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REGULATORY REVIEW


Adding Procedures to the ASC-Payable List ASCA advocacy bears fruit BY KARA NEWBURY


Advances in medical technology and changes in Medicare payment policy have expanded the list of procedures that


the Centers for Medicare & Medic- aid Services (CMS) will reimburse ASCs for providing to the program’s beneficiaries. ASCA has advocated for its members and urged CMS to add procedures to the ASC-payable list that can be performed safely on the Medicare population in the ASC setting. Since 2013, CMS has added 93 procedures to the ASC-payable list that were previously reimbursed only in hospitals.


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


20 ASC FOCUS MAY 2020 | ascfocus.org


Annual Review Process


As CMS describes in the CY 2009 OPPS/ASC final rule each year, the agency evaluates the ASC list of cov- ered surgical procedures and decides whether the procedures being pro- posed for removal from the OPPS inpatient-only (IPO) list should be included on the ASC list. In making those decisions, CMS must determine if these codes fall under any of the ASC list exclusionary criteria.


Criteria used for evaluation CMS excludes codes from the ASC- payable list that pose a significant safety risk to the beneficiary and those that


typically require medical monitoring and care


active past


midnight. In addition, the CMS med- ical officers evaluate whether a code


meets the following exclusionary cri- teria, found in 42 CFR §416.166: ■ ■


directly involves major blood vessels;


requires major or prolonged inva- sion of body cavities;





generally results in extensive blood loss;


■ emergent or life-threatening in nature; ■


commonly requires systemic throm- bolytic therapy;


■ ■


are designated as requiring inpatient care; 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 hos- pital outpatient department (HOPD) setting but not the ASC setting. So,


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