Efforts have positive impact on CMS final rules
Part of an effective advocacy strategy on behalf of musculoskeletal patients and orthopaedic surgeons involves working through the federal notice and comment rulemaking process. Several proposed rules are released annually, including the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System rules from the Centers for Medicare and Medicaid Services (CMS).
In its response to the proposed 2009 OPPS and ASC Payment System rules, the new Health Care Systems Committee (HCSC), under the leadership of Kevin J. Bozic, MD, was quite successful in advocating for change. Working with the Arthroscopy Association of North America (AANA), the HCSC recommended several changes in the Ambulatory Payment Classifications (APC) for arthroscopy and wrist procedures, many of which were accepted in the final rule.
In addition, the committee expressed its opposition to the potential expansion of the hospital-acquired condition policy to the hospital outpatient setting and commented on the new multiple imaging composite APCs.
In the final rule for calendar year (CY) 2009, CMS accepted the AAOS recommendations to reassign several Current Procedural Terminology (CPT) codes, including two knee and several wrist procedures; Table 1 shows the changes that were accepted in the final rule.
A request to reclassify several arthroscopic procedures to improve the precision of payment was not finalized, however, and the AAOS and AANA are continuing their efforts on this issue.
CMS implemented its inpatient hospital-acquired conditions payment policy on Oct. 1, 2008. Under this policy, CMS will no longer pay an additional amount for any listed condition that was not present on admission. CMS was interested in receiving comments and input on the appropriate criteria for selecting “healthcare-associated conditions,” potential healthcare-associated conditions, the infrastructure, and the impact on payment if the hospital-acquired condition policy was extended to other settings.
The HCSC conveyed the concerns of the AAOS with a healthcare-associated conditions policy in the hospital outpatient setting. The AAOS is pleased that CMS did not propose or finalize any policies related to healthcare-associated conditions in the CY 2009 OPPS/ASC final rule.
Multiple imaging composite APCs
The final rule includes a single payment to hospitals for multiple imaging procedures performed using the same modality in the outpatient setting, despite opposition from the AAOS and other organizations.
The single payment is not based on a percent reduction (such as the Physician Fee Schedule) but on costs from 2007 claims data. Regardless of whether two or five imaging procedures in the same modality are performed in the hospital outpatient setting, the hospital will receive the same single, prospectively set payment.
The five composite APCs were constructed from three modalities—ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). Separate APCs were established for CT and MRI with and without contrast. If one imaging procedure is performed with contrast and the other is performed in the same modality without contrast, the hospital will be paid for the APC with contrast.
ASC conditions for coverage
The AAOS was successful, however, in influencing the ASC conditions for coverage (CfC) specifications for what defines an overnight stay in the ASC setting—an issue not discussed in the proposed rule. In the final rule, CMS took the revised and new ASC requirements, responded to comments, and set final policies.
The original CMS proposal (Aug. 30, 2007) defined an overnight stay as a patient’s recovery going beyond 11:59 p.m. of the day on which the surgical procedure was performed. The final policy allows patients up to a 24-hour stay in an ASC, starting from the time of admission, which corresponds to the AAOS recommendation.