CMS proposal is big news for ambulatory surgery centers.
There is big news for ambulatory surgery centers (ASCs) as the Centers for Medicare & Medicaid Services (CMS) is proposing to allow 12 cardiac catheterization procedures to be performed in ASCs, according to the 2019 Outpatient Prospective Payment System (OPPS) proposed rule released on Wednesday.
Those procedures are CPT® 93451-93462. It should be noted though that CMS did not approve any cardiac procedures with coronary interventions. That means if it is determined that a patient requires a stent, the patient must be scheduled for that intervention at a hospital, most likely on a different day.
This will result in some inconvenience for the patient since it is common for patients now to undergo diagnostic catheterization with stenting at the same time if it is determined to be warranted. It will also increase costs to Medicare for those patients needing intervention as they will be paying the facility and the physician for two procedures.
Interestingly, in 2010, two physicians, Brahmajee K. Nallamothu, MD, MPH and Harlan M. Krumholz, MD, SM, published an article in the Journal of the American Medical Association entitled “Putting Ad Hoc PCI On Pause,” in which they argue that, except in myocardial infarctions, patients should have their diagnostic catherization and then meet with the physician to discuss the results and the treatment options. This move to allow these procedures at ASCs may allow the recommendations of these physicians to finally be adopted.
But for most readers of RACmonitor, the biggest news is that CMS has elected to make no status changes to any of the joint arthroplasty surgeries. That means total knee replacement remains off the inpatient only list, total hip replacement remains on the inpatient only list and no total joint replacements will be allowed at ambulatory surgery centers in 2019. That should come as a welcome relief after nearly a year of controversy over the status determinations for knee replacements as discussed in many RACmonitor articles and segments of Monitor Monday.
But that does not mean there are not changes that should be noted. In fact, it appears that CMS reads RACmonitor because they cleared up the ambiguity of status determinations for acute myocardial infarctions that was discussed by me in a RACmonitor article in November, 2017 by proposing to add HCPCS code C9606 to the inpatient only list to join HCPCS code 92941. CMS also proposed removing the code for anesthesia for total knee arthroplasty from the inpatient only list since the surgery itself is no longer inpatient only. One additional code is proposed to be removed, CPT code 31241 (Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery.)
In another interesting development, CMS asked for comments and recommendations on reducing the utilization of outpatient hospital services. In that discussion, CMS asks a question that few of us ever thought we would hear from CMS—”Should prior authorization be considered as a method for controlling overutilization of services?” CMS does not require prior authorization, although they have discussed using it in the future as part of their appropriate use criteria initiative for advanced imaging. We have all struggled getting approval for outpatient hospital imaging and infusions, with managed care payers preferring free-standing or office-based services because of their lower cost. If CMS adopts such programs, the future will be bleak.
CMS is also proposing to add an add-on payment for Exparel, an injected non-opioid nerve blocker, at ASCs in an attempt to reduce the use of opioids for patients who have undergone surgery. The CMS analysis of claims data noted a decrease in use of the medication recently at ASCs and hope that by paying for the medication, physicians will use Exparel instead of sending the patient home with a prescription for an opioid. It is interesting that the CMS data showed no decline in the use of Exparel in outpatient hospitals, so the agency is not proposing to institute an add-on payment for outpatient hospital. The differential usage at hospitals as compared to ASCs was not explored, but one can surmise that because ASCs are partially owned by the surgeons and anesthesiologists, the use of high cost drugs would be discouraged because of the adverse effects on the financial success of the ASC.
In the outpatient hospital setting, the medication costs are borne solely by the hospital, with the surgeon and anesthesiologist have no financial interest.
One item that may not get much attention, but which may represent a potential clue to future audits is a note about payments to partial hospitalization programs (PHP). CMS notes that they have seen an increase in the number of PHP claims billed with only three units of service per day. The agency is concerned that such a low number of units could suggest that the PHP requirements are not being met and that payment therefore may be non-compliant. PHPs would be wise to read this section of the rule and review their data.
Finally, there is one item in the rule which harkens to the old days of medicine. There is a request for approval of an device pass-through payment for BioBag.® The BioBag® is a biosurgical wound treatment (maggot therapy) indicated for debridement of nonhealing necrotic skin and soft tissue wounds, including pressure ulcers, venous stasis ulcers, neuropathic foot ulcers, and nonhealing traumatic or postsurgical wounds. Debridement, which is the action of removing devitalized tissue and bacteria from a wound, is required to treat or prevent infection and to allow the wound to progress through the healing process. This system contains disinfected, living larvae that remove the dead tissue from wounds and leave healthy tissue undisturbed. We’ll leave it at that.
Program Note:
Listen to Dr. Ronald Hirsch report the 2019 OPPS proposed rule on Monitor Monday, July 30, 10-10:30 a.m.ET.
The proposed rule can be found here.
