Understanding the CMS Changes for 2009

A new year is here, and with it comes changes in Medicare reimbursement (again) — and at least two more years until the transition is complete. In this second year in the transition, ambulatory surgery center (ASC) reimbursement is based on 50 percent of 2007 ASC rates and 50 percent of the published hospital outpatient department (HOPD) rate. When comparing the reimbursement of ASCs to that of HOPDs, the overall percentage has dropped from 63 percent in 2008 to 59 percent in 2009. Part of this drop in reimbursement is because HOPDs have received an inflationary increase in reimbursement in 2008 and 2009, while ASCs did not.

As you can see from Table 1, several specialties have an overall increase in reimbursement. However, as expected, others such as GI and pain management have decreased. The downward trend in reimbursement for these specialties and specific procedures means that it’s important to continue reassessing those procedures that already have minimal margins.

Table 1 

Effect on Specialties — 2009 Proposed Change in CMS Reimbursement   

In May 2009, the Centers for Medicare and Medicaid Services (CMS) is changing the definition of an ASC to “any 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.” This means that ASCs can now keep a patient overnight. Because of this, certain procedures that were previously thought to require an overnight stay were added to the ASC-approved list.

For 2009, CMS added a total of 30 procedures to the approved-procedures list, some of which were previously excluded and some newly added CPT codes from the American Medical Association. Additionally, there were changes to the lists of office-based and device-intensive procedures.

To obtain the 2009 CMS reimbursement list for ASCs and all of the information about office-based, device-intensive and ancillary procedures, click here. As changes are made quarterly in additions/deletions and reimbursement allowances for ancillary procedures, be sure to check regularly for updates.

The following are suggestions for tasks you may already have addressed in your preparation for 2009 changes. Review your fee schedule each time Medicare makes a major change in reimbursement allowances. Particularly check the device-intensive procedures as Medicare includes the reimbursement for the implant with the facility fee. Be aware that Medicare’s allowance for implants does not always cover cost.

• Example: 63685 — Insert/rep spinal neurostimulator
• Cost (depending on type) — $15,000 to $18,000
• Medicare 2009 allowance (including facility fee) — $14,366.35

CMS has established Conditions for Coverage (CfC) for ASCs. It is now required that ASCs gather data that will provide information on the quality of care provided to patients and its impact on patient outcome. Enactment of these CfCs will help ensure that ASCs are qualified to safely perform the broader and more complex range of services being covered in the ASC setting. The areas of focus for 2009 are:

• Strengthening patients’ rights regarding disclosure of physician financial interests; advance directives; grievances; and confidentiality.
• Imposing stronger obligations an ASCs to oversee its quality assessment and performance improvement (QAPI) program, while allowing ASCs flexibility to assess and improve patient services, outcomes and satisfaction.
• Emphasizing the importance of infection control practices.
• Strengthening the requirements for assessing the patient’s condition at admission and at discharge.
• Adopting a disaster preparedness plan.

Although overall the percentage of ASC to HOPD rates has declined, CMS continues to move forward in implementing the biggest change in reimbursement to surgery centers ever undertaken. If it has accomplished nothing else, it has inspired surgery centers to continue their efforts to remain the economic leaders in performing outpatient procedures.

Caryl A. Serbin, RN, BSN, LHRM, is president and founder of Surgery Consultants of America, Inc. and Serbin Surgery Center Billing, LLC.