ACS Advocacy Brief: September 14, 2023

ACS Comments on Outpatient and Surgical Center Proposed Rule

The ACS submitted comments to the Centers for Medicare & Medicaid Services (CMS) in response to the CY 2024 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule. This rule, which CMS issues annually, updates payment policies and quality provisions for services furnished in hospital outpatient departments and ASCs on or after January 1, 2024.

In its letter, the ACS requested that several anterior abdominal and parastomal hernia repair Current Procedural Terminology (CPT^®) codes be removed from the Inpatient Only (IPO) list, which would make such codes eligible for reimbursement in the outpatient and ambulatory settings. The College also urged CMS to maintain IPO status for certain bariatric and colectomy CPT codes, stating that patients undergoing these procedures require significant postoperative monitoring that cannot be safely provided in most outpatient departments.

In addition, the ACS supported the expansion of Medicare coverage for dental services that are substantially related and integral to the clinical success of organ transplantation and other surgeries.

The ACS also advocated for the alignment of quality efforts across CMS facility and physician programs. The College highlighted that the same emphasis should be put on quality in outpatient settings as is put on physician or inpatient facility quality programs, as more surgical services are directed to these settings. The ACS shared that an evidence-based programmatic approach that follows a similar structure as ACS quality programs would support CMS in achieving their goals of providing high-quality, affordable, and equitable care for patients across all care settings. Implementing a quality program designed around a condition or service line that aligns standardized processes and structures across the care team and facility, reinforced by high-quality data, would result in better, more patient-centric care and aid patients in making more informed decisions about where to seek care.

Read the College's full CY 2024 OPPS/ASC comment letter, and contact regulatory@facs.org for more information.

College Opposes “Unjustified” Add-on Code

The ACS also submitted comments to CMS in response to the calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) proposed rule. This rule, which CMS issues annually, updates payment policies and quality provisions for services furnished under the MPFS on or after January 1, 2024.

In its letter, the ACS opposed implementation of add-on code G2211 for separate payment for office/outpatient evaluation and management (E/M) visits, stating that this code is unjustified, duplicative, not resource-based, and would result in overpayment for certain specialties while reducing payment for surgeons and increasing out-of-pocket costs for patients.

The College also provided an in-depth response to a series of questions posed by CMS regarding methods for accurately defining and valuing E/M and other services. In addition, the ACS supported several other proposed policy changes, including delaying a policy that would define the “substantive portion” of a split (or shared) E/M visit as more than half of the total time spent by the physician and nonphysician practitioner performing the visit, along with the elimination of Appropriate Use Criteria (AUC) program requirements that were intended to subject advanced diagnostic imaging services to prior authorization.

The CY 2024 MPFS also included proposed updates to the Quality Payment Program (QPP) Performance Year 2024. The ACS opposed the proposed increase to the Merit-based Incentive Payment System (MIPS), which would increase the overall MIPS performance threshold to 82 points. The College stated that the increase would burden physician practices that still lack essential resources with requirements that are not positively impacting the quality of care.

The ACS responded to multiple requests for information advocating for an overhaul of the physician quality programs and recognition of specialty care in Accountable Care Organizations (ACOs). The College challenged CMS to work with the ACS and other stakeholders on developing measures that move the system towards patient-centered, standardized, programmatic care that delivers high-quality and affordability. In addition, the ACS highlighted the importance of providing actionable, understandable information to patients and caregivers about where they can seek care that aligns with their values.

Further, the College specifically discussed how CMS should consider using episode-based payment models aligned with quality programs designed around a condition or service line, such as ACS Trauma Programs, Geriatric Surgery Verification, Bariatric Surgery Accreditation, ACS Cancer program, and others to facilitate the transition to value-based care and offer patients transparent information about the care they seek.

Read the College's full CY 2024 MPFS comment letter, and contact regulatory@facs.org for more information.

Report Errors in 2022 MIPS Feedback by October 9

CMS recently released MIPS performance feedback and final scores for the 2022 Performance Year. This performance feedback determines whether a physician will receive a positive, neutral, or negative payment adjustment on Medicare services furnished in 2024. Surgeons can view this information on the Quality Payment Program (QPP) website using their HCQIS Access Role and Profile (HARP) credentials. For help registering for a HARP account, access the QPP Access User Guide.

CMS has also released several resources for more information:  

• 2022 MIPS Performance Feedback FAQs  
• 2022 MIPS Performance Feedback Patient-Level Data Reports Supplement
• 2024 MIPS Payment Year Payment Adjustment User Guide

If you believe there is an error in your MIPS performance feedback report, you should request an appeal, otherwise referred to as a targeted review, by October 9, 2023.

To submit a targeted review, you must sign into your account of the QPP website using your HARP credentials (the same credentials used to access and submit MIPS data) and click on “Targeted Review” on the left-hand navigation. If the targeted review request is approved and results in a scoring change, CMS will update the final score and associated payment adjustment (if applicable). Targeted review decisions are final and not eligible for further review. For more information about how to request a targeted review, refer to the 2022 Targeted Review User Guide.

For more information about MIPS performance feedback or the targeted review process, contact QualityDC@facs.org.

