ciation brings surgeons to CMS to pres- ent on the safety of specific codes to CMS’ medical officers. Although this process is time-consuming, it has been the most successful way to get codes added to the ASC-payable list. Over the past five rulemaking cycles, ASCA advocacy resulted in the addition of 56 codes. In 2019, there were 17 cardiol- ogy codes added. The remaining 39 codes added between 2015 and 2018 were all spine and gynecological.

Removing Codes from the IPO List In addition to moving codes from the HOPD to the ASC setting, ASCA also advocates for codes that first need to be removed from the IPO list. Even though codes are rarely taken off the IPO list and put directly on the ASC- payable list, ASCA views this as a long-term initiative, and the first step to ASC reimbursement is reimburse- ment in the HOPD setting. CMS staff

review the following

criteria to identify codes that may be removed from the IPO list: ■■

Most outpatient departments are equipped to provide the services to the Medicare population;


The simplest procedure described by the code may be performed in most outpatient departments;

■■ ■■

The procedure is related to codes already removed from the IPO list;

A determination is made that the procedure is being performed in numerous hospitals on an outpatient basis; and


A determination is made that the procedure can be appropriately and safely performed in an ASC and is on the list of approved ASC proce- dures or has been proposed by us for addition to the ASC list. The primary area in which ASCA

has advocated for codes to be removed from the IPO list is regarding total joint replacements. We have taken multiple orthopedic surgeons to meet with CMS to present on their outcomes data, pri- marily for total knee arthroplasty (TKA)

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.”

—Kara Newbury, ASCA

and total hip arthroplasty (THA). In addition, in August 2016, a surgeon who is a member of ASCA presented to the Advisory Panel on Hospital Out- patient Payment (HOP Panel). The purpose of the HOP Panel is to advise the secretary of the US Department of Health and Human Services (HHS) and the administrator of CMS on optimal strategies for addressing issues related to the clinical integrity of procedures within the OPPS, including “remov- ing procedures from the inpatient list for payment under the OPPS payment system.” The HOP Panel unanimously recommended that CMS remove TKA from its IPO list after the presentation. While the HOP Panel’s recommen- dations are not binding on CMS, it is helpful to have this body support the movement of this code to the outpa- tient setting. In 2017, CMS sought pub- lic comments on whether TKA should be removed from the inpatient-only list. In the 2018 proposed rule, CMS proposed the removal of TKA from the inpatient-only list, citing support

from the previous year’s comments in addition to acknowledging they have “taken into account the recommenda- tion from the summer 2016 HOP Panel meeting to remove the TKA procedure from the IPO list.” CMS also requested more information from the public on potentially removing THA from the IPO list but no action has yet been taken on that procedure. ASCA will continue to work with its

member facilities, specialty organiza- tions and other industry stakeholders to advocate for the expansion of the ASC- payable list. While the slow movement can be frustrating to those in our com- munity who know these procedures can be performed safely on the Medicare population, we are making progress and providing more access than ever to Medicare beneficiaries who will benefit from the high-quality surgical experi- ence ASCs provide.

Kara Newbury is ASCA’s regulatory counsel. Write her at

ASC FOCUS MAY 2019 | 29

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