Historically, the Centers for Medicare and Medicaid Services (CMS) has reimbursed items and services furnished by provider-based departments (PBDs), both on and off campus, under the Medicare Hospital Outpatient Prospective Payment System (OPPS). As of January 1, 2017, however, different reimbursement frameworks apply to so-called excepted PBD – i.e., on-campus PBDs and certain grandfathered PBDs – and non-excepted off-campus PBDs. Moreover, off-campus PBDs that qualify as “mid-build” may have to navigate both frameworks depending on the date of the services or items furnished.
In brief, items and services furnished in on-campus PBDs and grandfathered off-campus PBDs – i.e., off-campus PBDs that provided OPPS-covered items and services prior to November 2, 2015 – continue to be reimbursed under the OPPS. Conversely, off-campus PBDs that do not qualify for grandfathering are now reimbursed at new, site-specific Medicare Physician Fee Schedule rates. For an overview of the criteria for determining whether an off-campus PBD is grandfathered, the rules governing grandfathered status (including restrictions on relocation and change of ownership), and the new reimbursement structure for non-excepted off-campus PBDs, please click here.
In addition, certain off-campus PBDs that were “mid-build” prior to November 2, 2015 will be eligible for OPPS reimbursement effective January 1, 2018. Until January 1, 2018, however, items and services furnished by “mid-build” PBDs operational in 2017 will be reimbursed at the new rates established for non-excepted PBDs. For a summary of the “mid-build” requirements and reimbursement rules, please click here.