CMS is expected to announce the final payment rules for ASCs in the next few weeks. Here are four key changes to look for when the final rules are published in November.
1. Hospital market basket proposed to be used for ASC conversion factor calculations
CMS is proposing to replace the CPI-U with the hospital market basket as the annual update for the ASC conversion factor. This rule change is expected to have a favorable impact on the ASC conversion factor, but it will be highly de-pendent upon removing the secondary rescaler. As William Prentice, CEO of ASCA, noted in a blog post earlier this year, this is a “more realistic indicator of rising costs in the ASC space than what CMS has been using.” This will allow for a 2.8% inflation increase for ASCs when combined with the 0.8% productivity reduction mandated by the Affordable Care Act. Thus, the rate changes will vary across surgical procedures and specialty. CMS has proposed to implement this change for the period of CY 2019 to CY 2023 and then assess whether this change results in migration of services to ASCs from other settings over that five-year period.
2. Device-intensive code threshold proposed to be reduced from 40% to 30%
CMS is proposing to reduce the device-intensive threshold from 40% to 30%. It would also allow for single-use devices that meet the offset threshold to be eligible as a device-intensive procedure. Reducing the device-intensive threshold will have a favorable impact on reimbursement for surgeries that utilize high-cost de-vices and implants attributed to the 10% cost reduction of the threshold. This change would add 142 device-intensive procedures to the approved list, starting in 2019. It’s an exciting change that would allow many ASCs to offer procedures that were previously too expensive, driving additional cases to the ASC setting and providing consumers with more options for outpatient surgery.
3. Payment for non-opioid postoperative pain management drugs.
CMS has proposed to unpackage and pay separately for non-opioid pain management drugs provided in an ASC. Currently this applies to the drug EXPAR-EL® and is only proposed for ASCs, not HOPDs. This enables ASCs to have ac-cess to additional reimbursement for use of the drug and to provide a non-opioid alternative to patients, which is a response to the national opioid crisis in the US. EXPAREL® is often used as a long-lasting postoperative pain management solution in higher-acuity surgical cases such as total joints and spine procedures. Thus, this rule change also has the potential to favorably impact surgery migration to the ASC setting.
4. Expansion of the definition of a surgery procedure
CMS is likely to expand the definition of “surgery” for ASCs to include some “surgery-like” procedures. Effectively, this would allow ASCs to perform 12 cardiac catheterization procedures that fall outside the normal surgical code range. This enables ASCs to access additional cardiovascular procedures and encourages increased migration out of the hospital setting.
Overall, the proposed rules represent several key implications. They present increased momentum for closing the gap in reimbursement for HOPDs and ASCs, greater reimbursement for high-cost device-intensive procedures, and opportunity for ASCs to capture new and incremental volume for higher-acuity and cardiovascular procedures.
Once the final rules are published, ECG’s ASC team will provide an update on the out-come of the rule changes and what they mean for ASCs going forward.
Published October 29, 2018