CMS to Reprocess 2019 Excepted Off-Campus PBD Claims

Jan. 19, 2021


On Jan. 14, the Centers for Medicare & Medicaid Services (CMS) announced it would reprocess and recoup reimbursement made for certain outpatient clinic visit services provided in calendar year (CY) at excepted off-campus Provider-Based Departments (PBDs). CMS will begin reprocessing CY 2019 claims by July 1, 2021, with reimbursement reflecting the excepted off-campus PBD reimbursement rate finalized under the CY 2019 Outpatient Prospective Payment System (OPPS) rule. The CY 2019 OPPS rule finalized reimbursement for certain outpatient clinic visit services provided at excepted off-campus PBDs at 70% of the full OPPS rate.  CMS further reduced reimbursement rates to 40% of the full OPPS rate for CY 2020, aligning with reimbursement under the Medicare Physician Fee Schedule.

On Sept. 17, 2019, the U.S. District Court for D.C. invalidated the CY 2019 OPPS rule lowering excepted off-campus PBD reimbursement rates, and CMS reprocessed CY 2019 claims to restore the 100% payment rate.  However, on July 17, 2020, the U.S. Court of Appeals for the D.C. Circuit reversed the district court ruling, reinstating a CY 2019 reimbursement rate at 70% of the OPPS rate.

To see the estimated impact of this rule, please reference the CY 2019 OPPS final rule hospital-specific reports in the C-Suite on IHA’s website. Contact us with questions and comments.