2010 ASC Reimbursement Sees Ups and Downs
Offering a wider scope of services can offset any losses.
By Shelley C. Safian, MAOM/HSM, CPC-H, CPC-I, CCS-P, CHA
On Nov. 20, 2009, the Centers for Medicare & Medicaid Services (CMS) published the Final Rule in Federal Register regulation CMS-1414-FC,: Changes to the Hospital Outpatient Prospective Payment System and CY 2010 Payment Rates; Changes to the Ambulatory Surgical Center Payment System and CY 2010 Payment Rates. The determinations in this final rule are effective Jan. 1. Officially, these regulations only affect reimbursement from the federal government to Medicare participating providers and suppliers. It is not unusual, however, for private third-party payers to follow suit.
For an ambulatory surgical center (ASC) to become a Medicare participating provider, surgical services offered cannot require the patient to stay in the facility for more than 24 hours. Unexpected circumstances requiring a patient to stay longer should occur rarely. ASCs are not permitted to share space with a Medicare-participating independent diagnostic testing facility (IDTF) or a hospital (e.g., a hospital outpatient surgery department).
ASC Payment Rates
Per the final rule, the 2010 ASC conversion factor (CF) includes a 1.2 percent increase allowance for inflation. This is the first year that CMS is permitted, by law, to include such a payment update. The annual increase, the inflation allowance, and the wage adjustment for budget neutrality resulted in a final conversion factor of $41.873—higher than the proposed factor of $41.625 and an increase over the 2009 conversion factor of $41.393.
The new rates may be based on a 25/75 or 50/50 blend of 2007 payment rates and 2010 rates to create a transitional cushion, or they may be approved with no transition and be paid at 100 percent of the 2010 weights.
For many surgical and radiological procedures and services performed at an ASC, reimbursement rates are determined by applying a scaler to the payment amount approved for the outpatient prospective payment system (OPPS) relative weights. The proposed ASC scaler for 2010 was 0.9514; however, the final payment weight scaler for 2010 ASC reimbursement is 0.9567. Separately payable covered ancillary services with their own (or a predetermined) reimbursement rate are not subject to scaling.
Impact Varies With Specialty
Whether the 2010 changes are good news or bad news depends on the specialty focus of the procedure. Based on the changes without the transition (total implementation), procedures performed on the hematologic and lymphatic systems are looking at an estimated 40 percent increase in their reimbursement (a 22 percent increase with a 25/75 blend). Other specialties seeing strong increases are those providing services for the respiratory system (37 percent increase); musculoskeletal system (29 percent increase); and cardiovascular system (27 percent increase). ASC facilities that specialize in procedures on the genitourinary system and the auditory system can both look forward to an estimated 17 percent increase in their 2010 payments, while those providing procedures and services involving the integumentary system are looking at an estimated 20 percent increase.
Resource tip: For more information on payment changes by specialty, refer to Table 75 in the Final Rule, available for download on the ASC Payment > ASC Regulations and Notices > Details for CMS-1414-FC page of the CMS Web site: www.cms.hhs.gov/ASCPayment/ASCRN/ItemDetail.asp?ItemID=CMS1230100.
Procedures of the digestive system are looking at a 10 percent decrease. ASCs specializing in procedures treating the nervous system are expected to realize a 5 percent decrease with full implementation (or a 4 percent decrease with a 25/75 transition blend). Those treating the eye and ocular adnexa system, as well as those providing ancillary items and services, are looking at an estimated 1 percent decrease in Medicare program payments for the coming year with full implementation, or no change in reimbursement levels at all with the 25/75 blend.
Individual Procedure Rates
General estimations by specialty may provide a perspective that will support planning in your facility for 2010. Before deciding anything, however, you might find a clearer picture in the details. There are changes in the number of procedures approved for ASC provision reimbursement, as well as changes in the payment rates for specific procedures.
Although six ASC surgical procedures covered in 2009 are changed to office-based designation in 2010, the overall number of procedures slated for ASC payment coverage has increased (see Details for CMS-1414-FC: Table 62).
On the positive side, a total of 28 procedures are now ASC-covered surgical procedures for 2010. Specifically, four musculoskeletal CPT® procedure codes, nine digestive system procedures, five neurological procedures, and four procedures on the urinary system now are covered. Three new Category III codes now are ASC-approved. These include two codes for sacroplasty injection, 0200T Percutaneous sacral augmentation (sacroplasty), unilateral injection(s) including the use of a balloon or mechanical device, when used, 1 or more needles and 0201T Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, both with a proposed ASC payment indicator of G2 (non-office based surgical procedure), and with reimbursement rates of $881.92 and $1,272.77 respectively (higher than the proposed rates).
