REGULATORY REVIEW
Adding procedures to the ASC-payable list CMS decides to keep a procedure off the ASC procedure list based on the following exclusionary criteria: (1) Generally results in extensive blood loss; (2) Requires major or prolonged invasion of body cavities; (3) Directly involves major blood vessels; (4) Is generally emergent or life-threatening in nature; and (5) Commonly requires systemic thrombolytic therapy. In addition, if a code is on the inpatient- only list or an unlisted code, it cannot be performed in the ASC setting. If CMS excludes a code based on
one of the five exclusionary criteria above, it is not required to disclose which of the criteria makes the code ineligible for payment in the ASC set- ting. ASCA continues to be proactive in this respect and works regularly with clinicians to present information about the safety and efficacy of cer- tain procedures to CMS medical offi- cers. ASCA’s regulatory advocacy this year will focus on providing CMS with more in-depth clinical information to show that additional codes are safe for the ASC setting.
Potential Expansion of Surgical Code Definition In addition to the exclusionary crite- ria above, certain codes that ASCA would argue are surgical codes are not allowed to be performed as stand- alone procedures in the ASC setting because they fall outside of CMS’ definition of surgical codes. Accord- ing to CMS, surgical codes are typi- cally procedures described within the range of codes that the CPT Editorial Panel of the American Medical Asso- ciation (AMA) defines as “surgery” (CPT codes 10000 through 69999) and other codes that directly crosswalk or are clinically similar to procedures in the surgical range and are separately paid under the OPPS.
In 2003, Medicare paid ASCs 86 percent of the amount paid to HOPDs; today, Medicare pays ASCs 50 percent of the amount paid to HOPDs.”
—Kara Newbury, ASCA In the 2017 proposed payment
rule, CMS requested public com- ments regarding services that fall out- side their current definition but may be appropriate to include as covered surgical procedures payable when fur- nished in the ASC setting.
ASCA recommended that CMS
revise the definition of surgical pro- cedure so that it can better accommo- date existing procedures and proce- dures made available through technical advances that have not yet been con- sidered. As CMS considers expanding the definition of surgical procedures, ASCA requested the inclusion of diag- nostic and interventional cardiac pro- cedures currently covered when per- formed in the HOPD. While CMS did not make any pol-
icy changes regarding the definition of surgical codes in its 2018 payment rule, it indicated an interest in address- ing this issue in future rulemaking. This is one of ASCA’s top regulatory
priorities related to the 2019 payment rule. ASCA met with CMS payment policy staff in February to advocate for a change regarding CMS’ policy on defining surgical codes. ASCA members can stay up to
date on the advocacy efforts ASCA is undertaking on behalf of the ASC community by reading regular arti- cles like this one in ASC Focus maga- zine, ASCA’s special email alerts and public announcements and ASCA’s weekly “Government Affairs Update” digital newsletter delivered to members’ inboxes every Thurs- day. If you are not already receiv- ing that newsletter, you can sub- scribe here:
www.ascassociation.org/ governmentaffairsupdate. If you would like to be more involved, write Kara Newbury at knewbury@
ascassociation.org.
Kara Newbury is ASCA’s regulatory counsel. Write her at
knewbury@ascassociation.org.
ASC FOCUS APRIL 2018 |
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