Hurdles Slowing Down Migration of Procedures Barriers to moving complex procedures from HOPDs to your ASC BY CRISTINA BENTIN
CY 2021 brought policy and reimbursement changes that would seem to posi- tion ASCs favorably for an obvious migration of cases
from the hospital outpatient depart- ment (HOPD) to the ASC. The Cen- ters for Medicare & Medicaid Services (CMS) automatically added more than 267 cases to the CMS Covered Proce- dures List (CMS-CPL) due to a revi- sion of the exclusionary criteria which removed the top five exclusions criteria that originally prevented certain types of cases from being performed in an ASC setting. Current quality data and surgical procedure transparency tools provide the consumer a semblance of control when determining the site of care for common procedures. Yet, a higher volume of cases could migrate from the HOPD to the ASC if a few hurdles could be overcome.
Adjusted Hospital Market Basket In the 2019 Hospital Outpatient Pro- spective Payment System (OPPS) and
Table 1 Specialty
Orthopaedics GI
Pain
Ophthalmology Cardiology ENT
Urology Podiatry
CPT Code 29881 45380 62323 66984 93452 31267 52005 28295
ASC Reimbursement Rate
1335.09 526.70 322.32
1044.65 1410.59 2001.10 801.06
1335.09
HOPD Reimbursement Rate
2830.40 1036.96 634.59
2079.16 2899.02 5822.76 1792.99 2830.40
The reimbursement rate of ASCs as compared to the HOPD has been at approximately 50 percent. A comparison of ASC to HOPD approximate reimbursement(s) is provided and serves only as an example.
Ambulatory Surgical Cen- ter (ASC) Payment System (OPPS/ ASC) final rule, ASC payment sys- tem rates were updated according to the hospital market basket update for an interim period of five years. Dur- ing this five-year period, CMS would assess whether the change from the Consumer Price Index for All Urban Consumers (CPI-U) to the adjusted hospital market basket would result in a migration of certain procedures typically performed in the HOPD set- ting to the ASC setting. CMS antic- ipates a cost savings for the Medi- care program and its beneficiaries as well as being able to provide another option for a site of care. The migra-
18 ASC FOCUS APRIL 2021 |
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tion is slow due to several factors including budget neutrality adjust- ments that result in significantly lower reimbursement rates for ASCs for identical procedures performed in the HOPD setting.
Budget Neutrality/Weight Scalar CMS maintains
budget neutrality
within separate payment systems, for example, HOPD, ASC and physician’s office. CMS updates the ASC pay- ment system annually using relative payment weights equal to OPPS rela- tive payment weights for the same ser- vices, and then scales the ASC weights to maintain budget neutrality. Since the ASC payment rate is based on the HOPD, the already scaled HOPD rate is then scaled a second time to result in the ASC payment rate. The result is
an average reimbursement of about 50 percent (see table 1). CMS’ current approach to main- budget
taining neutrality in
the
ASC payment system is resulting in an increasingly higher dispar- ity in reimbursement for similar services provided in the ASC ver- sus HOPD settings. The cost to per- form these procedures as compared to the reimbursement received in the ASC makes it financially impossi- ble for the ASC to offer certain pro- cedures to the Medicare consumer. This is seen with the advocation and proposal of percutaneous coronary interventions (PCI) procedures in the ASC. The Medicare ASC reim- bursement rate, a rate of 75 percent less than that of HOPDs, does not
The advice and opinions expressed in this column are those of the author and do not represent official Ambulatory Surgery Center Association policy or opinion.
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