REGULATORY REVIEW


Evolution of Cardiology Procedures in ASCs Outcomes data and research will play a critical role in future expansion BY KARA NEWBURY


While the addition of many cardiology codes to the ASC covered pro- cedures list over the past three years may seem


sudden to some, this move is more than 15 years in the making. It began with the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003, which directed the US Department of Health and Human Services (HHS) secretary to imple- ment a revised payment system for surgical services furnished in ASCs. Although work related to ASC pay- ments was going on for years before the MMA was adopted, that law served as the catalyst for the payment system ASCs have today.


Shift to the Current ASC Payment System


After the enactment of the MMA, the Centers for Medicare & Medicaid Ser- vices (CMS) began working with stake- holders to revamp the ASC payment system. The revised payment system was proposed on August 23, 2006, and became effective on January 1, 2008. The biggest changes came from the payment system being tied to the hospi- tal outpatient prospective payment sys- tem (OPPS), with rates being derived from the OPPS rates. Although sweep- ing changes were made to how the pay- ment system was structured, for the most part, the definition of “surgical procedure” remained from pre-2008:


“Under the existing ASC payment system, we define a surgical pro- cedure as any procedure described within the range of Category I CPT codes that the CPT Editorial Panel of the American Medical Associa- tion (AMA) defines as ‘surgery’


20 ASC FOCUS MARCH 2021 | ascfocus.org


CMS believed that continuing to rely on the CPT definition of surgery was “administratively straightforward.” Given the sweeping changes CMS was making, and the great expansion of the ASC Covered Procedures List (ASC-CPL) at the time, CMS thought it prudent at the outset to continue to define surgery as it is defined by the CPT code set, which is also used to report services for payment under both the OPPS and the Medicare Physician Fee Schedule (MPFS).


2018 Rulemaking


(CPT codes 10000 through 69999). Under the revised payment system, we proposed to continue to define surgery using that standard.”


CMS did decide to include within the scope of surgical procedures pay- able in an ASC those procedures that are “described by Level II HCPCS codes or by Category III CPT codes that directly crosswalk to or are clinically similar to procedures in the CPT surgical range.” CMS included all three types of codes— Category I CPT codes in range, Level II HCPCS and Category III CPT—because they are all eligible for payment under the OPPS, and “to the extent it is reason- able to do so,” CMS aims for alignment in policies between the OPPS and ASC payment system. CMS recognized back in 2006 that “continuing to use this defini- tion of surgery would exclude from ASC payment certain invasive, ‘sur- gery-like’ procedures, such as car- diac catheterization or certain radi- ation treatment services which are assigned codes outside the CPT sur- gical range.” At the time, however,


After nearly a decade under the cur- rent payment system, in the sum- mer of 2017, CMS took its first steps toward expanding the definition of sur- gery, paving the way for more cardi- ology codes to be added to the ASC- CPL. In its proposed payment rule that year, CMS requested public comments regarding “services that do not directly crosswalk and are not clinically similar to procedures in the CPT surgical range, but that nonetheless may be appropri- ate to include as covered surgical pro- cedures payable when furnished in the ASC setting.” While requests for com- ment typically do not result in changes during that rulemaking cycle, they open the dialogue and indicate changes may be coming in future years. In its comments in response to that proposed rule, ASCA asserted that the definition also was inconsistent with how CMS defines surgery for other purposes. For example, in a 2009 National Coverage Determination in which CMS explained payment poli- cies for certain surgical errors, the definition was broader, indicating that surgical procedures include “all procedures described by the codes in the surgery section of the Cur-


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