ASCs Gain Significant Ground under Proposed Rule Medicare’s 2019 ASC payment proposal incorporates several ASCA requests BY KARA NEWBURY

The 2019 Hospital Out- patient Prospective Pay- ment System (OPPS) and Ambulatory Surgical Cen- ter Payment System Pay-

ment Rule that the Centers for Medicare & Medicaid Services (CMS) released at the end of July is the most positive for ASCs since 2009, when the ASC pay- ment system was aligned with the hos- pital outpatient department (HOPD) payment system. It also accommodates some important requests ASCA has made since that time.

Conversion Factor For the first time since the ASC and HOPD payment systems were aligned in 2009, CMS proposed to use the same update factor for our setting as it uses for hospitals. Under this pro- posal, CMS would update the ASC conversion factor using the hospital market basket (HMB) instead of the Consumer Price Index for All Urban Consumers (CPI-U). For CY 2019, CMS proposed to increase the conversion factor by 2 percent under the ASC Payment Sys- tem (for ASCs that meet the quality reporting requirements). This is cal- culated as 2.8 percent hospital market basket update minus the multi-factor productivity adjustment (MFP) of 0.8 percent. This adjustment is required under the Affordable Care Act (ACA). If the agency had proposed to continue using the CPI-U, the proposed effective update would have been 1.3 percent. For HOPDs, CMS proposed the

conversion factor to increase by 1.25 percent, which is calculated as a 2.8 percent for HMB minus MFP of 0.8 plus an additional 0.75 adjustment that is mandated for hospitals under the ACA. In its discussion on the update


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factor, CMS did request feedback on whether the 0.75 adjustment applied to hospitals should also be applied to ASCs. As the adjustment is statutorily required for hospitals but not ASCs, ASCA contends that would be beyond the agency’s authority to apply the same adjustment to ASCs. CMS indicated that,

if finalized,

the agency will use the hospital mar- ket basket to update ASC payments for CY 2019 through CY 2023. During that time, CMS will monitor volume to see if this policy has led to migration to the lower cost setting. It will also “assess the feasibility of collaborating with stakeholders to collect ASC cost data in a minimally burdensome man- ner and could propose a plan to col- lect such information.” ASCA has con- cerns with the burdens associated with cost reporting and will work closely with CMS on this issue.

Secondary Rescaling Unfortunately, CMS proposed to con- tinue the secondary rescaling that it has used since the ASC payment sys- tem was aligned with the HOPD pay-


ment system. The proposed ASC weight scalar of 0.8854 is lower than the 2018 final ASC weight scalar of 0.8995, which essentially negates any gains made through the update factor change. In its comments in response to the rule, ASCA proposed that CMS discontinue the ASC relative weight scalar or create a minimum relation- ship ratio of ASC to HOPD payments (set, for example, at 55 percent) to encourage migration of Medicare pro- cedures to the ASC setting.

Definition of Surgical Procedures and Evaluation of ASC-Payable List CMS proposed to revise the definition of “surgery” in the ASC payment sys- tem to account for certain “surgery- like” procedures that are assigned codes outside the Current Procedural Termi- nology (CPT) surgical range. As part of this evaluation, CMS has proposed the addition of 12 cardiac catheterization procedures to the ASC covered proce- dures list. These codes have typically fallen outside of the traditional surgical code range but meet the criteria of sur- gery according to other clinical defini- tions provided by organizations such as the American College of Surgeons. In addition, CMS is soliciting pub- lic comments on a proposal to reassess, and soliciting further public comments on, procedures recently added to the ASC covered procedures list. Under this proposal, CMS would assess codes added in 2015, 2016 and 2017, the majority of which were spine codes. In its comments, ASCA highlighted the safety and efficacy of these procedures in the ASC setting and cited current research confirming its assertions. There was no mention at all regard-

ing removing any more joint replace- ment codes from the inpatient-only list

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