ASCA Advocacy Achieves Victories in 2024 Final Payment Rule

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ASCA Advocacy Achieves Victories in 2024 Final Payment Rule

CMS adds total shoulder arthroplasty to ASC list

The Centers for Medicare & Medicaid Services (CMS) released its 2024 final payment rule for ASCs and hospital outpatient departments (HOPD) yesterday. CMS added multiple procedures to the ASC Covered Procedures List (ASC-CPL) that were not included in the proposed rule, including total shoulder arthroplasty (TSA).

Download the final rule.

"We thank CMS for heeding our request to move additional surgical procedures—including total shoulder arthroplasty—onto the ASC payable list,” said ASCA Chief Executive Officer Bill Prentice. "Doing so benefits both Medicare beneficiaries, who now have a lower-cost choice for the care they need, and the Medicare program itself, which will save millions of dollars as volume moves to the high-quality surgery center site of service."

ASCA advocated tirelessly to add TSA to the ASC-CPL. Most recently, on October 12, ASCA met with Doug Jacobs, MD, chief transformation officer at CMS, to raise concerns with the 2024 proposed payment rule. In the meeting, 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) were allowed to do so on the Medicare population but he was 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. ASCA has shared this research data with CMS.

Several ASCs enrolled as hospitals through the Hospitals Without Walls program established during the COVID-19 pandemic safely performed hundreds of TSAs on Medicare fee-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.

Update Factor Extension

CMS finalized its proposal to continue to align the ASC update factor with the one used to update HOPD payments, extending the five-year interim period an additional two calendar years (CY) through 2025. ASCA advocated for this extension.

The extension of this policy results in an effective update of 3.1 percent for ASCs—a combination of a 3.3 percent inflation update based on the hospital market basket and a productivity reduction of 0.2 percentage points mandated by the Affordable Care Act. This is an increase of 0.3 percent from the proposed rule. Please note that this is an average and updates might vary significantly by code and specialty.

Other initial observations about the 1,672-page final rule follow. ASCA will provide additional analysis soon, including a rate calculator that allows users to determine what ASCs will be paid locally under this final rule.

Dozens of Additions to the ASC-CPL

CMS finalized the addition of 37 surgical procedures to the ASC-CPL, including the 26 dental codes that were included in the proposed rule. The agency finalized the addition of the following 11 surgical codes (short descriptor in parentheses):

  • 21194 (Reconst lwr jaw w/graft)
  • 21195 (Reconst lwr jaw w/o fixation)
  • 23470 (Reconstruct shoulder joint)
  • 23472 (Reconstruct shoulder joint)
  • 27006 (Incision of hip tendons)
  • 27702 (Reconstruct ankle joint)
  • 29868 (Meniscal trnspl knee w/scpe)
  • 33289 (Tcat impl wrls p-art prs snr)
  • 37192 (Redo endovas vena cava filtr)
  • 60260 (Repeat thyroid surgery)
  • C9734 (U/s trtmt, not leiomyomata)

Other than TSA, ASCA also highlighted total ankle replacement (CPT 27702) in its comment letter to the proposed rule, citing research indicating these procedures are safely performed on an outpatient basis. In addition, CPTs 33289, 23470 and 37192 were on the list of procedures that ASCA requested for addition to the ASC-CPL.

Changes to ASC Quality Reporting Program

CMS adopted one new measure in this final rule, ASC-21: Risk-Standardized Patient Reported Outcome-Based Performance Measure (PRO-PM) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) in the ASC Setting (THA/TKA PRO-PM). The agency did push back mandatory reporting a year to the CY 2028 reporting period. Voluntary reporting begins with the CY 2026 and 2027 reporting periods.

CMS did not finalize its proposal to readopt ASC-7: ASC Facility Volume Data on Selected ASC Surgical Procedures. ASCA raised concerns with this measure in its comment letter.

ASCA will continue to analyze the final rule in detail and provide more information to help ASC operators understand its impact on their centers soon.