November 13, 2019

Calendar Year 2020 Hospital Outpatient Prospective Payment System Final Rule

On November 1, 2019, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2020 Hospital Outpatient Prospective Payment System (HOPPS) final rule. CMS received over 3,400 timely submitted comments on the proposed rule. The American College of Radiology (ACR®) submitted formal comments on the CY 2020 HOPPS proposed rule in September 2019. CMS estimates the total payments to OPPS providers will be approximately $79 billion for CY 2020, an increase of $6.3 billion compared to CY 2019 payments. The finalized changes are effective January 1, 2020.

Conversion Factor
CMS will increase the conversion factor by 2.6 percent bringing it up to $80.784 for CY 2020. CMS determined the conversion factor with the use of the Outpatient Department (OPD) fee schedule increase factor of 2.6 percent for CY 2020, the required wage index budget neutrality adjustment of approximately 0.9981, the cancer hospital payment adjustment of 0.9998 and the adjustment of 0.88 percentage point of projected OPPS spending for the difference in pass-through spending. Hospitals that fail to meet the reporting requirements of the Hospital Outpatient Quality Reporting (OQR) Program would be subject to a further reduction of 2.0 percentage points. The hospitals that fail to meet the reporting requirement would be subject to a conversion factor of $79.25.

Estimated Impact on Hospitals
CMS estimates that based on policies within this final rule, there will be a 1.3 percent overall increase in OPPS payments to providers. CMS estimates the total payments to OPPS providers will be approximately $79 billion for CY 2020. The estimated impact of the increase in the conversion factor is dependent of facility type. Impacts will differ for each hospital category based on the mix of services provided, location and other factors.

AMBULATORY PAYMENT CLASSIFICATION GROUP POLICIES

APC Placement of New Radiology CPT Codes
In March 2019, the ACR presented CMS with recommendations for new CPT codes within Ambulatory Payment Classifications (APCs) for CY 2020. The table below shows CMS’s finalized APC placement for CY 2020. In the proposed rule, CMS agreed with ACR recommendations except for 93985 (Duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to creation of hemodialysis access; complete bilateral study). In the final rule, CMS agreed with ACR’s recommendation for 93985 to be placed in APC 5523.

CMS did support the recommendations made by the ACR, the Society of Nuclear Medicine and Molecular Imaging, American College of Nuclear Medicine and American Society of Nuclear Cardiology to include several of the new NM codes in New Technology APCs. The table below shows the placement of new CPT codes for CY 2020. 

CMS APC Placement for New CPT Codes

CPT Code

 

Description

 

ACR Recommendation APC Placement

 

CMS Proposed APC Placement

 

CMS Finalized APC Placement

 

CY 2020 Payment Rate

 

Gastrointestinal Tract Imaging

 

74221

 

Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; double-contrast (eg, high-density barium and effervescent agent) study

 

5571

 

5571

 

5571

 

$182.20

 

Myocardial PET

 

78429

 

Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion(s), and/or ejection fraction(s), when performed) single study; with concurrently acquired computed tomography transmission scan

 

5593

 

5594

 

$1,443.00

 

78430

 

Myocardial imaging, positron emission tomography, perfusion study (including ventricular wall motion(s), and/or ejection fraction(s), when performed); single study, at rest or stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan

 

5594

 

5594

 

$1,443.00

 

78431

 

Myocardial imaging, positron emission tomography, perfusion study (including ventricular wall motion(s), and/or ejection fraction(s), when performed); multiple studies at rest and stress (exercise or pharmacologic), with concurrently acquired computed tomography transmission scan

 

5594

 

1522

 

$2,250.50

 

78432

 

Myocardial imaging, positron emission tomography, combined perfusion with metabolic evaluation study (including ventricular wall motion(s), and/or ejection fraction(s), when performed), dual radiotracer (e.g., myocardial viability);

 

5594

 

1523

 

$2,750.50

 

78433

 

Myocardial imaging, positron emission tomography, combined perfusion with metabolic evaluation study (including ventricular wall motion(s), and/or ejection fraction(s), when performed), dual radiotracer (e.g., myocardial viability); with concurrently acquired computed tomography transmission scan

 

5594

 

1523

 

$2,750.50

 

Lumbar Puncture

 

62328

 

Spinal puncture, lumbar, diagnostic; with fluoroscopic or CT guidance

 

