2016 Ambulatory Surgery Center (ASC) Payment System and Quality Reporting (ASCQR) Program Proposed Rule Released

2016 ASC Conversion Factor Projected at $44.605 for
Those Meeting Quality Reporting Requirements 

On July 1, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2016 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates proposed rule

ASC Conversion Factor

For CY 2016, CMS proposes to adjust the CY 2015 ASC conversion factor ($44.058) wage adjustment budget neutrality factor of 1.0014 in addition to the MFP-adjusted CPI-U update factor of 1.1%, which results in a proposed CY 2016 ASC conversion factor of $44.605 for ASCs meeting the quality reporting requirements.

For ASCs not meeting the quality reporting requirements, CMS is proposing to adjust the CY 2015 ASC conversion factor ($44.058) by the wage adjustment for budget neutrality factor of 1.0014 in addition to the quality reporting/MFP-adjusted CPI-U update factor of -0.9%, which results in a proposed CY 2016 ASC conversion factor of $43.723 for ASCs not meeting the quality reporting requirements.

ASC Quality Reporting Program (ASCQR)

CMS is not proposing to add any new measures to the program in this proposed rule, but is requesting comment o n two outcome measures for future consideration. The two measures are:

  • Normothermia Outcome, which assesses the percentage of patients having surgical procedures under general or neuroaxial anesthesia of 60 minutes or more in duration who are normothermic within 15 minutes of arrival in the post-anesthesia care unit.
  • Unplanned Anterior Vitrectomy, which assesses the percentage of cataract surgery patients who have an unplanned anterior vitrectomy (removal of the vitreous present in the anterior chamber of the eye).

Corneal Tissue

For CY 2016, CMS is proposing to limit the separate payment policy for corneal
tissue acquisition costs in the hospital outpatient department and ASC to only corneal tissue that is used in a corneal transplant procedure. In the ASC, CMS would include corneal tissue procurement as a covered ancillary service only when it is integral to the performance of a corneal transplant procedure that is an ASC covered surgical procedure, and pay separately for this service under the ASC payment system.  This proposal would mean that CMS would not make separate payment for corneal tissue when used in any non-transplant procedure.  Therefore, CMS would make packaged payment for all tissues used as patch grafts in glaucoma shunt surgery. 

Newness Criteria for New Technology IOL (NTIOL)

CMS is proposing that, beginning in CY 2016, any application for a new NTIOL class must fulfill an additional criterion.  CMS proposes that beginning January 1, 2016, an NTIOL application will only be evaluated by CMS for a new IOL class if the IOL has received initial FDA premarket approval within the 3 years prior to the NTIOL application submission date.

Separately Payable Drugs Proposed for Unconditional Packaging

CMS is proposing to package payment for four drugs based on their primary function as a supply in a surgical procedure, which typically means that the drug or biological is integral to, dependent on, or supportive of a surgical procedure. These drugs include HCPCS code J7315, mytomycin ophthalmic, 0.2mg for glaucoma surgery to be packaged in 2016 and HCPCS code C9447 injection, phenylephrine and ketorolac, 4 ml vial for cataract surgery, to be packaged in 2018.  CMS notes that C9447, that would otherwise be packaged in CY 2016 currently has pass-through payment status. Therefore, they are not proposing to package HCPCS code C9447 until CY 2018, after its drug pass-through payment status has expired.

Proposed 2016 Payment Rates 

 

HCPCS

Short Description     

Proposed 2016 Payment Rate

66984     

Cataract surg w/iol, 1 stage

$971.01

66982

Cataract surgery, complex

$971.01

66821

After cataract laser surgery

$250.77

15823

Revision of upper eyelid

$782.37

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