Impacted: Off-Campus Provider-Based Departments billing OPPS

Reason Codes: Not applicable

Claim Coding Impact: Not applicable

Description of Issue: The American Hospital Association challenged CMS's use of its authority under Subsection (t)(2)(F) of the Medicare statute to pay for certain outpatient clinic visit services provided at excepted off-campus Provider-Based Departments (PBDs) at the same rate that CMS uses to pay non-excepted off-campus PBDs for those services under the separate Physician Fee Schedule as finalized with Final Rule, Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting, 83 Fed. Reg. 58,818 (Nov. 21, 2018) (Rule).   The United States District Court for the District of Columbia issued instructions for CMS to immediately cease the clinic visit provided at excepted off-campus PBDs payment reduction for CY 2019 implemented with final Rule, Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting, 83 Fed. Reg. 58,818 (Nov. 21, 2018) (Rule).

Noridian Action Required: Noridian will mass adjust claims.

02/05/20 - Noridian will start adjustments on 02/10/20.

02/27/20 - Noridian is continuing to mass adjust claims.

Provider/Supplier Action Required: No provider action needed.

Proposed Resolution/Solution: CMS installed a revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines. The revised Pricer went into production on 11/04/19, and applies to claims with a line item date of service of 01/01/19, and after. Starting 01/01/20, and over the next few months, the Medicare Administrative Contactors will automatically reprocess claims paid at the reduced rate.

Date Reported: 12/19/19

Date Resolved:

Last Updated Feb 27, 2020