5442

 

5442

 

5442

 

$624.98

 

62329

 

Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter); with fluoroscopic or CT guidance

 

5442

 

5442

 

5442

 

$624.98

 

SPECT-CT procedures

 

78831

 

Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s), (includes vascular flow and blood pool imaging when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, single area (e.g., head, neck, chest pelvis), single day of imaging

 

5593

 

5593

 

$1,272.05

 

78832

 

Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s), (includes vascular flow and blood pool imaging when performed); tomographic (SPECT), minimum 2 areas (e.g., pelvis and knees, abdomen and pelvis), single day of imaging, or single of imaging over 2 or more days

 

 

 

5593

 

5594

 

$1,443.00

 

78835

 

Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s), (includes vascular flow and blood pool imaging when performed); tomographic (SPECT) with concurrently acquired computed tomography (CT) transmission scan for anatomical review, localization and determination/detection of pathology, minimum 2 areas (e.g., pelvis and knees, abdomen and pelvis), single day of imaging, or single area of imaging over 2 or more days imaging

 

 

 

5594

 

 

 

 

 

78831

 

Radiopharmaceutical localization of tumor, inflammatory process or distribution of radiopharmaceutical agent(s), (includes vascular flow and blood pool imaging when performed); tomographic (SPECT), minimum 2 areas (e.g., pelvis and knees, abdomen and pelvis), single day of imaging, or single of imaging over 2 or more days

 

 

 

5593

 

5593

 

$1,272.05

 

Duplex Scan Arterial Inflow- Venous Outflow Upper Extremity

 

93985

 

Duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to creation of hemodialysis access; complete bilateral study

 

5523

 

5522

 

5523

 

$233.01

 

93986

 

Duplex scan of arterial inflow and venous outflow for preoperative vessel assessment prior to creation of hemodialysis access; complete unilateral study

 

5522

 

5522

 

5522

 

$112.07

 

 

Imaging APCs

CMS did not make changes to the APC structure for imaging codes. The seven payment categories remain. However, CMS has moved codes within these payment categories of which would cause changed pricing for 2020.

CY 2020 Imaging APCs

APC

 

Group Title

 

SI

 

Relative Weight

 

CY 2019 Payment Rate

 

CY 2020 Payment Rate

 

5521

 

Level 1 Imaging without Contrast

 

S*

 

0.9878

 

$62.30

 

$79.80

 

5522

 

Level 2 Imaging without Contrast

 

S

 

1.3873

 

$112.51

 

$112.07

 

5523

 

Level 3 Imaging without Contrast

 

S

 

2.8844

 

$230.56

 

$233.01

 

5524

 

Level 4 Imaging without Contrast

 

S

 

5.9607

 

$497.49

 

$481.53

 

5571

 

Level 1 Imaging with Contrast

 

S

 

2.2554

 

$201.74

 

$182.20

 

5572

 

Level 2 Imaging with Contrast

 

S

 

4.7263

 

$385.88

 

$381.81

 

5573

 

Level 3 Imaging with Contras

 

S

 

8.4267

 

$691.75

 

$680.74

 

*Procedure or Service, Not Discounted When Multiple; Paid under OPPS; separate APC payment.

 

APC Exceptions to the 2-Times Rule
CMS made exceptions to the 2-times rule based on the following criteria: resource homogeneity, clinical homogeneity, hospital outpatient setting utilization, frequency of service (volume) and opportunity for up-coding and code fragments.

Table 11, below, lists the 17 APCs that CMS will exempt from the 2-times rule for 2020 based on claims data from January 1, 2018, through December 31, 2018 and processed on or before June 30, 2019.

Table 11. APC Exceptions to the 2 Times Rule for 2020

2020 APC

 

APC Title

 

5112

 

Level 2 Musculoskeletal Procedures

 

5161

 

Level 1 ENT Procedures

 

5181

 

Level 1 Vascular Procedures

 

5311

 

Level 1 Lower GI Procedures

 

5521

 

Level 1 Imaging without Contrast

 

5522

 

Level 2 Imaging without Contrast

 

5523

 

Level 3 Imaging without Contrast

 

5524

 

Level 4 Imaging without Contrast

 

5571

 

Level 1 Imaging with Contrast

 

5593

 

Level 3 Nuclear Medicine and Related Services

 

5612

 

Level 2 Therapeutic Radiation Treatment Preparation

 

