ASC & HOPD Proposed Payment Rates
The Centers for Medicare and Medicaid Services (CMS) released 2019 proposed payment rule for ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs) on July 25, 2018.
American Society of Interventional Pain Physicians (ASIPP) and the Society of Interventional Pain Management Surgery Centers (SIPMS) are proud to announce that CMS has addressed a number of long requested priorities effecting interventional pain management with increase in rates for multiple procedures.
Our longstanding work with CMS and congress for last 18 months has resulted in these changes effecting interventional pain management. We are very grateful to multiple chairs and members of the congress as we know our Bill 5804 even proposes further changes in calculation methodology that would be helpful in balancing payment rates to office settings also. In addition, appointment of an ASC member to Hospital Outpatient Payment panel is also major achievement, said Chairman of the Board of the American Society of Interventional Pain Physicians. (HR 6138)
1. Percutaneous adhesiolysis procedure has been increased from a national rate of $350.20 to $400.09, a 14.2% increase, but still 13% lower than 2016 rate, and 50% less than 2015.
2. Cervical and lumbar interlaminar epidural injections have been increased from $283.10 to $315.48, a 11.4% increase below 3.6% compared to 2016, and 14% less than 2015.
3. Transforaminal epidural injections have seen an increase of 14.2% from $350.20 to $400.09.
4. Multiple other procedures such as pudendal neurolysis, intercostal neurolysis, intercostal nerve blocks, axillary nerve block, brachial plexus block, also have seen increases.
5. Among the other procedures seeing significant increases are removal of spinal electrode plate, removal of spinal electrode percutaneous array, and tunneling of intrathecal or epidural catheter, but offset by implant or replacement of subcutaneous reservoir with overall some increase.
6. Some of the major changes include the following:
● Align update factors, moving the ASCs to hospital market basket that is used to update HOPD payments.
● Under the proposal CMS would use the hospital market basket to update ASC payments for the 5-year period of calendar year (CY 2019 through CY 2013).
7. The average update this year is 2% compared to no update of less than 1% in the past. Overall, ASCs would see an average overall covered procedures, an effective update of 2% - a combination of a 2.8% inflation update based on the hospital market basket and a productivity reduction mandated by the Affordable Care Act of 0.8 percentage points.
However, this may not apply across the board and there may be significant changes.
In addition, the statutory 2% reduction remains in effect until at least 2014 unless congress acts.
8. Lower Intensive Procedure Threshold:
CMS is also proposed to define ASC device-intensive procedures as those procedures with a device offset percentage greater than 30% based on the standard Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) rate-setting methodology. The current threshold is 40%.
9. Proposed Changes to List:
CMS is proposing to revise their definition of "surgery" in the ASC payment system to account for certain "surgery-like" procedures that are assigned codes outside the Current Procedural Terminology (CPT) surgical range.
10. Proposed Payment for Non-Opioid Pain Management Therapy:
CMS is also proposing to provide separate payment for nonopioid pain management drugs that function as a supply when used in a surgical procedure when a procedure is performed in an ASC.
11. Changes to the ASC Quality Reporting Program:
Implications of some of these changes are not known yet. We will be bringing these to you in the coming days.