There are currently around 1,740 procedures on CMS' inpatient only list, which is reviewed and updated annually. However, CMS proposed eliminating the inpatient only list in 2021 after years of receiving comments advising the agency to allow physicians to decide on the clinical site of service.
The move could be a boon for some ASCs if private payers decide to follow CMS' lead and cover more procedures in the outpatient setting, but CMS will need to go a step further to really expand access to ASCs.
"Eliminating Medicare's inpatient-only list might incentivize some private payers to pay for procedures in the outpatient setting that they only reimburse in the inpatient setting now," said Bill Prentice, CEO of ASCA. "To expand Medicare beneficiaries' access to care in the ASC setting, however, CMS needs to eliminate the ASC payable list and begin reimbursing ASCs for all the same procedures it reimburses in hospital outpatient departments."
The inpatient only list was created in 2000 to identify procedures that would need more than 24 hours of stay to recover. Since then, many high-profile procedures to the list, including total knee replacement, have been removed and added to the ASC payable list.
CMS noted some stakeholders have commented that excluding procedures from outpatient payments could have adverse effects on surgical care advances. However, others support the inpatient only list and consider it an important tool to decide whether procedures should be performed in the outpatient setting.
"We have concluded that we no longer believe there is a need for the IPO list in order to identify services that require inpatient care," states the report. "Instead, we agree with past commenters that the physician should use his or her clinical knowledge and judgement together with consideration of the beneficiary's specific needs, to determine whether a procedure can be performed appropriately in the hospital outpatient setting or whether inpatient care is required for the beneficiary, subject to the general coverage rule requiring that any procedure be reasonable and necessary. We believe that this change will ensure maximum availability of services to beneficiaries in the outpatient setting."
CMS cited the advances in medical technologies over the past two decades as making minimally invasive, outpatient surgeries possible for previously large and complex procedures. The agency proposed a "transitional period" over the next three years where hundreds of procedures would be priced under the OPPS, which will give providers time to adjust to the changes.
For 2021, CMS proposed removing 266 orthopedic procedures from the inpatient only list, which you can find here.
The agency also proposed adding 11 procedures to the ASC payable list next year.