5691

 

Level 1 Drug Administration

 

5721

 

Level 1 Diagnostic Tests and Related Services

 

5731

 

Level 1 Minor Procedures

 

5734

 

Level 4 Minor Procedures

 

5822

 

Level 2 Health and Behavior Services

 

5823

 

Level 3 Health and Behavior Services

 

 

Comprehensive APCs
For CY 2020, CMS finalized the creation of two new comprehensive APCs (C-APCs). CMS’s new C-APCs include the following: C-APC 5182 (Level 2 Vascular Procedures) and C–APC 5461 (Level 1 Neurostimulator and Related Procedures). This increases the total number of C-APCs to 67. The complete list of C-APCs can be found in addendum J of the final rule.

Changes to New Technology APCs
CMS will continue its policy to retain services within New Technology APC groups until they obtain adequate claims data to substantiate reassignment of the service to a clinically appropriate APC. 

Changes to MRgFUS
Currently, there are four CPT/HCPCS codes that describe magnetic resonance image-guided, high-intensity focused ultrasound (MRgFUS) procedures. For 2020, CMS will assign three of the codes to standard APCs and will maintain procedures described by CPT code 0398T to a New Technology APC.

Based on the 37 claims, CMS calculated a geometric mean cost of approximately $8,829, an arithmetic mean of $10,021 and a median of $11,985 for CPT code 0398T. CMS believes that the arithmetic mean is the most appropriate representative cost of the procedures described by CPT code 0398T. CMS finalized to maintain the procedure described by CPT code 0398T to APC 1575 (New Technology – Level 38 ($10,001-$15,000), with a payment rate of $12,500.50. Table 12 from the final rule, below, shows the placement and payment rates for MRgFUS procedures.

Table 12. CY 2020 Status Indicator (SI), APC Assignment, And Payment Rate for the MRgFUS Procedures

CPT/
HCPCS
Code

Long Descriptor

CY
2019
OPPS
SI

CY
2019
OPPS
APC

CY 2019
OPPS
Payment
Rate

CY 2020
OPPS SI

CY 2020
OPPS
APC

CY 2020
OPPS
Payment
Rate

0071T

Focused ultrasound
ablation of uterine
leiomyomata,
including MR
guidance; total
leiomyomata
volume less than
200 cc of tissue.

J1*

5414

$2,361.27

J1

5414

$2,564.60

0072T

Focused
ultrasound
ablation of
uterine
leiomyomata,
including MR
guidance; total
leiomyomata
volume greater or
equal to 200 cc of
tissue.

J1

5414

$2,361.27

J1

5414

$2,564.60

0398T

Magnetic
resonance image
guided high-
intensity focused
ultrasound
(mrgfus),
stereotactic
ablation lesion,
intracranial for
movement disorder
including
stereotactic
navigation and
frame placement
when performed.

S**

1575

$12,500.50

S

1575

$12,500.50

C9734

Focused ultrasound
ablation/therapeutic
intervention, other
than uterine
leiomyomata, with
magnetic resonance
(MR) guidance.

J1

5115

$10,713.88

J1

5115

$11,960.25

*Hospital Part B Services Paid Through a Comprehensive APC; aid under OPPS; all covered Part B services on the claim are packaged with the primary "J1" service for the claim, except services with OPPS status indicator of "F","G", "H", "L" and "U"; ambulance services; diagnostic and screening mammography; rehabilitation therapy services; new technology services; self-administered drugs; all preventive services; and certain Part B inpatient services.
** Procedure or Service, Not Discounted When Multiple; Paid under OPPS; separate APC payment.

Brachtherapy
Since 2010, CMS has used the standard OPPS payment methodology for brachytherapy sources, with payment rates based on source-specific costs as required by statute. CMS will make no changes to its brachytherapy policy for 2020.

Alternative Pathway to the OPPS Device Pass-Through Substantial Clinical Improvement Criterion for Transformative New Device
Similar to the policy in the Inpatient Prospective Payment System final rule, CMS will implement policy for alternative pathway to qualifying for device pass-through payment status, under which the “substantial clinical improvement” criterion would not apply.

If a medical device is part of the US Food and Drug Administration’s Breakthrough Devices Program and received marketing authorization, it will not be evaluated for substantial clinical improvement for the purposes of determining device pass-through payment status. The device will still need to meet the eligibility criteria, the other criteria for establishing device categories, and the cost criterion. CMS will establish this alternative pathway for device pass-through payment applications for new medical devices received on or after January 1, 2020.

