ASCA pitched 62 other surgical codes routinely performed in ASCs for non-Medicare patients, including total shoulder replacements, but CMS declined to add them.
“Clinicians in the ASC community recommended that more than 60 procedure codes be added to our Medicare payable list and CMS has proposed to add none of them,” Mr. Prentice told Becker’s. “We are extremely frustrated that CMS continues to use the utterly mysterious and undefined term ‘typical Medicare beneficiary’ when determining whether to add procedures to the list. Surgery centers are specifically designed to treat the subset of patients whose underlying overall health, as determined by their surgeon, makes them good candidates for care in our setting. Until CMS recognizes that, the Medicare program will waste untold millions of dollars each year by trapping care in higher cost settings.”
CMS pays for total shoulder replacements at hospital outpatient departments but has so far declined to allow the same for ASCs, despite the same nurses, staff and surgeons performing those cases on otherwise healthy patients. Mr. Prentice said CMS’ decision was “mystifying” and the agency is “wasting millions of dollars each year by trapping care in higher-cost settings.”
In 2021, migrating some total knee replacements from HOPDs to ASCs reduced costs to Medicare by $75 million, according to Mr. Prentice.
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