will not truly see migration until they fix that problem as well.

Support expansion of the ASC-CPL. ASCA has long advocated that proce- dures that can safely be performed in HOPDs also are safe for the ASC set- ting and should be added to the ASC Covered Procedures List (ASC-CPL). While ASCA was pleased to see the addition of 267 codes to the ASC-CPL for 2021, our clinicians have indicated there are more codes that they would like to see added to the ASC-CPL. A recent policy change currently pre- cludes their future consideration.

Inpatient-Only List In 2021 rulemaking, CMS began the process of eliminating the inpatient- only (IPO) list over the next few years. Presumably, as a safeguard to ensure procedures were not immediately added to the ASC-CPL, CMS modi- fied the ASC Code of Federal Regula- tion (CFR) language to exclude from ASC-CPL consideration “procedures designated as requiring inpatient care under 419.22(n) as of December 31, 2020.” As worded, this prohibits CMS from adding codes to the ASC-CPL that were on the IPO list as of 2020 for as long as this language is in the CFR. We highlighted this problem in our 2021 comment letter, but the lan- guage was finalized as written.

Unlisted Codes

The CFR also precludes from consider- ation on the ASC-CPL procedures that are “only able to be reported using a CPT unlisted surgical procedure code.” There is no clear safety rationale for this provision, and commercial payers commonly provide ASCs the flexibil- ity to use unlisted CPT codes to report procedures. Facilities must document why they need to use the unlisted code and receive approval from the payer to be reimbursed. This also is a practice

Due to problematic payment policies, such as the ASC weight scalar, CMS will not realize its desired Medicare cost reductions as there will be no incentive for providers to migrate services to our facilities.”

—Kara Newbury, ASCA

CMS permits for HOPDs and physician offices but not for ASCs. One unlisted code that is requested by our members annually is 41899 (dental surgery procedure), as it is the only CPT code available for dental sur- gery. While it is not significant for the Medicare population, this procedure is frequently performed on pediatric den- tal patients, many of whom are cov- ered by Medicaid. Some state Med- icaid plans only reimburse ASCs for codes found on the ASC-CPL, which causes access issues. ASCA is support- ing the American Dental Association (ADA) efforts on this issue. The ADA has requested a new HCPCS Level II Code for dental rehabilitation surgery,


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but some apparent roadblocks might require statutory change, as CMS does not typically cover dental procedures. At our March 1 meeting with CMS

staff, we raised both issues, with the problematic IPO-list language taking priority. Patterson used total shoulder arthroplasty, a procedure his ASC has been performing for years, as a code that will be precluded from addition on the ASC-CPL due to the CFR lan- guage. We were asked by staff what codes we think should be added that will be excluded from consideration, and ASCA followed up with data sup- porting codes that should be added to the ASC-CPL.

2022 Outlook: Changes to the IPO- list language are more likely than the removal of the prohibition on add- ing unlisted codes to the ASC-CPL, although neither are likely to happen for 2022. ASCA staff would like to at least see language in the 2022 rule indicating CMS’ willingness to con- sider codes that were on the IPO list as of December 31, 2020, in the future. While the recent expansion of the

procedure list demonstrates confidence in the safety of ASCs, no matter how many codes are payable in our setting, the top 10 codes by volume remain the same and represent 55 percent of ASC Fee for Service (FFS) Medicare volume. The top 100 codes by volume represent 88 percent of ASC FFS Medicare vol- ume. Due to problematic payment poli- cies, such as the ASC weight scalar, CMS will not realize its desired Medicare cost reductions as there will be no incentive for providers to migrate services to our facilities. ASCA will keep fighting for these and other policy changes that must be addressed to ensure ASCs across the country remain viable and are able to include Medicare volume as a viable part of their payer mix.

Kara Newbury is ASCA’s director of Govern- ment Affairs and regulatory counsel. Write her at

ASC FOCUS MAY 2021 | 31

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