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CMS 2023 Rule Changes for ASCs: Reimbursement Implications and Key Takeaways

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ASCs can see more opportunities to expand services from the advantageous changes to payment rates and logic in the CMS 2023 final rules published on November 1. However, some of the changes fall short such as the limited number of codes that were added to the ASC covered procedure list (CPL).

In the final rules, the ASC rates will receive an overall increase of 3.8%—based on the hospital market basket adjustment factor of 4.1% and reduced by a productivity factor of 0.3%. This is the overall increase; individual rate increases vary by procedure code.

CMS introduced a complexity adjustment factor that increases reimbursement when a select surgical procedure that is an add-on code (N1) is performed with a designated primary procedure code. This increase is attributed to the additional cost associated with the complexity of the case when the primary code is performed with a specified add-on code. There are 55 primary CPT codes that are designated for a complexity adjustment when performed with select add-on codes. Example procedure types include, but are not limited to, spine vertebroplasty, cardiac catheterization, angioplasty, insertion and replacement of a pacemaker, bronchoscopy, ERCP, and thyroidectomy.

The Ambulatory Surgery Center Association requested 47 procedure codes to be added to the ASC CPL—yet only 4 new procedures were added to the list[1], including:

  • 19307 Mastectomy, modified radical, including axillary lymph nodes, with or without pectoralis minor muscle, but excluding pectoralis major muscle
  • 37193 Retrieval (removal) of intravascular vena cava filter, endovascular approach including vascular access, vessel selection, and radiological supervision and interpretation, intraprocedural road mapping, and imaging guidance (ultrasound and fluoroscopy), when performed
  • 38531 Biopsy or excision of lymph node(s); open, inguinofemoral node(s)
  • 43774 Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components
Despite the limited number of procedure codes added to the CPL in 2023, the quantity of codes approved by CMS over the past five years has been meaningful. The expansion of the ASC CPL—coupled with the annual rate adjustment alignment with the hospital market basket (which was a favorable result of historical ASC rule changes)—and the addition of the complexity adjustment factor in 2023 will continue to drive surgery migration from the hospital to ASCs.


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Editor: Jessyca Yoppolo

Footnotes

  • 1.

    CPT codes and descriptions are copyright 2021 American Medical Association (AMA). All Rights Reserved.