REGULATORY REVIEW


arthroplasty (TKA) since CMS previ- ously showed an interest in moving that code off the inpatient-only (IPO) list. In January 2016, an ASCA ortho- pedic surgeon met with CMS to pres- ent outcomes data for TKA and total hip arthroplasty (THA). In August 2016, an ASCA member surgeon presented to the Advisory Panel on Hospital Outpatient Payment (HOP Panel) on the safety and efficacy of TKA being done in the ASC setting. The HOP Panel advises the secretary of the US Department of Health & Human Ser- vices (HHS) and the CMS administra- tor on strategies for addressing issues related to the clinical integrity of pro- cedures within the OPPS, including “removing procedures from the inpa- tient list for payment under the OPPS payment system.” After that presen- tation, the HOP Panel unanimously recommended that CMS remove TKA from its IPO list. While the HOP Panel’s recommendations are not binding, it is helpful to have this body support the movement of this code to the outpatient setting. In the 2017 proposed rule, released in July 2016, CMS sought public comments on whether TKA should be removed from the IPO list. While CMS did not take any action on this proposal, the agency indicated in the final rule that the majority of the feedback received was positive.


2017: In the 2018 proposed rule, CMS proposed the removal of TKA from the IPO list, citing support from the previous year’s comments in addition to acknowledging it had “taken into account the recommendation from the summer 2016 HOP Panel meeting to remove the TKA procedure from the IPO list.” CMS also requested more information from the public on poten- tially removing THA from the IPO list, but no further action was taken on that procedure. CMS received mainly positive comments, many from ASCA members as part of the association’s


tain its existing definition of surgical procedures but indicated the agency would consider the feedback received in future rulemaking.


2018: ASCA partnered with a large cardiology practice to present to CMS medical officers cardiology codes that could be considered surgical under a revised definition and are safely per- formed in ASCs. As a result, CMS finalized its proposal to revise the defi- nition of “surgery” in the ASC payment system to account for certain “surgery- like” procedures that are assigned codes outside the surgical range and added 17 cardiac catheterization codes to the ASC-CPL for 2019.


Since 2013, CMS has added 360 procedures that were previously reimbursed only in hospitals to the ASC-CPL.”


—Kara Newbury, ASCA


grassroots comment writing campaign. CMS finalized the removal of TKA from the IPO list. CMS also requested public com- ments on “surgery-like” procedures, or services that are described by codes outside the typical surgical range (CPT 10000–69999), that might be appro- priate to include as covered surgical procedures payable when furnished in the ASC setting. CMS expressed par- ticular


interest in additional criteria that the agency might be able to use when considering whether a procedure is surgery-like and could be included on the ASC payable list. ASCA agreed that strict adherence to the CPT surgi- cal code groupings does not properly account for advances in treatment and the dynamic nature of ambulatory sur- gery and requested the inclusion of 38 cardiology codes to the payable list under a revised definition of sur- gery. For 2018, CMS decided to main-


2019: While happy with the cardiol- ogy codes that were added for 2019, ASCA had requested many other codes that had not been finalized. In the 2020 rulemaking cycle, CMS did propose and finalize the addition of several more cardiology codes to the ASC-CPL. ASCA also continued to push CMS for the addition of TKA to the ASC- CPL, and in the summer of 2019, the agency did just that. CMS received mostly positive feedback on the addi- tion of TKA to the ASC-CPL and finalized its addition for 2020. In addi- tion, THA and six spine codes were removed from the IPO list, setting up their potential migration to the ASC setting in future years.


2020: The largest change to the ASC- CPL since the payment systems were aligned came in the fall of 2020, when CMS finalized the addition of 267 codes to the ASC-CPL for 2021. Of note, CMS added THA to the ASC- CPL for 2021. Most of these codes— 256—were added due to a revision of the ASC-CPL criteria under 42 CFR 416.166, which retained the general standard criteria but eliminated five of the general exclusion criteria.


ASC FOCUS AUGUST 2021 | ascfocus.org 17


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