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Tony Mira, Chairman and Chief Executive Officer of MiraMed

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The 2019 OPPS/ASC Payment Rule: Implications for Anesthesia Groups

Summary: The 2019 OPPS/ASC final rule adds 12 cardiac catheterization procedures and five additional cardiology procedures to the ASC list of covered procedures. As a result, many anesthesia groups will see a change in the mix of procedures at their ASCs starting in 2019 and should begin planning accordingly.

The Centers for Medicare and Medicaid Services (CMS) published the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Payment System final rule on November 1, 2018.

In our view, the change of greatest significance to anesthesia groups is the continuation of the shift toward procedures that can be performed in ambulatory settings that comes with the new policy.

Recognizing the dynamic nature of ambulatory surgery, the final rule modifies the definition of surgery in the ASC payment system to include certain "surgery-like" procedures that are assigned codes outside the CPT surgical range. The new policy also adds 12 cardiac catheterization procedures to the ASC list of covered procedures, as well as five additional cardiology procedures. As a result, many anesthesia groups will see changes in the mix of procedures currently performed in their facilities.

Anesthesia groups might want to begin thinking now about how the changes coming in 2019 will affect staffing needs and procedure volume in their ASCs and plan accordingly. The expansion of procedures performed in ASCs starting next year could have safety implications for some groups as well. Some ASCs may be more equipped than others to handle the changes. How prepared are your facilities to manage the types of procedures that were added and that could be coming your way?

Another key change for anesthesia groups is CMS's decision to remove CPT Code 01402 (Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty) from the inpatient only (IPO) list. CMS believes CPT 01402 merits removal because it is closely related to CPT Code 27447 (Arthroplasty, knee, condyle and plateau; medical and lateral compartments with or without patella resurfacing (total knee arthroplasty), which was removed from the IPO list in 2018, and because the service is already being performed in many hospitals on an outpatient basis.

Despite the change, it's worth keeping in mind CMS's reminder to providers that "the removal of any procedure from the IPO list does not mandate that all cases be performed on an outpatient basis. Rather, such removal allows for Medicare payment to be made to the hospital when the procedure is performed in the hospital outpatient department setting. . . We continue to believe that the decision regarding the most appropriate care setting for a given surgical procedure is a complex medical judgment made by the physician based on the beneficiary's individual clinical needs and preferences and on the general requirement that any procedure be reasonable and necessary."

In 2019, CMS will also finalize its proposal to pay separately at the average sales price (ASP) plus six percent for non-opioid pain management drugs (e.g., Exparel) that function as a supply in ASCs. And it will remove the three recently revised pain communication questions from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience of care survey effective with October 2019 discharges for 2021 payment determinations—one year earlier than proposed. Based on comments, CMS agreed not to publicly report the three revised pain communication questions on Hospital Compare, although it will "continue to consider the value of collecting data that relates to pain management." 

The complete final rule is available here. A fact sheet on the final rule is available here.

With best wishes,

Tony Mira

President and CEO

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