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2019 ASC Final Rule Released: CMS Will Update ASC Payment with Hospital Market Basket Following ASCRS and Ophthalmic Community Advocacy

As we alerted you earlier today, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2019 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates final rule. In addition, CMS released a fact sheet on the final rule.

ASC Conversion Factor

Following ASCRS and ophthalmic community advocacy, CMS will update ASC payment rates using the hospital market basket rather than the consumer price index-urban (CPI-U) for 2019 through 2023. CMS notes that this change will promote site-neutrality between hospitals and ASCs and encourage the migration of services from the hospital setting to the lower cost ASC setting. ASCRS and the ophthalmic community have long sought this change and supported the policy in our comments on the proposed rule.

For CY 2019, CMS will adjust the CY 2018 ASC conversion factor ($45.575) by the proposed wage index budget neutrality factor of 1.0004 in addition to the MFP-adjusted hospital market basket update factor of 2.1%, which results in a CY 2019 ASC conversion factor of $46.551 for ASCs meeting the quality reporting requirements.

For ASCs not meeting the quality reporting requirements, CMS will adjust the CY 2018 ASC conversion factor ($45.575) by the proposed wage index budget neutrality factor of 1.0004 in addition to the quality reporting/MFP-adjusted hospital market basket update factor of 0.1%, which results in a CY 2019 ASC conversion factor of $45.639 for ASCs not meeting the quality reporting requirements.

Separate Payment for Non-Opioid Pain Management Drugs

CMS is finalizing its policy to unpackage and pay separately at average sales price (ASP) plus 6% for the cost of non-opioid pain management drugs that function as surgical supplies when they are furnished in the ASC setting for CY 2019. Currently, only one non-opioid drug, Exparel, is packaged as a supply. To the extent that other non-opioid pain management drugs become available in 2019, this policy would also apply to those drugs. In our comments on the proposed rule, ASCRS recommended that CMS pay separately for all FDA-approved drugs with any post-operative indication. We will continue to advocate for this change.

ASC Quality Reporting Program (ASCQR)

In this final rule, CMS reversed its proposal and will retain the problematic ASC-11, Cataracts: Improvement in Patient's Visual Function within 90 Days. However, reporting for this measure will remain voluntary. CMS will also retain this measure in the hospital outpatient setting. CMS is also retaining four ASC quality measures in the ASCQR program--ASC-1, Patient Burns; ASC-2, Patient Falls; ASC-3, Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant; and ASC-4, All-Cause Hospital Transfer/Admission--but will not require ASCs to report them as CMS evaluates their inclusion in the program.

For 2020 payment, CMS removed the following measure:

  • ASC-8: Influenza Vaccination Coverage Among Healthcare Personnel.

For 2021 Payment, CMS removed the following measure:

  • ASC-10, Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps-Avoidance of Inappropriate Use.

Additional information will be detailed in upcoming editions of Washington Watch Weekly. For questions, please contact Allison Madson, manager of regulatory affairs, at 703-591-2220 or amadson@ascrs.org.