CMS Establishes New ASC Conditions of Coverage

CMS has issued the final Outpatient Prospective Payment System/Ambulatory Surgical Center Payment System (OPPS/ASC) rule, which establishes new conditions for coverage for ASCs that “reflect current ASC practice by focusing on the care provided to patients and the impact of that care on patient outcomes.” The final rule also sets the ASC update for calendar year 2009 at 0 percent and adds 27 procedures to the ASC list.

Here is an over view of the new conditions for coverage.

  1. An ASC will be defined as a distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following admission.
  2. ASCs will have to strengthen patients’ rights regarding disclosure of physician financial interests in the ASC; advance directives; the grievance process; and confidentiality of clinical records.
  3. An ASC governing body will have stronger obligations to oversee its quality assessment and performance improvement (QAPI) program; ASCs will have flexibility to use their own information to assess and improve patient services, outcomes, and satisfaction.
  4. Infection control practices are emphasized.
  5. There will be stronger requirements for assessing a patient’s condition at admission to verify that the surgery is appropriate and safe for the patient in an ASC setting, and at discharge to ensure appropriate post-surgical care for the patient.
  6. ASCs will have to adopt disaster-preparedness plans.

The most important and heatedly contested of these is the first, which was originally much stricter. However, in response to comments submitted in response to a proposed rule that was published in the Aug. 31, 2007 Federal Register, the new conditions for coverage define an ASC as a distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission.

The proposed rule would have provided that the patient’s treatment was not expected to require an overnight stay, defined as requiring active monitoring by qualified medical personnel, regardless of whether it is provided in the ASC, after 11:59 p.m. on the day of admission.

CMS is adding 27 surgical procedures to the list of procedures for which Medicare will pay when furnished in an ASC. These include 13 procedures for which the American Medical Association’s CPT Editorial Panel has created new codes and descriptors, and 14 procedures that were previously excluded from payment under the ASC payment system.

CMS is also adding eight procedures to the list of office-based procedures (subject to payment at the lesser of the amount paid to physicians under the MPFS office practice expense or the standard ASC rate), and updating the lists of device-intensive procedures and covered ancillary services and their rates, consistent with the final CY 2009 OPPS policies.

The revised ASC payment rates were established to reflect the same relativity of resource use among services as under the OPPS, taking into consideration the lower costs of the services in an ASC and maintaining budget neutrality in the payment system. The law does not allow an inflation update to the ASC payment system for CY 2009.

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