Wednesday, October 28, 2015

2015-10-27: House Legislation re Outpatient Center Definition and Payment

As of October 27, 2015 (pending vote in House).


11                       PARTMENTS OF A PROVIDER.

12          Section 1833(t) of the Social Security Act (42 U.S.C.

13  1395l(t)) is amended—

14                 (1) in paragraph  (1)(B)—

15                         (A) in clause (iii), by striking ‘‘but’’ at the

16                 end;

17                         (B) in clause (iv), by striking the period at

18                 the end and inserting ‘‘; and’’; and

19                         (C) by adding at the end the following new

20                 clause:

21                                ‘‘(v) does not include applicable items

22                         and  services (as  defined in  subparagraph

23                         (A) of paragraph  (21))  that  are  furnished

24                         on  or  after  January   1,  2017,  by an  off-

25                         campus  outpatient   department   of  a  pro-

3                 (2)  by  adding  at  the  end  the  following new

4          paragraph:

5                 ‘‘(21) SERVICES  FURNISHED   BY  AN   OFF-CAM-


7                         ‘‘(A) APPLICABLE  ITEMS AND  SERVICES.—

8                 For  purposes  of paragraph  (1)(B)(v)  and  this

9                 paragraph,  the term ‘applicable items and serv-

10                 ices’ means items and services other than emer-

11                 gency   department   services  (identified,   as   of

12                 January   1,  2015,  by  HCPCS   codes  99281–

13                 99285  (and  as  subsequently  modified  by  the

14                 Secretary)).

15                         ‘‘(B)  OFF-CAMPUS  OUTPATIENT   DEPART-

16                 MENT  OF  A PROVIDER.—

17                                ‘‘(i)  I GENERAL.—For  purposes  of

18                         paragraph   (1)(B)(v)  and  this  paragraph,

19                         subject to clause (ii), the term ‘off-campus

20                         outpatient    department    of    a     provider’

21                         means a department  of a provider (as  de-

22                         fined in section 413.65(a)(2)  of title 42 of

23                         the Code of Federal  Regulations, as in ef-

24                         fect as of the date of the enactment of this

25                         paragraph)  that  is not located—

2                                such   section  413.65(a)(2))   of   such

3                                provider; or

4                                        ‘‘(II)    within  the    distance   (de-

5                                scribed in such definition of campus)

6                                from a  remote  location of a  hospital

7                                facility  (as   defined  in  such  section

8                                413.65(a)(2)).

9                                ‘‘(ii)   EXCEPTION.—For     purposes of

10                         paragraph   (1)(B)(v)  and  this  paragraph,

11                         the   term   ‘off-campus  outpatient depart-

12                         ment of a provider’ shall not include a de-

13                         partment  of a provider (as so defined) that

14                         was billing under  this  subsection with re-

15                         spect  to  covered OPD  services  furnished

16                         prior  to the date  of the enactment  of this

17                         paragraph.

18                         ‘‘(C) AVAILABILITY   OF   PAYMENT  UNDER

19                 OTHER  PAYMENT  SYSTEMS.—Payments for ap-

20                 plicable items and services furnished by an off-

21                 campus  outpatient   department   of  a  provider

22                 that  are described in paragraph  (1)(B)(v)  shall

23                 be made under  the  applicable payment  system

24                 under  this  part   (other  than   under  this  sub-

1                 section)  if the  requirements  for  such  payment

2                 are otherwise met.

3                         ‘‘(D) INFORMATION NEEDED   FOR   IMPLE-

4                 MENTATION.—Each     hospital   shall  provide to

5                 the Secretary such information as the Secretary

6                 determines appropriate  to implement this para-

7                 graph  and paragraph  (1)(B)(v)  (which may in-

8                 clude  reporting   of  information  on  a  hospital

9                 claim using a code or modifier and reporting in-

10                 formation  about  off-campus outpatient  depart-

11                 ments of a provider on the enrollment form de-

12                 scribed in section 1866(j)).

13                         ‘‘(E) LIMITATIONS.—There shall be no ad-

14                 ministrative   or  judicial  review  under   section

15                 1869,  section  1878,  or  otherwise  of  the  fol-

16                 lowing:

17                                ‘‘(i) The determination of the applica-

18                         ble items and services under subparagraph

19                         (A) and applicable payment systems under

20                         subparagraph  (C).

21                                ‘‘(ii) The  determination  of whether a

22                         department  of a  provider meets  the  term

23                         described in subparagraph  (B).

1                                ‘‘(iii) Any information  that  hospitals

2                         are  required  to  report  pursuant   to  sub-

3                         paragraph  (D).’’.

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