Performance of percutaneous coronary intervention (PCI) procedures in the Ambulatory Surgery Center (ASC) setting; ongoing difficulties for some cardiovascular imaging modalities to find proper APC placement; and prior authorization for certain classes of services were the primary areas of focus in formal comments sent by the ACC to the Centers for Medicare and Medicaid Services (CMS) addressing the proposed 2020 Hospital Outpatient Prospective Payment System (OPPS) rule.

The ACC's comments specifically support the proposed addition of three PCI procedures reported with six CPT codes to the ASC Covered Procedures List for CY 2020. They also urge CMS to place cardiac CT codes with more resource intensive and clinically similar services in a higher payment APC, such as 5572 or 5573, while stakeholders work to identify better methods to account for costs. Additionally, CMS proposes to assign 0503T to New Technology APC 1509 for services with costs between $701 and $800. The ACC recommends CMS not finalize this proposal, and instead consider changes in future rulemaking with at least one additional year of data, as this proposal stemmed from an analysis of only 78 single-frequency claims and 844 total claims submitted for payment during 2018.

The letter also recommends CMS not implement a proposed prior authorization process for provisional affirmation of coverage before a covered OPD service is furnished to a beneficiary and before the claim is submitted for processing. Based on the proposed rule, this requirement would begin on/after July 1, 2020. However, the ACC believes this proposal remains unnecessarily broad. The College also urges the Agency to consider numerous issues with prior authorization that are currently experienced through Medicare Advantage (MA) and other health plans.

Finally, in response to requirements for public disclosure of all hospital standard charges for all items and services, the ACC encouraged CMS to build on additional efforts to provide patients with important health data through the development and implementation of an industry-wide open application program interface (API) standard. The ACC also suggested CMS develop a pilot program prior to full implementation, should the Agency choose to move forward on this proposal.

CMS is expected to release the final OPPS rule by Nov. 2. ACC leaders and Advocacy staff will continue to collaborate with CMS, partner cardiovascular societies and the broader medical community as the rulemaking process moves forward.

Clinical Topics: Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention

Keywords: ACC Advocacy, Centers for Medicare and Medicaid Services, U.S., Medicaid, Ambulatory Surgical Procedures, Current Procedural Terminology, Hospital Charges, Health Expenditures, Percutaneous Coronary Intervention

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