REGULATORY REVIEW


The ASC Procedure List Puzzle How does CMS decide? Are Medicare policies stifling migration to the ASC setting? BY KARA NEWBURY


A


dvances in medical technology and patient safety are creating


an ever-growing list of procedures appropriate for ambulatory settings and have expanded the types of patients who can be treated outside the hospital. Despite these advances, the Centers for Medicare & Medicaid Services’ (CMS) payment policies could be responsible for the slow or negative growth in Medicare volume in the ASC setting that we are seeing today and at least partly responsible for the historically low numbers of new ASCs entering the marketplace.


Lack of Transparency CMS’ process for determining whether to move procedures to its list of ASC- covered procedures lacks transparency. The ASC list of covered procedures is an “exclusionary list,” meaning that ASCs should be allowed to perform any surgical procedure that is not designated as an “inpatient only procedure” unless CMS has explicitly determined that the procedure would raise one or more specific safety concerns found at 42 CFR §416.166 and listed below: ■


Typically requires active medical monitoring and care past midnight; ■ Directly involves major blood vessels; ■


■ ■ Every year during the rulemaking


process, CMS evaluates the proce- dures excluded from its list of pro- cedures that it will reimburse ASCs for providing, as well as procedures newly removed from its inpatient-only list, and determines if any additional procedure should be moved to the ASC-payable list based on the crite- ria above. In the 2014 proposed ASC payment rule, CMS recommended that no procedures be moved to the ASC payable


list, but provided no


specific justification for why particu- lar procedures are excluded from the ASC list. As ASCA has done repeat- edly in the past, in its comment letter to CMS, it urged the agency to bring transparency to its decision-making and disclose the specific reason that a procedure has been excluded from the list of ASC-covered procedures. CMS, ASCA suggested, could


provide


Poses a significant safety risk to the beneficiary;


Requires major or prolonged inva- sion of body cavities;


Generally results in extensive blood loss;


■ Emergent in nature;


■ Life-threatening in nature; ■


■


Commonly requires systemic throm- bolytic therapy; or


Can only be reported using an unlisted surgical procedure code


28 ASC FOCUS JUNE/JULY 2014


greater transparency by including an appendix of the procedures Medicare reimburses in the hospital outpatient department (HOPD) setting but not in the ASC setting and including a code that corresponds to one of the specific reasons for exclusion listed above. ASCA also asked the agency to disclose the clinical evidence upon which the rationale for exclusion is based. Such transparency would foster a constructive dialogue as CMS evaluates additions to the ASC list of covered procedures.


Lack of Payment List Parity Currently, Medicare and its benefi- ciaries pay 81 percent more for pro- cedures done in an HOPD instead of an ASC. Exacerbating the costs to the Medicare system, there are nearly 500 codes that are reimbursed in the HOPD but not the ASC. When procedures that


could be done safely in the ASC are not included on the payable list, it is the system that pays the price. ASCA coordinated a meeting with CMS policy staff and an ASC sur- geon who is performing some of these excluded codes on a regular basis with excellent results. However, it is not feasible for industry clinicians to address all 500 procedures that are currently excluded, so ASCA also sur- veyed ASCs to guide its recommen- dations regarding which procedures CMS should add to the ASC payable list. We received many responses and, using the survey results as guidance, identified procedures that are currently being paid for by commercial payers, but not by Medicare, and would not raise any of the specific safety con- cerns that bar a procedure from being added to the ASC list of covered pro- cedures. In our comments to CMS, ASCA advocated for 37 procedures to be added to the ASC-payable list.


High Volume Codes In its comments, ASCA provided a separate analysis of procedures with high Medicare volume—defined as 1,000 cases or more performed annually in the HOPD setting—that surgeons routinely perform in ASCs for commercial payer cases, but cannot obtain Medicare reimbursement for performing. The chart that appears on page 29 includes the current HOPD cost for the procedures, as well as the 2011 volume done in the HOPD setting, which can help illustrate the cost savings that could be achieved by moving these procedures to the lower cost, high-quality ASC setting. For example, a radical mastectomy (CPT code 19307) has high Medicare volume in the outpatient setting but is


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