Calculation and Use of Cost-to-Charge Ratios (CCRs)
Despite stating in the CY 2020 HOPPS proposed rule that the CT and MR policy would go into effect on January 1, 2020, CMS finalized policy for a two-year transition based on public comments. In 2020, CMS will begin a two-year phase of the policy that will apply 50 percent of the payment impact. For CY 2020, CMS will calculate imaging payment rates using both the transition method (excluding providers using a square feet allocation method) and the standard methodology that includes all providers regardless of allocation method. In CY 2021, the transition will end and fully implement the CT and MR cost data regardless of the cost allocation method.

CMS received numerous public comments regarding the policy, with many commenters asking to further delay an implementation or to provide a transition period. One commenter requested the CMS work with hospital organizations to educate the hospital community on how to report these costs on the CT and MR CCRs in hopes of transitioning to the new policy. CMS addressed comments stating that they have continued to make the OPPS a more prospective payment system, which includes greater packaging and the use of comprehensive APC’s. CMS responded to the ACR’s concern regarding the duplicative effects of the Deficit Reduction Act, stating they understood the payment reductions for imaging services under OPPS could have significant payment impacts under the physician fee schedule (PFS) where the technical component is capped at the OPPS rate and would continue to monitor the potential impacts of payment changes in the PFS.

Despite public comments, CMS does still intend to fully implement the new cost allocation methodology in January 1, 2021. For 2020, CMS will be in the two-year phased-in transition period where 50 percent of the payment will be based on the standard methodology and 50 percent will be based on the transition methodology that excludes providers using the “square feet” cost allocation method. For 2021, CMS will set the imaging APC payment rates based solely on using the standard methodology, which include all providers regardless of cost allocation method.

The table below illustrates the estimated impact on geometric mean costs for CT and MRI APCs under the blended approach of utilizing 50 percent of the transitional payment methodology and 50 percent of the standard payment methodology for 2020. 

Table 4. Estimated Cost Impact for CT and MRI APCs Under 50/50 Blended Geometric Mean Cost, Compared To Standard Geometric Mean Cost For CY 2020

APC

 

APC Descriptor

 

Providers Using “Square Foot” Included – Geometric Mean Cost

 

Providers using “Square Foot” excluded – Geometric Meat Cost

 

Blended Geometric Mean Cost

 

% Impact
of Blend
Relative to
Geometric
Mean Cost
Including
“Square
Foot”
Providers

 

5521

 

Level 1 Imaging without Contrast

 

$79.08

 

$77.07

 

$78.08

 

-1.3%

 

5522

 

Level 2 Imaging without Contrast

 

$106.56

 

$112.75

 

$109.66

 

2.9%

 

5523

 

Level 3 Imaging without Contrast

 

$223.58

 

$232.46

 

$228.02

 

2.0%

 

5524

 

Level 4 Imaging without Contrast

 

$459.90

 

$482.50

 

$471.20

 

2.5%

 

5571

 

Level 1 Imaging with Contrast

 

$172.59

 

$183.98

 

$178.29

 

3.3%

 

5572

 

Level 2 Imaging with Contrast

 

$359.49

 

$387.74

 

$373.62

 

3.9%

 

5573

 

Level 3 Imaging with Contrast

 

$660.06

 

$672.21

 

$666.14

 

0.9%

 

8005

 

CT and CTA without Contrast Composite

 

$221.27

 

$252.37

 

$236.82

 

7.0%

 

8006

 

CT and CTA with Contrast Composite

 

$427.99

 

$474.48

 

$451.24

 

5.4%

 

8007

 

MRI and MRA without Contrast Composite

 

$514.85

 

$548.08

 

$531.47

 

3.2%

 

8008

 

MRI and MRA with Contrast Composite

 

$820.27

 

$873.30

 

$846.79

 

3.2%

 

 

The ACR has raised concerns in the past regarding the use of claims from hospitals that continue to report under the “square foot” cost allocation method noting that it would underestimate the true costs of CT and MR studies. CMS has given the hospitals six years to adjust their cost allocation methods from “square foot” to either “direct” or the “dollar” method. These changes are the result of a study that was done by the Research Triangle Institute (RTI) back in 2007 . Although the ACR has argued that the RTI study and data which back it up are outdated, CMS is adamant about continuing with full implementation of the policy.

