CODING


adequately cover the procedure and device costs in certain ASC markets. The initial costs it would take to


increase ASC reimbursement rates by eliminating the weight scalar will ultimately result in a significant cost savings to the Medicare pro- gram estimated in the billions over- time. ASCA’s 2020 Medicare pay- ment data analysis report, Reducing Medicare Costs by Migrating Vol- ume from HOPD to ASC provides a


complete analysis


excerpts listed below: ■


with a few


“During the eight-year period from 2011 to 2018, the total Medicare savings generated by ASCs was $28.7 billion.


■


During the 10-year period from 2019 to 2028, projected total Medi- care savings generated by ASCs is estimated to be $73.4 billion.


■


In the 2020 OPPS/ASC final rule, CMS estimated that moving just 5% of coronary interventions from HOPDs to ASCs would save $20 million in program payments and $5 million in beneficiary copayments.


■


HOPDs currently perform roughly 130,000 PCIs per year on Medi- care beneficiaries at a payment rate 75 percent higher than the ASC rate. Even excluding TKA, THA and other orthopedic procedures that might be approved for pay- ment in future years, musculoskel- etal surgeries performed in ASCs are expected to save Medicare more than $1 billion per year by 2028.


■


HOPDs performed more than 53,000 TKAs in 2018 (the first year of eli- gibility for payment), which CMS reports was roughly 25 percent of all Medicare TKAs.”


Lack of Transparency


Despite the transparency of quality of care and the advocation of quality reporting by the ASC industry, there is no one-stop shop for the consumer to access this information. Physician’s


Source: Medicare.gov


A higher volume of cases could migrate from the HOPD to the ASC if a few hurdles could be overcome.”


— Cristina Bentin, Coding Compliance Management LLC


office, HOPD and ASC data is con- fined to respective payment systems and not located in a data base where all systems can be accessed and compared under one dashboard. Furthermore, HOPDs do not report on exactly the same quality reporting program stan- dards as the ASC facilities and until such time that they are, the compari- son is apples to oranges.


CMS launched an online Proce- dure Price Lookup tool a few years ago that allows consumers to com- pare the Medicare payments for cer- tain procedures performed in the ASC versus the HOPD. While many cases


performed in an ASC reflect an obvi- ous cost savings for the beneficiary as compared to the HOPD, there are other complex procedures that have a higher out-of-pocket cost for the con- sumer. This creates a snowball effect in that the provider keeps the case at the HOPD to save the consumer the additional expense.


Higher Copay In many cases, the higher expense is due to a higher copay of a specific subset of complex procedures per- formed in the ASC not found in the HOPD. The HOPD surgery copay is capped while the ASC surgery copay for these higher-cost complex proce- dures is not. As a result, these com- plex procedures, such as the total knee arthroplasty (TKA), are not readily migrating to the ASC if the Medicare beneficiary cannot afford the ASC copay. If CMS does not see cases migrating to the ASC, the fear is CMS will not continue to update the ASC payment rates based on the hos- pital market basket after the 5-year period (see screenshot above).


ASC FOCUS APRIL 2021 | ascfocus.org 19


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