Digital Debut

ASCA Releases Procedure List Survey Results

Total joints remain a priority

BY KARA NEWBURY | MARCH 2019

At a February meeting, Centers for Medicare & Medicaid Services (CMS) officials asked ASCA representatives for codes that should be added to the ASC-payable list for 2020. In response, ASCA conducted a brief survey of its members, which wrapped up earlier this month.

Procedure List Survey Questions

Participants were asked to complete one survey for each procedure they would like added to Medicare’s ASC-payable list. The survey asked if the facility is currently performing the procedure and, if so, the age range of those patients. It is helpful for ASCA staff to be able to show the volume of a procedure being done, and even more helpful if those patients undergoing those procedures are at or near Medicare age.

The survey also asked for names of payers that are reimbursing for the procedure and whether the procedure meets any of the exclusionary criteria found in Code of Federal Regulations §416.166. If CMS determines that a procedure meets some or all the exclusionary criteria, they will not add those codes to the ASC-payable list. Codes are excluded from the ASC-payable list if they typically require medical care and monitoring past midnight, generally result in extensive blood loss, require major or prolonged invasion of body cavities, directly involve major blood vessels and commonly requires systemic thrombolytic therapy. In addition, codes that are on Medicare’s inpatient-only list and unlisted codes are excluded from the ASC-payable list.

Continue Reading Below

Codes Requested That Are Payable in HOPDs but Not ASCs

HCPCS	Short Descriptor	HOPD Rate
21365	Opn tx complx malar fx	$4,424.23
23470	Reconstruct shoulder joint	$10,713.88
27447	Total knee arthroplasty	$10,713.88
41899	Dental surgery procedure	$206.14
58290	Vag hyst complex	$6,344.41
91040	Esoph balloon distension tst	$455.27
92920	Prq cardiac angioplast 1 art	$4,678.53
92928	Prq card stent w/angio 1 vsl	$9,669.04
92937	Prq revasc byp graft 1 vsl	$9,669.04
92960	Cardioversion electric ext	$526.49

Survey Results

There were 96 submissions including a few duplications of codes. There were 73 unique codes that were submitted for consideration. Of those, 45 are already found on the ASC-payable list but they are packaged in the ASC setting. Of those 45, 23 are packaged every time they are performed in the hospital outpatient department (HOPD) and 22 are conditionally packaged. That means those 22 codes are only reimbursed when they are the sole procedure performed; otherwise they are packaged with the primary code. In addition, there were six codes that were requested that are packaged in the HOPD. This means that even if ASCA were to be successful in moving these codes to the ASC-payable list, they would not receive separate reimbursement.

The next largest group of requested codes, 12, are currently on the inpatient-only list. Within this group, total hip arthroplasty (THA) was requested seven times and total shoulder arthroplasty (TSA) was requested four times. It is helpful for ASCA to have this data so we know what is currently being performed in ASCs, but it is generally a multi-year process for those codes to be considered for the ASC-payable list.

Total joints were popular codes in this survey, with eight responses for total knee arthroplasty (TKA) in addition to the responses referenced above for THA and TSA. It was a several year process but ASCA was successful in helping move TKA off the inpatient-only list, so it is now payable in HOPDs. However, there was much backlash from the hospital community, as many were claiming CMS was requiring them to perform these procedures on an outpatient basis.

There were 10 codes, included in the table at right, that currently have a reimbursement amount in the HOPD setting but are not currently on the ASC-payable list. One of those codes, 41899 (dental surgery procedure) is an unlisted code. Since unlisted codes are specifically excluded in ASC regulations, this would be a more difficult process to see added.

ASCA will be advocating for the other nine codes that were requested. Please note that ASCs are currently getting paid approximately half of what HOPDs receive for performing the same procedures. Some of these codes, particularly the orthopedic codes, would probably be classified as device-intensive, meaning the ASC reimbursement rate reflects the full device cost that is reflected in the HOPD rate. As such the difference in reimbursement would be less significant.

ASCA appreciates everyone who completed the survey, as this information will help us advocate for the expansion of the list of procedures that CMS considers clinically appropriate for ASCs to provide to Medicare beneficiaries.

Read the upcoming Regulatory Review in the May 2019 issue of ASC Focus for a more in-depth look into CMS’ process for determining whether to add codes to the ASC-payable list. For more information on ASCA’s regulatory advocacy efforts, please write Kara Newbury.