After a seven-year delay, CMS finally will expand its list of Medicare-paid procedures at ambulatory surgery centers, effective July 1. CMS is adding 303 codes and deleting 140, for a net increase of 163 codes and $5 million more a year in Medicare payments. So why aren't ASC physicians cheering?
For one thing, after so much time, $5 million is a tiny increase to the $1.3 billion that Medicare paid to ASCs in 2001. Also, ASC physicians are disappointed that several common ASC procedures did not make the list.
Finally, many physicians chafe under any kind of list of allowable procedures, arguing that they should be able to decide what is safe and what isn't in an ASC.
"I don't understand why the government has to tell us what we can and cannot do," says John DeLoach, M.D., medical director of Springhill Surgery Center in North Little Rock, Ark.
DeLoach cites the omission from the list of laparoscopic cholecystectomies, a high-volume procedure that he has done in his ASC since 1990. It is a procedure that commercial insurers, which don't have to abide by the Medicare list, usually pay for at ASCs.
"I'm amazed as to why they would not be in the list," DeLoach says.
The original CMS list had included the procedure, but the American College of Surgeons recommended against it, according to CMS officials. DeLoach, an ACS member, says his next step is to campaign to change the college's policy on lap cholis.
The college and other opponents of allowing procedures such as lap cholis to be done in ASCs argue that some high-risk patients should be near a hospital in case they have complications.
But DeLoach says he can pick out high-risk patients in advance and send them to the hospital. He thinks oversight should be taken care of that way, rather than with an outright ban.
Other procedures that ASC doctors say should have been on the list are treatment of toe fractures, removing a ruptured disk, diagnostic laryngoscopy and some ophthalmic laser procedures.
ASC physicians are quick to add they are happy that the list was finally updated, but they are pessimistic that many more procedures will be added.
Under law, the list should be updated every two years. CMS officials, who have a policy of not identifying themselves, say they delayed because the agency is short-staffed and has had other tasks, such as researching Medicare reform proposals.
Current additions to the list involve all major specialties. Deletions had a minimal effect because most involved procedures usually done in a physician's office.
To determine what should be on the list, CMS officials say they are required to apply a set of standards that places limits on the length of the operation and amount of blood loss and that checks whether the operation is frequently done in a hospital inpatient department.
The standards require some professional judgment. But rather than using a panel of physicians to apply them, CMS officials say they rely on comments from groups ranging from the college of surgeons to hospitals, groups that have their own agendas.
Many ASC physicians think it is time to replace the ASC list with the much longer list of allowable procedures for hospital outpatient facilities. That would mean the ASC list would expand from the current 2,472 CPT codes to 8,000 slightly different HCPCS codes for outpatient facilities, including some nonsurgical codes.
David Shapiro, M.D., president of the American Association of Ambulatory Surgery Centers, says merging the lists would be in keeping with other bold moves the federal government is considering for ASC payments. "If the federal government eliminates payment distinctions, maybe it's time to eliminate the separate lists for ASCs and outpatient facilities," he says.
New codes on the blockFast facts about the new list of Medicare-approved ASC procedures
Remuneration indicationsCMS is supposed to use the following criteria to select ASC procedures that will be paid by Medicare:
Source: David Shapiro, M.D., AAASC president