Proposed Rule Aligns With ASCA Asks

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Proposed Rule Aligns With ASCA Asks

CMS recommends adding 11 codes to the ASC-CPL list in 2021 and suggests an effective update of 2.6 percent

ASCs can be optimistic about the 2021 proposed payment rule for ASCs and hospital outpatient departments (HOPDs) that the Centers for Medicare & Medicaid Services (CMS) released last week. The tone of the rule was positive toward ASCs and a common thread running through was a recognition that physician decision-making is the best arbiter for determining the appropriate setting for beneficiary care.

In the rule, CMS proposed to add 11 codes to the ASC Covered Procedures List (ASC-CPL), including total hip arthroplasty (THA). It also proposed two alternative proposals regarding the CPL that are being considered for finalization in 2021.

Other initial observations about the 785-page proposal include:

Average Rate Update of 2.6 Percent

CMS proposed to continue to align the ASC update factor with that used to update HOPD payments. Under the proposal, CMS would continue to use the hospital market basket to update ASC payments for calendar year (CY) 2021 through CY 2023 as the agency assesses this policy’s impact on volume migration.

If the proposed rule were to be finalized as drafted, ASCs would see, on average over all covered procedures, an effective update of 2.6 percent—a combination of a 3.0 percent inflation update based on the hospital market basket and a productivity reduction mandated by the Affordable Care Act of 0.4 percentage points. This is an average and updates might vary significantly by code and specialty. To find the local rates for codes, download the 2021 proposed rule version of the Medicare Rate Calculator, an ASCA members-only resource, available on ASCA’s Medicare Payment Resources web page.

Prior to 2019, the Consumer Price Index for All-Urban Consumers (CPI-U) was used as the update factor for ASCs. The CPI-U takes into account consumer purchasing preferences. During a national public health emergency, which has a far-reaching impact on the national economy, basing the ASC update on consumer behavior would be much less favorable than the hospital market basket.

The information below provides a comparison between the 2021 ASC and HOPD reimbursement proposals:

Inflation update factor 3.0% 3.0%
Productivity reduction mandated by the ACA 0.4 percentage points 0.4 percentage points
Effective update 2.6% 2.6%
Conversion factor $48.984 $83.697

Proposed Additions to the ASC Covered Procedures List

CMS proposed to add 11 codes to the ASC-CPL list in 2021. These codes should meet the criteria under 42 CFR 416.166(b) that states covered codes must be separately paid under the OPPS, must not be expected to pose a significant safety risk to a Medicare beneficiary when performed in an ASC, and for which standard medical practice dictates that the beneficiary would not typically be expected to require active medical monitoring and care at midnight following the procedure. The general exclusion criteria used under the ASC payment system to evaluate the safety of procedures for performance in an ASC, found at 42 CFR 416.166(c), also are reviewed before CMS considers codes for addition and provide that covered surgical procedures do not include those surgical procedures that: (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 under 42 CFR 419.22(n); (7) can only be reported using a CPT unlisted surgical procedure code; or (8) are otherwise excluded under 42 CFR 411.15. After evaluating codes based on the above criteria, CMS proposed to add the following to the ASC-CPL for 2021:

  • 0266T (Implt/rpl crtd sns dev total)
  • 0268T (Implt/rpl crtd sns dev gen)
  • 0404T (Trnscrv uterin fibroid abltj)
  • 21365 (Opn tx complx malar fx)
  • 27130 (Total hip arthroplasty)
  • 27412 (Autochondrocyte implant knee)
  • 57282 (Colpopexy extraperitoneal)
  • 57283 (Colpopexy intraperitoneal)
  • 57425 (Laparoscopy surg colpopexy)
  • C9764 (Revasc intravasc lithotripsy)
  • C9766 (Revasc intra lithotrip-ather)

CMS also proposed two alternatives for adding codes to the ASC-CPL. Both alternatives would revise the exclusionary criteria under 42 CFR 416.166 (c) by eliminating 42 CFR 416.166 (c)(1) – (5).

The first alternative would:

  • establish a nomination process for CY 2021 through which external stakeholders, such as professional specialty societies, would nominate procedures for addition to the ASC-CPL. Nominations would be due to CMS by March 1 and CMS would review and finalize procedures through annual rulemaking, beginning with the CY 2022 rule. If CMS were to disagree with the addition of a nominated code, the agency would provide a rationale for exclusion;
  • the second alternative would use the revised ASC-CPL criteria under 42 CFR 416.166 to consider codes for addition in 2021. Under this alternative, CMS would add 267 surgery or surgery-like codes to the ASC-CPL.

Proposal to Eliminate Inpatient Only List Over Next Three Years

Keeping with the theme of clinical discretion to select site of service, CMS proposed to transition codes off the inpatient only (IPO) list over a three-year period, with the list completely eliminated by 2024. CMS has proposed to start with 300 musculoskeletal services for removal from the IPO list in 2021.

No New Measures Proposed for the ASC Quality Reporting Program

CMS has not proposed to remove any existing measures or to adopt any new measures for the CY 2023 payment determination.

Comments on the proposed rule are due October 5, 2020.

ASCA will continue to analyze the rule and provide more resources to help ASC operators understand the impact of the proposal on their centers and tools to help members with their comments.