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CMS is reviewing reimbursement for some spine surgeries in ASCs. Here's what that means for you (whether or not you have ASCs).

September 25, 2018

    The safety of certain surgeries are under question after publicized patient deaths that were linked to complications associated with surgeries performed in the ASC setting. As a result, CMS plans to review 38 procedures to determine if they're safely performed in the ASC setting. These procedures are currently reimbursable in the ASC setting and have been since 2015—the list includes high-revenue procedures such as spine surgery, lumbar, cervical spinal fusions, among others.

    Want to learn more about what the outpatient shift means for your business? View the slide deck

    If CMS decides to stop covering these procedures in ASC settings, the outpatient shift of several important surgeries could slow.

    More procedures could be at risk

    This proposed rule shows CMS' willingness to reevaluate procedures that have been given the go-ahead to be performed in the ASC setting. CMS has also proposed to revisit approved procedures at least every two years. If instituted, this could make Medicare reimbursement for outpatient surgeries more uncertain.  

    What happens next

    CMS is currently soliciting comments on offering these procedures in the ASC setting, and on the proposed review process. The comment period will close at the end of September, and CMS will release a final ruling at the end of the year.

    How to prepare

    If you are a hospital with an ASC…

    Hospitals with ASCs should assess the potential financial impact on the organization should the outpatient shift for these select procedures diminish. Track your organization's volumes and Medicare case mix for each of the 38 procedure codes to estimate the financial impact of having a portion of these procedures shift back to the hospital setting.

    Additionally, to support your existing ASC investment, identify opportunities to grow volumes for other alternative low-acuity procedures at lower risk of reimbursement uncertainty. Consult the Market Scenario Planner to forecast growth in ASC-eligible cases within Gastroenterology and Ophthalmology to gauge market opportunity.

    If you are a hospital without an ASC…

    Understand where utilization of these at-risk procedures currently falls out within your market, and ensure you have the appropriate resources in the event of a coverage reversal. Monitor referral patterns and keep a pulse on consumer preferences for surgery in your market to ensure you’re poised to capture these services—no  matter what CMS decides.


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