New Year, New You
The start of the year is a great time to clear the decks mentally and review for yourself what works and what does not....
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By: Jeanine Watson, MSN, RN, CNOR(E), CASC
Published: 12/4/2024
Well, here we are, approaching the end of 2024. I am surprised at how quickly each year goes by, and how each year seems to go faster than the year before. Instead of focusing on end-of-year activities, I have decided to look to 2025 and identify the proposed changes that will impact HOPDs and ASCs.
The major CMS change in 2025 for ASCs is the Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey reporting requirement, which my colleague Jonny Marr, MHA, BSN, RN, CNAMB, covered in depth last issue. However, there are a few additional changes that you may want to keep an eye on.
CMS issued its Final Rule for 2025 payment rates for HOPDs and ASCs on Nov. 1. The Outpatient Prospective Payment System (OPPS) rates will increase by 2.9% for HOPDs and ASCs that meet applicable quality reporting requirements, a 0.3% increase from what CMS originally proposed in July. This update is based on the final hospital market basket percentage increase of 3.4%, reduced by a 0.5 percentage point productivity adjustment.
Another proposed change in 2025 may provide some good news for administrators. CMS is proposing to implement the Consolidated Appropriations Act (CAA) of 2023, which provides temporary additional payments for certain non-opioid treatments for pain relief in HOPDs and ASCs from Jan. 1, 2025, through Dec. 31, 2027. This is part of CMS’ efforts to promote alternative pain management options and reduce reliance on opioids.
Specifically, CMS has qualified six drugs and one device as non-opioid treatments for pain relief, and proposes these products be paid separately in both the HOPD and ASC setting starting in Calendar Year 2025. Here is the proposed list:
Now, this is good news for sure, but there are some challenges to consider. Non-opioid drugs and devices can be expensive, and the reimbursement rates may be lower than the actual cost. Non-opioid alternatives are very popular with patients, however, so implementing these drugs and device may contribute to increased patient satisfaction and shorter recovery times, which may offset any unreimbursed cost.
The billing process for these drugs and devices can be complex, requiring accurate coding and documentation. Any errors in billing can lead to claim denials or delays in reimbursement. Administrators will need to create a process to capture the charges, ensure complete documentation and submit the billing accurately and efficiently.
The change is limited to two calendar years. Starting Jan. 1, 2028, the cost of the drugs and device will no longer be reimbursed separately. This will increase the overall cost of the case, so administrators at that time will need to evaluate the financial, operational and outcome measures data to determine whether to continue using the drugs and device. As with any limited-time program, administrators will need to be prepared with a plan that will begin prior to the expiration of the program.
Administrators should make a point to start the evaluation of these practices mid-year 2027 to avoid surprises. Think of this like those trial subscriptions that you enjoy for a limited time, but once they expire, you are either auto-enrolled or charged a higher price. If you are like me, I forget about too many of these, so now I set calendar reminders.
This year’s CMS rule also includes policies that align with several key goals of the outgoing Biden administration, including:
It’s not immediately clear what impact, if any, the incoming administration will have on the 2025 changes.
The CMS 2025 Rule also adds 21 medical and dental procedures to the ASC Covered Procedures List. The procedures were determined to meet safety standards and not require active medical monitoring beyond midnight following the procedure.
Although this is good news for many administrators, others were hoping for more codes to be approved, as well as the retirement of the ASC-20 COVID-19 Vaccination Coverage Among Health Care Personnel reporting requirement. Hopefully, we will see those changes in 2026.
In addition to the payment changes, changes to the Ambulatory Surgery Center Quality Reporting (ASCQR) program are proposed, including the adoption of:
There’s also action at the state level. Some states have made legal changes in relation to certificate of need, personal injury protection and required participation in the prescription monitoring program, to name a few. Review local state laws for changes that may impact you now and in the future.
To quote my late, great dad Rico Ayala, “The will to prepare must be as strong, or stronger, than the will to succeed.” With those wise words in mind, I’ll finish this annual review with a few tips to help you prepare for success in 2025.
• Review and understand the changes. Make sure to communicate the changes to your administrative and financial teams, including the 2.9% payment increase and the expanded list of procedures. This will facilitate strategic planning and budgeting decisions.
• Update billing and coding practices. Make sure your billing and coding staff are trained on the new procedures added to the ASC Covered Procedures List, including those items that are now reimbursed separately.
• Enhance quality reporting. Implement a robust data collection and reporting system to ensure accurate and timely submission of quality measures. Perform regular reviews of your performance on these measures to identify areas for improvement.
• Invest in staff training. Provide ongoing education and training for your clinical and administrative staff on the latest CMS guidelines and quality reporting requirements.
• Optimize operational efficiency. Evaluate your current operations to identify opportunities for efficiency improvements. Streamlining processes can reduce costs and improve patient throughput, which is crucial for maintaining profitability.
• Expand service lines. Consider adding the newly covered procedures to your service offerings. This can increase patient volume, resulting in increased revenue. Make sure you completely evaluate your facility and staff to ensure you are equipped and trained to provide any new service.
• Engage with industry associations. Professional associations like AORN and ASCA can provide information, assistance and resources that can help you learn more about best practices and upcoming changes.
I hope you find this information helpful as you plan for the new year. I wish you and your teams health and happiness in 2025, and I look forward to bringing you more information to support your success!
As always, remember that you can find useful resources for ASC administrators and surgical facility leaders at aorn.us/ascadmin-resources. OSM
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