Free for use under the Pixabay Content LicenseAfter a somewhat disappointing rulemaking cycle for ambulatory surgery centers (ASCs) this year, 2025’s discussions with federal regulators will become all the more important.
And a return to a Trump administration means ASC stakeholders will need to start those conversations sooner rather than later.
“We’re really going to get on the ball very early in the year in 2025,” Kara Newbury, chief advocacy officer for Ambulatory Surgery Center Association (ASCA), said during a recent podcast from the national industry group.
The U.S. Centers for Medicare & Medicaid Services (CMS) releases proposed and finalized payment rules for each upcoming year for the various parts of health care reimbursed by Medicare. For ASCs, the agency’s final payment rule for 2025 was released on Nov. 1.
ASC operators and advocates are often disappointed with the outcome of this regular rulemaking process, and the Nov. 1 rule was no exception. In particular, the industry has grown frustrated with regulators seemingly treating hospitals and outpatient settings very differently while writing off feedback from the ASC leaders who have offered it.
“Despite our proven ability to save Medicare billions of dollars, a bias in favor of hospitals and against surgery centers seems to have prevailed at CMS under both Republican and Democratic administrations, and that’s what we fight with every year,” ASCA President Bill Prentice said on the podcast.
The 2025 final payment rule for ASCs features an effective payment update of 2.9% for ASCs, a figure that includes a 3.4% inflation update based on the hospital market basket and a downward productivity adjustment of 0.5 percentage points.
That’s good for a minor increase over what CMS first proposed.
The update will vary depending on procedural codes, with the top-100 ASC codes seeing an estimated update of about 2.93%, according to ASCA data.
“[That’s] just slightly better, obviously, than the 2.9%,” Newbury said. “And then for the top-10 codes by volume, it’s not quite as good. It’s only about a 2.5% update for those codes.”
While ASCs would like to see a more positive payment update for the coming year, the more significant disappointments with CMS rulemaking revolve around the lack of procedural codes added to the agency’s approved-procedures list.
ASCA, for example, had advocated adding new cardiovascular and spine codes for 2025. CMS did not move forward with ASCA’s suggestions, with little feedback as to why, according to Prentice and Newbury.
“In reference to the cardiovascular codes, CMS said, ‘Many of these codes have associated inpatient admissions where the beneficiary would require active medical care and monitoring at midnight following the procedure,’” Newbury explained. “Well, it would be nice to know which of the procedures that we requested they feel would require that, because the data that we shared with them, we feel, does not indicate that.”
As for the musculoskeletal codes, CMS in its rationale said supporting evidence for those codes had “significant limitations,” including selection bias and “absence of age groups representative of the Medicare population.”
In its final rule, CMS finalized the addition of 21 procedures to the ASC covered-procedures list, including 19 dental codes. It likewise added two adipose-derived regenerative cell therapy codes.
The changes that CMS finalized related to the ASC Quality Reporting (ASCQR) Program also raise concerns within the industry.
These include the Facility Commitment to Health Equity measure, which will go live in 2025 with 2027 payment implications. CMS also finalized two measures around social determinants of health, which have payment implications for 2028.
Social determinants of health are factors that influence an individual’s health and well-being, such as access to transportation, access to nutritious food, and having a network of friends or family for emotional support.
“Our ultimate question and concern is: Is the ASC the appropriate setting for this?” Newbury said. “And truly, we don’t believe it is.”
To secure continued positive payment updates, add more procedures to the covered-procedures list and fine-tune ASCQR, ASCA and other stakeholders will need to build new relationships with the officials appointed by the Trump administration.
One advantage in that effort is having recently worked with the Trump administration before President Joe Biden’s term began, Prentice noted.
“We do have some experience with the prior Trump administration, where, in the last year of that administration, they greatly expanded the procedure list for both us and hospital outpatient departments,” he said. “In fact, I think there was an effort to do away with the inpatient-only list.”
“Of course, we don’t know who will lead the agencies this time and whether they’ll have the same or similar mindset or not, but at least there is some hope that, maybe next year, we will have a more welcoming ear to our interest in moving procedures [to ASCs],” he continued.
