Growing Medicare’s ASC-Payable List ASCA continues to advocate for expanded coverage BY KARA NEWBURY

While advances in medi- cal technology and changes in Medicare payment policy over the past four decades have expanded the list of

procedures for which the Centers for Medicare & Medicaid Services (CMS) will reimburse ASCs, Medicare policies have not kept pace with innovation. There are more than 300 procedures that are reimbursed in hospital outpatient depart- ments (HOPD) but not ASCs. Other procedures, such as total hip, shoulder, wrist and ankle, that ASCs are perform- ing safely on non-Medicare patients are still on the inpatient-only (IPO) list. ASCA is asking CMS to add codes to the ASC-payable list that our clinicians know can be performed safely on the Medicare population in the ASC setting.

History In 1982, CMS began covering and reimbursing for surgical procedures performed on Medicare beneficiaries in ASCs, initially covering only 200 codes. Since the ASC payment sys- tem was overhauled under the Medi- care Prescription Drug,


ment, and Modernization Act of 2003 (MMA), tying the ASC payment sys- tem to the hospital outpatient pro- spective payment system (OPPS), the number of surgical codes that are sep- arately payable in the ASC setting has held steady around 3,500 codes. The MMA requires CMS to work with appropriate medical organizations to specify surgical procedures that “can be performed safely on an ambulatory basis in an ambulatory surgical cen- ter.” Since the payment systems were aligned, CMS has chosen to evalu- ate the list every year during the rule- making process, although the statute only requires the list be reviewed and updated at least every two years.

28 ASC FOCUS MAY 2019 |


Visit ASCA’s website 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. GovtAffairsUpdate

Annual Review Process

As CMS discussed in the CY 2009 OPPS/ASC final rule with comment period, the agency will annually eval- uate the ASC list of covered surgical procedures and review the procedures that are being proposed for removal from the OPPS IPO list for possible inclusion on the ASC list of covered surgical procedures. As part of this review, CMS must determine if these codes fall under any of the ASC list exclusionary criteria.

Criteria used for evaluation Since the new payment system was established beginning with claims on January 1, 2008, CMS medical offi- cers have evaluated the procedures excluded from the ASC-payable list to determine if any additional proce- dure should be added to the list. CMS excludes codes from the ASC-payable list that are on the inpatient-only list and typically require active medical monitoring and care past midnight. In addition, CMS medical officers evalu- ate whether a code meets the follow-

ing exclusionary criteria, found at 42 CFR §416.166: ■■

Poses a significant safety risk to the beneficiary;

■■ Typically requires active medical

monitoring and care past midnight; ■■ Directly involves major blood vessels; ■■


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

List Review and Evaluation There are thousands of codes that are on the inpatient-only list, and more than 300 codes payable in the HOPD setting but not the ASC setting. So, how does CMS effectively evaluate whether to move codes to the ASC- payable list? At this point, there is no set process for submitting codes for approval—there is no form to fill out nor a set meeting to attend. ASCA has long requested that CMS allow ASCs to perform all the same proce- dures HOPDs can perform since the Conditions of Participation that must be met by HOPDs and the Conditions for Coverage for ASCs are essentially identical. CMS has not been inclined to make what they feel is a big change. Instead, CMS relies on various spe- cialty groups, industry leaders and organizations, such as ASCA, to pro- actively bring individual procedures to them for review on a more piece- meal basis.

ASCA uses trends found in the annual procedure list survey that it sends to members to determine which codes it should pursue. Then, the asso-

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