ASCA Advocates for More Codes to be Added to ASC-CPL

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ASCA Advocates for More Codes to be Added to ASC-CPL

Members weigh in through surveys

On March 17, ASCA staff met virtually with the Centers for Medicare & Medicaid Services (CMS) staff responsible for payment policies in ASCs. At the meeting, the participants discussed mainly the ASC Covered Procedures List (ASC-CPL). ASCA submitted 47 codes for consideration for addition to the ASC-CPL in 2023. ASCA members specified these codes earlier this year, with total joint replacement, spine and cardiology codes being the highest requested. When reviewing the codes with CMS, ASCA staff emphasized that 41 of the 47 requested procedures were performed in an outpatient setting a majority of the time.

Nomination Process

In the meeting, ASCA staff raised concerns about confusion over the nomination process to submit codes. The CMS website states, “In the CY 2022 OPPS [Outpatient Prospective Payment System]/ASC final rule with comment period, CMS finalized the adoption of a nomination process to allow an external party to nominate a surgical procedure to be added to the ASC CPL beginning with the CY 2023 rulemaking cycle.”

However, the Code of Federal Regulations indicates the process will start next year, as 42 CFR §416.166(d) states that “(1) Nominations. On or after January 1, 2023, an external party may nominate 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.”

CMS staff confirmed that although the formal nomination process was not yet operational, they would consider the codes ASCA sent them for inclusion in 2023.

Criteria for Inclusion on the ASC-CPL

In the CY 2022 OPPS/ASC rule, CMS reestablished the general standards and general exclusions for coverage on the ASC-CPL that were in place prior to 2021. When CMS reverted to the old criteria for consideration of codes for addition to the ASC-CPL, this policy change resulted in the removal of 255 codes from the ASC-CPL in 2022 that had just been added to the ASC-CPL in 2021.

The general standards, found in 42 CFR §416.166(b), indicate that procedures may be covered in the ASC setting if they are separately payable under the OPPS, would not be expected to pose a significant safety risk to a Medicare beneficiary when performed in an ASC, and would not typically require active medical monitoring and care at midnight following the procedure.

The general exclusions, found in 42 CFR §416.166(c), outline the criteria that will typically exclude a procedure from the ASC-CPL. For instance, if a procedure generally results in extensive blood loss or is emergent or life-threatening in nature, it is not a good candidate for the ASC-CPL. Two other important criteria are the exclusion of unlisted surgical procedures from the ASC-CPL, as well as those designated as requiring inpatient care.

ASCA Member Requests

Throughout the year, ASCA receives requests from members for adding procedures to the ASC-CPL. In addition, ASCA typically conducts a member survey, proactively soliciting codes from the ASC community. This year, ASCA conducted a survey from January 27 to February 11, and received requests for 110 procedures to be added to the ASC-CPL in 2023.

Already on ASC-CPL

Of those 110, 23 are already on the ASC-CPL. The majority (15) are packaged, meaning they are not separately payable. While ASCA is cognizant of reimbursement issues that limit our facilities’ ability to perform cases, such as inadequate reimbursement for the primary codes that are used with packaged codes, for this outreach effort we focused on codes that are payable under OPPS but not in the ASC setting.

Of the 23 codes requested that are already on the ASC-CPL, we received two requests for total hip arthroplasty. This procedure became payable in the ASC setting in 2021 and remains payable. It was not one of the 255 codes removed from the ASC-CPL in 2022 because it was added based on the general standards and general exclusions that are in effect, not the revised criteria that were only in place in 2021.

IPO List

ASCA members requested to add 24 codes that are on the inpatient-only (IPO) list. As indicated above, procedures that CMS believes require inpatient care are ineligible for the ASC-CPL. While ASCA can continue to advocate for codes to be removed from the IPO list, that would only then make them payable under OPPS. It takes multiple years to move codes off the IPO list so that they are payable under OPPS and then in future years payable in the ASC setting.

Packaged under OPPS

Members also requested to add 15 codes that are packaged under OPPS. ASCA has taken note of these codes, as well as those packaged in the ASC-CPL, and will work with CMS to address adequate reimbursement for the procedures. However, since getting these codes added to the ASC-CPL would not provide any additional reimbursement for ASCs at this time, we excluded them from our list we sent to CMS for consideration.

Unlisted Code

ASCA often gets requests for unlisted codes to be added to the ASC-CPL and this year was no exception. We got a request to add arthroscopy of joint (CPT 29999), which is an unlisted code and excluded from consideration for the ASC-CPL. We have long questioned CMS’ blanket exclusion of all unlisted codes and will continue to advocate for this to be changed.

Codes for Consideration

After removing those codes already on the ASC-CPL, those on the IPO list and those packaged under OPPS or unlisted, 47 codes remained for ASCA to submit to CMS for consideration. Total shoulder (CPT 23472) has been the top code requested by ASCA members over the last two years and was requested 10 times in the member survey. Total ankle (CPT 27702) also received multiple requests through our survey. CMS had proposed to move both of these codes back on the IPO list for 2022 but ASCA pushed back hard on that proposal in our CY 2022 OPPS/ASC comment letter. We provided research and data that highlight these procedures are being done safely in the outpatient setting and requested those in our community to send letters as well. CMS did not finalize its proposal to move either back to the IPO list, meaning they remain eligible for consideration for the ASC-CPL. ASCA will continue to advocate strongly for their addition to the ASC-CPL.

While there was not significant volume in the ASC setting for many of the 255 codes that CMS removed from the ASC-CPL in 2022, 18 of the 47 codes ASCA requested for addition to the ASC-CPL for 2023 are those that were payable in 2021 and then removed in 2022. We will continue to advocate for those and all procedures requested by our members.

Please write Kara Newbury with questions.