New Rule Allows More Types of Surgeries for Medicare Patients In Outpatient Setting

New Rule Allows More Types of Surgeries for Medicare Patients In Outpatient Setting

In a final rule that set payment rates and policies for Medicare patients effective January 1, 2021, the U.S. Centers for Medicare & Medicaid Services (CMS) made significant adjustments that will allow hospital outpatient departments (HOPD) and ambulatory surgery centers (ASC) to perform a wider range of surgical procedures for Medicare beneficiaries. The changes also give Medicare patients greater access to the many benefits of outpatient surgical care. 

One important change introduced in the rule establishes a three-year plan to eliminate the hospital inpatient-only list. This new policy will ultimately allow physicians to decide which procedures they can perform safely in the HOPD setting rather than relying on Medicare officials to make those determinations. Another important change the rule contains moves 267 procedures onto the ASC Covered Procedures List (ASC-CPL), which means that ASCs can now perform 267 procedures for Medicare patients they could not provide for those patients previously.

One of the procedures the new rule allows ASCs to be reimbursed for performing for Medicare patients for the first times is total hip replacement. ASCs have been asking to be able to provide this procedure for some time and escalated those requests after Medicare moved total knee arthroplasty and knee mosaicplasty to the ASC-CPL previously.

“We are pleased that these changes allow patients and physicians to make more of the decisions about where these surgeries will take place rather than those decisions being up to federal officials,” said Cammy Gilstrap, Director of Cascade Surgicenter.

In the coming years, orthopedic outpatient procedures are expected to surge. A 13% increase is expected in outpatient orthopedic surgeries in the next five years. Hip and knee replacement surgeries will increase over 200% in the next five years with growth projected to be 580% for hip replacement, and 752% for knee replacement over the next ten years.

In partnership with Cascade Surgicenter, physicians at The Center Orthopedic & Neurosurgical Care & Research began researching outpatient total joint replacement in 2012. With the development of advanced protocols and pathways by staff, the first outpatient total knee replacement was done in 2015. The Center and Cascade Surgicenter now average more than thirty outpatient joint replacements a month.

The pandemic has posed a particular challenge to all outpatient surgery providers, but the recent changes to the ASC-CPL gives Medicare patients more flexibility in accessing the care they need when hospitals are forced to limit patient volume. “Because the pandemic has forced many ASCs to close, thereby decreasing Medicare beneficiary access to care in that setting, we believe allowing greater flexibility for physicians and patients to choose ASCs as the site of care, particularly during the pandemic, would help to alleviate both access to care concerns for elective procedures as well as access to emergency care concerns for hospital outpatient departments,” states the rule.