Q&A: MPFS rate for OPPS, non-excepted provider-based departments

Q. Where can we find the new Medicare Physician Fee Schedule (MPFS) rate for outpatient prospective payment system (OPPS), non-excepted departments? It didn’t seem to be clearly located on the MPFS final rule relative value units (RVU) file. Are we supposed to assume an exact 50% reduction of the OPPS rate?

A. Yes, you can assume an exact 50% reduction of the OPPS rate. The new site of service specific MPFS rate for off-campus PBDs is not published in the MPFS because it is not based on relative value units. Essentially, this is an OPPS rate with 50% applied and certain things such as outliers turned off. Although they're calling it MPFS, it really has no relationship to the MPFS. The new law for payment of off-campus PBDs doesn’t allow for payment under the OPPS after January 1, 2017 so CMS could not call the rate an OPPS rate. They had to consider the rate to be under a different payment system, in this case the MPFS, even though it is based on the OPPS. This may change in the future. CMS stated that for now they are going to apply a 50% reduction to the OPPS rate but they are looking to adjust that in the future.

All OPPS policies, including packaging and the multiple procedure reduction, are going to apply before the 50% reduction is calculated so it is really very different from the MPFS. To illustrate: if a physician performs two surgical procedures, such as removal of two lesions at a non-excepted off-campus PBD the highest paying service is subject to the 50% reduction under the new MPFS rate, paying half of what it previously paid. The second service is automatically reduced by 50% under the multiple procedure reduction, but would then be reduced by another 50% for the new MPFS rate; therefore, the second service pays only 25% of the original rate. Additionally, if there were any diagnostic or other packaged services provided that day, they would be packaged prior to application of the new rate and therefore, would not result in any additional payment.

Editor’s note: This question was answered by Kimberly Anderwood Hoy Baker, JD, CPC, director of Medicare and Compliance for HCPro, a division of BLR, in Middleton, Massachusetts.

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