REGULATORY REVIEW


are generally reduced by half of their usual rates. For a list of codes not sub- ject to multiple procedure discounting, visit “Multiple Procedure Discounting Exempt,” a members-only page avail- able on the Payment Resources section of ASCA’s web site.


Potential Downward Adjustment As a reminder, ASCs must meet all Ambulatory Surgical Center Quality Reporting (ASCQR) Program requirements in order to receive the full ASC annual program update. For more information, visit www.ascassociation. org/federalregulations/qualityreporting.


Other Payment Methodologies CMS uses different methods to set ASC payment rates for office-based procedures, separately payable radiol- ogy services, separately payable drugs and device-intensive procedures. Office-based procedures are defined


as those furnished in physicians’ offices at least 50 percent of the time. Pay- ment for these procedures is set at the lower of the standard ASC rate or the practice expense portion—this amount covers equipment, supplies, non-phy- sician staff and overhead expenses of a service—of the physician fee sched- ule rate that applies when the service is furnished in a physician’s office. CMS applies the same policy to separately payable radiology services. When separately payable drugs


are furnished in ASCs, CMS pays ASCs the same amount it pays under the OPPS. Device-intensive procedures are defined as OPPS services for which the device cost is packaged into the procedure payment and the cost of the device accounts for at least 40 per- cent of the total payment based on the OPPS payment. CMS divides the pay- ment into a device portion and a non- device portion. CMS pays the ASC the same amount it would under the OPPS for the device portion but pays the


22 ASC FOCUS APRIL 2016


ASCs must meet all Ambulatory Surgical Center Quality Reporting (ASCQR) Program requirements in order to receive the full ASC annual program update. For more information, visit www.ascassociation. org/federalregulations/ qualityreporting.”


—Kara Newbury, ASCA


integrity of the Ambulatory Payment Classification (APC) groups and their associated weights, which are major elements of the OPPS. The panel is technical in nature and may advise on the following issues: ■


addressing whether procedures within an APC group are simi- lar both clinically and in terms of resource use;


lower amount for the non-device por- tion of the service.


Advisory Panel on Hospital Outpatient Payments Reviewing all of the data provided by hospitals and trying to come up with accurate payment rates for thousands of codes is a daunting task. To provide CMS with some perspective from the entities whose payments are impacted, the Advisory Panel on Hospital Out- patient Payments, or HOP, was estab- lished. The HOP advises the secre- tary of the US Department of Health and Human Services (HHS) and the administrator of CMS on the clinical


Track the Latest Regulatory and Legislative News for ASCs


Visit ASCA’s web site every week to stay up to date on the latest government affairs news affecting the ASC industry. Every week, ASCA’s Government Affairs Update newsletter is posted online for ASCA members to read. The weekly newsletter tracks and analyzes the latest legislative and regulatory developments concerning ASCs.


www.ascassociation.org/ GovtAffairsUpdate


reconfiguring APCs (for example, splitting of APCs, moving HCPCS codes from one APC to another and moving HCPCS codes from new technology APCs to clinical APCs); ■ evaluating APC group weights; ■


■


reviewing packaging the cost of items and services, including drugs and devices, into procedures and services, including the methodol- ogy for packaging and the impact of packaging the cost of those items and services on APC group structure and payment;


■


removing procedures from the inpa- tient list for payment under the OPPS; and


■


using claims and cost report data for CMS’ determination of APC group costs.


The panel consists of up to 15 members who are representatives of hospitals or health systems. Unfortu- nately, the ASC industry is not repre- sented on this panel, even though ASC payments are clearly impacted by the group’s recommendations. ASCA is trying to change this situation through ASCA’s signature piece of legislation, the ASC Quality and Access Act of 2015, which would statutorily require the HOP to include at least one ASC representative.


Kara Newbury is ASCA’s regulatory counsel. Write her at knewbury@ascassociation.org.


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