Knowledge Base Article

CMS utilizes five criteria to determine whether or not a procedure should be removed from the Inpatient Only (IPO) List and assigned to an Ambulatory Payment Category (APC) group for payment under the OPPS when provided in the hospital outpatient setting. They do not require that all five criteria be met to remove a procedure from the IPO list. The five criteria includes the following: 

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.

Procedures Proposed for Removal

CMS proposed removing CPT code 31241 (Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery) and CPT code 01402 (Anesthesia for open or surgical arthroscopic procedures of knee joint; total knee arthroplasty). In general, commenters supported the proposals and CMS adopted as final without modification the removal of both codes from the IPO list for CY 2019.

Procedure Proposed for Adding to the IPO List

CMS proposed to add HCPCS code C9606 to the IPO list.  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).” Commenters supported this proposal and CMS adopted as final without modification the addition of this code to the IPO list for CY 2019.

Solicitation of Comments for Potential Removal of Procedure from IPO List

In the Proposed Rule, CMS sought 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).

Commenters referenced personal experience with this procedure, advancements and safety of the procedure, and patients’ experience after undergoing the procedure. They argued that procedures related to CPT 0266T are “commonly being performed safely in the hospital outpatient department.”

CMS determined that this procedure is similar to another procedure already being performed in numerous hospitals on an outpatient basis and therefor finalized the removal of this code from the CY 2019 IPO list.

Public Requests for Removal of Procedures on the IPO List

Commenters recommend the removal of several procedures not proposed by CMS but were related to other procedures recently removed from the IPO list. “In addition, several commenters recommended the removal of all orthopaedic, arthroplasty, and joint replacement procedures from the IPO list.” Specific procedure codes requested to be removed are listed in the table below.   

CMS agreed with commenters that CPT Code 00670 is appropriate for removal and are removing this procedure. CMS notes “because this spine procedure code is an add-on code, in accordance with the regulations at 42 CFR 419.2(b)(18), under the OPPS, this procedure is packaged with the associated procedure and assigned status indicator “N” (Items and Services Packaged into APC Rates) for CY 2019.”

As for the remaining four laminectomy procedure codes (63265, 63266, 63267, and 63268), CMS plans to continue to review the appropriateness of potential removal from the IPO list for subsequent rulemaking.

CMS does not believe they have sufficient data to support removing all orthopaedic, arthroplasty, and joint replacement procedures from the IPO list. They “encourage stakeholders to submit specific procedures, along with evidence, to support their requests for removal from the IPO list.”

Codes Finalized for “Removal from” or “Addition to” the IPO List for CY 2091

The following table details the finalized changes to the CY 2019 IPO List.

‍Where to Find the CY 2019 Inpatient Only Procedure List

The complete list of procedures codes that Medicare will pay as inpatient only procedures in CY 2019 can be found in Addendum E to the CY 2019 OPPS/ASC final rule at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html.

Ambulatory Surgical Center (ASC) – CMS’s definition of “Surgery” Revised

“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 ASC list and payment rates for covered surgical procedures and covered ancillary services in ASCs. 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, to identify any 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 that 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.

In the CY 2019 OPPS Final Rule, CMS finalized the “proposal to define a surgical procedure under the ASC payment system as any procedure described within the range of Category I CPT codes that the CPT Editorial Panel of the American Medical Association (AMA) defines as “surgery” (CPT codes 10000 through 69999) (72 FR 42478), as well as procedures that are described by Level II HCPCS codes or by Category I CPT codes or by Category III CPT codes that directly crosswalk or are clinically similar to procedures in the CPT surgical range that we have determined are not expected to pose a significant risk to beneficiary safety when performed in an ASC, for which standard medical practice dictates that the beneficiary would not typically be expected to require an overnight stay following the procedure, and are separately paid under the OPPS.”

Finalized Updates to the ASC Covered Surgical Procedures List

With the change in the definition of “surgery” to account for “surgery-like” procedures CMS proposed and finalized the addition of twelve cardiac catheterization procedures to the list for CY 2019. Based on public comments, CMS also finalized the addition of five procedures performed during cardiac catheterization procedures to the list of ASC covered surgical procedures (CPT codes 93566, 93567, 93568, 93571, and 93572). The following table includes the HCPCS code, long code descriptors and payment indicators as displayed in Table 60 of the Final Rule.

‍Resources

CMS-1695-FC: Hospital Outpatient Prospective Payment – Notice of Final Rulemaking with Comment for CY 2019: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1695-FC.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

Link to CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/cms-finalizes-medicare-hospital-outpatient-prospective-payment-system-and-ambulatory-surgical-center