Dissecting the Revised ASC Payment System


What the sweeping reimbursement changes mean to you.

Starting in January, Medicare will make the most extensive changes in payment for ambulatory surgery facility services since the inception of the program. Under regulations released last month from the CMS, Medicare will pay ASCs in virtually the same method - though not at the same amounts - that it pays hospital outpatient departments. A primary goal of these changes is to lead physicians and patients to determine the best site of service for surgical services based on safety and quality of the care rather than on the reimbursement or co-payment. It's expected that, over time, there will be a substantial relocation of services among ASCs, HOPDs and physicians' offices. Here, we break down 10 key components of the new system.

1 From 9 grouper rates to 1,000 APCs.
Medicare now pays for about 2,500 services in ASCs at nine rates, with methods that haven't changed much since 1990. Payments to facilities range from $333 to $1,339, with few add-ons. Under the new system, payments will be made using the ambulatory payment classifications from Medicare's outpatient prospective payment system. CMS also will reimburse ASCs for about 3,300 more procedures, each grouped in more than 1,000 APCs, each with its own payment rate.

2 CMS will dramatically expand the number of services paid in ASCs.
New rules will exclude from the ASC covered services list only those procedures determined to be too risky to be performed in the ASC setting or those that would routinely require a patient to be in the facility at midnight. About 790 surgical services will be added, two-thirds of which are now excluded because they're predominantly performed in doctors' offices.

3 ASC payment rates will be a constant percentage of the OPPS rates.
CMS's current estimate of the percentage is 65 percent, up from the 62 percent proposed last year. This percentage is calculated by the CMS actuaries to insure the new ASC system is budget neutral relative to the current system; the difference is thought to be justified because hospitals must be open 24/7, have obligations to provide uncompensated care, face higher safety standards and so forth. As an example, Medicare will pay an ASC about $1,005 for a complex cataract procedure (CPT code 66982) and a hospital $1,542.

4 ASC payment rates will be automatically revised in the future.
The relative payment rates in the two settings will be the same, and as OPPS relative payment rates change, ASC rates will change commensurately. One advantage of this arrangement is that OPPS payment rates are recalibrated each year. Because of the direct linkage of the relative weights in the two settings, ASC payment rates will be automatically revised to reflect secular changes in technology and other factors.

5 High-cost implants might be feasible.
CMS, in a change from its proposed rule, will make separate payment for radiology services integral to surgeries, brachytherapy sources, expensive drugs and some implantable devices. CMS has identified "device-intensive" APCs that, because of the high proportion of their costs represented by devices, will only be partly subject to the 65 percent adjustment for payment in an ASC. As a result, insertion of pacemakers and other high-cost implantables in ASCs may be economically feasible.

4 Key Policies of the New ASC Payment System




Separately Payable Radiology Services. CMS will provide separate ASC payment for certain ancillary services that are integral to the performance of a covered surgical procedure billed by the ASC on the same day, provided that separate payment for the radiology service would be made under the OPPS. Radiology services include all Category I CPT codes in the radiology range established by CPT, from 70000 to 79999, Category III CPT codes and Level II HCPCS codes.

If a patient has an ultrasound-guided, vacuum-assisted breast biopsy, Medicare will cover 19103 (Biopsy of breast; percutaneous, automated vacuum-assisted or rotating biopsy device, using imaging guidance) and 76942 (Ultrasonic guidance for needle placement, imaging supervision and interpretation).

ASCs will now be reimbursed for many of the radiological procedures that are integral to surgical procedures.

Separately Payable Drugs and Biologicals. This final policy will provide separate payment for those drugs and biologicals that are separately paid under the OPPS when those items are provided on the same day as and integral to the performance of a covered surgical procedure in an ASC. Separate ASC payment for these drugs and biologicals will be made at the OPPS payment rate for the same calendar quarter.

A patient undergoes a sigmoidoscopy with submucosal injection of Botox into both sides of an anal fissure. CMS will cover both codes 45335 (Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance) and J0585 (Botulinum toxin type A, per unit).

