2008 Update: Approved Procedure List Grows -- but Not All ASCs Will Win

A number of procedures may become more common in hospitals, once again
CMS has issued a final rule spelling out how it will pay for services in ASCs starting Jan. 1. "This is the rule they’ve been waiting for forever and ever," says Laurie Castillo, CPC, CPC-H, CCS-P, with Castillo Consulting in Manassas, Va.
The good news: CMS will pay for an extra 790 procedures in ASCs. Medicare will refuse to pay for a procedure in an ASC only if the surgery involves a "significant safety risk" or if it requires an overnight stay. CMS is also proposing to add several more surgical procedures to the covered list later on.
The bad news: CMS wants to cap ASC payments at about 65 percent of the payment levels in the outpatient hospital setting (the level could be more like 67 percent, depending on what data CMS ends up using). This reduced payment takes into account the lower costs of furnishing services in the ASC setting, CMS says. Medicare will phase in this new payment rate over four years, from 2008 through 2011.
And for any procedure a physician performs in the office, CMS won’t pay more in the ASC than it would in the office.
CMS will pay for services not included in the list of ASC covered procedures using the facility practice expense (PE) amount, not the higher nonfacility PE amount.
Also, for procedures involving "high-cost devices," in which the cost of the device is more than half the median cost of the procedure, CMS will pay 100 percent of the outpatient amount for the device itself. But for the service cost, CMS will still only pay around 65 percent of the outpatient amount.
More good news: If your physician owns a stake in an ASC, he can still send patients to that ASC for radiology, imaging and outpatient prescription drugs. The doctor won’t be violating the law by referring patients to the physician-owned facility for those services, CMS proposes.

Some Will Benefit More Than Others

If your ASC is a multispecialty facility, the new payment levels may be a wash, says Kathy Bryant, executive director of the Federated Ambulatory Surgery Association (FASA). But almost half of the 4,600 ASCs serving Medicare are single-specialty facilities. And the rule will be great for some specialties and not so great for others.
Gastroenterologists and pain-management physicians will see a reimbursement cut if ASC payments drop to 65 percent of the outpatient level, Bryant says. But the same payment rates will mean an increase in reimbursement for most orthopedic procedures, she adds.
As a result, single-specialty GI or [...]

- Published on 2007-10-25