Table 2, below, illustrates the relative effect on imaging APC payments after removing cost data for providers that report CT and MRI standard cost centers using “square feet” as the cost allocation method. Table 3, below, of the final rule provides statistical values based on the CT and MRI standard cost center CCRs using the different cost allocation methods.

Table 2. Percentage Change in Estimated Cost for CT and MRI APCS When Excluding Claims From Provider Using “Square Feet” As the Cost Allocation Method

APC

 

APC Descriptor

 

Percentage Change

 

5521

 

Level 1 Imaging without Contrast

 

-2.5%

 

5522

 

Level 2 Imaging without Contrast

 

5.8%

 

5523

 

Level 3 Imaging without Contrast

 

4.0%

 

5524

 

Level 4 Imaging without Contrast

 

4.9%

 

5571

 

Level 1 Imaging with Contrast

 

6.6%

 

5572

 

Level 2 Imaging with Contrast

 

7.9%

 

5573

 

Level 3 Imaging with Contrast

 

1.8%

 

8005

 

CT and CTA without Contrast Composite

 

14.1%

 

8006

 

CT and CTA with Contrast Composite

 

10.9%

 

8007

 

MRI and MRA without Contrast Composite

 

6.5%

 

8008

 

MRI and MRA with Contrast Composite

 

6.5%

 

 

1Cromwell, J., & Dalton, K. (2007, January). A Study of Charge Compression in Calculating DRG Relative Weights (Rep.). Retrieved July 1, 2019, from Centers for Medicare and Medicaid Services website: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/downloads/Dalton.pdf

Table 3. CCR Statistical Values Based on Use of Different Cost Allocation Methods

Cost Allocation Method

CT

MR

Median CCR

Mean CCR

Median CCR

Mean CCR

All Providers

0.0356

0.0496

0.0772

0.1026

Square Feet Only

0.0288

0.0445

0.0674

0.0930

Direct Assign

0.0506

0.0585

0.0978

0.1186

Dollar Value

0.0424

0.0560

0.0875

0.1146

Direct Assign and Dollar Value

0.0425

0.0562

0.0879

0.1147

CMS will continue to monitor OPPS imaging payments to consider the potential impacts of payment changes on the physician fee schedule and ambulatory surgical center payment systems.

CT Lung Cancer Screening
CMS will continue to place G0297 (Low Dose CT for Lung Cancer Screening) in the lowest Imaging without Contrast APC (5521), with payment rate of $79.80. In addition, CMS will place G0296 (visit to determine lung LDCT eligibility) in APC 5822, with a payment rate of $78.53. The ACR has raised concerns about the inadequate payments for CT lung screening based on flawed hospital data in the past rules.

Policy Packaged Drugs, Biologicals and Radiopharmaceuticals
The CMS will continue paying for drugs and therapeutic radiopharmaceuticals at ASP + 6% as set forth in the CY 2010 HOPPS Final Rule. CMS finalized an increased threshold payment for therapeutic radiopharmaceuticals of $130, where CMS will package those that are priced less or equal to $130 into the APC payments and pay separately for those that meet or exceed this threshold amount.

Other HOPPS Payment Policies

Payment Adjustments to Cancer Hospitals
The Affordable Care Act requires an adjustment to cancer hospitals’ outpatient payments to bring each hospital’s payment-to-cost ratio (PCR) up to the level of the PCR for all other hospitals, the target PCR. The changes in additional payments from year to year are budget neutral. The 21st Century Cures Act reduced the target PCR by 1.0 percentage point and excludes the reduction from OPPS budget neutrality.

The cancer hospital adjustment is applied at cost report settlement rather than on a claim by claim basis. For 2020, CMS updated its calculations using the latest available cost data and identified a target PCR of 0.89. CMS Table 6, below, displays the hospital-specific payment adjustment for each of the 11 cancer hospitals, with increases in OPPS payments for 2020 ranging from 7.1 percent to 50.2 percent.

