CMS Issues Final 2021 ASC Payment Rule: 2.4% Increase for Facilities

On December 2, the Centers for Medicare and Medicaid Services (CMS) issued its final CY 2021 payment rate regulation for hospital outpatient departments (HOPD) and ambulatory surgery centers (ASC).

ASC Payment Rate Updates

CMS has agreed, for the period 2019-2023, to update ASC payment rates by the Hospital Market Basket rather than the lower Consumer Price Index-Urban. OOSS has been a leader in the effort to effectuate this change for over 20 years, seeking to persuade both CMS and Congress of its merits. Under this new policy, ASCs receive the same update as hospitals, subject to certain adjustments.

Under the ASC payment system, facilities receive a percentage of the relative weight assigned to a code for procedures furnished in HOPDs. The relative weights are re-calibrated each year based on a complex formula that takes into account a number of factors, including changes in hospitals’ costs in providing such services and the mandate that the ASC payment system remain budget-neutral. 

Under the final rule, ASC payment rates will be updated by 2.4 percent in 2021. Note that this is an average increase and that updates will vary by code, specialty and locality. OOSS will provide you with rates for specific ophthalmic surgical procedures when they are published by CMS.

ASC Quality Reporting

For the past several years, OOSS and the ASC and ophthalmology communities have been engaged in the process of developing and proposing new and appropriate ophthalmic ASC measures. The agency adopted in 2018 a new ophthalmic quality measure, “ASC 14: Unplanned Anterior Vitrectomy,” which assesses the percentage of cataract surgery patients who have the procedure in an ASC. For 2021, CMS did not accept our recommendation that a quality measure for TASS be adopted but indicated that this and other proposed quality measures will be further considered in the future.

Separate Payment for Non-Opioid Pain Management Drugs

In our comments to the agency, OOSS recommended that CMS develop a policy that covers and pays for drugs that are administered at the time of ophthalmic surgery, and have an FDA-approved indication to treat/prevent postoperative issues, such as pain and/or inflammation, separately under Medicare Part B. For 2021, CMS has decided to pay for Omidria separate and apart from the facility fee. 

The final regulation can be reviewed here.