On August 4, 2020, CMS发布了对对asc至关重要的两个报告计划的拟议裁决:2021年医院门诊预期支付系统(OPPS)和门诊手术中心(ASC)支付系统和质量报告计划. As part of this ruling, CMS has proposed adding 11 procedures to the ASC covered procedures list (CPL), including total hip arthroplasty (THA) (CPT code 27130).
When a CPT code is removed from the inpatient only (IPO) list, 历史趋势表明,将这一程序纳入ASC CPL需要两年时间. 首先,代码在被批准并添加到ASC列表之前被批准为HOPD列表. For example, 全膝关节置换术(TKA) (CPT 27447)于2018年从IPO名单中删除,并于2020年加入ASC CPL.
In contrast, 在从IPO名单中删除并添加到HOPD名单仅一年后(2019年),现在正在考虑将其纳入ASC CPL。. 缩短了CMS批准ASC CPL的时间,加快了手术迁移.
Factors Influencing Total Joint Migration
The number of THA and TKA cases is projected to increase from 1.1 million to approximately 1.预计到2026年将有900万例,51%的髋关节和膝关节置换术将在美国进行 outpatient setting. 许多 因素 促成了关节置换术病例移出医院环境:
- CMS(医疗保险受益人)和商业支付者历来都推动使用对asc作为替代方案, lower-cost site of care.
- 向ASC CPL添加程序为更有效地利用医疗资源和基础设施创造了机会——新型冠状病毒肺炎大流行加速了这一点. 预计在ASC环境中可以安全治疗的患者将越来越多地从医院转移出去, and hospital capacity will be reserved to treat more acute patients.
- Improved patient selection protocols have been developed.
- Younger patients are undergoing THA and TKA procedures.
- Surgical techniques and pain control measures have advanced.
- 越来越多的研究表明,当日出院关节置换术的安全性和有效性.
Key Considerations
许多 (if not most) organizations could see material implications from the CMS proposed 2021 rule to add THA to the Medicare ASC CPL; however, the true impact of these changes will vary for each state, facility, and service line structure, based on some of the considerations we discuss below.
收入
CMS has proposed payment for THA at $8,923.98 in the ASC and $12,558.56 in the HOPD. CPT 27130 (THA)被提议作为opps下的“器械密集型”代码,以支付指标J8标识,并被CMS指定为调整了可归因于植入物成本的定价. 除了拟议的8,923美元的费率外,医疗保险不会向对asc支付额外的植入费用.98, which is based on the national unadjusted payment rate.
Implant Reimbursement
THA implant costs vary (based on 心电图’s experience) by brand, physician preference, and the clinical indications of the patient, and are impacted by the ASC’s contractual relationship with its implant vendor. ASC及其医师领导成功管理植入物成本的能力将决定ASC是否认为实施tha在经济上可行. 例如,在2021年拟议规则中,分配给CPT 27130的设备抵消金额为6,040美元.99, which is attributed to the implant cost allocated for the case. The remaining portion, $2,882.99, is allocated for the procedure. This does not provide significant dollars for an ASC to do the Medicare case—in fact, the implant may cost the ASC more than the total reimbursement amount. This device offset value attributed to the implant is based on hospital reporting data; 对asc may not have the buying power of a hospital due to smaller purchasing volumes.
迫切需要的是,尚未进行病例成本计算的医疗中心开始这样做,以确定商业支付者所需的费率目标, assess their payer contracts, and evaluate whether their rates are adequate to cover the costs associated with THAs. If the CMS rule is passed in 2021, case costing can determine whether there will be losses on Medicare cases.Managed Care Contracting
许多商业支付者使用医疗保险ASC费用表作为建立自己的报销率的指南. 对asc, 其现有商业付款人合约的偿还比率尚未包括医疗费用的偿还, may use the Medicare rates as a benchmark to establish and negotiate rates. Therefore, ASC必须对所有外科云顶集团40011官网进行病例成本分析,不仅要考虑直接手术成本和可能存在的差异, especially with implant types, but also any capital expenditures that have been or will be incurred. If losses are realized with Medicare and government payers, this should also be factored into rate targets with commercial payers, and it is important to be able to schedule all cases in a day, regardless of the payer class.
Extended Recovery Care and State Regulations
许多 states allow for extended recovery care that may range from 24 to 72 hours (e.g., Florida, Colorado, New Hampshire, Nevada, Oregon). 对asc将需要了解他们各自州的法规,以确定延长康复护理是否是一种选择,并了解具体的时间参数.
Construction, Capacity, and Capabilities
尚未执行tha的asa应评估其是否拥有资源(空间), equipment, trained staff) to add total joints. A list of key tasks includes the following:
- 确保有足够的空间存放额外的设备和物资,以支持整个联合项目.
- 评估购买设备的资本需求,这些设备可能需要在ASC中建立一个完整的联合项目.
- Work with surgeons to establish protocols, create patient selection criteria, and provide patient education.
- Engage staff from the start to make them feel part of the process.
- Evaluate staff expertise, identify gaps that may need to be filled, and provide education and training as appropriate.
新型冠状病毒肺炎
During the early months of the 新型冠状病毒肺炎 pandemic, 病人因为害怕而不愿意去医院做选择性手术 increased risk of exposure. As a result, some 对asc have now reported an upswing in total joint replacements after reopening to surgery cases. ASC Quality Collaboration conducted a survey to learn the impact of the virus on centers and their patients. According to 710 respondents, 超过84,总共进行了000次手术,全部是在未感染的患者身上进行的,很少有中心报告手术后14天内与新型冠状病毒肺炎相关的感染. 对asc的设施流量较少,并且在手术前对患者及其云顶集团40011官网和工作人员实施了严格的预筛查方案. 对asc已经证明它们是一个安全的云顶集团场所,并遵循与医院相同的患者安全和感染控制指南.
A Glimpse of the Future: Elimination of the IPO List?
In the 2021 OPPS proposed rule, CMS已就在三年内从IPO名单中删除所有代码征求意见, with a complete elimination of the list by 2024. This provides opportunity for surgeries to be performed in the HOPD setting. 然而, 由于另一项CMS规则条款,它可能会对添加到ASC清单中的额外总联合程序提出限制-该条款建议修改标准,允许在ASC CPL上批准代码,以排除419下指定为需要住院治疗的程序.22(n) as of December 31, 2020. 因此, 如果此规定,则有机会将其他案例添加到ASC PL列表中,可能需要对规则进行一些额外的修改, under 419.22(n) in the proposed rule, is passed without change.
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Published October 26, 2020