Proposed Changes to the Inpatient Only List & ASC Covered Surgical Procedures for 2019

on Tuesday, 31 July 2018. All News Items | Documentation | Coding

CMS Releases the CY 2019 OPPS Proposed Rule

Over the past few years CMS has released major Proposed and Final Rules right before a Holiday. However, this year the 4th of July came and went with no Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule. Finally, CMS provided us with some last minute summer reading with the release of this Proposed Rule on Wednesday July 25th.

While a bit more obscure than Independence Day, July 25th has been designated as National Merry-Go-Round Day, Hot Fudge Sundae Day, Thread the Needle Day and Wine and Cheese Day. Take your pick on which one goes best with reading the Proposed Rule. You could choose the metaphorical meaning of National Thread the Needle Day of “finding a path through two opposing views.” Whether the path meets or not, you can almost always anticipate opposing views prompting comments. Or go the route of needing a little wine and cheese to temper the opposing views. Again, take your pick.

Now let’s delve into what changes are being proposed specific to the Inpatient Only (IPO) List and ASC Covered Procedure List (CPL).

Inpatient Only List

CMS utilizes the following specific criteria when determining whether or not a procedure should be removed from the IPO List and assigned to an Ambulatory Payment Category (APC) group for payment under the OPPS when provided in the hospital outpatient setting:

  1. Most outpatient departments are equipped to provide the services to the Medicare population.
  2. The simplest procedure described by the code may be performed in most outpatient departments.
  3. The procedure is related to codes that we have already removed from the IPO list.
  4. A determination is made that the procedure is being performed in numerous hospitals on an outpatient basis.
  5. A determination is made that the procedure can be appropriately and safely performed in an ASC, and is on the list of approved ASC procedures or has been proposed by us for addition to the ASC list.

CMS does not require that all five criteria be met to remove a procedure from the IPO List. For Calendar Year (CY) 2019, CMS is proposing to remove two procedures and add one procedure to the IPO List.

Procedures Proposed for Removal

The following table details the two procedures proposed for removal by CPT code, CPT code description, the criteria CMS believes the procedures meet for removal from the IPO List, proposed Comprehensive Ambulatory Payment Category (C-APC) and Proposed Status Indicator (SI).

Proposed Procedures for Removal from the IPO List
CPT CodeCPT Code DescriptionCriteria Met for RemovalProposed C-APCProposed Status Indicator
31241 Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery 3 5153 (Level 3 Airway Endoscopy) J1
01402 Anesthesia for open or surgical arthroscopic procedures of knee joint; total knee arthroplasty (TKA) 3 and 4 “This procedure is typically billed with CPT 27447 (TKA), which was removed from the IPO list for CY 2018 (82 FR 52526)

Procedure Proposed for Adding to the IPO List

“The IPO list specifies those procedures and services for which the hospital will be paid only when the procedures are provided in the inpatient setting because of the nature of the procedure, the underlying physical condition of the patient, or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged (76 FR 74353).”

CMS is proposing to add HCPCS code C9606 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel). They “believe that the procedure should be added to the IPO list because this procedure is performed during acute myocardial infarction and it is similar to the procedure described by CPT code 92941 (Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, artherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel), which was added to the IPO list for CY 2018 (82 FR 52526).”

Solicitation of Comments for Potential Removal of Procedure from IPO List

Around this time last year CMS sought public comments on whether or not the partial hip arthroplasty (PHA) and total hip arthroplasty (THA) CPT codes should be removed from the IPO list and whether these procedures meet criteria to be added to the ASC CPL. In the 2018 OPPS Final Rule CMS thanked commenters for their detailed responses and noted they would consider them in future policymaking.

Though a week after July 25th, for hospitals, it is Hot Fudge Sundae worthy to note the 2019 OPPS/ASC Proposed Rule does not include a proposal to remove PHA/THA procedures from the IPO List. The extra cool whip on top is that no major joint procedure (TKA, PHA, and THA) is being proposed for addition to the ASC CPL.

CMS is seeking comments on whether or not CPT code 0266T meets any criteria for removal from the IPO List and the APC assignment and Status Indicator for this code. This code describes the implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed).

Ambulatory Surgical Center (ASC) – Proposal to revise CMS’s definition of “Surgery”

“Covered surgical procedures in an ASC are surgical procedures that are separately paid under the OPPS, that would not be expected to pose a significant risk to beneficiary safety when performed in an ASC, and for which standard medical practice dictates that the beneficiary would not typically be expected to require active medical monitoring and care at midnight following the procedure (“overnight stay”).”

Annually, CMS updates “the lists of, and payment rates for, covered surgical procedures and covered ancillary services in ASCs in conjunction with” the final rulemaking process to update the OPPS and ASC payment system. This process includes a review of excluded surgical procedures (including all procedures newly proposed for removal from the OPPS inpatient list), new codes, and codes with revised descriptors” believed to meet criteria for designation as an ASC covered procedure or covered ancillary service.

Historically, CMS’s definition of a covered surgical procedure has excluded from ASC payment “certain invasive, “surgery-like” procedures, such as cardiac catheterization.” In the CY 2018 OPPS/ASC final rule CMS noted that some stakeholders suggested that certain procedures outside the CPT surgical range but are similar to surgical procedures currently covered in an ASC setting should be ASC covered surgical procedures. Certain cardiovascular procedures were recommended due to their similarity to currently-covered peripheral endovascular procedures in the surgical code range for surgery and cardiovascular system.

CMS notes “after further consideration of comments…we are proposing to revise our definition of “surgery” for CY 2019 to account for “surgery-like” procedures that are assigned codes outside the CPT surgical range (10000-69999).”

Proposed Updates to the ASC Covered Surgical Procedures List

With the proposal to change the definition of “surgery” to account for “surgery-like” procedures CMS is proposing to add 12 cardiac catheterization procedures to the list for CY 2019. The following table includes the HCPCS code, long code descriptors and payment indicators as displayed in Table 40 of the Proposed Rule.

Proposed Additions to the List of ASC Covered Surgical Procedures for CY 2019
CY 2019 CPT CodeCY 2019 Long DescriptorProposed CY 2019 ASC Payment Indicator
93451 Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed G2
93452 Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed G2
93453 Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed G2
93454 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation G2
93455 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography G2
93456 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right heart catheterization G2
93457 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization G2
93458 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed G2
93459 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography G2
93460 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed G2
93461 Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography G2
93462 Left heart catheterization by transseptal puncture through intact septum or by transapical puncture (list separately in addition to code for primary procedure) N1

CMS is accepting comments on the Proposed Rule up to 5 p.m. EST on Monday September 24, 2018.

Resources

2019 OPPS Display Copy Proposed Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-15958.pdf

2019 OPPS Proposed Rule in the Federal Register: https://www.gpo.gov/fdsys/pkg/FR-2018-07-31/pdf/2018-15958.pdf

Link to CMS Fact Sheet released 7/25/2018: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-25.html

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc.  Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. 

 

In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Risk Assessment (CRA) Tool. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

 

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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