2018 Proposed Payment Rule Comment Resources

Submit Your Comment Letter to CMS

All comments must be submitted by September 11.


Template Letters

ASCA has provided draft comment letters that your facility can customize before submitting your letter to CMS. There are separate letters for four different aspects of the proposed rule: addition of new codes, removal of total knee arthroplasty (TKA) and total hip arthroplasty (THA) from the inpatient-only list, the OAS CAHPS quality reporting measures and the Consumer Price Index for All Urban Consumers (CPI-U).

  • Procedure List: Requesting codes be added to the ASC-payable list;
  • Removing TKA and THA from Inpatient-Only List: Providing support for CMS’ request for information on removing total knee arthroplasty and total hip arthroplasty from Medicare’s inpatient-only list;
  • CPI-U to Hospital Market Basket: Advocating for ASC payments to be updated based on the same update factor as HOPDs, the hospital market basket, to stop the growing disparity in payments.
  • OAS CAHPS Survey & Quality Measures: Supporting a delay to the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery (OAS CAHPS) survey until the survey is shortened and there is an electronic option; and

You can download and edit the template letters by clicking the button below.

Download Draft Comment Letters

The most effective letters incorporate your facility-specific information. In addition, if possible, we recommend that you copy and paste the comment letter onto your center's own letterhead.

For help customizing your letter, please contact Kara Newbury at knewbury@ascassociation.org.


Sample Language

Below is sample language that can be incorporated into comments if you would rather not submit a formal letter, or want to mix and match issues. The most persuasive comments will also include individual details regarding how the proposed changes will impact your center.


Use of CPI-U as ASC Update Factor

CMS must replace the Consumer Price Index for Urban Consumers (CPI-U) as the mechanism to update ASC payments. The market basket that adjusts hospital outpatient department (HOPD) payments more closely reflects the cost structure of ASCs than does the basket of goods implied by the CPI-U.

Further, the Affordable Care Act requires CMS to reduce the update by a measure of productivity gains, which inappropriately subjects ASCs to two productivity adjustments: improvements reflected in the price of consumer purchased goods and the additional ACA-mandated reduction.

Aligning the outpatient update and productivity factors across two settings will help minimize the silos around settings of care that are inconsistent with the Secretary’s desire to harmonize payments.


Cost Savings to Medicare and Beneficiaries

ASCs play an integral role in the health care delivery system because they are able to save the system and beneficiaries money by being efficient and lean, without compromising quality and stellar outcomes.

Recent Research Highlighting Cost Savings and Quality Care Cost savings – industry-driven study:

An analysis by researchers at the University of California-Berkeley Nicholas C. Petris Center on Health Care Markets and Consumer Welfare found that ASCs saved the Medicare program and its beneficiaries $7.5 billion during the four-year period from 2008 to 2011 over what would have been paid if care had been provided in other settings. The Berkeley researchers also project that ASCs have the potential to save the Medicare system an additional $57.6 billion over the next decade if policymakers take steps to encourage the use of these innovative healthcare facilities within the Medicare system.

Cost savings – government study:

The U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) found that outpatient surgical procedures performed in ASCs saved Medicare almost $7 billion and saved beneficiaries an additional $2 billion during CYs 2007 through 2011, and have the potential for even greater savings in the future.

Efficiency and quality outcomes, even on more vulnerable patient populations:

A study published recently in the prestigious journal Health Affairs found that ASCs both save money and increase efficiency within the Medicare system, even as they “provide high quality care, even for the most vulnerable patients.”


Procedure List

General comments:
With technological advances driving procedures from the inpatient to the outpatient setting, we urge CMS to leverage the high-quality and cost-effective care that ASCs provide by adding procedures to the list of ASC covered services. It is common for HOPDs to be located off the hospital’s main campus and look a lot like freestanding ASCs. There are 345 codes which are prposed to be reimbursable in 2018 when performed in the HOPD but not the ASC. If procedures are safe and appropriate in HOPDs that look and operate essentially like freestanding ASCs, they are safe and appropriate in ASCs. As such, we request that these codes be added to the ASC-payable list.

Codes your facility believes should be added (please add your specific requests):
Our physicians have identified the following procedures as those that result in positive outcomes when performed on non-Medicare patients in the ASC setting, and should be added to the ASC list of covered procedures. [More persuasive letters will include clinical data. If there are procedures currently on the ASC-payable list that are clinically-similar to the requested codes, that also helps].

Spine code additions:
We appreciate CMS’ proposal to move the following 3 procedures listed below to the ASC list of payable procedures for 2018:

  • 22856 (Cerv artific diskectomy), which has a J8 payment indicator, meaning it is a device-intensive code;
  • 22858 (Second level cer diskectomy), which has an N1 payment indicator, meaning it is packaged and not separately payable; and
  • 58572 (Tlh uterus over 250 g), which has a G2 payment indicator, meaning it is a non-office-based surgical code

These codes are currently done safely and effectively in the ASC setting on non-Medicare patients, and allowing for reimbursement for 22856 and 58572 will help save Medicare and its beneficiaries money while allowing patients access to care in a high-quality setting.

However, while we appreciate that CMS has acknowledged that 22858 is safe and effective when done in the ASC setting, the addition of a level comes without significant additional expense. Without payment, facilities will not be able to perform this procedure.

Removal of Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) from Inpatient-Only List
CMS proposed removing total knee arthroplasty (TKA) from the inpatient-only list, and requested information on potentially removing total hip arthroplasty (THA) from the inpatient-only list as well. Our facility has been performing these procedures safely and effectively for [number of years] and we strongly support removing both procedures from the inpatient-only list. We perform [number of procedures] annually, and believe many Medicare patients would be excellent candidates for TKA and THA in the ASC setting. As such, we request that CMS strongly consider moving these procedures to the ASC setting as well, to provide Medicare patients with access to our high-quality, lower-cost setting.


Quality Reporting

Our facility participates in, and supports, the ASC Quality Reporting (ASCQR) Program. While I strongly support public reporting and quality measurement, I was happy to see that CMS proposed to delay the five new measures based on the use of the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery (OAS CAHPS). There are serious administrative and cost burdens the survey would place on my facility, and the following should be addressed before CMS mandates this survey:

  • Adding an electronic survey option. Internet access and email accounts are common in today’s society, and I believe that CMS should add an electronic mode as an option for conducting the OAS CAHPS survey. This will also reduce the cost of administering the survey, as phone and mail options are cost-prohibitive.
  • Survey length.The survey should be significantly shortened. The inclusion of 13 demographic questions in the “About You” section of the survey is excessive. In addition, 24 questions regarding the patient’s experience is extremely high. Our facility has found we achieve the highest response rate with short, concise surveys of no more than 5-10 questions. Our fear is that the return rate for a 37-question survey will be extremely low, and patients and facilities will not be able to glean any meaningful information due to low responses rates.
  • Required number of completed surveys. Requiring 300 completed surveys would be burdensome for my ASC, as well as many other facilities. ASCs are often small businesses, with two or fewer operating rooms. When inpatient hospitals were first required to utilize the HCAHPS survey, they only had to achieve 100 completed surveys. Setting higher expectations from the start for smaller providers like ASCs is unreasonable, and I request that if you make the survey mandatory in the future, the initial requirement be set at 100 completed surveys.


Submitting Comments

Click the "Submit Comments" button below when you are ready to send your letter to CMS. Reminder, all comments must be submitted by September 11.

Submit Comments

For help customizing your letter, please contact Kara Newbury at knewbury@ascassociation.org.