Many of the approved changes to specific procedures reflect the overall financial impact discussed earlier. For example, colonoscopy and biopsy (45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple), diagnostic colonoscopy (45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)), and lesion removal colonoscopy (45385 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique) are all estimated to reflect the 11 percent decrease in payments with full implementation, but only an estimated 5 percent decrease with a 25/75 blend transition (see Details for CMS-1414-FC: Table 76). Colon screening procedures (HCPCS Level II, G0105 Colorectal cancer screening; colonoscopy on individual at high risk and G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) are slated for potential 17 percent and 16 percent decreases, respectively, with full implementation; or an 8 percent decease for both under a 25/75 blend.
Arthroscopic surgeries, however, are estimated to have healthy increases in reimbursement, especially on the knee (29880 and 29881 Arthroscopy, knee, surgical; (medial OR lateral, including any meniscal shaving)) at 30 percent increase for full implementation and 17 percent with a 25/75 blend, arthroscopy on the shoulder (29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release) estimated at 54 percent increase with full implementation (28 percent with the 25/75 blend), and rotator cuff repair (29827 Arthroscopy, shoulder, surgical; with rotator cuff repair), with a 42 percent increase for full implementation (or 22 percent at 25/75 transition blended rates). The correction of a hammertoe (28285 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)) has an estimated payment that is 25 percent higher in 2010 with full implementation, or 14 percent at 25/75.
But, it is not looking up for all things musculoskeletal. For example, injections of anesthetic agents in additional levels (add-on code 64480 Injection, anesthetic agent and/or steroid, transforaminal epidural; cervical or thoracic, each additional level (List separately in addition to code for primary procedure)) will decrease an estimated 8 percent with full implementation, or decrease 4 percent at the transitional 25/75 blended rate. Add-on code 64484 Injection, anesthetic agent and/or steroid, transforaminal epidural; lumbar or sacral, each additional level (List separately in addition to code for primary procedure) will have a greater affect on reimbursement with a 38 percent decrease for the fully implemented rate, and a 19 percent decrease at the 25/75 blended rate.
Those facilities performing cataract surgeries (specifically codes 66982 Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage and 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (one stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification)) can expect an estimated 2 percent decrease in reimbursement (with full implementation), and a harder hit with an estimated 20 percent decrease under full implementation (or 10 percent decrease with the 25/75 blend) when providing a discussion of a secondary membranous cataract using laser surgery (66821 Discission of secondary membranous cataract (opacified posterior lens capsule and/or anterior hyaloid); laser surgery (eg, YAG laser) (one or more stages)). Perhaps the ASC can make up some of those losses when performing a blepharoplasty of excessive skin weighing down the upper lid (15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid). This procedure will bring in an estimated 21 percent increase with full implementation, or 15 percent with 25/75 transition rates; while the repair of blepharoptosis, external approach of a (tarso) levator resection or advancement (67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach) is estimated to bring in 2 percent additional with full implementation, or no change at all if the 25/75 transitional blended rate applies.
New to ASCs
One of the new ASC-covered surgical procedures for 2010 is 0193T Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence. This code has a 2010 third year transition payment weight of 19.1572, with a third year transition payment of $802.17 (see Details for CMS-1414-FC: Addendum AA). Removal of kidney stones (specifically CPT® 50080 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; up to 2 cm and 50081 Percutaneous nephrostolithotomy or pyelostolithotomy, with or without dilation, endoscopy, lithotripsy, stenting, or basket extraction; over 2 cm), now ASC-covered procedures, have a 2010 third year transition payment of $1,870 each. Urinary-cutaneous anastomosis revisions or any type of urostomy (50727 Revision of urinary-cutaneous anastomosis (any type urostomy)) have a transition payment of $802.17.
Open transluminal balloon angioplasty, both venous (35460 Transluminal balloon angioplasty, open; venous) and for brachiocephalic trunk or branches (35475 Transluminal balloon angioplasty, percutaneous; brachiocephalic trunk or branches, each vessel), will become 2010 ASC-covered procedures, each with a transition payment weight of 48.4864 and a transition payment of $2,030.27.
The newly-approved, ASC-covered procedure to repair a tibial non-union or mal-union (27720 Repair of nonunion or malunion, tibia; without graft, (eg, compression technique)) has been assigned a transition payment weight of 43.499 to be reimbursed at a transition payment of $1,821.43.
The Bottom Line
As a result of this update to the ASC payment system, the additional expenditures for 2010 from the federal government to Medicare providers and suppliers are estimated at $33 million.
In 2010, many ASC facilities may discover long-term financial security by offering a wider scope of services. This variety may enable the facility to better balance the negatives with more positives. Creating diversification of third-party payers with which your facility participates, types of procedures performed, and ancillary services offered, can protect your facility’s financial health now and into the future.
Shelley C. Safian, MAOM/HSM, CPC-H, CPC-I, CCS-P, CHA, is a health information management (HIM) consultant performing revenue efficiency audits for physicians offices. She is also an associate university professor teaching medical billing and coding and HIM courses. She has written five books on coding, reimbursement, and HIM compliance.
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