Hospital Outpatient Prospective Payment System (OPPS) Final Rule- CY2023

The Centers for Medicare & Medicaid Services (CMS) provided the OPPS Final Rule for CY2023 in the Federal Register on November 23, 2022. Provisions in this rule will be effective for dates of service on or after January 1, 2023.

Significant changes for drug reimbursement and coding occur in three areas: 340B-acquired drugs, non-opioid pain management reimbursement in Ambulatory Surgery Centers (ASC) and Hospital Outpatient Departments (HOPD), and new requirements for reporting waste in HOPD.

340B-acquired Drugs

In light of the Supreme Court decision in American Hospital Association v. Becerra, 142 S. Ct. 1896 (2022), CMS is applying the default rate, generally average sales price (ASP) plus 6 percent, to 340B acquired drugs and biologicals and removing the increase to the conversion factor that was made in CY 2018 to implement the 340B policy in a budget neutral manner. These changes are reflected in posted ASP Pricing Files and Addendum B reimbursement rates.

Non-opioid pain management

CMS will provide separate payment for five drugs in the ASC setting (but not in the HOPD setting) as non-opioid pain management drugs that function as supplies (Exparel, Omidria, Dextenza, Xaracoll, and Posimir). Note that Zynrelef received pass-through payment status on April 1, 2022 and is therefore eligible for separate payment in both the ASC and HOPD setting in CY2023. 

Drug Waste Reporting in Hospital Outpatient Departments

New reporting requirements for drugs where there is no discarded waste were detailed in the CY2023 Physician Fee Schedule Rule and summarized in a recent Visante newsletter and podcast

The following links and notes provide additional information on changes in drug reimbursement in HOPD for CY2023:

1. Pass-through expirations CY 2022– 32 drugs will have pass-through payment end on December 31, 2022. Table 57 (page 198 pdf)
2. Pass-through Drugs and biologicals that will receive one to four quarters of separate payment in CY 2023- 43 drugs will receive separate payment in one or more quarters in CY2023. Table 58 (pg 202 pdf)
3. Pass-through Drugs and biologicals with pass-through payment status to expire after CY2023 (with pass-through payment end dates)- 49 drugs will continue with pass-through status throughout CY2023. Table 59 (pg 208 pdf)
4. Packaging Threshold– CMS raises the per-day cost packaging threshold for separate payments from $130 to $135.
5. Biosimilars– Visante has provided a recent newsletter that details payment increases for biosimilars.

Hope this summary is helpful in evaluating your reimbursement for the coming year!

SHOUT-OUT

1. All pharmacy revenue cycle teams should review the OPPS CY 2023 Rule Final Rule and ensure systems are updated by January 1, 2023.