American Gastroenterological Association - Advancing the Science and Practice of Gastroenterology

CMS Releases 2011 Final Rule on HOPDs and ASCs

On Nov. 2, CMS released its final rule affecting 4,000 hospital outpatient departments (HOPD) and 5,000 ambulatory surgery centers (ASCs) for services furnished on or after Jan. 1, 2011. The rule, which implements both policy changes from CMS and recent health- care reform legislation from the Patient Protection and Affordable Care Act (ACA), will be published in the Nov. 24 Federal Register.

See the impact on commonly billed GI procedures in the HOPD and ASC settings. 

Read the CMS press release and fact sheet.  

Under the final rule, the ACA waives beneficiary cost-sharing for most Medicare-covered preventive services, including the initial preventive physical examination, or “Welcome to Medicare Visit.” This waiver applies not only to the 20 percent coinsurance for the physician’s service, but also to any cost-sharing relating to the separate payment to the facility when the service is furnished in an HOPD or ASC setting. The AGA advocated heavily for this change and is pleased that CMS is implementing this waiver in all three settings — physician, HOPD and ASC. AGA continues to work with our advocates in Congress to ensure that the coinsurance is also waived when a screening colonoscopy becomes therapeutic. 

ASCs

Since Jan. 1, 2008, ASCs have been paid under a revised ASC payment system through which ASC rates are paid at a percentage of outpatient prospective payment system (OPPS) weights. The four-year phase-in is now complete, and beginning in 2011, ASC rates will be based solely on OPPS relative weights. CMS projects total Medicare payments of approximately $4 billion to ASCs in 2011.

The 2011 ASC conversion factor will be $41.939 reflecting an update of 0.2 percent. CMS will continue to base ASC payment updates on the CPI-U, although the GI societies and other specialties continue to advocate to CMS and Congress that ASC payments should be updated by the hospital market basket index.

CMS estimates that the proposed update to ASC rates for 2011 will result in a 4 percent decrease in aggregate payment amounts for digestive system procedures. The effect on individual GI procedures will vary from 0 percent to -8 percent. Decreases for commonly billed GI procedures follow; the negative impact is less than what was proposed earlier this year:

43239 Upper GI endoscopy, biopsy, -7 percent
43235 Upper GI endoscopy, diagnosis, 0 percent
45378 Diagnostic colonoscopy, -5 percent
45380 Colonoscopy and biopsy, -5 percent
45385 Lesion removal colonoscopy, -5 percent
G0105 Colorectal scrn; hi risk ind, -8 percent
G0121 Colon ca scrn not hi rsk ind, -8 percent
 

CMS is not requiring quality reporting for ASCs in 2011. Instead, CMS will be developing a report to the Congress, as directed by the reform bill, articulating a path toward implementing value-based purchasing in ASCs.
 

Hospital Outpatient Departments (HOPD)

For 2011, the hospital market basket is projected to be 2.6 percent, but the reform bill requires it to be reduced by 0.25 percent, leaving the HOPD update at 2.35 percent. CMS projects total Medicare payments of approximately $39 billion to HOPDs in 2011. The HOPD conversion factor for 2011 is set at $68.876. For hospitals not meeting quality requirements, their conversion will be reduced to $67.530.

Despite an alternate proposal submitted by the GI societies, CMS finalized its proposals to reassign GI endoscopy CPT codes 43216, 43242, 43510, and 43870 from APC 0141 (Level 1 Upper GI Procedures) to APC 0422 (Level II Upper GI Procedures). CMS is also finalizing its proposal to assign CPT code 43240 to APC 0141 and to continue to assign CPT code 43228 to APC 0422.

The final rule also contains graduate medical education provisions addressed in the health-care reform law. This includes the distribution of unused Medicare resident slots and the permanent redistribution of slots from closed hospitals. Lastly, the rule finalized the set of measures that must be reported by HOPDs to qualify for the full payment update in the succeeding year and makes it easier to prepare for these requirements.

 

Updated 11/03/10