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 performed in ASCs. As a result, CMS finalized its proposal to revise the definition 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.
2019: While happy with the cardiology 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 addition of TKA to the ASC-CPL and finalized its addition for 2020. In addition, 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.
Since the payment systems were aligned, devices have been packaged in the surgical reimbursement rate. If the device cost represented 50 percent of the entire procedure cost when performed in a hospital outpatient department (HOPD), the procedure was designated as device-intensive and the device cost was fully contemplated in the reimbursement rate. In 2008, the first year of the revised payment system, there were 45 device-intensive codes in the ASC payment system.
Impact of the New Payment System on Device-Intensive Codes
By 2012, ASCs, on average, were receiving 56 percent of the HOPD reimbursement for the same code. So, if there is a code that is $1,000 when performed in an HOPD but the device costs are $499, since the code does not meet the device offset threshold, the ASC would only receive approximately $560. The device itself was covered, but not much else. ASCA ramped up its efforts on this issue, arguing that the agency should lower the threshold to encourage migration of these procedures with high device costs.
2015 Payment Rule
In the 2015 proposed payment rule, CMS proposed to lower the device offset percentage from 50 to 40 percent. ASCA asked CMS to lower the proposed 40 percent threshold to 30 percent since the ASC conversion factor at the time was approximately 60 percent of the HOPD conversion factor (30/50 = 60 percent). CMS ignored ASCA’s proposal at the time and finalized the 40 percent device offset. Still, the number of device-intensive codes increased from 75 in 2014 to 137 in 2015 under this policy change.
2019 Payment Rule
ASCA continued to advocate for the 30 percent threshold, and in 2019, CMS obliged. This increased the number of device-intensive codes from 154 in 2018 to 264 in 2019. ASCA commended CMS for making this change and provided data from the 50 to 40 percent threshold change to indicate the type of impact CMS might see with this new policy. In the first year following the effective date of that policy—2015—there was a clear migration of services from the HOPD to the ASC setting among the procedures affected by the changed device-intensive threshold, so ASCA anticipates a further reduction in the device-intensive threshold will lead to migration of services from HOPDs to ASCs.
TRACK THE LATEST REGULATORY AND LEGISLATIVE NEWS FOR ASCs
Visit ASCA’s website every week to stay up to date on the latest government affairs news affecting the ASC industry. Every week, ASCA’s Government Affairs Update newsletter is posted online for ASCA members to read. The weekly newsletter tracks and analyzes the latest legislative and regulatory developments concerning ASCs.
One of the biggest achievements for ASCA and the ASC community came in the 2019 OPPS/ASC Payment rule. For the first time since the OPPS and ASC payment systems were aligned in 2009, CMS indicated it would use the same update factor for the ASC setting as it uses for hospitals, updating the ASC conversion factor using the hospital market basket instead of the Consumer Price Index for All Urban Consumers (CPI-U). ASCA had been advocating for this change for years, and it has been a key part of the ASC Quality & Access Act that ASCA supports.
CMS is using the hospital market basket to update ASC payments for CY 2019 through CY 2023. During this time, the agency will monitor volume to see if this policy leads to migration to the lower-cost ASC setting. While the long-term goal is to have this change be made permanent, a five-year trial period was far beyond what ASCA had seen in the decade preceding this policy change.
ASCA will continue to work with its member facilities and industry stakeholders to advocate for the expansion of the ASC-CPL, a lower device-intensive threshold and permanent alignment of the ASC conversion factor with that used for the OPPS. While change often happens slowly when dealing with the federal government, ASCA is making progress and providing more access than ever to Medicare beneficiaries who will benefit from the high-quality surgical experience ASCs provide.