New bundled sinus codes don’t account for additional resources

November 2017 – Vol. 36, No. 10

On September 6, the AAO-HNS submitted comments on the CY 2018 Medicare Program: Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems and Quality Reporting Programs proposed rule. The main issue that could impact AAO-HNS members is the proposed payment for new bundled sinus codes in the ASC.

The Academy noted concerns regarding the Centers for Medicare & Medicaid Services (CMS) proposal to pay the same amount for a single endoscopy code as the new endoscopy sinus surgery bundled codes. The Academy does not believe it makes sense to pay the new bundled codes at the same rate as the individual sinus codes. CMS is not capturing the additional resources or time that an ASC will need to pay for additional anesthesia, non-physician clinical staff, and supply costs involved (e.g., additional costs for drugs and IV fluids). Based on the data, CMS proposes to pay for the new bundled procedures that involve two services but pay zero dollars for the additional procedure. This results in a proposed 38 percent reimbursement reduction, or a reduction of $1,635 for a bilateral procedure (from $4,270 in CY 2017 to $2,562 in CY 2018). We are concerned that the lack of appropriate payment for ASCs may result in moving the more complex cases to the OPPS setting instead of the lower cost ASC setting, thereby adding cost into the healthcare system.

Our response recommended that CMS determine some other payment for these new bundled codes that more accurately reflects the ASC costs and resources. We offered to help CMS develop the new payment methodology. Also, since CMS does not yet have data with combined code claims, we strongly urged CMS to collect the claims under the current system and then revisit to determine what the claims show.

Other comments addressed the following issues: 1) CY 2018 Comprehensive Ambulatory Payment Classifications (C-APCs); 2) Imaging APCs; and 3) Changes for Computed Tomography (CT) under the Protecting Access to Medicare Act of 2014 (PAMA).