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Fact Sheet on Outpatient Interventional Procedures in Ambulatory Surgery Centers or
Hospital Outpatient Departments
With a membership of 3,000, the American Society of Interventional Pain Physicians (ASIPP) is the largest organization in the country that represents those physicians and others involved in trying to alleviate the intractable pain experienced by millions of Americans. There are approximately 6,500 physicians practicing interventional pain management in the United States. Hospital outpatient departments and ambulatory surgery centers are important sites of service for the delivery of interventional pain services. While some interventional pain services can be provided safely in appropriate office settings, providing interventional pain services in a setting that does not have the safety precautions associated with ambulatory surgery centers or hospital outpatient departments will place patients at risk.
Interventional pain services are often characterized by the placement of surgical length needles in the spine or areas adjacent to the spine to deliver target specific anesthetic agents, to remove scar tissue, or to deliver a solution designed to interrupt a nerve’s ability to transmit a pain sensation. Although these services carry with them significant possible complications, including paralysis, respiratory and cardiac arrest, and even death, these techniques are safe and effective when performed in an appropriate setting, like an ASC or hospital outpatient department, that includes the necessary safety precautions.
- In a March 28, 2003 Final Rule, the Centers for Medicare and Medicaid Services essentially abandoned their initial plan to delete most interventional pain services from the ASC approved list. This development is a huge victory for interventional pain patients. It follows the personal intervention of Secretary Tommy Thompson and at least 30 Members of Congress. We are most grateful for this assistance, and we thank all those responsible
ASCs receive a facility fee for certain procedures, which must be on an approved list. The ASC fee schedule is divided into nine payment groups, which are not clinically coherent, with rates that range from $333 to $1339. These payment rates are based upon 1986 survey data and are updated periodically based on the consumer price index. The nine payment groups makes the inclusion of new services difficult and increases the likelihood of under and overpayments. As a result, there are sometimes disparities between ASC and hospital outpatient department (HOPD) payments.
Hospital outpatient department payments changed in 2000 based on ambulatory payment classification (APC). The payments for interventional procedures were extremely low, ranging from $105 to $181.
- In 2001, the American Society of Interventional Pain Physicians requested regrouping and reclassification of interventional techniques under the existing APC system. ASIPP was concerned about patient access, which was clearly threatened by the APC structure. ASIPP demonstrated that lesser services were inappropriately grouped with significantly more costly and complex services with a consequence that many services were grossly underpaid to the point that even very efficient hospitals were not able to cover their costs leading to closure of interventional pain programs in such places as Yale University and the University of Massachusetts. ASIPP presented a cohesive and comprehensive classification for regrouping based on clinical similarities and resource similarities.
- The APC Commission, and subsequently CMS, accepted this classification resulting in higher payments for almost all interventional procedures which was reasonable and cost effective for hospitals to provide these services.
- In 2004, the HOPD schedule classified interventional techniques into three groups and reimbursed these as follows: Level I, Level II, Level III, Level IV nerve blocks put codes in 1 line.
- In 2005, the HOPD proposed schedule, CMS has changed these classifications and moved multiple procedures resulting in a reduction in reimbursement of as high as 63%. The schedule also increased for some procedures 164% without justification.
- ASIPP agrees with some reductions with spinal puncture, as well as subsequent or add-on procedures. However, reductions for neurolytic blocks of intercostal nerves – CPT 64620, celiac plexus neurolytic block – CPT 64680, adhesiolysis – CPT 62263 and 62264 are not only inappropriate but will lead to access issues.
- Thus, we request that CMS reverse their position on these specific requested codes.
- The following shows graphic representation of reimbursement changes in hospital outpatient departments (mainly due to the efforts of ASIPP and the understanding of CMS and the APC Commission) which are issues related to interventional pain management.
- The Medicare Modernization Act (MMA) froze ASC payments at the 2003 levels until 2009, providing time for study and review. The General Accounting Office (GAO) is required to study and compare the cost of delivering the services in ASC and HOPD settings to determine if the HOPD prospective payment system would be an acceptable option for use in ASCs.
- There are significant differences between ASCs and hospital outpatient departments, even though they may perform many of the same procedures. ASCs typically offer more convenient locations and shorter waiting times than HOPDs. Further, co-insurance is lower for ASCs.
- Based on reports from MedPAC and OIG, the Medicare Modernization Act, and GAO study underway, the ASC payment structure will be changed and it will likely be based upon HOPD rates.
- ASIPP agrees that the methodology for ASC rates to be based upon HOPD rates is reasonable, but stresses the necessity of receiving 100% of the HOPD rate to ensure adequate cost coverage for lower group procedures, presently in Group I and II, which covers most interventional procedures. Thus, ASIPP argues that a portion of the HOPD rates would be insufficient to cover costs in ASCs and would create access problems for beneficiaries in interventional pain management settings. To ensure continued access, it should be ensured that any payment changes accurately reflect the cost of delivering services.
- Additional concerns for ASCs is that of the addition of replacement and new procedures, which include CPT 62264 describing percutaneous adhesiolysis on one day basis, CPT 0027T describing endoscopic adhesiolysis, CPT 62290 and 62291 describing discography procedures. These procedures are reimbursed at a higher rate at present in the office settings, as well as HOPD settings. Adding these codes to ASCs will only add to increased savings rather than being more expensive. These additions could be done in the proposed schedule easily.
- Even if ASC and HOPD rates are the same-as requested by ASIPP-for Group I and Group II procedures, applying multiple procedure rules in the surgery setting reduces the overall cost as the reimbursement will be reduced by 50% for the second procedure. This is not applicable in hospital outpatient settings. Thus, it will result in savings for Medicare program.
We thank you for your interest in and commitment to interventional pain patients.
For more information, please contact ASIPP’s Government Affairs Counsel Tim Hutchinson ([email protected]) or
Randi Hutchinson at Dickstein Shapiro Morin & Oshinsky, LLP at (202 955-6600 or [email protected]) or
Allison Shuren at Arent Fox , Kintner, Plotkin & Kahn, PLLC at (202) 775-5712 or [email protected]
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