2027 OPPS final rule released: Three things you must know

By Brian Murphy

The 2027 OPPS final rule is out; here’s three things you should know. Or at least, three I think you should know.

 

1.Inpatient Only List (IPO) nears the end

CMS finalized the removal of 637 services from the following clinical families: auditory, digestive, endocrine, female genital, hemic and lymphatic systems, integumentary, male genital, maternity care and delivery, mediastinum and diaphragm, respiratory, and urinary.

Too many codes to list here but see link below.

The IPO list is slated for full removal on Jan. 1, 2028.

Important distinction: Removal of procedures from the IPO list does not mean they SHOULD be performed OP, just that CMS believes in some circumstances they safely CAN. That’s a massive difference.

You can still do them IP if the situation warrants. The removal of the IPO list unfortunately makes billing a lot more difficult; a payer can render their own opinion, and deny a more expensive IP procedure on the basis it could have been safety performed OP.

This makes supporting documentation and comorbidity capture even more critical.

CDI must follow the care curve and the settings in which it is rendered. The writing is on the wall for widespread outpatient CDI adoption.

 

2. A shot under scrutiny: Expansion of prior authorization

CMS identified through data analysis that billing for botulinum toxin injection procedures in the hospital outpatient setting increased in volume. It couldn’t find any explanations or justifications, and someone at the agency decided “further program integrity action was warranted.”

That action? Prior authorization for eight codes.

The scrutiny of this particular injection is not the issue, it’s CMS’ use of prior authorization. MA organizations use prior authorization all the time, but you see it very infrequently in Traditional Medicare (TM).

This further blurs an increasingly blurry line, begging the question: Do we need both MA and TM?

CMS adds this citation; you can bet this won’t be the last time we see it:

In the CY 2020 OPPS/ASC final rule with comment period, CMS established a prior authorization process for certain hospital outpatient department  services using our authority under section 1833(t)(2)(F) of the Act, which requires the Secretary to develop “a method for controlling unnecessary increases in the volume of covered OPD services.”

Again, it’s not about the injection, it’s about the use of prior authorization as a mechanism of cost control.

 

3. Separate payment for Software as a Medical Service (SaMS)

Finally, a revenue opportunity you don’t want to miss.

We’ve seen rapid developments in the OP setting in the use of software-based technologies to diagnose disease and support clinical decision-making. CMS recognized this by reclassifying Software as a Service (SaaS) to Software as a Medical Service (SaMS) and by assigning New Technology APCs as an interim step toward a broader payment policy.

CMS identified the following new technology APC ranges starting Jan. 1, 2027:

• APC 1491—1599: New Technology APCs with graduated cost/payment bands
• APC 1901—1908: Additional New Technology APCs

 

Reference

CMS, Calendar Year 2027 Hospital Outpatient Prospective Payment System (OPPS): https://www.cms.gov/newsroom/fact-sheets/calendar-year-2027-hospital-outpatient-prospective-payment-system-opps-ambulatory-surgical-center-0