CMS ISSUES TWO SIGNIFICANT PROPOSED RULES: 2023 ASC PAYMENT UPDATE OF 2.7 PERCENT; REQUEST FOR COMMENTS ON ESTABLISHING PAYMENT FOR OFFICE CATARACT SURGERY

Proposed 2023 ASC Payment Rates for Ophthalmic Services

Coverage of Drugs Used During Cataract Surgery
 
For the past couple of years, CMS has provided separate payment for non-opioid pain management drugs and biologicals that function as supplies in the ASC setting when those products are FDA approved, have an FDA-approved indication for pain management or as an analgesic, and have a per-day cost above the HOPD drug packaging threshold.  CMS is proposing separate payment for Dextenza under this authority as well as continued payment for Omidria.  CMS is soliciting comments, for possible inclusion in the final 2023 ASC payment rule, on other such drugs that might qualify for additional payment.
 
ASC Quality Reporting
 
Last year, CMS finalized a requirement that, for purposes of CY 2027 payment determinations, would have required that ASCs report on ASC-11, Cataracts: Improvement in Patient’s Visual Function within 90 Days Following Cataract Surgery.  Responding to the strenuous objections of OOSS, and the ophthalmology and ASC communities, CMS is now proposing to change the measure from mandatory to voluntary. 
 
CMS is also soliciting comments regarding the advisability of establishing quality measures that would apply uniquely to specialty centers, e.g., ophthalmology, GI.  No such measures have been proposed but CMS offered examples of the types of measures that might be developed for the ophthalmology center, e.g., Cataract:  Difference Between Planned and Final Refraction; Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery; Cataracts: Patient Satisfaction within 90 Days Following Cataract Surgery. 
 
Payment for New Technology IOLs
 
ASCs that implant lenses that have secured NTIOL status receive an additional $50 in facility reimbursement. CMS reports that there were no applications submitted by ophthalmics manufacturers requesting NTIOL status for lenses for the 2023 ASC payment rate rulemaking.  As an incentive for innovation in new and innovative monofocal lens technologies, OOSS will be recommending in our comments on the proposed rule that the $50 payment be increased to $100.
 
Physician Payment Rule: Solicitation of Comments Regarding Establishment of Non-Facility Payments for Cataract and Other Eye Procedures
 
Advocates of Medicare reimbursement for office cataract surgery have nominated cataract, MIGS, and vitrectomy codes as potentially “misvalued” because there is currently no established non-facility payment rate for these global 90-day surgical procedures.  CMS points out that these are complex surgical eye procedures that require dedicated space, equipment, and personnel, including anesthesia staff (as in the case of Medicare-certified ASCs). Nonetheless, in the proposed physician payment rule published last week, the agency is soliciting comments regarding whether these services are appropriate for performance in a non-HOPD on non-ASC facility.  
 
In our comments to CMS, OOSS will articulate in detail the significant patient health and safety concerns associated with office cataract surgery.  These facilities are unregulated by Medicare or the states. They are not required to meet the rigorous standards applied to ASCs that govern anesthesia care, staff qualifications, oversight, life safety, infection control, to name just a few.  Given the age and comorbidity status of the vast majority of our patients, only the ASC or HOPD are appropriate sites of service for complex ophthalmic procedures.  
 
The proposed ASC regulation can be reviewed here.    
 
The proposed physician payment regulation can be reviewed here.  
 
 
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OOSS will keep you abreast of further developments as well as instructions for OOSS members to submit public comments on the proposed regulation. Should you have any questions regarding the rule, please contact Michael Romansky, JD at mromansky@OOSS.org.