Payment rates decline for some specialties

Final outpatient payment rule released for '09

Newly released 2009 payment rates for ambulatory surgery will be painful for certain specialties, says Kathy Bryant, president of the Ambulatory Surgery Center Association. For example, gastrointestinal cases have a 7% decrease, which is added to a 5% decrease last year, Bryant says.

Despite objections from the ASC Association, the Centers for Medicare & Medicaid Services (CMS) insisted on using secondary rescaling of ASC relative weights in setting payments for the final rule, Bryant says. The ASC Association and others groups strongly support the use of the same ambulatory payment classifications (APCs) and relative weights in creating a payment system encompassing the services offered by both hospital outpatient departments (HOPDs) and ASCs. Rescaling the ASC relative weights the second time reduces payments to ASCs and further exacerbates the growing gap between ASC and HOPD payments, the ASC Association contends. If CMS hadn't used secondary rescaling, the rates would be about a 1½ percentage higher, she says.

"I'm so discouraged. It's that the rates are now lower than what they should be," Bryant says.

The final payment rates apply to services furnished on or after Jan. 1, 2009.

The rule includes final changes to the Medicare Conditions for Coverage (CfCs) for ASCs that is less restrictive than a revision proposed last year. In response to comments submitted in response to a proposed rule, the new CfCs are less restrictive than first proposed. Changes resulted from comments from the industry that were critical of the draft language. The new CfCs says this definition is applied to ASCs: ". . . ASC means any distinct entity that operates exclusively for the purpose of providing surgical services to 'patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission.'" The proposed rule would have provided that the patient's treatment was not expected to require an overnight stay, defined as requiring active monitoring by qualified medical personnel, regardless of whether it is provided in the ASC, after 11:59 p.m. on the day of admission.

In the final rule, CMS says, "There may be rare instances when a Medicare patient is required to stay beyond 24 hours due to an unexpected result from a surgery that would require further monitoring and care. Such a stay would be unplanned, and the ASC would continue to be responsible for the patient and provide care until the patient is stable and able to be discharged in accordance with the ASC regulations and facility policy."

For ASCs that are doing overnight care, the change from the proposed to final rule is a huge improvement, Bryant says. "The language in the proposed rule wouldn't have allowed any procedures to be done if there was going to be overnight care anywhere," she says. "Now it says there can be overnight care in the ASC, and even there, it allows up to 24 hours. That's a big improvement beyond midnight, which is what they had in proposed rule."

According to CMS, the new CfCs will help ensure ASCs are safely equipped and qualified to perform a broader range of services under the ASC payment system. They also will help improve assurance of the quality and safety of the care patients receive in ASCs, CMS says.

New procedures added to ASC list

CMS is adding 27 surgical procedures to the list of procedures for which Medicare will pay when furnished in an ASC. The Healthcare Common Procedure Coding System (HCPCS) code and procedures are:

  • 15170, Acell graft trunk/arms/legs;
  • 15171, Acell graft trunk/arm/leg add-on;
  • 15175, Acellular graft, face/neck/hands feet/genitalia;
  • 15176, Acell graft, face/neck/hands feet/genitalia add-on;
  • 20696, Comp multiplane ext fixation, $1,206.09;
  • 20697, Comp ext fixate strut change, $802.10;
  • 34490, Removal of vein clot;
  • 36455, Blood exchange/transfuse nonnewborn;
  • 41530, Tongue base vol reduction, $695.85
  • 43273, Endoscopic pancreatoscopy, $885.21;
  • 46930, Destroy internal hemorrhoids, $127.68;
  • 49324, Lap insertion perm ip cath;
  • 49325, Lap revision perm ip cath;
  • 49326, Lap with omentopexy add-on;
  • 49652, Lap vent/abd hernia repair, $1,529.28;
  • 49653, Lap vent/abd hern proc comp, $1,529.28;
  • 49654, Lap including hernia repair, $1,529.28;
  • 49655 Lap inc hern repair comp, $1,529.28;
  • 49656, Lap inc hernia repair recur, $1,529.28;
  • 49657, Lap inc hern recur comp, $1,529.28;
  • 55706, Prostate saturation sampling, $466.09;
  • 62267, Interdiscal perq aspir, dx, $180.53;
  • 64448, N block inj fem, cont inf;
  • 64449, N block inj, lumbar plexus;
  • 64455, N block inj, plantar digit, $18.75;
  • 64632, N block inj, common digit, $34.26;
  • 65756, Corneal trnspl, endothelial, $1,532.41;

There were a number of procedures deleted from the inpatient list, but they weren't added to the ASC list, Bryant points out. However, CMS did examine those procedures and considered adding them, as they will every year, she says. "As we can accumulate evidence, we'll be able to demonstrate that it is appropriate for the ASC, and get more and more [procedures] added," Bryant says.

ASCs do not receive an inflation update in 2009, because it will be the second year of a four-year transition to having the ASC payments match those of hospitals under the OPPS.

In another change in the file rule, CMS revised the proposed language to state that when the ASC conducts drills, at least annually, to test the disaster preparedness plan's effectiveness, the ASC must complete a written evaluation of each drill and "promptly" implement any corrections to the plan, instead of "immediately" as proposed.


For more information on the final payment rule, contact these people at CMS about the following issues:

  • Sheila Blackstock. Phone: (410) 786-3502. Reporting of quality data issues.
  • Dana Burley. Phone: (410) 786-0378. Payment changes for ambulatory surgical centers (ASCs).
  • Alberta Dwivedi. Phone: (410) 786-0378. Payment changes or hospital outpatient departments.
  • Jacqueline Morgan. Phone: (410) 786-4282, Joan A. Moliki. Phone: (410) 786-5526. Steve Miller. Phone: (410) 786-6656. Jeannie Miller. Phone: (410) 786-3164, ASC conditions for coverage issues.

At press time, the final rule with comment was scheduled to appear in the Nov. 18, 2008, Federal Register. Comments on designated provisions are due by 5 p.m. Eastern on Dec. 29. To access the final rule, go to [Editor's note: An e-mail alert about the final rule was sent Oct. 31, 2008. If you didn't receive the alert, we don't have your e-mail address. Contact customer service at or (800) 688-2421.]