CMS adds 25 procedures, deletes 100 from ASC list

Proposed changes, if accepted, take effect July 1

The proposed update to the ambulatory surgery center (ASC) list of approved procedures has been published by the Centers for Medicare & Medicaid Services (CMS), and the proposals are a mixed bag for ASCs, according to industry sources.

The rule was published in the Nov. 26, 2004, Federal Register. (See resource, below, for information on how to access.) CMS is expected to publish the final update in the spring, and the changes are expected to take effect July 1, 2005.

"The good news is that CMS is again taking seriously its commitment to update the ASC list every two years," says Eric Zimmerman, JD, partner with McDermott Will & Emery in Washington, DC.

Also, CMS is proposing to add 25 procedures to the ASC list. If finalized, the additional procedures would give ASCs greater flexibility to furnish a wider array of surgical cases, according to the American Association of Ambulatory Surgery Centers (AAASC) in Johnson City, TN. (See list of additions.)

"Some of these procedures AAASC has been trying to add since 1998," says Craig Jeffries, Esq., executive director. Jeffries points to the following as procedures that have long been sought as additions: reconstruction of chin (21120), augmentation of lower jawbone (21125), colonoscopy with stent (44397), proctosigmoidoscopy with stent (45327), and repair of bladder defect (57288). Repair of bladder defect was performed 43,876 times in 2003, and 15,788 of those cases were performed in hospital outpatient departments, according to the Federated Ambulatory Surgery Association (FASA) in Alexandria, VA.

The proposed additions also include knee arthroscopy (29873), which has been performed in ASCs safely and efficiently for some time, according to FASA.

The bad news is that CMS is proposing to delete four codes for every one that it adds, says Kathy Bryant, executive vice president of FASA. (See list of deletions.)

"These deletions will represent a major decrease in access for some Medicare beneficiaries," Bryant says. In fact, the 10 highest volume procedures that are being deleted were performed 128,000 times in 2003, she says. "This is a major problem," Bryant adds.

Additionally, CMS is proposing to delete some procedures — particularly cystoscopy procedures — which absolutely should remain on the ASC list, according to Zimmerman. There were 58,872 cystocopies (52000) performed in 2003, according to FASA.

"It’s bad for patients when their site-of-service options are reduced because of reimbursement considerations," he says.

Additionally, CMS failed to add dozens of other procedures that members of the industry have attempted to add for some time, explains Zimmerman. These procedures include ligation of hemorrhoid(s) (46221), ligation of hemorrhoids (46946), urine voiding pressure study (51795), intra-abdominal pressure test (51797), repair of detached retina (67105), and treatment of retina (67145), according to the AAASC.

Industry sources also are frustrated over the fact that some procedures are not on the list, while similar ones are. Removal of lesions are one example, Bryant says. "Sometimes it is nonsensical which are and which are not," she says. "For example, sometimes they are the same size but on different parts of the body — one being on [the list] and one not."

The most important step outpatient surgery managers can take now is to submit comments, Bryant emphasizes. Unlike congressional proposals, CMS reacts more to good information than volume, she says. "In fact, lots of comments with little information sometimes leads CMS to conclude that things shouldn’t be changed," Bryant adds.

Provide your industry association with information on the procedures you want added and how they meet the criteria to be on the ASC list, she says. Please be specific, Bryant asks. "For example, what is the average time it takes to perform the procedure and average recovery time? Is there significant blood loss?" she says. "The more data that can be provided the better."

FASA has a form on its web site for submitting data. (Go to Under "What’s New at FASA?" click on "Proposed Update to the Medicare ASC List Released." Then click on "Give Your Feedback — Codes to be Added.")

Also, encourage your surgeons to contact their national medical specialty societies and the Chicago-based American College of Surgeons to comment in support of the procedures, Bryant suggests.

"This is extremely important as we often fail to get procedures added when one of these groups objects to something being on the ASC list," she says. "If the medical specialties only hear from people who object to procedures being on the ASC list and not those who want the procedure on the list, the medical specialty is likely to file comments opposing the addition or supporting a deletion. "

Send the surgeons’ comments to your industry association so the association leaders can follow up with the surgeons’ groups, Bryant says. "We meet with them regularly, and knowing someone has contacted them helps us," she adds.

[Editor’s note: Comments on the proposed additions and deletions must be submitted by Jan. 25, 2005. Comments may be submitted on the web at or Refer to file CMS-1478-P. Attachments should be in Microsoft Word (preferred), WordPerfect, or Excel. Comments also may be sent by mail (one original and two copies) to Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1478-P, P.O. Box 8013, Baltimore, MD 21244-8013.]


For more information, contact:

  • Centers for Medicare & Medicaid Services, Baltimore. Chuck Braver. E-mail:
  • Craig Jeffries, Esq. Executive Director. The American Association of Ambulatory Surgery Centers, P.O. Box 5271, Johnson City, TN 37602. Phone: (800) 237-3768. Fax: (423) 282-9712. E-mail: Web:
  • Federated Ambulatory Surgery Association, Alexandria, VA. E-mail:

For a full copy of the proposed rule, go to Also, copies of the Nov. 26, 2004, Federal Register are available free at