By Bill Prentice
Since the first of January, ASCs and hospital outpatient departments (HOPDs) that provide care to Medicare patients have been operating under new payment rules the Centers for Medicare & Medicaid Services (CMS) finalized last November. Some of the provisions in the new rules help promote patient access to care in the ASC setting and help the Medicare program take advantage of the cost savings ASCs make possible. Others fall short of those goals.
Expanding Access
One very positive development affecting patient access to care in ASCs is CMS’ decision to provide complexity adjustments for combinations of certain service codes and add-on procedure codes that are eligible for a complexity adjustment under the hospital outpatient prospective payment system (OPPS). While add-on codes do not receive additional reimbursement when packaged into primary codes, the addition of the add-on codes to a primary procedure code often changes the complexity and the cost of the procedure. This new policy bumps reimbursement for the procedure to a rate that better reflects the actual costs involved in providing all the procedures involved in the case, making it possible for ASCs to provide more of these services for Medicare patients and expanding the patients’ options for obtaining the care they need.
Good News, Bad News
When it comes to procedures added to the ASC Covered Procedures List, there is good news and bad news for Medicare patients who want to take advantage of the many benefits ASCs provide. The good news is that CMS added four new procedures to this list:
- CPT 19307 (a mastectomy procedure)
- CPT 37193 (a transcatheteral procedure)
- CPT 38531 (an excision procedure on the lymph nodes)
- CPT 43774 (a laparoscopic bariatric procedure)
The bad news is that this short list means that CMS decided not to add 43 other procedures ASCA requested. Since those other procedures are being performed safely and successfully for privately insured patients, this decision means that Medicare beneficiaries who could have these procedures safely in an ASC are being denied that opportunity and forced, instead, to seek these services in higher-cost settings, costing the Medicare program and its beneficiaries more. ASCA will continue to reach out to CMS to discuss the rationale behind these decisions and ways to effect change.
The payment updates ASCs and HOPDs received for 2023 to account for inflation also contained some good news and some bad. Because ASC and HOPD updates are currently based on the hospital market basket, both received, on average, a 3.8 percent update (a hospital market basket increase of 4.1 percent reduced by a 0.3 percentage point productivity adjustment both entities are subject to at this time).
The good news is that the final rate was higher than the rate contained in the original proposal. The bad news is that this update falls far short of accounting for the rising costs ASCs are confronting in staffing, services and supplies. CMS needs to do more to support ASCs in confronting the rising costs of providing care or risk losing access to the many benefits ASCs offer, including outstanding patient outcomes and significant cost savings. ASCA will continue to talk with CMS about solutions.
Quality Reporting
ASCA and the ASC community continue to support CMS in its efforts to improve the ASC quality reporting program. We also support making both the ASC and HOPD programs more actionable for care providers, as minimally burdensome as possible and more useful to patients trying to select the best site of service for the outpatient surgical care they need. To that end, we commend CMS’ decision to suspend mandatory reporting for ASC-11: Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery and keep the measure voluntary at this time. We continue to assert, however, that since data collection for this measure requires a burdensome collection process involving outreach to outside offices that are not under the direct control of the ASC and this measure involves data the physician, rather than the ASC, already collects and assesses over time, this measure should be removed from the ASC quality reporting program.
We also continue to question why the ASC and HOPD quality reporting programs still do not include more directly comparable outcomes measures that are reported in the same way to allow patients to make direct comparisons between the two sites of service.
What ASCs Can Do in 2023
If you work in or with an ASC and haven’t already made plans to join ASCA on Capitol Hill in Washington, D.C., February 27-March 1, for National Advocacy Day – an event that will be in person for the first time in three years – please consider joining now. You can find more information on ASCA’s website or by contacting Maia Kunkel.
If you want to be involved but can’t make it into Washington, D.C., that week, consider conducting a facility tour for your members of Congress or your state and local officials. ASCA can help. Please contact Maia Kunkel to find out how.
There are two more ways you and your ASC can be involved:
Make sure your ASC is a member of ASCA. If you work in an ASC that is not already a member, please contact Mykal Cox for information and join today. If your ASC was an ASCA member in 2022, please make sure to renew your ASCA membership in 2023. We cannot do the advocacy work we do on behalf of your ASC and the entire ASC community without our members’ support.
Join ASCA in Louisville, Kentucky, for ASCA 2023, May 17-20, this year. There, you will have multiple opportunities to learn more about ASC advocacy and have access to 2½ days of top-quality education developed specifically for ASCs. You will also have formal and informal networking opportunities you can use to connect with your colleagues from across the country and learn how they are managing the many challenges confronting ASCs this year.
– Bill Prentice is the chief executive officer of the Ambulatory Surgery Center Association (ASCA).
