On Jan. 1, 2020, the CY 2020 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule will take effect, removing six spinal procedures from the inpatient-only list.
The changes mean that Medicare will reimburse for the procedures in both the hospital outpatient and inpatient settings.
Here, four spine surgeons provide insight into how these changes will impact the spine field.
Note: Responses are lightly edited for style and clarity.
Brian Gill, MD. Nebraska Spine Hospital (Omaha): The CMS final rule to remove six spine procedures from the hospital inpatient-only list is an attempt to drive care to lower-cost facilities such as ASCs. The four laminectomy codes are already done as an outpatient basis for the most part although they have been deemed inpatient only cases. I am concerned about the ramifications of moving the lumbar interbody fusion codes to an outpatient basis. I suspect private health insurers will quickly follow changing their respective policies.
The risk is being shifted from the insurers to the facilities and physicians. Will the reimbursement rates be altered as well? I practice in a state whereby patients who have their procedure in an ASC have to be discharged before midnight. This is not the case in other states that have a 23 hour rule. It will be quite difficult to perform a posterior lumbar fusion for a Medicare patient and discharge home the same day.
William Rambo, MD. Midlands Orthopaedics & Neurosurgery (Columbia, S.C.): By removing posterior lumbar fusions (22633 and 22634) and additional laminectomy codes (63265, 63266, 63267 and 63268) from the inpatient only list, CMS has appropriately acknowledged that advancements in surgical technique make these procedures well-suited to a lower-cost outpatient setting for otherwise healthy patients. Unfortunately, hospitals often struggle with these transitions, defaulting to an outpatient admission status across the board because of a fear of being audited.
Surgeons are required to provide extensive documentation to secure inpatient admission for those patients who require it. Medicare patients also have additional cost-share — namely, medications — for outpatient procedures, which is challenging to explain if the hospital converts an inpatient admission by the surgeon to an outpatient admission prior to discharge. So, the removal of these CPTs from the IPO list is a clinical win, but the administrative complexity it creates for the surgeon, hospital and patient is challenging.
Rafe Sales, MD. Summit Spine Institute (West Haven-Sylvan, Ore.) and Providence Brain and Spine Institute (Portland, Ore.): When CMS removes the six procedures from the inpatient only list, I am sure we will see more of these procedures being taken from the hospital to the ASC setting. Every case on the list can be safely performed as an outpatient procedure, and therefore this ruling is a natural result of what is already being done with excellent results in the community. We in the spine community have seen excellent results with well selected one- and two-level lumbar fusions in the outpatient setting and CMS carefully reviewed this data prior to allowing these to be taken off the inpatient only list. Therefore, we will most certainly see more of these cases transition to the ASC environment and the outpatient setting.
Robert Brady, MD. Norwalk (Conn.) Hospital and OrthoConnecticut (Danbury, Conn.): CMS rule changes have typically been aimed at lowering the costs of healthcare. I believe this upcoming rule change will accomplish two goals. The first is to further encourage the transition of hospital-based surgical procedures towards outpatient surgical centers. It is well known that surgical centers can perform most all procedures at a lower cost and typically with greater efficiency. The second consequence is that the new rule will make it easier for payers to deny inpatient admission costs and put a greater burden on physicians and surgeons to justify and meet inpatient criteria.