Kara Newbury is the ASC Association’s (ASCA) regulatory counsel. In this position, she spearheads ASCA’s federal regulatory efforts, primarily working with the Centers for Medicare & Medicaid Services.
Q: What are the key details from the 2016 proposed payment rule that you feel ASCs should know about?
Kara Newbury: There are many details of the 2016 proposed payment rule that will affect ASCs, but the following are specifics to which ASCs should pay particular attention.
Rate updates: ASC payment rates would increase approximately 1.1% on average under the proposed rule.
Procedure list: The Centers for Medicare & Medicaid Services (CMS) proposed to move 11 codes, primarily spine and gynecological, to the ASC-payable list. The codes are as follows: 0171T, 0172T, 57120, 57310, 58260, 58262, 58543, 58544, 58553, 58554 and 58573.
CMS also moved seven codes, including several spine, off of the inpatient-only list. The codes are as follows: 0312T, 20936, 20937, 20938, 22552, 54411 and 54417. While that does not impact ASCs for 2016, it does indicate that CMS believes those codes are safely performed in the outpatient setting. ASCA will advocate strongly to see those codes moved to the ASC-payable list.
Device-intensive codes: The number of ASC codes that will be classified as “device intensive” would increase from 137 codes to 186 codes in calendar year 2016. When CMS designates a procedure as device-intensive, this indicates that the device portion of the cost, based on hospital outpatient department (HOPD) cost data, is greater than 40 percent of the cost of the entire procedure. Prior to 2015, the threshold was 50 percent. CMS has proposed to continue using the 40 percent threshold in 2016. ASCA will be advocating for the threshold to be lowered to 30 percent, since ASCs are reimbursed much less (approximately 55% of the HOPD rate) for the non-device portion of the procedure.
Quality reporting program: No new measures were proposed for 2016. However, CMS has proposed to make the deadline for reporting all web-based measures May 15, 2016. Currently, measures that are reported via QualityNet (ASC-6, ASC-7, ASC-9 and ASC-10) must be submitted by September 30, 2015, thanks to a reporting extension announced by CMS late last month.
Also, while not specific to ASCs, CMS is, in general, moving its policies away from payment for each individual service to payment more comprehensively for the entire episode of care. This is fine if the primary code is reimbursed adequately, but ASCA remains concerned that packaging secondary codes into a primary code without increasing the reimbursement for the primary code will only serve to drive procedures back to the higher-cost settings of care.
Q: Is the proposed payment rule good news, bad news or somewhere in between?
KN: There were no revolutionary changes for ASCs in the proposed rule. ASCA continues to be disappointed that CMS uses the default update factor, the Consumer Price Index for All Urban Consumers (CPI-U), to update ASC payments. While HOPD payments are updated based on the inpatient hospital market basket, which takes into consideration the cost of supplies and equipment that all outpatient healthcare facilities much purchase and maintain, the CPI-U is based on the price of consumer goods such as gasoline and milk. This year, ASCA will, once again, request that CMS move away from the inaccurate CPI-U as an update factor and, instead, update ASCs using the same hospital market basket it uses for HOPDs. This will not result in equal payments, but it will stop the growing disparity in payment amounts. As healthcare costs continue to rise, CMS needs to encourage migration to the lower-cost, high-quality ASC setting instead of continuing policies that discourage this movement.
ASCA was pleased to see that CMS proposed adding the 11 codes to the ASC-payable list for 2016, but we would like to see a major expansion of codes on the ASC-payable list. ASCA believes CMS should be more transparent when determining whether or not codes should migrate to the ASC-payable list.
Q: What does ASCA hope will change in the final rule, and when will that likely be released?
KN: The final rule is statutorily required to be released at least 60 days prior to January 1 every year. Last year, the 2015 final rule was released on October 31, 2014.
As mentioned above, ASCA continues to ask CMS to use a more appropriate update factor for ASC payments.
We believe that any code CMS deems to be safe and effective for the HOPD setting should also be on the ASC-payable list. There are currently 329 codes that are separately payable in the HOPD setting but not the ASC. ASCA will continue to request transparency as to the ASC-payable list.
As stated earlier, we are pleased to see that CMS has proposed to add 11 new codes to the ASC-payable list, acknowledging that these procedures are performed safely and effectively in the ASC setting. ASCA requests that CMS provide the clinical reason for excluding other codes so that we may refute the exclusion with research and outcomes data.
Q: What can ASCs do to help bring about these changes and guide payment policy in 2016 and beyond?
KN: ASCs can submit their comments in response to the proposed changes via this webpage by August 31, 2015. ASCA will have talking points available soon, and is always willing to work with individual facilities on crafting customized letters.
For more information, contact Kara Newbury at firstname.lastname@example.org.