CMS issues pay proposal, but rates could be less

Debt ceiling deal in Congress could cut 2%

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The Centers for Medicare & Medicaid Services' (CMS') proposed fee schedule for Medicare outpatient services for calendar year 2013 would boost hospital outpatient payment rates by a net of 2.1%, while ambulatory surgical centers would see a 1.3% net increase. However, according to Bobby Hillert, executive director of the Texas Ambulatory Surgery Center Society, as a result of last year's debt ceiling deal in Congress, all Medicare providers will witness a 2% cut if the sequestration happens.1

"Congress will have to decide soon," Hillert said.

Medicare providers will continue to bill for normal Medicare rates, he said. Providers will be reimbursed at 98 cents on the dollar, "so this could result in a 0.1% increase for HOPDs [hospital outpatient departments]," Hillert said.

As a result of sequestration due to last year's debt ceiling deal in Congress, Medicare will see a 2% cut if Congress does not act, Hillert said. "This would result in a .7% cut for ASCs in 2013," he said.

The Ambulatory Surgery Center Association (ASCA) blasted CMS for its use of an urban consumers variation of the Consumer Price Index. According to ASCA, this index results in a payment calculation of roughly $43 for ASCs compared to nearly $72 for hospitals for some undefined aggregate set of services.

The ASC community potentially will see the gap in reimbursement between hospital outpatient departments (HOPDs) and ASCs widen, according to the ASCA. Although CMS did explicitly recognize that "the CPI-U [Consumer Price Index for All Urban Consumers] ... may not best reflect inflation in the cost of providing ASC services," it declined to adopt the hospital market basket as the basis for updating ASC payments, the ASCA says. "This disparity in updates could mean that the gap between ASC payments and HOPD payments would increase from 56% to 58%," the ASCA says. To correct this problem, ASCA is supporting federal legislation: the "ASC Quality & Access Act of 2011."

CMS states in the proposal that it would like to change the payment methodology for ambulatory classification services "from median costs to geometric mean costs" to determine the relative payment weights of services, a switch from the median cost measure the agency has used since the inception of the Outpatient Prospective Payment System (OPPS). The agency claims that geometric mean costs "better reflect average costs of services than the median," but adds that the geometric mean already has been used in the inpatient prospective payment system (IPPS) for more than a decade. CMS states that such a move with the outpatient system "would have a limited payment impact on most providers, with a small number experiencing payment gains or losses based on their service-mix."

In its proposal, CMS indicates that payment for medical device-intensive procedures will be the same for ASCs as for hospitals. The statement explains that the phrase "device-intensive procedure" is defined as one in which the device "accounts for more than 50% of the cost.

Sixteen new procedures were added to the ASC list of payable procedures beginning Jan. 1, 2013. (See list, below.)Six procedures were on a list of ASC covered procedures proposed for permanent office-based designation for 2013. (See list, below. For physician fee schedule highlights, see below.)

The agency is accepting comments until Sept. 4. To access the proposal, go to http://bit.ly/NcUSSZ.

Reference

  1. Hillert B. "CMS Releases ASC & Physician Payment 2013 Proposed Rules." Texas ASC Society Newsletter. July 13, 2012.

Proposed New ASC Covered Surgical Procedures for CY 2013

• 37205 (2012 HCPCS) — Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity arteries), percutaneous; initial vessel. G2 (2013 Payment Indicator).

• 37206 (2012 HCPCS) — Transcatheter placement of an intravascular stent(s) (except coronary, carotid, vertebral, iliac, and lower extremity arteries), percutaneous; each additional vessel (list separately in addition to code for primary procedure). G2 (2013 Payment Indicator).

• 37224 — Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal angioplasty. G2 (2013 Payment Indicator).

• 37225 — Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with atherectomy, includes angioplasty within the same vessel, when performed. G2 (2013 Payment Indicator).

• 37226 — Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed. G2 (2013 Payment Indicator).

• 37227 — Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed. G2 (2013 Payment Indicator).

• 37228 — Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty. G2 (2013 Payment Indicator).

• 37229 — Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed. G2 (2013 Payment Indicator).

• 37230 — Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed. G2 (2013 Payment Indicator).

• 37231 — Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed. G2 (2013 Payment Indicator).

• 37232 — Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal angioplasty (list separately in addition to code for primary procedure). G2 (2013 Payment Indicator).

• 37233 — Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with atherectomy, includes angioplasty within the same vessel, when performed (list separately in addition to code for primary procedure). G2 (2013 Payment Indicator).

• 37234 — Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s), includes angioplasty within the same vessel, when performed (list separately in addition to code for primary procedure). G2 (2013 Payment Indicator).

• 37235 — Revascularization, endovascular, open or percutaneous, tibial/peroneal artery, unilateral, each additional vessel; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed (list separately in addition to code for primary procedure). G2 (2013 Payment Indicator).

• 0299T — Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care; initial wound. R2 (2013 temporary office-based payment indicator)

• 0300T — Extracorporeal shock wave for integumentary wound healing, high energy, including topical application and dressing care. R2 (2013 temporary office-based payment indicator).


ASC Covered Surgical Procedures Proposed for Permanent Office-based Designation for 2013

The Centers for Medicare and Medicaid Services proposed to permanently designate the following codes as office-based because they were performed more than 50% of the time in physicians' offices.

• 31295 (2012 CPT code) — Nasal/sinus endoscopy, surgical; with dilation of maxillary sinus ostium (e.g., balloon dilation), transnasal or via canine fossa. G2 2012 ambulatory surgery center (ASC) payment; P2 2013 ASC payment.

• 31296 — Nasal/sinus endoscopy, surgical; with dilation of frontal sinus ostium (e.g., balloon dilation. G2 2012 ASC payment; P2 2013 ASC payment.

• 31297 — Nasal/sinus endoscopy, surgical; with dilation of sphenoid sinus ostium (e.g., balloon dilation. G2 2012 ASC payment; P2 2013 ASC payment.

• 53860 — Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence. G2 2012 ASC payment; P2 2013 ASC payment.

• 64566 — Posterior tibial neurostimulation, percutaneous needle electrode, single treatment, includes programming. G2 2012 ASC payment; P2 2013 ASC payment.

• G0365 — Vessel mapping of vessels for hemodialysis access (services for preoperative vessel mapping prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow. G2 2012 ASC payment; P2 2013 ASC payment.


Physician Fee Schedule Highlights

• The physician fee schedule included a provision that would send Medicare reimbursement payments for pain management services directly to certified registered nurse anesthetists (CRNAs) in states where CRNAs are allowed to furnish them. While several industry publications indicated that this move was a significant story, it was expected. The Centers for Medicare and Medicaid Services (CMS) indicated that they would like to leave scope of practice issues up to states.

• Physicians, like all Medicare providers, will face a 2% cut for all services if the sequestration events occur.

• Congress will be required to act at the end of this year to prevent massive Medicare physician payment cuts (approximately 24%). CMS proposed 7% payment increases for family physicians. Cuts to certain specialists would offset this family physician increase.

• "A proposal to revise a regulation that only allows Medicare to pay for portable X-rays ordered by an MD or DO. The revised regulations would allow Medicare to pay for portable X-ray services ordered by physicians and non-physician practitioners acting within the scope of their Medicare benefit and state law."

• "A proposal to include additional Medicare-covered preventive services on the list of services that can be provided via an interactive telecommunications system."

Source: Hillert B. "CMS Releases ASC & Physician Payment 2013 Proposed Rules." Texas ASC Society Newsletter. July 13, 2012.