Table 6. Percentage Increase in OPPS Payments to Each Cancer Hospital For CY 2020, Due To The Cancer Hospital Payment Adjustment Policy

Provider Number

 

Hospital Name

 

Estimated Percentage Increase in OPPS Payments for CY 2020 due to Payment Adjustment

 

050146

 

City of Hope Comprehensive Cancer Center

 

36.7%

 

050660

 

USC Norris Cancer Hospital

 

23.0%

 

100079

 

Sylvester Comprehensive Cancer Center

 

7.1%

 

100271

 

H. Lee Moffitt Cancer Center & Research Institute

 

23.1%

 

220162

 

Dana-Farber Cancer Institute

 

36.1%

 

330154

 

Memorial Sloan-Kettering Cancer Center

 

48.0%

 

330354

 

Roswell Park Cancer Institute

 

20.7%

 

360242

 

James Cancer Hospital & Solove Research Institute

 

21.1%

 

390196

 

Fox Chase Cancer Center

 

9.5%

 

450076

 

M.D. Anderson Cancer Center

 

42.1%

 

500138

 

Seattle Cancer Care Alliance

 

50.2%

 

 

Measure Changes within the Hospital OQR Program
CMS finalized to remove one measure from the Hospital OQR Program beginning with the 2022 payment determination. CMS will remove OP-33: External Beam Radiotherapy for Bone Metastases under removal Factor 8, the costs associated with a measure outweigh the benefit of its continued use in the program. This measure will be removed beginning with CY 2020 encounters (January 2020) used in the CY 2022 payment determination and for subsequent years.

Method to Control Unnecessary Increases in the Volume of Clinic Visit Services Furnished in Excepted Off-Campus Provider-Based Departments
In the CY 2019 HOPPS final rule, CMS finalized policy that removed the payment between sites of service. For CY 2020, the second year of the 2-year phase-in, CMS stated it will apply the total reduction in payment that is applied if these departments (departments that bill the modifier “PO” on claims lines) are paid the site-specific PFS rate for the clinic visit service described by HCPCS code G0463.

The PFS-equivalent rate for CY 2020 is 40 percent of the OPPS payment (that is, 60 percent less than the proposed OPPS rate) for CY 2020. CMS estimates savings of approximately $800 million for CY 2020, with approximately $640 million of the savings accruing to CMS, and roughly $160 million saved by Medicare beneficiaries.

In the final rule, CMS acknowledged that the district court removed the volume control policy for CY 2019. CMS state they will ensure affected 2019 claims for clinic visits are paid consistent with the court’s order. CMS continues to believe this policy is appropriate and will not make a change to the second year of the two-year phase-in of the clinic visit policy.

Supervision Level for Outpatient Therapeutic Services in Hospitals and Critical Access Hospitals
In response to concerns expressed by stakeholders, on March 15, 2010, CMS instructed all Medicare Administrative Contractors not to evaluate or enforce the supervision requirements for therapeutic services provided to outpatients in critical access hospitals (CAHs) from January 1 to December 31, 2010. This policy had been extended by various methods until December 31, 2019. The enforcement instructions and legislative actions that have been in place since 2010 created a two-tiered system of physician supervision requirements for hospital outpatient therapeutic services for providers in the Medicare program. CMS noted that stakeholders asked CMS to continue non-enforcement due to difficulties in recruiting both physician and non-physician practitioners (NPP) to practice in rural hospitals and CAH. CMS stated stakeholders find it particularly difficult to furnish direct supervision specialty services, such as radiation oncology services, that cannot be directly supervised by an emergency department physician or NPP due to the volume of emergency patients or lack of specialty expertise to provide services.

CMS finalized policy to change the generally applicable minimum required level of supervision for hospital outpatient therapeutic services from direct supervision to general supervision for services furnished by all hospitals and CAHs. General supervision means that the procedure is furnished under the physician's overall direction and control, but that the physician's presence is not required during the performance of the procedure.

CMS will continue to have the Hospital Outpatient Payment Panel provide guidance on the appropriate supervision levels for hospital outpatient services. CMS is seeking public comment on whether specific types of services, such as chemotherapy administration or radiation therapy, should be excepted from this proposal.

Requirements for Hospitals to Make Public a List of Their Standard Charges
In the CY 2020 HOPPS proposed rule, CMS included a proposal to require hospitals make public their “standard charges.” CMS did not address these proposals in the final rule and intend to include this in a separate final rule. CMS stated they intend to summarize and respond to public comments on the proposed policies in a forthcoming final rule. This final rule is currently for review at the Office of Management and Budget.