Understand how we got here — and how to move forward.

Blog Post

7 policies cancer programs need to know from Medicare's 2022 final rules

By Ashley Riley

November 12, 2021

    The revisions to the Radiation Oncology Model (RO Model) were by far the biggest news for cancer programs from the Calendar Year (CY) 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule CMS released last week. But in all the excitement about the RO Model revisions, we're guessing you may have missed some of the other finalized policies.

    Don't worry—we've summarized four other policies impacting cancer programs from the CY 2022 OPPS/ASC final rule (in addition to the highlights from the RO Model revisions) for you below. We've also included two notable policies from the CY 2022 Medicare Physician Fee Schedule (MPFS) final rule and Fiscal Year (FY) 2022 Inpatient Prospective Payment System (IPPS) final rule.

    Dec. 2 webinar: What the final outpatient and physician payment rules mean for health care

    1. RO Model still starting in January, but likely with some flexibilities

    CMS finalized most of its proposed RO Model revisions in the CY 2022 OPPS/ASC final rule without modification, including that the RO Model will start on January 1, 2022. But notably, CMS's proposals to adopt an extreme and uncontrollable circumstances (EUC) policy for the RO Model and to create tracks for participants were finalized with modifications.

    Under the finalized EUC policy, CMS intends to make RO Model requirements for quality reporting, participation in an AHRQ-listed patient safety organization, and peer review for treatment plans optional for participants for performance year 1 (unless the Secretary terminates his renewal of the Covid-19 public health emergency prior to January 1, 2022). If these flexibilities are implemented, the 2% quality withhold will not be applied to professional episode payments in performance year 1. CMS does not intend to amend the model performance period under the EUC policy.

    CMS also finalized that there will be three tracks (instead of two as proposed) for RO Model participants related to Quality Payment Program status. Track One will be for professional and dual participants who comply with all RO requirements, including CEHRT, and is expected to qualify as both an Advanced APM and MIPS APM. Track Two will be for professional and dual participants who comply with all RO requirements except for CEHRT and is expected to qualify as a MIPS APM only. Track Three will be for all other participants and will not qualify as an Advanced APM or MIPS APM.

    2. 340B payment rate will stay at ASP-22.5%

    CMS announced in the CY 2022 OPPS/ASC final rule that it will continue the payment rate of ASP-22.5% for 340B-acquired drugs for CY 2022. The agency believes this rate represents the minimum discount 340B covered entities receive. This more closely aligns the payment rate with the resources expended to acquire such drugs, while also recognizing the intent of the 340B program to allow covered entities to stretch scare resources in ways that enable them to continue providing access to care for patients.

    CMS also hopes that keeping the payment rate consistent will give hospitals much-needed certainty amidst the Covid-19 public health emergency. And 340B providers can hopefully breathe a small sigh of relief that, unlike in previous rules, CMS did not indicate or even hint at the fact that it would make further cuts to the payment rate in the future.

    3. New Breast Screening Recall Rates OQR measure adopted

    CMS finalized the addition of the Breast Screening Recall Rates measure (OP-39) to the Hospital Outpatient Quality Reporting (OQR) Program beginning with the CY 2023 payment determination (based on 2020-2021 data). This facility-level measure is calculated as the percentage of screening mammography and digital breast tomosynthesis (DBT) studies that are followed by a diagnostic mammography, diagnostic DBT, breast ultrasound, or breast MRI study performed in an outpatient or office setting on the same day or within 45 days. Fortunately, the measure is claims-based, so providers don't need to report any additional information to CMS.

    CMS considers 5-12% as the appropriate range for recall rates based on clinical evidence. Facilities with recall rates lower than 5% are likely missing some cancer cases, while those with recall rates higher than 12% are likely recalling some patients unnecessarily. CMS recommends facilities use the results from this measure to identify opportunities for improving care efficiency and quality. However, there is no financial penalty for facilities performing outside of the target recall rate range.

    4. Radiation therapy and drug administration reimbursement will increase slightly

    HOPD reimbursement for almost all levels of radiation therapy, radiation treatment preparation, and drug administration ambulatory payment classifications (APCs) will increase by 2% in 2022 compared to 2021. The exceptions are the level 1 radiation therapy APC, which will increase by only 1%, and the level 4 drug administration APC, which will increase by 5%. Notably, no radiation or drug administration APCs will see a decrease in reimbursement for 2022.

    5. Beneficiaries will no longer have to pay coinsurance for additional procedures related to planned colorectal screening tests

    Both the CY 2022 OPPS/ASC and CY 2022 MPFS final rules include provisions reflecting the changes to beneficiary coinsurance for colorectal cancer screening tests made under the Consolidated Appropriations Act (CAA) of 2021. Section 122 of the CAA effectively states that screening flexible sigmoidoscopies and colonoscopies are still considered screening procedures (and should be paid as such) even if they lead to additional procedures, such as the removal of tissue, during the same clinical encounter. As such, Medicare beneficiary coinsurance for these procedures will be gradually reduced from the 20-25% coinsurance beneficiaries are currently responsible for when these are billed as diagnostic procedures to the 0% coinsurance associated with screening procedures between CY 2022 and CY 2030.

    Although CMS finalized its proposal in the CY 2022 OPPS/ASC final rule to view all surgical services provided on the same date as a planned screening colonoscopy or flexible sigmoidoscopy as part of the same clinical encounter as the screening test for the purpose of determining coinsurance, the agency noted that it will monitor claims data for increases in surgeries performed on the same date as but unrelated to the colorectal cancer screening test and consider revising its policy if there is a notable increase or abuse of the policy.

    6. PAs can bill directly to Medicare now

    In the CY 2022 MPFS final rule, CMS implemented section 403 of the CAA authorizing physician assistants (PAs) to bill Medicare directly for services they provide under Part B starting on January 1, 2022. Currently, Medicare can only make payment to the employer or independent contractor of a PA. With this policy change, cancer programs should rethink how they use PAs to ensure top-of-license practice and maximize reimbursement.   

    Read more about the CY 2022 MPFS final rule

    7. CAR T-cell therapy DRG assigned new procedures codes and revised name

    In the FY 2022 IPPS final rule, CMS assigned 16 new procedure codes to the CAR T-cell therapy DRG (MS-DRG 018) in addition to the two procedures codes that were assigned to it when it first became active on October 1, 2020. CMS also revised the name of the DRG from "Chimeric Antigen Receptor (CAR) T-cell Immunotherapy" to "Chimeric Antigen Receptor (CAR) T-cell and Other Immunotherapies."

    Although these are relatively minor changes, they help create a clearer path for reimbursement for future cell therapies that aren't autologous CAR T-cell therapies by making room for their inclusion in the DRG.   

    More from Advisory Board about Medicare’s 2022 final rules

    Stay Up to Date: What the final outpatient and physician payment rules mean for health care

    Thursday, December 2 | 3 p.m. ET

    calendarThe final rules for both outpatient and physician reimbursement are due out by early November. Join Christopher Kerns and health policy expert Heather Bell as they talk through what made it into the final rules, including the biggest changes, surprises, and long-term implications for the entire industry.

    Register now

    Have a Question?


    Ask our experts a question on any topic in health care by visiting our member portal, AskAdvisory.