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Four Implications of the Changes in the ASC Medicare Rules on Commercial Payer Contracting

Changes In Asc Mecidare Rules On Commercial Payer Contracting Web

The Centers for Medicare & Medicaid Services (CMS) released the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System on November 2, 2018. While this may seem like old news, many ASCs are still working out what these changes will mean for them. In recent presentations at the Nashville ASCA meeting and the Seattle WASCA meeting, both in May, we went through these changes in depth. This blog provides an overview of the key takeaways, including a distilled list of four implications of the changes and ramifications for your ASC.

1. Rate calculation now sets ASCs and HOPDs on the same update factor.

CMS’s ASC rule replaced the CPI-U with the hospital market basket as the annual update for the ASC conversion factor.

What this means for ASCs: This sets ASCs and HOPDs on the same update factor, which is expected to have a favorable impact on ASC reimbursement.

2. Device-intensive code offset threshold has been reduced.

The device-intensive code offset percentage threshold has been reduced from 40% to 30% for procedure codes with single-use devices to be eligible as a device-intensive procedure. Reducing the threshold has a favorable impact on reimbursement for eligible procedures.

What this means for ASCs: The trickle-down effect of a device-intensive code rule change has positive implications for surgery migration to the ASC setting, and the volume of device-intensive surgeries brought to the ASC setting could increase.

3. CMS is rewarding non-opioid pain management.

CMS will provide separate payment for non-opioid pain management “drugs that function as a supply” when used in a surgical procedure performed in an ASC. Currently this applies to HCPCS code C92920—the drug EXPAREL®—and is approved for ASCs and not for HOPDs.

What this means for ASCs: Surgeons and ASC leadership now have the ability to use EXPAREL® for Medicare patients.

4. The definition of surgery has changed

CMS modified the definition of surgery, which expanded the ASC-approved list. As a result of the rule change, 17 cardiac catheterization procedure codes were added to the ASC-approved list.

What this means for ASCs: This expansion of the ASC list provides the opportunity for ASCs to perform new high-volume procedures and expand partnerships with cardiovascular physicians.

Commercial payers often follow CMS’s lead, and ASCs should review their commercial contracts for reimbursement impacts based on these CMS changes.

We will likely see a continued shift toward more cost-effective solutions for patients and payers, and CMS plays a big role in this process. To gainshare in this expanding market space, ASC leaders will need to be aware of upcoming CMS changes and the implications on the rest of their patient population and payer contracts.

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