CMS 2018 Final Rule To Impact Orthopedics ASCs

The Center for Medicare and Medicaid Services (CMS) has issued the final rules on Ambulatory Surgical Center (ASC) reimbursement and changes that could have important implication on the orthopedics billing in ASC. The rule includes update to payment policies, payment rates and also the quality provisions for the services provided under the Physician Fee Schedule (PFS). The rule will be applicable on and after January 1, 2018. The final for the Payment rule provides 1.2 percent increase in ASC reimbursement and having effect on reimbursement of orthopedics billing at ASC.

Total Knee Replacement Removed From Inpatient Only List

CMS has finally implemented the long awaited rule of billing for removing the total knee replacement from the inpatient-only list. Though CMS hasn’t added the procedure to an ASC payable list, though many ASC providers who work on Total Knee replacement do feel that this means the arthroplasty can be added to the ASC payable list. The total knee replacement involves removing the damaged knee and replacing it with artificial knee implant.

Recent Advancement in the knee replacement surgery reduces the risk and creates the path on outpatient basis. Improved perioperative anesthesia, resulting into minimum invasive technique of rehabilitation procedure makes the procedure safe and with same day discharge.

The rule change has created confusion among the physician regarding how to interpret the new rule. Hospitals, surgeons and payers are all interpreting the rule according to their understanding. Further their seem to be no single consistency in the rule leading to the uncertainty about what needs to be concluded. An additional concern is that reporting of the Medicare Advantage plan which will be directing the network towards the TKA for an outpatient status.

Addition To Create ASC Payable List

CPT 22856

Used For:

Total disc arthroplasty (artificial disc), anterior approach, including discectomy with endplate preparation (includes osteophytectomy for nerve root or spinal cord decompression and micro dissection), single interspace, cervical.

CPT 22858 – Second Level

Used For:

Cervical disc arthroplasty with discectomy Artificial Total Disc Replacement involves the replacement of a degenerating intervertebral disc with an artificial disc in adults with degenerative disc disease (DDD) in either the lumbar or cervical region of the spine. The artificial disc is intended to preserve range of motion (ROM) and reduce pain, and prevent adjacent disc degeneration. Like knee arthroplasty, cervical disc arthroplasty can also be performed using minimally-invasive techniques and patients can go home in less than 24 hours.

Quality Reporting:

CMS has finalized the new ASC payment system and quality reporting (ASCQR) measure to impact the orthopedic surgery center. This would be targeted towards


Hospital Visits after Orthopedic Ambulatory Surgical Center procedure, which leads to assesses all-cause, unplanned hospital visit within seven days of orthopedic procedure.

Payment Rates:

Overall, ASC reimbursement rate will increase 1.2 percent in 2018. Hospital Outpatient department will lead to increase in 1.35 percent increase.

Orthopedics deals with major procedures and many of the rules would vary according to the payer’s contract. ASC reimbursement is complex and it makes more difficult with ever changing compliance regulations. For more info how your ASC facility can bill for orthopedics billing visit us.