ASCs will now be reimbursed for many of the drugs and biologicals that are integral to surgical procedures.

Procedures Requiring Anesthesia - Discontinued Before Anesthesia is Administered. When a procedure is discontinued after the patient is prepared for the procedure and taken to the OR, but before the administration of anesthesia, ASCs should report modifier -73 (Discontinued outpatient procedure before anesthesia administration) appended to the discontinued procedure and they will receive 50 percent of the ASC payment for the planned surgical procedure.

A patient scheduled for rotator cuff repair develops chest pain in the OR. Anesthesia isn't administered, and the surgery is aborted. Code and bill 29827-73 (Arthroscopy, shoulder, surgical; with rotator cuff repair - Discontinued outpatient procedure before anesthesia administration). CMS will reimburse half the payment rate for 29827.

Many ASCs didn't receive reimbursement from Medicare carriers for discontinued procedures, so now there's an opportunity to receive some compensation.

Procedures Requiring Anesthesia - Discontinued After Anesthesia is Administered. Report procedures that are interrupted after their initiation or the administration of anesthesia using modifier -74 (Discontinued outpatient procedure after anesthesia administration) appended to the interrupted procedure and the full ASC payment for the covered surgical procedure will be made. CMS says the costs incurred for discontinued procedures that were initiated to some degree are as significant as those for a completed procedure.

A patient scheduled for secondary closure of wound dehiscence develops bradycardia after she's put under general anesthesia. The surgery is aborted. Code and bill 13160-74 (Secondary closure of surgical wound or dehiscence, extensive or complicated - Discontinued outpatient procedure after anesthesia administration) to receive 100 percent of the payment rate for 13160.

Many ASCs received little or no reimbursement from Medicare carriers for discontinued procedures after anesthesia was administered, so now there's an opportunity to receive full compensation.

- Lolita M. Jones, RHIA, CCS

Ms. Jones ("[email protected]")) performs ASC coding audits and training. She is the author of the book, The New Medicare ASC Payment System, available at writeOutLink("www.ezmeded.com",1).

6 Numbers still subject to change.
While the system's design and general policies are fixed, the rates and other numerical parameters could change. The values to take effect Jan. 1 will be updated in a new final regulation due about Nov. 1.

7 Four-year transition.
Given the magnitude of the changes, CMS decided to blunt their effect by providing a four-year transition for existing services. In 2008, 75 percent of ASC payments for old services will be based on the old system and 25 percent on the new. Services newly added to the ASC list will receive the new payment rate immediately.

8 GI and pain management take a hit.
CMS estimated the effect of the new system on ASC spending by surgical specialty. All areas except gastrointestinal and pain management procedures show increases, some of them large, as a result of the change. GI procedures are projected to decline 4 percent in 2008 (and 15 percent once the transition is fully implemented). Spending for eye procedures in ASCs is expected to rise modestly.

9 What about hospitals?
The overall effect on hospitals isn't entirely clear. Surely some surgical services will migrate toward ASCs over time as ASCs add services in response to the expanded list and improved payment rates for many services. On the other hand, ASCs may be less attractive sites for some services that they now provide in high volumes, and some patients requiring these services may wind up in HOPDs as a result.

10 To prevent economic incentives from biasing site choice...
While physicians (and beneficiaries) should have improved ability to choose where services are delivered based on clinical conditions, CMS has limited the ASC payment for services primarily provided in a physician's office to the office-based practice expense payment made under the physician fee schedule. If a physician delivers a service in an ASC that isn't on the ASC list, the physician will only receive the lower, facility-level practice expense payment. CMS has proposed changes in the physician self-referral ("Stark") regulations to accommodate radiology services delivered as an integral part of surgery in an ASC.

Cases will continue to migrate to ASCs
CMS estimates that Medicare spending for ASCs will rise by $270 million over spending in 2006 as a result of the changes. CMS assumes that 25 percent of the volume of new ASC services will migrate from hospitals in the next two years, and 15 percent of the new services currently provided in physicians' offices will move over four years.

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