Medicare Introduces New ASC Procedure Request Process

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Medicare Introduces New ASC Procedure Request Process

Advocate for your ASC and encourage CMS to act

BY KARA NEWBURY | JANUARY 2024

The Centers for Medicare & Medicaid Services (CMS) recently rolled out the ASC Covered Procedures List (ASC-CPL) Pre-Proposed Rule Recommendation Request, a new way to submit codes for consideration. With a March 1, 2024, submission deadline, now is the time to advocate for procedures to be added in 2025.

While advances in medical technology and changes in Medicare payment policy have expanded the list of procedures for which CMS will reimburse ASCs, Medicare policies still lag innovation. ASCA has taken the lead in addressing this issue, encouraging CMS to add codes to the ASC-CPL that ASC clinicians are performing safely on the Medicare population in the surgery center setting. Over the past decade, with the help of its members, ASCA has successfully advocated for approximately 150 codes that CMS added to the ASC-CPL, including total shoulder arthroplasty and total ankle replacement in 2024.

Overview

Section 1833(i)(1) of the Social Security Act requires the secretary of the US Department of Health and Human Services (HHS) to specify surgical procedures that can be performed safely on an ambulatory basis in an ASC. CMS reviews and updates the procedures, collectively referred to as the ASC-CPL, annually, but prior to this year, there was no formal process for sharing codes for consideration with CMS.

Over the years, ASCA has used trends found in its annual procedure list survey sent to its members to determine which codes should be pursued. ASC surgeons have presented to CMS medical officers on the safety of specific codes. Although this process is time-consuming, it has been the most successful way to get codes added to the ASC-payable list.

While ASCA will continue to use this process to pursue codes that are requested the most by its members, it appreciates CMS’ new pre-proposed rule recommendation process.

Pre-Proposed Rule Covered Procedures List Recommendation Process

CMS recently added the following language to the Code of Federal Regulations (CFR) at 42 CFR §416.166(d):

Additions to the list of ASC covered surgical procedures. Surgical procedures are added to the list of ASC covered surgical procedures as follows:

  1. Pre-proposed rule covered procedures list (CPL) recommendation process. On or after January 1, 2024, an external party may recommend a surgical procedure by March 1 of a calendar year for the list of ASC covered surgical procedures for the following calendar year.
  2. Inclusion in rulemaking. If CMS identifies a surgical procedure that meets the requirements at paragraph (a) of this section, including a surgical procedure nominated under paragraph (d)(1) of this section, it will propose to add the surgical procedure to the list of ASC covered surgical procedures in the next available annual rulemaking.

While CMS is not required to publish all codes requested but only those which the agency chooses to propose for addition, ASCA has asked CMS to be more transparent with the process and publish any requested procedures for which they receive supporting documentation.

Registration

To submit codes for consideration, register as a MEARIS user. This process allows all interested stakeholders the opportunity to submit codes for consideration through the MEARIS application system. The registration process is quick and straight forward; plug in your name and email address, choose a security question and answer, and provide a password.

Once you have an account, complete your ASC-CPL Pre-Proposed Rule Recommendation Request. You will also have the flexibility to save your work and come back to the application at a later time.

Submission Process

Once you find the application, titled ASC-CPL Pre-Proposed Rule Recommendation Request, first enter the codes you are requesting for addition. CMS also included on the form an option to request a code for removal from the ASC-CPL, so please verify you are requesting codes to be added, not removed.

Next, you will be asked if the code or codes requested meet the regulatory criteria at 42 CFR §416.166(b). This includes the general standards that the surgical procedure

  • must be eligible for payment under the hospital outpatient prospective payment system (OPPS);
  • must not be expected to pose a significant safety risk to a Medicare beneficiary when performed in an ASC; and
  • is not one for which standard medical practice dictates that the beneficiary would typically be expected to require active medical monitoring and care at midnight following the procedure.

Additionally, procedures are not likely to be placed on the ASC-CPL if they meet any of the following specific exclusions at 42 CFR §416.166(c):

  1. generally result in extensive blood loss 
  2. require major or prolonged invasion of body cavities
  3. directly involve major blood vessels
  4. are generally emergent or life-threatening in nature
  5. commonly require systemic thrombolytic therapy
  6. are designated as requiring inpatient care
  7. can only be reported using a CPT unlisted surgical procedure code or
  8. are otherwise excluded under §411.15

You will have the opportunity to provide any supporting documentation or information. While this is not required, the more outcomes or quality information, research and volume data you can provide showing you are currently performing these procedures successfully on other patient populations, the more compelling your case will be.

Upon submission, you will receive a system confirmation that your information has been received. CMS might request additional information and/or documentation regarding your submission via a request for information (RFI). This request will show up as a task on your home page and you will be notified via email about the “Task Due.”

While interested parties will still be able to submit comments in response to the CY 2025 ASC proposed rule during the public comment period, this pre-rulemaking process is the best opportunity for ASCs to have their codes added to the ASC-CPL.

If you have codes that you want to see CMS add but you do not want to submit them yourself, you can still complete ASCA’s ASC-CPL survey. After review and approval by the ASCA Government Affairs Committee, ASCA will submit codes through the new ASC-CPL Pre-Proposed Rule Recommendation Request process by the March 1, 2024, deadline.

Write Kara Newbury at knewbury@ascassociation.org with questions.