Much of the talk in the last few months has been about the changes proposed by the Centers for Medicare & Medicaid Services (CMS) to the physician evaluation and management code selection and payment regulations in the 2019 Proposed Physician Fee Schedule Rule. And there was a collective national sigh of relief when CMS elected to defer any drastic changes until 2021.
With the continuing confusion over the removal of total knee arthroplasty from the inpatient only list, there was more relief when CMS declined to remove total hip arthroplasty from the inpatient only list and chose not to add either total hip or knee arthroplasty to the list of surgeries allowed in ambulatory surgery centers (ASCs).
But hospitals might not want to take too long to celebrate that temporary reprieve since CMS did adopt a change which may have significant financial implications for hospitals. In the Outpatient Prospective Payment System Final Rule, CMS is adding 17 cardiac procedures to the list of ASC-approved procedures. These 17 procedures, represented by CPT codes 93451-93462 and 93566-93568, 93571, and 93572, include left and right heart catheterization and cardiac angiography. In 2016, there were over 523,000 cardiac catheterizations with those CPT codes performed on outpatient Medicare beneficiaries in hospitals, resulting in an estimated $682,000,000 in payments for those procedures.
Most are aware of the use of emergent coronary angiography and percutaneous cardiac intervention with stenting as a common life-saving treatment for heart attacks. Additionally, every day in thousands of hospitals around the country patients undergo elective coronary angiography for chest pain or other symptoms that are not deemed to be emergent and therefore are being electively scheduled and performed. Often, these are accompanied by an intervention such as stent placement. (There is an ongoing debate in the medical literature on the effectiveness of cardiac stenting for patients who are not having a heart attack, and interested readers should do an internet search for articles on the ORBITA trial.)
Under current Medicare regulations, that testing must be performed in a hospital, usually as an outpatient with a hospital stay lasting several hours to overnight. But if cardiac catheterization and
angiography are allowed in ASCs, that might change. The financial implications both to providers and the Medicare Trust Fund are fascinating to analyze.
Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic.