CMS-Proposed Rule: Changes to the Ambulatory Surgical Center Payment

The Center for Medicare and Medicaid Services (CMS) proposed a new rule that will update the payment policies and rates. The update will specifically cater to Hospital Outpatient and Ambulatory Surgical Centers (ASC). The rules will set forth a motion to promote efficient service and promote higher quality service for all the Medicare beneficiaries.  The proposed rule will replace the current ASC payment system laid out during 2013 which accounted for around $4.10 billion.

The proposed rule for 2018 would revise the Medicare hospitals outpatient prospective payment system (OPPS) and the Ambulatory Surgical Center (ASC).  To implement different changes which have been derived from different experience the change will include various factors which will be calculated to determine the payment rate for Medicare services paid for ASC.

Medicare currently pays more than 4,000 hospitals which include general acute care hospital, long-term acute, Children’s, cancer, inpatient psychiatric hospitals.  For all the above hospitals outpatient services were paid according to the OPPS. Services under the OPPS are classified into different payment groups- Ambulatory Payment Classification (APCs). Services included under the APC are clinically similar and payment is set for each of the APC.  Each of the payment rates is adjusted according to the different geographic regions.

Usually, Medicare beneficiaries share the cost of service which is laid by CMS. This can be up to 20 percent of coinsurance or certain service. A copayment under the Medicare law should not exceed more than 40 percent of the total payment. CMS has laid down the rules where an overall beneficiary of the Medicare is now required to pay to be 20 percent through coinsurance.

Currently, there are approx. 5,000 Medicare participating ASC facilities and since 2008 all the facilities are paid under the revised rule. Under the revised rule all hospital outpatient settings are based on the ASC payment rate wherein APC out weights for any services. In the rule, CMS adopted criteria that allowed for more procedure and service to be covered when the patient visits an ASC setting.

The revised ASC payment is established to reflect on criteria as the same relative resource is used for the procedure as under outpatient payment. Considering the lower cost of the surgical procedure at ASC the new revised rule was to maintain the budget neutrality in the payment system.

Changes in Ambulatory Surgical Center payment rate

CMS is proposing the increase of ASC payment rate by 1.3 percent or by consumer price index for urban areas to 2.2 percent minus the multifactor productivity adjustment by 0.9 percent.  CMS also has stated that they believe that the payment rate will be stable at 57 percent for the proposed service.

Proposed revision for the payment under new technology intraocular lenses

CMS has also proposed significant revisions to the regulations for the new technology intraocular lens. The CMS is also proposing the FDA’s approval in labeling the claim for a specific clinical benefit based on the new characteristics of the lens.

Ambulatory Surgical Center quality measure reporting

CMS has concluded to measure the facilities on eight quality measures which are to be reported under the ASC quality reporting. Five of those would apply to the encounters at the beginning. CMS is also proposing the requirement to include procedural quality data reporting for updating different measures and data completion requirement. This also includes 2 percent payment reduction when the requirements are not met.

Medical Billers and Coders with a 19-year experience in ASC coding and billing is working on the proposed rules to understand different affecting areas of your revenue generation. This would not include the detailed analysis based on your facility but understanding the patient care requirements. Medical Billers and Coders will provide you with the detailed analysis of your revenue generation including the loss areas of revenue leak.