Changes to Medicare pay, quality measures finalized for hospitals and ASCs in 2015
Executive Summary
In the Calendar Year 2015 Medicare final payment rule, hospital outpatient Prospective Payment System (OPPS) payments are estimated to increase by 2.2%, and the adjusted update factor for ambulatory surgery centers is 1.4%.
- Eleven codes were added to the ASC-payable list codes.
- The quality measure "Facility Seven-Day Risk-Standardized Hospital Visit Rate after Outpatient Colonoscopy" was finalized. Also finalized was the May 15, 2015, reporting deadline for "Influenza Vaccination Coverage among Healthcare Personnel" through the National Healthcare Safety Network (NHSN). Someone from every facility must register with the NHSN, and this process can take several weeks.
[Editor’s note: Same-Day Surgery tweeted about these changes Oct. 31 and Nov. 3. To keep up with breaking news as it happens, follow us on Twitter @SameDaySurgery.)
The Centers for Medicare & Medicaid Services (CMS) has issued the Calendar Year 2015 policy changes and payment rates final rule for the hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. Overall OPPS payments are estimated to increase by 2.2%, and the adjusted update factor for ASCs is 1.4%.
The ASC increase is based on a projected rate of inflation of 1.9% minus a 0.5 percentage point productivity adjustment required by the Affordable Care Act. Hospital outpatient departments (HOPDs) will receive an increase based on a 2.9% market basket minus a 0.5% adjustment for economy-wide productivity and a 0.2 percentage point adjustment required by statute.
As in previous years, the Ambulatory Surgery Center Association (ASCA) had proposed that CMS align the HOPD and ASC update factors to prevent a continuing divergence in payment rates by using the hospital market basket to determine the update factor for ASCs.
"While we are pleased to see a slight increase in our payments over the proposed rule, we are extremely disappointed that CMS continues to undervalue ASC payments by using the CPI-U [Consumer Price Index for all urban consumers] to update them when even their own actuaries have indicated that the CPI-U is inappropriate," said ASCA CEO Bill Prentice. "Using different update factors for ASCs and HOPDs widens the gap between HOPD payments and ASC payments, further incentivizes a disturbing trend of conversions of ASCs to HOPDs, and increases costs to the Medicare program, its beneficiaries, and taxpayers who support the program."
CMS also finalized a significant change to its device-intensive policy that will benefit ASCs, according to the ASCA. In its final rule, CMS defines ASC device-intensive procedures as procedures assigned to any ambulatory payment classification (APC) group with a device cost greater than 40% of the total cost of the procedure in the HOPD setting. The previous threshold was 50%.
In a released statement, the association said, "ASCA has consistently advocated for a lower threshold, and in our comments to CMS, noted that there are approximately 163 procedures that are allowed to be performed in the ASC setting but are not because our facilities are not adequately reimbursed for the devices involved. Even at the 40% threshold there are about 50 codes with high device costs that will now become economically feasible for ASCs to begin performing, saving Medicare and its beneficiaries millions of dollars annually."
Codes added to ASC list
CMS added the following 10 spine codes to the ASC-payable list:
- 22551, Neck spine fuse&remov bel c2;
- 22554, Neck spine fusion;
- 22612, Lumbar spine fusion;
- 22614, Spine fusion extra segment;
- 63020, Neck spine disk surgery;
- 63030, Low back disk surgery;
- 63042, Laminotomy single lumbar;
- 63045, Removal of spinal lamina;
- 63047, Removal of spinal lamina;
- 63056, Decompress spinal cord;
- CMS also added the following code:
- CPT 63044, Laminotomy, additional lumbar.
CMS also agreed with ASCA’s assessment that CPT codes 22551, 22554, and 22612 were assigned to the wrong APC group, the association said. CMS moved these codes to APC 0425, which has a higher reimbursement.
"ASCA appreciates CMS’ recognition that these procedures are safely and effectively performed in ASCs," Prentice said. "However, until such time as the devices and secondary codes ASCA requested in its comment letter are added to the ASC payable list, it will not be economically feasible for many of these codes to be performed in the ASC setting."
At press time, the final rule was scheduled to appear in the Nov. 10, 2014, Federal Register and can be downloaded at http://1.usa.gov/10bobzs. The provisions in the rule generally will take effect on Jan. 1, 2015. The public comment period will close on Dec. 30, 2014. (For changes to quality reporting rules, see story, below.)
