HRS Continues Work Ahead of 2025 Changes to Medicare’s ASC Covered Procedures List (ASC CPL)
On April 17th, HRS President Jodie L. Hurwitz, MD, FHRS and HRS Health Policy and Regulatory Affairs Committee Chair Christopher F. Liu, MD, FHRS shared an update with HRS members on the work performed to date, much of it in conjunction with the American College of Cardiology (ACC), as the Centers for Medicare & Medicaid Services prepares to update the list of procedures for which Medicare will pay when they are performed in the ambulatory surgery center setting.
As noted by Dr. Hurwitz and Dr. Liu,
Since the public health emergency (PHE) due to the COVID-19 pandemic, efforts have been made to increase patient access to different sites of care. In the electrophysiology (EP) community, these efforts have included feasibility assessments regarding the performance of cardiac ablation procedures in the Ambulatory Surgical Center (ASC) setting. Recently, given favorable (albeit limited) clinical safety data in the ASC setting, interest has progressively increased.
HRS has developed an approach that bears in mind the CMS process for updating the ASC CPL. In essence, CMS reviews and updates the ASC CPL annually and interested parties may submit recommendations for revisions additions to the ASC CPL, and HRS knows that cardiac ablations have again been submitted to CMS for addition to the ASC CPL in CY 2025. CMS will evaluate those submissions against the criteria it has laid out in regulation.
- First, CMS must believe that the procedure's addition to the ASC CPL "would not be expected to pose a significant safety risk to a Medicare beneficiary when performed in an ASC, and for which standard medical practice dictates that the beneficiary would not typically be expected to require active medical monitoring and care at midnight following the procedure."
- Further, CMS has established a list of exclusionary criteria that would prevent a procedure's addition to the list, such as if the procedure is generally emergent or life-threatening in nature or commonly requires systemic thrombolytic therapy.
Acknowledging that the statutory references to maintaining a list of procedures payable by Medicare in the ASC setting refer to "surgical procedures," until CY 2019, CMS would only consider codes in the "surgery" range of the CPT code book (i.e. CPT codes 10000 through 69999) eligible for the ASC CPL. For CY 2019, CMS finalized a policy that expanded eligibility for the ASC CPL to codes outside of the CPT surgery range to those that "directly crosswalk or are clinically similar to procedures in the Category I CPT code surgical range." This created the relatively recent opportunity for procedures outside the "surgery" CPT code range to become eligible for the ASC CPL.
However, it is important to remember that these procedures are subject to the additional qualification that the procedure "directly crosswalk or [is] clinically similar to procedures in the Category I CPT code surgical range" whereas CPT codes in the surgery range carry a presumption of inclusion that procedures outside the CPT "surgery" range codes are required to overcome.
With these parameters in mind, HRS has continued its work to research the safe expansion of cardiac ablations into sites of services to improve patient access to medically necessary services. HRS is awaiting the release of the CY 2025 Hospital Outpatient Prospective Payment System (OPPS) and ASC Payment System proposed rule, which is expected in early July 2024 to see if CMS makes a proposal related to payment for cardiac ablations in the ASC setting. At that time, HRS will submit comments to CMS for consideration. The final rule with the CMS decision about the ASC CPL for 2025 will be published in November 2024. In the interim, HRS and ACC will write to CMS to request a meeting. Read the full position statement from Dr. Hurwitz and Dr. Liu.