CMS rule expands coverage of PCI at ambulatory centers

CMS has finalized a rule that states, come Jan. 1, it will begin paying for certain percutaneous coronary interventions (PCIs) performed at ambulatory surgical centers (ASCs) in the U.S.

The rule, finalized on Nov. 1 and slated for official publication Nov. 12, solidifies CMS’ earlier proposal to add six stenting and angioplasty interventions to its covered procedures list (CPL) for the calendar year 2020. Other updates to the ASC CPL roster include total knee arthroplasty and a knee mosaicplasty procedure.

CMS said in the rule that it assessed each of the eight proposed procedures against regulatory safety criteria.

“Although the proposed coronary intervention procedures may involve blood vessels that could be considered major, as stated in the Aug. 2, 2007, ASC final rule, we believe the involvement of major blood vessels is best considered in the context of the clinical characteristics of individual procedures,” the agency stated. “We do not believe that it is logically or clinically consistent to exclude certain cardiac procedures from the list of ASC covered surgical procedures on the basis of the involvement of major blood vessels yet continue to provide ASC payment for similar procedures...that have a history of safe performance in ASCs.”

Similar interventions already covered by CMS include mechanicochemical destruction of insufficient veins in the arms or legs and stent insertion through the groin.

During a public comment period this fall, some people expressed concern that while ASCs are likely well-equipped to safely perform PCIs on Medicare beneficiaries, without defined criteria for risk stratification, those beneficiaries could be exposed to significant risk. Others worried that PCI procedures should be performed exclusively in hospital settings, where there’s onsite surgical backup in case of an emergency.

CMS did acknowledge that “a majority of Medicare beneficiaries may not be suitable candidates to receive these procedures in an ASC setting”—mostly due to unmodifiable risk factors like age and comorbidities—but maintained that it was important to cover ASC PCIs for for those who are good candidates.

The coronary intervention procedures and add-ons for 2020 are as follows:

  • CPT code 92920: Percutaneous transluminal coronary angioplasty; single major coronary artery or branch
  • CPT code 92921: Percutaneous transluminal coronary angioplasty; each additional branch of a major coronary artery
  • CPT code 92928: Percutaneous transcatheter placement of intracoronary stents with coronary angioplasty; single major coronary artery or branch
  • CPT code 92929: Percutaneous transcatheter placement of intracoronary stents with coronary angioplasty; each additional branch
  • CPT code C9600: Percutaneous transcatheter placement of drug-eluting intracoronary stents with coronary angioplasty; single major coronary artery or branch
  • CPT code C9601: Percutaneous transcatheter placement of drug-eluting intracoronary stents with coronary angioplasty; each additional branch 

CMS estimated that in 2019, it shelled out around $184 million in payments to ASCs for cardiovascular care—a number that’s expected to jump by 5% in 2020. Using 2018 utilization data and proposed 2020 outpatient prospective payment system (OPPS) and ASC payment rates, the agency estimated that if 5% of coronary intervention procedures move from hospital outpatient settings to ASC settings as a result of this policy, Medicare payments will be reduced by approximately $20 million in 2020.

Total beneficiary copayments would also decline, by around $5 million in 2020.

“The calendar year 2020 OPPS/ACS Payment System final rule with comment period further advances the agency’s commitment to strengthening Medicare, rethinking rural health, unleashing innovation, reducing provider burden and strengthening program integrity so that hospitals and ambulatory surgical centers can operate with better flexibility and patients have what they need to become active healthcare consumers,” CMS said in a statement issued earlier this month.

The final rule will go into effect Jan. 1, 2020.