ACS Encourages Congress to Strengthen Health Systems Globally

Senator Benjamin L. Cardin (D-MD), a member of the Senate Foreign Relations Committee and chair of the Subcommittee on State Department and US Agency for International Development (USAID) Management, International Operations, and Bilateral International Development, recently requested feedback from global health experts on actions Congress could take to improve how the US works with local partnerships to strengthen the overall performance of health systems globally.

The ACS responded with actions Congress could take, including:

• Improving the J-1 Visa program to strengthen training opportunities through bilateral exchanges and allowing clinical medical education training in the US that includes “hands-on” experiences to be an allowable use of Health Systems Strengthening (HSS) funding
• Supporting funding for neglected surgical conditions

Healthcare providers from high-income countries (HICs) frequently perform clinical care in healthcare institutions in low- and middle-income countries (LMICs); however, reciprocal opportunities for trainees and faculty from LMICs to participate in hands-on clinical educational rotations do not exist in the US. Amending the existing J-1 Visa program under the authority of the US Department of State to allow for short-term, supervised clinical medical training experiences that provide patient contact for international physicians and postgraduates would create bilateral exchanges that would “promote equity in medical education globally, strengthen and build health care delivery worldwide, facilitate medical education partnerships, drive innovation, and promote global health stability.”

The ACS continues to seek funding for neglected surgical conditions globally. Each year, global deaths from conditions requiring surgical care far exceed those from HIV/AIDS, tuberculosis, and malaria, combined. However, the burden of conditions requiring surgical intervention is neglected as a public health strategy. The ACS was pleased to see language in the Fiscal Year 2024 House and Senate State Foreign Operations and Related Programs appropriations bills encouraging USAID to utilize funds for neglected surgical conditions; however, no funding was attached to that report language. Utilizing HSS to fund surgical intervention for neglected conditions would emphasize a commitment to global surgical care.

 Read the full response here.

Lawmakers Introduce Bill to Reform Step Therapy Protocols

Senators Lisa Murkowski (R-AK) and Maggie Hassan (D-NH), along with Representatives Brad Wenstrup, DPM (R-OH) and Raul Ruiz, MD (D-CA), have introduced the Safe Step Act in their respective chambers; this legislation would help ensure that patients can safely and efficiently access the medications they need.

Many insurance providers require a specific sequence in which certain prescription medications are covered, known as step therapy. Under step therapy protocols, patients may be required to try different medications and treatments before their insurer will cover the drug originally prescribed by their physician. While step therapy can be an important tool to contain the cost of prescription drugs, in some circumstances, it has negative impacts on patients, including delayed access to the most effective treatment, severe side effects, and irreversible disease progression.

The Safe Step Act would require health plans to provide a clear and transparent exception process for any medication step therapy protocol and grant exemptions when a patient has already tried and failed on a required drug, when a patient is stable on their current medication, or when a required drug or delayed treatment would harm the patient. The ACS has long supported policies that improve surgical patient care, lessen administrative burdens, and streamline clinical workflow, and the Safe Step Act will put healthcare decisions in the hands of patients and their doctors.

Read the ACS letter of support here.

Register Today for November In-Person ACS Coding Course in Chicago

The next in-person ACS/Karen Zupko & Associates (KZA) Current Procedural Terminology (CPT) coding course is November 2-3 in Chicago, Illinois. Register today!

Thursday, November 2, 1:00–5:00 pm

Reporting Hospital E/M Codes and Split/Shared and Critical Care Services Course

2 years into the new outpatient E/M guidelines, difficulties surrounding their interpretation continue.  The information overload continues in 2023 with new E/M codes for inpatient/facility encounters, where all E/M will be reported based on either medical decision making or time. Additionally, CPT has made major changes in how the category of code is selected, including deletions in observation codes, combining initial hospital with observation codes, and reporting more than one E/M code per day.

This course will distill the primary issues in determining the problem, data, and risk elements that combine to arrive at a level of service based on medical decision-making. How many problems are enough? What separates exacerbation from severe exacerbation? How do you define minor versus major risk? Do procedure risks make a difference? Learn about changes to Medicare’s billing rules for both split/shared services and critical care. Keep up on these important changes to avoid risks to your revenue and becoming an audit target.

Friday, November 3, 8:00 am–4:00 pm

General Surgery: Revenue and RVU Optimization

Revenue and RVU optimization depend on good documentation and coding accuracy by both surgeons and billing staff.  This course sifts through all that is new and important in general surgery coding and packs it into an intensive, fast-paced day. 

This year's agenda covers all you need to know to code and document accurately and efficiently in 2023 and beyond, including how to accurately code the new abdominal hernia codes which have been totally revamped, along with coding for endoscopy, colorectal, breast, appendix, gall bladder, liver, intraabdominal tumor, and endocrine procedures. Real-life cases and discussions that link clinical procedures to the selection of codes make this course ideal for surgeons and coding staff. You'll learn why documentation and modifiers are as essential as the code selected, and how to capture all potential revenue by improving your notes. 

Hyatt Centric Chicago Magnificent Mile – close to Chicago landmarks

Rate: $209/night (plus tax)
Hotel Cut-Off Date: October 12, 2023
Call: 1-877-803-7534

Book your room here.

ACS members and their staff receive a registration discount. For more information about registration, email KZA at education@karenzupko.com, or call 312-642-8310. 

For more information about the 2023 ACS in-person coding courses, visit the KZA website, or send an email to practicemanagement@facs.org.