On August 4, the Centers for Medicare & Medicaid Services (CMS) released the Changes to Hospital Outpatient Prospective Payment System (OPPS) for the 2021 calendar year (CY). The proposed regulations were published in the Federal Register on August 12, and comments are due by October 5.
CMS has also announced that it is waiving the 60-day publication requirement for the Final Rule, instead replacing it with a 30-day notification. This means that although the final rule will be effective January 1, 2021, it may not be published until December 1 – instead of the typical November 1 target publication date.

The updates proposed for CY 2021 will require changes to your chargemaster and reporting, and with less time to implement the changes than usual, so it is more important than ever to ensure your team understands what will need to be done so they can act quickly.




To help you prepare your staff, we’ve put together a summary of the provisions in the proposed rule that will have the greatest impact on your coding:

Key Takeaway No. 1: New APCs and APC-specific policies

The proposed rule includes the creation of two comprehensive Ambulatory Payment Classifications (APCs) that will affect 18 CPT/HCPCS codes and create a Level 8 in the urological procedure clinical family and a Level 5 in the neurostimulator procedure clinical family. CMS also re-evaluated payments under new technology APCs and updated APC-specific policies. All of these could affect payments, with the new comprehensive APCs in particular having potential increases in payment of more than $1,100 and $800, respectively.

Key Takeaway No. 2: Changes in pass-through payments

The proposed rule also features changes to pass-through payments for several new devices, as well as changes to the pass-through payments for a number of drugs and biologicals. Comments on pass-through payments and the use of existing HCPCS codes with certain devices can be made through October 5; this offers the opportunity to make sure your voice is heard as these decisions are being made. The proposed pass-through payment changes will affect more than 25 HCPCS codes.

Key Takeaway No. 3: Nonrecurring policy changes

CMS has announced a number of nonrecurring policy changes in the proposed rule, and is also still accepting comments on many of them, such as those associated with COVID testing and supervision requirements for a number of services. CMS has also proposed delays in the review of certain inpatient hospital admissions, and is seeking comments on whether the medical review exemption time period continues to be appropriate, or if a longer or shorter period may be warranted. This is because many of these services will be removed from the inpatient-only list (IPO) as part of the transition toward the elimination of the list – so it is imperative to submit a comment if this is an issue that affects your organization.

Key Takeaway No. 4: Prior authorization additions

With the proposed rule, CMS also announced that it would be adding a number of new services to the prior authorization list. Five services were added to this list for CY 2020: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation. The CY 2021 rule adds two new categories of services – cervical fusion with disc removal and implanted spinal neurostimulators – which will be subject to prior authorization for dates of service on or after July 1, 2021.

Key Takeaway No. 5: Added and deleted codes

As in every proposed rule, there are also a number of new codes being added and deleted, and it’s important to understand how these will affect your organization. With the proposed rule, both CMS and AMA are introducing placeholder codes for added codes so will overview several of the code groups to begin discussion with coding and chargemaster staff for implementation of new charges.

How to Prepare Now

These key takeaways are just the tip of the iceberg, but with the potentially shortened countdown between the final rule’s publication and effective dates for implementation, it’s critical to make sure your team has a solid understanding of what will have the greatest impact on your organization, and the changes that need to be made to ensure correct payment and compliance.

Watch a complimentary rebroadcast to make sure you and your team will have the information needed to be prepared for the coding and regulatory updates coming for CY 2021. Click here to access the webinar.