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American Pain Society
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Glenview, IL 60025
David E. Joranson, MSSW and Michael A. Ashburn, MD MPH, Department Editors
Michael A. Ashburn, MD MPH
The Health Care Financing Administration (HCFA) has proposed new rules regarding determination of practice expenses and payment for procedures completed at an ambulatory surgical center (ASC).
The changes in the determination of the practice expense component of the MFS has led to double-digit percentage increases in the majority of codes of interest to pain management practitioners.
The first of the two rules, proposed in June, creates new relative values for the practice expense component of the resource-based relative value scale. it also creates a differential between private physician's office and facility (i.e., hospital and ASC) settings. The impact of the changes in Medicare fee schedule (MFS) payments for the two settings appears in Table 1.
The changes in the determination of the practice expense component of the MFS has led to double-digit percentage increases in the majority of codes of interest to pain management practitioners. However, some codes have received significant reductions in the proposed payment schedule.
Several of the 203 codes that HCFA proposes to delete from the ASC list are of interest to the pain community; many of the nerve block codes have been deleted.
On June 12 HCFA published a proposed rule on the coverage and payment of procedures provided in an ASC. If finalized, this rule would change the list of procedures eligible for payment of facility fees if performed at an ASC and would change the amount paid to an ASC for eligible procedures.
Currently, HCFA recognizes eight facility payment levels for 2, 280 surgical procedures performed in more than 2,400 Medicare-approved ASCs. The rule proposes an overhaul in both of the two criteria used to determine whether a service will be included on the ASC list as a covered service. In addition, the rule proposes a change in the system of payment through an expansion in the number of payment levels from 8 to 105
To generate a facility fee, a procedure must be on the ASC list. If a procedure is not on the ASC list, no facility fee will be paid, even if the procedure was completed at an ASC.
For determining whether a surgical procedure is covered when performed in an ASC, HCFA's current criteria mandate that the procedure cannot exceed 90 minutes in length or require more than 4 hours of recovery time. In addition, procedures that are performed on an inpatient basis 20% of the time or less or in a physician's office 50% of the time or more are excluded from coverage. HCFA proposes to base its review for coverage on more subjective data by relying on clinical criteria. For example, procedures that generally result in extensive blood loss, require major or prolonged invasion of body cavities, directly involve major blood vessels, or are emergent or life threatening will be excluded in general from the ASC list.
HCFA proposes to include a total of 2,499 surgical procedures on the ASC list and to delete 203 codes from the current ASC list because they are not safe or otherwise reasonable and necessary in an ASC setting. Several of the 203 codes that HCFA proposes to delete from the ASC list are of interest to the pain community; many of the nerve block codes have been deleted.
Once HCFA has determined that a service should be included on the ASC list, the next step will be to assign the service to one of the 105 proposed ambulatory payment classification (APC) groupings. This system will expand the specificity of payment from the current eight levels, but it also creates a system in which payment for some surgical procedures will increase and payment for others will be significantly reduced.
HCFA based the APC system on a framework of ambulatory payment groupings developed by the 3M Company. HCFA made changes to these classifications based on the time required to perform the procedures and the cost of necessary supplies and equipment. In addition, the practice expense relative values and data from the Medicare Physician Payment Schedule were used in the review. The actual payment for each APC is based on data collected in 1994 via the Medicare Ambulatory Surgical Payment Rate Survey on facility overhead expenses and procedure-specific charges.
The new payment system for hospital outpatient procedures will also use the APC system. This means that procedures eliminated from the ASC list will not be eligible for facility fee payment in the hospital outpatient setting under the proposed rule.
The proposed rule is more than 200 pages long. It is available on the Federal Register home page at http://www.nara.gov/fedreg/.
