If your practice has an Ambulatory Surgical Center (ASC), you’re part of the millions Medicaid saves every year. However, you reap fewer benefits than Hospital Outpatient Departments (HOPDs). A new bill on the table could serve to ease some of the burden your ASC faces, especially relating to the variable CMS ASC approved procedure list.

CMS ASC Approved Procedure List: H.R. 4350 Creates Transparency

On September 17, 2019, the US House of Representatives introduced H.R. 4350: Ambulatory Surgical Center Quality and Access Act of 2019. This bill’s intent is to amend title XVIII of the Social Security Act to modernize payments for ambulatory surgical centers under the Medicare program, and for other purposes.

The bill proposes several reforms, including:

• Update reimbursement for ASC services using the same update factor as HOPDs. Medicare is currently paying hospital outpatient departments (HOPDs) nearly twice as much as it pays ASCs for the same services. H.R. 4350 would require CMS to appropriately update ASC payments.
• Create transparency of quality reporting and Medicare Beneficiary Information. When a CMS quality measure is applicable to both the ASC and HOPD settings, CMS would be required to post the results online in a side-by-side comparison.
• Add an ASC representative to the Advisory Panel on Hospital Outpatient Payment. This benefits ASCs because decisions made by the panel impact ASC facility fees and the list of procedures that Medicare will reimburse ASCs for providing.
• Disclose criteria used to determine ASC Procedure List. R. 4350 would require CMS to disclose which of the criteria triggered the exclusion, and it would also prohibit CMS from excluding procedures reported with unlisted codes from the ASC setting.

CMS ASC Approved Procedure List Limitations

ASCs provide same-day outpatient surgical, diagnostic, and preventive procedures as a lower cost and more convenient alternative to a hospital inpatient stay. However, certain procedures may be too complex to be deemed safe to perform in an ASC setting. There is, consequently, a CMS ASC approved procedure list that limits what procedures Medicare will cover in an ASC setting.

Specifically, CMS reserves the right to exclude a procedure if it meets any of its criteria for concern, such as if the procedure will:

• Is on the inpatient only list
• Require an overnight stay or require medical care or monitoring past midnight
• Pose a significant safety risk to the patient
• Result in extensive blood loss
• Involve major blood vessels
• Be of a life-threatening or emergent nature
• Require reporting with an unlisted surgical procedure code
• Require prolonged invasion of a body cavity
• Require systemic thrombolytic therapy to dissolve blood clots

Fluctuating CMS ASC Approved Procedure List Challenges

The list of procedures that CMS approves for ASCs is constantly changing. A new CMS ASC approved procedure list is published annually, and CMS reserves the right to modify that list at periodic intervals during the year as well. This poses several challenges for ASCs. For example:

• Attempting to add new procedures to your surgical center to boost revenue could backfire. With a fluctuating CMS ASC approved procedure list you have no way of knowing which procedures CMS will approve from year to year or if the agency will remove procedures unexpectedly.

• CMS can deny payment or exclude a procedure from the list if it meets their criteria for exclusion. Unfortunately for ASCs, CMS isn’t currently required to disclose which of the criteria caused them to do so. This complicates your right to challenge a reimbursement denial for a previously approved procedure.

Get ready for the 2020 CMS ASC Approved Procedure List

CMS has recently released the CY 2020 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule which includes the prospective changes to the CMS ASC approved procedure list. CMS is proposing adding:

• Total Knee Arthroplasty (TKA)
• Knee Mosaicplasty
• Three additional coronary intervention procedures

You can download the proposed rule from the Federal Register here.

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