Digital Debut
ASCA Meets with CMS to Discuss 2024 Proposed Payment Rule
The agency’s chief transformation officer attends the meeting
BY KARA NEWBURY | OCTOBER 2023
On Thursday, October 12, ASCA representatives met virtually with Doug Jacobs, MD, chief transformation officer of the Center for Medicare at the Centers for Medicare & Medicaid Services (CMS). According to his bio, Jacobs leads “center-wide efforts to move the health care system towards value-based care, advance health equity, and promote delivery system transformation.” Ryan Howe, who serves as the acting director for the Center for Medicare’s Hospital & Ambulatory Policy Group, joined Jacobs in the meeting along with a few other CMS staff.
ASCA requested this meeting to discuss concerns with the 2024 proposed payment rule for ASCs and hospital outpatient departments (HOPD), which was released on July 13. Since the 2024 final rule is due out within the next two weeks, CMS staff mainly listened, as they are unable to comment on specific proposals in the rule. The meeting allowed ASCA to introduce itself to Jacobs and highlight some of its formal comments submitted in response to the proposed rule. Once the 2024 final rule is released in early November, ASCA will request a meeting to discuss 2025 rulemaking.
ASCA Chief Executive Officer Bill Prentice began the discussion by expressing disappointment with CMS’ lack of transparency regarding additions to the ASC Covered Procedures List (ASC-CPL). Although ASCA provided a list of 63 codes for procedures that are being performed safely in ASCs on non-Medicare populations to be added to the ASC-CPL, CMS added only one of the requested codes—G0330 (Facility svs dental rehab)—as part of a larger policy change that includes the proposed addition of 26 dental surgical codes. CMS provided no comment on the lack of inclusion of the other surgical codes ASCA proposed for addition to the ASC-CPL, which also included total shoulder arthroplasty (TSA).
Total Shoulder Arthroplasty
David Weinstein, MD, ASCA Board member and orthopedic surgeon with the Surgical Center of the Rockies in Colorado Springs, Colorado, discussed TSA (CPT 23472). He questioned why his colleagues performing total knee arthroplasty (TKA) and total hip arthroplasty (THA) are allowed to do so on the Medicare population but he is not allowed to perform TSA on the same population. Weinstein referenced research showing stellar outcomes of TSA performed in the outpatient setting, supported by his own experiences performing TSA in the ASC setting.
Several ASCs enrolled as hospitals through the Hospital Without Walls program established during the COVID-19 pandemic safely performed hundreds of TSAs on Medicare fees-for-service (FFS) beneficiaries. In addition, according to CMS Physician/Supplier Procedure Summary (PSPS) data, 36,159 TSAs were performed on Medicare FFS beneficiaries in HOPDs in 2021, which indicates that there is significant TSA outpatient volume.
New Pre-Proposed Rule CPL Recommendation Process
During the CMS meeting, ASCA also raised concerns with the lack of information in the rule for the new Pre-Proposed Rule CPL Recommendation Process that will go into effect on January 1, 2024, with a deadline for submissions of March 1, 2024. This new process will provide stakeholders with an online portal through which to submit codes they would like to see added to the ASC-CPL.
In the 2022 rulemaking cycle, CMS indicated that if the agency disagrees with the addition of a nominated code, it will provide a rationale for exclusion in the final rule. However, during the discussion, ASCA raised concerns with the Code of Federal Regulations language on the recommendation request process that indicates CMS is required to publish only the codes they are proposing for addition, not all codes that are requested. In response, the meeting, CMS staff indicated that if they are inundated with requests, it might not be feasible to publish all codes that are requested but ultimately not proposed for addition. It did sound, however, that the agency will try to publish information on codes that are requested but ultimately not proposed for addition when feasible. ASCA will continue to press CMS on this issue.
Evaluating Codes Based on the ‘Typical’ Medicare Beneficiary
During the CMS meeting, ASCA also raised concerns with CMS’ assessment that before codes can be added to the ASC-CPL they should be deemed safe for the “typical Medicare beneficiary.” In the 2022 proposed rule, CMS referred to the typical beneficiary as one “whose health status is representative of the broader Medicare population.” As ASCA has commented, if CMS is adopting a standard to allow ASCs to perform only procedures that are safe for the typical Medicare beneficiary, there would need to be a much more detailed explanation of who this language represents because on its face, this language could practically eliminate the ASC-CPL altogether. It is more reasonable to determine whether a subset of the population is suitable and allow for the clinician to then decide which of their patients are eligible for care in an ASC.
ASC Quality Reporting Program
Representatives from the CMS Center for Clinical Standards and Quality also attended the meeting, so ASCA took a few minutes to express concerns with the increased burden of proposals regarding the ASC Quality Reporting (ASCQR) Program. ASCA has long-embraced quality reporting and supports the collection and submission of publicly available data that can guide patients to the appropriate healthcare setting. However, as expressed in its comment letter, ASCA is concerned that CMS fails to adequately consider the cost burden on facilities when establishing new quality measures.
Of note, beginning in 2025, ASCs will be required to contract with a third-party vendor to administer the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) Survey. As ASCA discussed its comments, CMS should allow for an electronic-only survey option to reduce the financial burden on ASCs.
Write Kara Newbury at knewbury@ascassociation.org with questions.